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SUMMARY Background Blood in Australia is sourced through voluntary, non-remunerated donations. With periodic shortages in supply, increasing demand for blood products and a donor base that is perceived to be unsustainable, remuneration has been proposed as a means to improve donation rates. Objective To examine community attitudes to remunerated blood donation in Australia. Method A national random telephone survey of Australian adults age 18-70 was conducted ( n = 1024). Associations were tested using a chi-square (χ2) test for linear distribution. Results Reimbursement for the cost of travel to donate blood was supported by more respondents (46%) than reimbursement for time (19%). Non-donors were more likely to support a payment compared to donors ( P = 0·002). Twelve per cent of respondents thought they would be more likely to donate if remunerated while 10% thought they would be less likely. The majority (76%) thought that a payment would not change whether or not they would donate, while 85% thought that it would make other people more likely to donate. The average amount considered to be reasonable reimbursement was AU$30. Conclusion Despite the common perception that other people would be motivated to donate blood with the introduction of a financial incentive, remuneration may provide minimal incentive in Australia and is unlikely to increase donor participation for the time being. [ABSTRACT FROM AUTHOR]

Background: Lower extremity amputation results in significant global morbidity and mortality. Australia appears to have a paucity of studies investigating lower extremity amputation. The primary aim of this retrospective study was to investigate key conditions associated with lower extremity amputations in an Australian population. Secondary objectives were to determine the influence of age and sex on lower extremity amputations, and the reliability of hospital coded amputations. Methods: Lower extremity amputation cases performed at the Princess Alexandra Hospital (Brisbane, Australia) between July 2006 and June 2007 were identified through the relevant hospital discharge dataset (n = 197). All eligible clinical records were interrogated for age, sex, key condition associated with amputation, amputation site, first ever amputation status and the accuracy of the original hospital coding. Exclusion criteria included records unavailable for audit and cases where the key condition was unable to be determined. Chi-squared, t-tests, ANOVA and post hoc tests were used to determine differences between groups. Kappa statistics were used to measure reliability between coded and audited amputations. A minimum significance level of p < 0.05 was used throughout. Results: One hundred and eighty-six cases were eligible and audited. Overall 69% were male, 56% were first amputations, 54% were major amputations, and mean age was 62 ± 16 years. Key conditions associated included type 2 diabetes (53%), peripheral arterial disease (non-diabetes) (18%), trauma (8%), type 1 diabetes (7%) and malignant tumours (5%). Differences in ages at amputation were associated with trauma 36 ± 10 years, type 1 diabetes 52 ± 12 years and type 2 diabetes 67 ± 10 years (p < 0.01). Reliability of original hospital coding was high with Kappa values over 0.8 for all variables. Conclusions: This study, the first in over 20 years to report on all levels of lower extremity amputations in Australia, found that people undergoing amputation are more likely to be older, male and have diabetes. It is recommended that large prospective studies are implemented and national lower extremity amputation rates are established to address the large preventable burden of lower extremity amputation in Australia. [ABSTRACT FROM AUTHOR]

Background: To test the hypothesis that Intensive Care Unit (ICU) doctors and nurses differ in their personal preferences for treatment from the general population, and whether doctors and nurses make different choices when thinking about themselves, as compared to when they are treating a patient., Methods: Cross sectional, observational study conducted in 13 ICUs in Australia in 2017 using a discrete choice experiment survey. Respondents completed a series of choice sets, based on hypothetical situations which varied in the severity or likelihood of: death, cognitive impairment, need for prolonged treatment, need for assistance with care or requiring residential care., Results: A total of 980 ICU staff (233 doctors and 747 nurses) participated in the study. ICU staff place the highest value on avoiding ending up in a dependent state. The ICU staff were more likely to choose to discontinue therapy when the prognosis was worse, compared with the general population. There was consensus between ICU staff personal views and the treatment pathway likely to be followed in 69% of the choices considered by nurses and 70% of those faced by doctors. In 27% (1614/5945 responses) of the nurses and 23% of the doctors (435/1870 responses), they felt that aggressive treatment would be continued for the hypothetical patient but they would not want that for themselves., Conclusion: The likelihood of returning to independence (or not requiring care assistance) was reported as the most important factor for ICU staff (and the general population) in deciding whether to receive ongoing treatments. Goals of care discussions should focus on this, over likelihood of survival., (© 2021. The Author(s).)

Background: Hip fractures are a common and painful emergency presentation amongst elderly patients and are associated with significant morbidity and mortality. This study observed the frequency of documentation of pain scores and use of nerve blocks in hip fracture patients in a regional Australian ED and describes current practice in relation to national guidelines., Methods: This was a retrospective single-site observational study and included all patients with a recorded ED diagnosis of fracture neck of femur over the age of 18 presenting between 1 July 2017 and 31 December 2017 to a regional ED. Data collection included patient demographics, pain scores and analgesia administered., Results: Ninety-three patients were included in analysis. This population had a high proportion of patients who had a residential address remote to the base hospital. Thirty-eight patients (41%) had a documented pain score within 30min and the frequency of nerve blocks was 45%., Conclusion: Management of pain for patients with hip fracture in this regional ED varied from Australian guidelines and practice in other Australian EDs, demonstrating potential areas for further research and quality improvement in assessing and treating pain in older adults. Geographic remoteness may be an important factor., (Copyright © 2020 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.)

Overtraining, exhaustion, and burnout are widely recognized problems amongst elite athletes. The present research addresses this issue by exploring the extent to which high-quality athlete leadership is associated with elite athletes' health and burnout. Participants (120 male athletes from three top-division Australian football teams) were asked to rate the quality of each of their teammates in four different leadership roles (i.e. as task and motivational leaders on the field and as social and external leaders off the field), and also to indicate their identification with their team as well as their self-reported health and burnout. Findings indicated that (a) being seen to be a good athlete leader by other members of the team and (b) having a good athlete leader on the team were both positively associated with better team member health and lower burnout. This relationship was mediated by athletes' identification with their team, suggesting that leaders enhance athletes' health and reduce athlete burnout by creating and maintaining a sense of shared identity in their team. This, in turn, suggests that coaches can foster an optimal team environment by developing the leadership potential of their athlete leaders - in particular, their skills that foster a sense of shared team identification. This is in the interests not only of team performance but also of team members' health and burnout.

Objective: To determine whether absorbable or nonabsorbable mesh repair of large hiatus hernias is followed by less recurrences at late follow-up compared to sutured repair., Summary of Background Data: Radiological recurrences have been reported in up to 30% of patients after repair of large hiatus hernias, and mesh repair has been proposed as a solution. Earlier trials have revealed mixed outcomes and early outcomes from a trial reported previously revealed no short-term advantages for mesh repair., Methods: Multicentre prospective double-blind randomized controlled trial of 3 methods of hiatus hernia repair; sutures versus absorbable mesh versus nonabsorbable mesh. Primary outcome - hernia recurrence assessed by barium meal X-ray and endoscopy at 3-4 years. Secondary outcomes - clinical symptom scores at 2, 3, and 5 years., Results: 126 patients were enrolled - 43 sutures, 41 absorbable mesh, and 42 nonabsorbable mesh. Clinical outcomes were obtained at 5 years in 89.9%, and objective follow-up was obtained in 72.3%. A recurrent hernia (any size) was identified in 39.3% after suture repair, 56.7% - absorbable mesh, and 42.9% - nonabsorbable mesh (P = 0.371). Clinical outcomes were similar at 5 years, except chest pain, diarrhea, and bloat symptoms which were more common after repair with absorbable mesh., Conclusions: No advantages were demonstrated for mesh repair at up to 5 years follow-up, and symptom outcomes were worse after repair with absorbable mesh. The longer-term results from this trial do not support mesh repair for large hiatus hernias.

Background: There is limited evidence for the use of postoperative antibiotics for simple appendicitis (SA) in children. Our aim was to conduct a prospective double-blinded randomized controlled trial to investigate this after a laparoscopic appendicectomy., Methods: Following ethical approval, children (≤16 years) undergoing appendicectomy were recruited at a single institution. Patients were randomized intraoperatively to receive either 2 postoperative intravenous doses of placebo or antibiotics (Abx). All patients received a dose of Abx at induction of anesthesia. Primary outcome was the incidence of postoperative wound infection (WI), and secondary outcome was the incidence of intra-abdominal abscess formation. Data are reported as number of cases (%), median (range), relative risk, and analyzed using Mann Whitney U test, Chi-square test, as appropriate, a P-value ≤0.05 was considered significant., Results: A total of 304 patients were randomized. Sixty-one were subsequently excluded due to protocol violations or recruitment errors; therefore, 243 were included in the final analysis. One hundred twenty-two patients received placebo and 121 Intravenous Abx. There was no difference between the sex (50F/72 M vs 47F/74 M, P = 0.8), median age (12.4 vs 12.2 years, P = 0.5), and postoperative length of stay in a hospital (27.2 vs 25.6 hours, P = 0.7). There was also no difference in the preoperative blood results. A total of 9 WIs occurred: 8/122 (6.6%) placebo versus 1/121 (0.8%) Abx, P = 0.01 [relative risk for WI 7.9 (95% confidence interval: 1.0-62.4)]. There were no intra-abdominal abscess in either groups., Conclusions: This prospective randomized double blinded randomized controlled trial has revealed a significant decrease in WI rates by giving 2 postoperative intravenous doses of Abx, suggesting postoperative Abx are of benefit in SA.

The purpose of this study was (1) accurately estimate longitudinal relationships between decimal age (i.e., chronological and relative) and performance in Australian female 100 m (N = 765) and 200 m (N = 428) Breaststroke swimmers (10-18 years); and (2) determine whether corrective adjustment procedures could remove Relative Age Effects (RAEs) in an independent sample of age-matched 100 m (N = 2,491) and 200 m (N = 1,698) state/national level Breaststroke swimmers. In Part 1, growth curve modelling quantified longitudinal relationships between decimal age and swimming performance. In Part 2, relative age distributions (Quartile 1-4) for "All", "Top 25%" and "10%" of swimming times were examined based on raw and correctively adjusted swim times for age-groups. Based on raw swim times, finding identified RAE effect sizes increased in magnitude (small-medium) with selection level ("All"-"Top 25%") in 12-14 years age-groups for both events. However, when correctively adjusted swim performances were examined, RAEs were primarily absent across all age-groups and selection levels. Using longitudinal reference data, corrective adjustment procedures removed relative age advantages in female youth Breaststroke performance. Removing the influence of relative age-related differences is predicted to improve the accuracy of identifying genuinely skilled youth swimmers.

Purpose: It is unknown whether protocols targeting systematic prevention and treatment of fever achieve lower mean body temperature than usual care in intensive care unit (ICU) patients. The objective of the Randomised Evaluation of Active Control of temperature vs. ORdinary temperature management trial was to confirm the feasibility of such a protocol with a view to conducting a larger trial., Methods: We randomly assigned 184 adults without acute brain pathologies who had a fever in the previous 12 h, and were expected to be ventilated beyond the calendar day after recruitment, to systematic prevention and treatment of fever or usual care. The primary outcome was mean body temperature in the ICU within 7 days of randomisation. Secondary outcomes included in-hospital mortality, ICU-free days and survival time censored at hospital discharge., Results: Compared with usual temperature management, active management significantly reduced mean temperature. In both groups, fever generally abated within 72 h. The mean temperature difference between groups was greatest in the first 48 h, when it was generally in the order of 0.5 °C. Overall, 23 of 89 patients assigned to active management (25.8%) and 23 of 89 patients assigned to usual management (25.8%) died in hospital (odds ratio 1.0, 95% CI 0.51-1.96, P = 1.0). There were no statistically significant differences between groups in ICU-free days or survival to day 90., Conclusions: Active temperature management reduced body temperature compared with usual care; however, fever abated rapidly, even in patients assigned to usual care, and the magnitude of temperature separation was small., Trial Registration: Australian and New Zealand Clinical Trials Registry Number, ACTRN12616001285448.

Purpose: Data on childhood intensive care unit (ICU) deaths are needed to identify changing patterns of intensive care resource utilization. We sought to determine the epidemiology and mode of pediatric ICU deaths in Australia and New Zealand (ANZ)., Methods: This was a retrospective, descriptive study of multicenter data from pediatric and mixed ICUs reported to the ANZ Pediatric Intensive Care Registry and binational Government census. All patients < 16 years admitted to an ICU between 1 January 2006 and 31 December 2016 were included. Primary outcome was ICU mortality. Subject characteristics and trends over time were evaluated., Results: Of 103,367 ICU admissions, there were 2672 (2.6%) deaths, with 87.6% of deaths occurring in specialized pediatric ICUs. The proportion of ANZ childhood deaths occurring in ICU was 12%, increasing by 43% over the study period. Unadjusted (0.1% per year, 95% CI 0.096-0.104; p < 0.001) and risk-adjusted (0.1%/year, 95% CI 0.07-0.13; p < 0.001) ICU mortality rates fell. Across all admission sources and diagnostic groups, mortality declined except following pre-ICU cardiopulmonary arrest where increased mortality was observed. Half of the deaths followed withdrawal of life-sustaining therapy (51%), remaining constant throughout the study. Deaths despite maximal resuscitation declined (0.92%/year, 95% CI 0.89-0.95%; p < 0.001) and brain death diagnoses increased (0.72%/year, 95% CI 0.69-0.75%; p = 0.001)., Conclusions: Unadjusted and risk-adjusted mortality for children admitted to ANZ ICUs is declining. Half of pediatric ICU deaths follow withdrawal of life-sustaining therapy. Epidemiology and mode of pediatric ICU death are changing. Further investigation at an international level will inform benchmarking, resource allocation and training requirements for pediatric critical care.

Background and Aim: Adenoma detection rate (ADR) is an important quality metric in colonoscopy. However, there is conflicting evidence around factors that influence ADR. This study aims to investigate the effect of time of day and endoscopist background on ADR and sessile serrated adenoma/polyp detection rate (SSA/P-DR) for screening colonoscopies., Methods: Consecutive patients undergoing colonoscopy in 2016 were retrospectively evaluated. Primary outcome was the effect of time of day and endoscopist specialty on screening ADR. Secondary outcomes included evaluation of the same factors on SSA/P-DR and other metrics and collinearity of ADR and SSA/P-DR. Linear regression models were used for association between ADR, time of day, and endoscopist background. Bowel preparation, endoscopist, session, patient age, and gender were adjusted for. Linear regression model was also used for comparing ADR and SSA/P-DR. Chi-square was used for difference of proportions., Results: Two thousand six hundred fifty-seven colonoscopies, of which 558 were screening colonoscopies, were performed. The adjusted mean ADR (screening) was 36.8% in the morning compared with 30.5% in the afternoon (P < 0.0001) and was 36.8% for gastroenterologists compared with 30.4% for surgeons (P < 0.0001). For every 1-h delay in commencing the procedure, there was a reduction in mean ADR by 3.4%. Using a linear regression model, a statistically significant positive association was found between ADR and SSA/P-DR (P < 0.0001)., Conclusions: Morning and afternoon sessions and gastroenterologists and surgeons achieved the minimum standards recommended for ADR. Afternoon lists and surgeons were associated with a lower ADR compared with morning and gastroenterologists, respectively. Additionally, SSA/P-DR showed collinearity with ADR., (© 2018 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Introduction: Armed forces view their officers' character as foundational to their ability to lead the personnel entrusted to them. The character of junior officers is of particular interest, because they must increasingly make quick, morally-laden decisions while dispersed among civilians without time to consult their commanders. However, little is systematically known about the character of officers. Accordingly, the present study was aimed at mapping Australian Army junior officers' perceptions of the chief aspects of their own character and also those of their main role models, specifically, their senior officers, including their trustworthiness as an essential aspect of effective leadership. The present study also tested whether these character perceptions were aligned with four core values of the Australian Army - courage, initiative, teamwork, and respect - which are intended to shape the character of its personnel., Materials and Methods: The respondents (N = 171 lieutenants) ranked how well each of 24 positive character strengths applied to themselves as individuals. To test the alignment of these rankings with the respondents' perception of their leaders' character, respondents nominated the five top strengths of their effective leaders. This study was approved by the Australian Defence Human Research Ethics Committee (ADHREC 009-2013)., Results: With regard to the first aim, five character strengths - integrity, leadership, good judgment, trustworthy, and teamworker - were ranked by the respondents as being their chief personal strengths at frequencies significantly above those expected from random allocation.With regard to the second aim, the respondents aligned the rankings of their character strengths with those of their effective leaders through the entire list, not just the highest-ranking items. Nevertheless, there were two significant differences. The respondents assigned their leaders higher ranks for wisdom than for themselves, but assigned lower ranks to their leaders for being trustworthy.With regard to the third aim, the respondents' perceptions of their chief character strengths were not well aligned with the four core values of the Australian Army. Teamworker was given a significant top ranking, but courage, initiative, and respectful were not. Thus, the respondents did not appear to respond according to organizational demand characteristics., Conclusions: The present study achieved its aims. First, it revealed five character strengths that junior officers in the Australian Army tended to see as their own chief strengths. Second, the junior officers saw their character strengths as aligned with those of their senior officers. By and large, this alignment extended across all the character strengths, regardless of their specific ranking. Subject to further experimental testing, this finding provides correlational evidence that junior officers may model their character on what they see in their senior officers. Third, in contrast, the junior officers' rankings were not well aligned with the Australian Army's stated core values. The junior officers saw teamworker as one of their chief strengths, but not courage, initiative, or respectful. This pattern does not imply that the junior officers rejected strengths as valuable but only that they are not among the junior officers' own chief strengths., (© Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Despite international guidelines, regional differences in treatment of vasodilatory shock remain. We characterized these differences using data from Angiotensin II in High Output Shock (ATHOS-3) trial., Methods: The 321 patients treated in the ATHOS-3 trial were included. Baseline and hour-48 data were analyzed for differences in demographics, clinical characteristics, and treatment patterns, and grouped into four geographical areas: United States, Canada, Europe, and Australasia. Differences were analyzed by Kruskal-Wallis tests for continuous, and chi-square tests for categorical data. Temporal analysis compared changes in the treatment of shock during the treatment period., Results: Differences in baseline characteristics across geographic areas were noted in BMI, albumin, CVP, MELD score, APACHE II score, and total SOFA score. Baseline norepinephrine and norepinephrine equivalent doses (NED) were higher (p < .0001 and p = .0494, respectively), and vasopressin use was lower (p < .0001) in Europe. Baseline steroids were utilized more in the US and Canada (p = .0011)., Conclusions: Management of vasodilatory shock differs globally with respect to utilization of steroids and vasopressors. This practice heterogeneity may influence shock trials interpretation and patient outcomes, though more definitive evidence would require larger prospective intervention data., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: While a downward trend in unintentional drowning deaths in Australia has been observed, little is known about intentional drowning mortality. Limited information on intentional drowning death impedes the planning, implementation, and evaluation of prevention strategies. This study aims to describe rates of intentional fatal drowning in Australia and compare these to other categories of drowning., Methods: Data were sourced from the Australian Bureau of Statistics (ABS) over a 9-year period (2006-2014). Rates and trends of intentional drowning were compared with unintentional, water-transport related and undetermined intent drowning. Rates of intentional drowning deaths across gender, age groups, states/territories, remoteness of residence and First Peoples of Australia were calculated. Relative risk (RR) (95% confidence interval [CI]) was calculated, and chi-square tests of independence were performed (p < 0.05)., Results: The crude mortality rate for intentional drowning deaths in Australia over the study period was 0.23/100000, lower than unintentional drowning (0.89/100000). Males were 1.6 (CI: 1.4-2.0) times more likely than females to intentionally drown, however females made up a significantly larger proportion of intentional drowning deaths (38.2%) compared to unintentional deaths (22.4%) (χ 2  = 47.3; df = 1; p < 0.05). A significant linear association between age group and intentional drowning was observed (χ 2  = 131.3; p < 0.05), with individuals aged 75 years and over 32.6 times more likely to intentionally drown. Non-Indigenous peoples were 4.1 times more likely to intentionally drown in comparison to First Peoples of Australia. Residents of Inner Regional, Outer Regional, and Major Cities were 4.2 times (CI: 0.6-30.0), 4.1 times (CI: 0.6-29.9), and 4.0 times (CI: 0.6-28.6) more likely to intentionally drown, respectively, compared with residents of Very Remote areas., Conclusions: This study adds to the limited evidence currently available about intentional drowning rates and trends in Australia. Being male, of older age groups, non-Indigenous, residing in Inner and Outer Regional areas, and Major Cities were risk factors for intentional drowning deaths. Improving data collection systems and furthering understanding of the risk factors of intentional drowning, as well as the development, implementation, and evaluation of prevention programmes, are required to reduce the risk of intentional drowning death in Australia.

Objective: This study aimed to investigate changes in maternal body mass index (BMI), blood pressure and glycemic level and infant birthweight using an online educational program compared to standard clinic-based GDM education., Design: A preliminary randomized controlled trial of the online intervention was conducted in Melbourne, Australia between 2014 and 2015. A total of 110 women were randomized to (1) the control group and received standard clinic-based GDM education; or (2) the intervention group and received standard care plus the web-based education program. Data were collected at two time points: baseline and 12 weeks postpartum. Infant birthweight was also recorded. Chi-squared test, independent t-test and paired t-test were used to compare outcomes., Participants: Pregnant women with newly diagnosed GDM, in the Western region of Melbourne, Australia., Findings: Statistically significant differences were reported between intervention and control groups in maternal weight and glycemia post-intervention (p < 0.05). More women in the intervention group than in the control group reported weight loss post-intervention (90.4% vs 48.3%, p < 0.001), and were considered a healthy weight (BMI = 18.5, 24.9kg/m 2 ) at 12 weeks postpartum (44.2% vs 31%). More women in the intervention group had attended for follow up OGTT at 12 weeks postpartum (96.2% vs 70.7%, p < 0.001). Comparing measures pre- and post-intervention in the intervention group, maternal BMI was lower [(28.60 ± 7.93) vs (29.60 ± 8.32); p = 0.000], maternal systolic blood pressure was increased but within normal range [(108.19 ± 11.80) vs (107.29 ± 12.13); p = 0.001], and maternal glycemic level returned to within normal limits [(4.86 ± 0.42) vs (8.80 ± 2.50); p = 0.026]. Most women in both groups gave birth to normal birthweight infants (92.3% and 94.8%). These findings are offset by differences in the groups at baseline., Key Conclusions: Findings suggest that the education intervention had a positive impact on women's postpartum weight and attendance at OGTT by 12 weeks postpartum. No effect was found on maternal blood pressure or infant birthweight. Further studies with matched intervention and control groups are needed to achieve more definitive conclusions., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Normal C-reactive protein (CRP) and white cell count (WCC) are often used to exclude a diagnosis of acute appendicitis in the Emergency Department (ED). Retrospective review of 281 adult patients with acute appendicitis was performed to study the incidence of normal CRP and WCC on admission and examine any possible predisposing factors., Method: Retrospective analysis of patient clinical records yielded CRP, WCC, operative diagnosis, time of symptom onset, imaging results and history and examination features. Case-control analysis was performed with patients with normal CRP and WCC considered the case group and those with raised CRP or WCC considered controls. Groups were compared using Mann-Whitney U-test and chi-squared analysis., Results: Of 281 consecutive patients with histologically proven appendicitis, 24 (8.54%) had normal CRP and WCC on presentation to ED. There were no significant differences in age, sex or time to blood collection between groups. Three patients had normal WCC and CRP and an Alvarado score of 4 or less on presentation. Three patients had persistently normal CRP and WCC on repeated testing. There was a trend towards earlier presentation in patients with normal CRP and WCC with 75.0% versus 58.4% presenting within 24 h of symptom onset (OR 2.14, P = 0.112)., Conclusion: Acute appendicitis remains diagnostically challenging and cannot be excluded on the basis of normal CRP and WCC. Serial clinical and biochemical assessment is warranted in patients with acute abdominal pain, particularly in those presenting early after symptom onset., (© 2016 Royal Australasian College of Surgeons.)

The burden of malnutrition in Indigenous people is a major health priority and this study's aims are to understand health outcomes among Indigenous and non-Indigenous patients. This cohort study includes 608 medical inpatients in three regional hospitals. Participants were screened for malnutrition using the Subjective Global Assessment tool. Hospital length of stay, discharge destination, 30-day and six-month hospital readmission and survival were measured. Although no significant difference was observed between Indigenous participants who were malnourished or nourished ( p = 0.120), malnourished Indigenous participants were more likely to be readmitted back into hospital within 30 days (Relative Risk ( RR ) 1.53, 95% CI 1.19⁻1.97, p = 0.002) and six months ( RR 1.40, 95% Confidence Interval (CI) 1.05⁻1.88, p = 0.018), and less likely to be alive at six months ( RR 1.63, 95% CI 1.20⁻2.21, p = 0.015) than non-Indigenous participants. Malnutrition was associated with higher mortality (Hazards Ratio ( HR ) 3.32, 95% CI 1.87⁻5.89, p < 0.001) for all participants, and independent predictors for six-month mortality included being malnourished ( HR 2.10, 95% CI 1.16⁻3.79, p = 0.014), advanced age ( HR 1.04, 95% CI 1.02⁻1.06, p = 0.001), increased acute disease severity (Acute Physiology and Chronic Health Evaluation score, HR 1.03, 95% CI 1.01⁻1.05, p = 0.002) and higher chronic disease index (Charlson Comorbidity Index, HR 1.36, 95% CI 1.16⁻3.79, p = 0.014). Malnutrition in regional Australia is associated with increased healthcare utilization and decreased survival. New approaches to malnutrition-risk screening, increased dietetic resourcing and nutrition programs to proactively identify and address malnutrition in this context are urgently required.

Background: Adrenal incidentalomas are increasingly diagnosed and include a wide spectrum of lesions from benign adenomas to secreting or malignant lesions. The aim of the present study is to report a large single-institution experience of patients undergoing surgery for adrenal incidentaloma with particular attention to their diagnosis and post-operative course and the evolution of surgical practice over time., Methods: From 1993 to 2013, 274 patients underwent adrenalectomy for incidentaloma. All patients underwent standardized clinical, hormonal and imaging assessments., Results: Patients were mainly female (63.1%; n = 173), and the median age of patients was 56.5 years. After a complete hormonal evaluation, 47.9% (n = 129) of incidentalomas were classified as secreting tumours, including 24.4% (n = 67) subclinical cortisol-secreting adenomas and 18.9% (n = 52) pheochromocytomas. Adrenocortical carcinomas represented 9.5% (n = 26) of incidentalomas, and the risk of malignancy was significantly correlated with tumour size. The conversion rate after laparoscopic adrenalectomy (90.9%; n = 249) was 3.2% (n = 8). The overall morbidity rate was 13.9%, which included a 4.4% rate of severe morbidity (Clavien-Dindo ≥3). From 2008 onwards, there was a significant decrease (P < 0.001) in the use of surgical approaches for non-secreting adenomas., Conclusion: After a complete work-up, half of the incidentalomas were classified as subclinical oversecreting adrenal lesions and 10% proved to be malignant adrenocortical carcinomas. The debatable use of surgical approaches for benign nonfunctioning adenomas significantly decreased over time., (© 2017 Royal Australasian College of Surgeons.)

Background: Many plastic surgery departments in Australasia have experienced increasing referrals for management of skin lesions. This has driven a demand for new strategies to decrease patient waiting time and administrative costs. The aim of this study was to determine if a purpose-built See and Treat skin cancer clinic could provide a faster skin cancer treatment pathway with comparable clinical outcomes and acceptability to patients., Methods: This was a prospective observational study of patients treated through the See and Treat clinic with a retrospective control cohort. The prospective 'See and Treat' cohort included a consecutive series of 106 patients, while the retrospective cohort included a consecutive series of 200 patients. Patient demographics, time from referral to surgery and operative measures were analysed. One hundred patients in the prospective cohort completed an anonymous satisfaction survey regarding their treatment., Results: The average time from referral to surgery was reduced from 121 days in the retrospective cohort to 60 days in the See and Treat cohort (P < 0.001). Rates of complete excision of malignant and premalignant lesions were not different between the two groups, being 93% (178/191) and 91% (76/84), respectively (P = 0.609). Ninety-five percent (95/100) of patients were satisfied with their See and Treat experience overall., Conclusion: We show that a considerable reduction in the time between referral and surgery can be achieved through a See and Treat clinic without compromise of the success of surgical treatment. Moreover, such a treatment pathway has been shown to be acceptable, and largely preferable, to patients., (© 2017 Royal Australasian College of Surgeons.)

Background: Comprehensive discharge planning is important for successful transitions from hospital to home after stroke. The aim of this study was to describe the quality of discharge planning received by patients discharged home from acute care, identify factors associated with a positive discharge experience, and assess the influence of discharge quality on outcomes., Method: Patients discharged to the community and registered in the Australian Stroke Clinical Registry in 2014 were invited to participate. Patient-perceived discharge quality was evaluated using the Prescriptions, Ready to re-enter community, Education, Placement, Assurance of safety, Realistic expectations, Empowerment, Directed to appropriate services questionnaire (recall at 3-9 months). Factors associated with higher discharge quality scores were identified and associations between quality scores of more than 80% and outcomes were investigated using multivariable, multilevel regression analyses., Results: There were 200 of 434 eligible registrants who responded; responders and nonresponders were similar with respect to age, sex, and type of stroke. The average overall quality score was 73% (standard deviation: 21). However, only 18% received all aspects of discharge care planning. Quality scores of more than 80% were independently associated with receiving hospital specific information (odds ratio: 5.7, 95% confidence interval [CI]: 2.7, 12.4), and referral to a local support group (odds ratio: 2.5, 95% CI: 1.1, 5.9). Discharge quality scores of more than 80% were associated with higher European Quality of Life-5 Dimensions EQ-5D scores (coefficient: .1, 95% CI: .04, .2) and a reduction in the rate of unmet needs reported at 3-9 months postdischarge (incidence rate ratio: .5, 95% CI: .3, .7)., Conclusion: We provide new information on the quality of discharge planning from acute care after stroke. Aspects of discharge planning that correlate with quality of care may reduce unmet needs and improve quality of life outcomes., (Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the detailed associations of albuminuria among a contemporary cohort of Aboriginal and Torres Strait Islander people to inform strategies for chronic kidney disease prevention and management., Methods: A cross-sectional analysis of Indigenous participants of the eGFR Study., Measures: Clinical, biochemical and anthropometric measures were collected (including body-circumferences, blood pressure (BP); triglycerides, HbA1c, liver function tests, creatinine; urine- microscopic-haem, albumin: creatinine ratio (ACR), prescriptions- angiotensin converting enzyme inhibitor or angiotensin receptor II antagonist (ACEI/ARB). Albuminuria and diabetes were defined by an ACR>3.0 mg/mmol, and HbA1c≥48 mmol/mol or prior history respectively. Waist: hip ratio (WHR), and estimated glomerular filtration rate (eGFR) were calculated. ACR was non-normally distributed; a logarithmic transformation was applied (in base 2), with each unit increase in log2-albuminuria representing a doubling of ACR., Results: 591 participants were assessed (71% Aboriginal, 61.6% female, mean age 45.1 years, BMI 30.2 kg/m 2 , WHR 0.94, eGFR 99.2 ml/min/1.73m 2 ). The overall prevalence of albuminuria, diabetes, microscopic-haem and ACEI/ARB use was 41.5%, 41.5%, 17.8% and 34.7% respectively; 69.3% of adults with albuminuria and diabetes received an ACEI/ARB. Using multivariable linear regression modelling, the potentially modifiable factors independently associated with log2-albuminuria were microscopic-haem, diabetes, WHR, systolic BP, alkaline phosphatase (all positive) and eGFR (inverse)., Conclusion: Albuminuria is associated with diabetes, central obesity and haematuria. High ACEI/ARB prescribing for adults with diabetes and albuminuria was observed. Further understanding of the links between fat deposition, haematuria and albuminuria is required., (© 2016 Asian Pacific Society of Nephrology.)

Background: Safety climate evaluation is increasingly used by hospitals as part of quality improvement initiatives. Consequently, it is necessary to have validated tools to measure changes., Objective: To evaluate the construct validity and internal consistency of a survey tool to measure Australian hospital pharmacy patient safety climate., Methods: A 42 item cross-sectional survey was used to evaluate the patient safety climate of 607 Australian hospital pharmacy staff. Survey responses were initially mapped to the factor structure previously identified in European community pharmacy. However, as the data did not adequately fit the community pharmacy model, participants were randomly split into two groups with exploratory factor analysis performed on the first group (n = 302) and confirmatory factor analyses performed on the second group (n = 305)., Results: Following exploratory factor analysis (59.3% variance explained) and confirmatory factor analysis, a 6-factor model containing 28 items was obtained with satisfactory model fit (χ 2 (335) = 664.61 p < 0.001, RMSEA = 0.06, CFI = 0.93, TLI = 0.92), internal reliability (α > 0.643) and model nesting between the groups (Δχ 2 (22) = 30.87, p = 0.10). Three factors (blame culture, organisational learning and working conditions) were similar to those identified in European community pharmacy and labelled identically. Three additional factors (preoccupation with improvement; comfort to question authority; and safety issues being swept under the carpet) highlight hierarchical issues present in hospital settings., Conclusions: This study has demonstrated the validity of a survey to evaluate patient safety climate of Australian hospital pharmacy staff. Importantly, this validated factor structure may be used to evaluate changes in safety climate over time., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Patients with Fontan physiology may eventually require heart transplantation (HT). We determined the rates and outcomes of HT in a national, population-based multicentre study., Methods: From 1990 to 2015, 1369 patients underwent the Fontan procedure as recorded in the Australia and New Zealand Fontan Registry. We identified those who underwent HT and analysed their outcomes. We compared rates of HT between two catchment areas. In area 1 (n=721), patients were referred to the national paediatric HT programme or its associated adult programme. In area 2 (n=648), patients were referred to the national paediatric HT programme or one of the other adult HT programmes., Results: Mean follow-up time post-Fontan was 11±8 years. Freedom from Fontan failure was 74%±3.9% at 20 years. HT was performed in 34 patients. Patients living in area 1 were more likely to have HT (4.0%, 29/721 vs 0.8%, 5/648, p<0.001) with a cumulative proportion of 3.4% vs 0.7% at 10 years and 6.8% vs 1.2% at 20 years (p=0.002). Area 1 patients were more likely to undergo HT (hazard ratio 4.7, 95% CI 1.7 to 13.5, p=0.003) on multivariable regression. Post-HT survival at 1, 5 and 10 years was 91%, 78% and 71%, respectively. Compared with other patients with congenital heart disease (n=87), Fontan patients had similar in-hospital outcomes and long-term survival., Conclusions: Although HT after the Fontan procedure can be achieved with excellent outcomes, most patients with Fontan failure do not undergo HT. Significant regional differences in rates of HT in Fontan patients exist., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Clinical outcomes of patients with end-stage kidney disease (ESKD) receiving renal replacement therapy (RRT) secondary to IgA nephropathy (IgAN) have not been well described., Aim: To investigate the characteristics, treatments and outcomes of ESKD because of kidney-limited IgAN and Henoch-Schönlein purpura nephritis (HSPN) in the Australian and New Zealand RRT populations., Methods: All ESKD patients who commenced RRT in Australia and New Zealand between 1971 and 2012 were included. Dialysis and transplant outcomes were evaluated in both a contemporary cohort (1998-2012) and the entire cohort (1971-2012)., Results: Of 63 297 ESKD patients, 3721 had kidney-limited IgAN, and 131 had HSPN. For the contemporary cohort of IgAN patients on dialysis (n = 2194), 10-year patient survival was 65%. Of 1368 contemporary IgAN patients who received their first renal allograft, 10-year patient, overall renal allograft and death-censored renal allograft survival were 93%, 82% and 88%, respectively. Using multivariable Cox regression analysis, patients with IgAN had favourable dialysis patient survival (adjusted hazard ratio (HR) 0.63, 95% confidence interval (CI) 0.57-0.69), overall renal allograft survival (HR 0.67, 95% CI 0.57-0.79) and renal transplant patient survival (HR 0.58, 95% CI 0.45-0.74) compared with ESKD controls. Similar results were found in the entire cohort and when using competing-risks models. Compared with kidney-limited IgAN patients, those with HSPN had worse dialysis patient survival (HR 1.94, 95% CI 1.02-3.69), overall renal allograft survival (HR 3.40, 95% CI 1.00-11.55) and renal transplant patient survival (HR 3.50, 95% CI 1.03-11.92)., Conclusion: IgAN ESKD was associated with better dialysis and renal transplant outcomes compared with other forms of ESKD. The survival outcomes of ESKD patients with HSPN were worse than kidney-limited IgAN., (© 2015 Asian Pacific Society of Nephrology.)

Objective: To describe the associations between body composition and hormonal and inflammatory factors measured 5 years prior and tibial cartilage volume in young adults, and to explore if these factors contribute to the sex difference in tibial cartilage volume., Methods: Subjects broadly representative of the young adult Australian population (n = 328, ages 31-41 years, 47.3% women) were selected. They underwent T1-weighted fat-suppressed magnetic resonance imaging (MRI) of their knees. Tibial cartilage volume was measured from MRI. Sex hormone binding globulin (SHBG) and testosterone in a subset of women and C-reactive protein (CRP) level and fibrinogen in both sexes were measured 5 years prior. Body mass index (BMI), fat mass, and lean mass were calculated from height, weight, and skinfolds., Results: In multivariable analyses, correlates of tibial cartilage volume included lean body mass (β = 26.4 mm(3) ; 95% confidence interval [95% CI] 13.6, 39.1), fat mass (β = -11.8 mm(3) ; 95% CI -22.2, -1.4), and fibrinogen (β = -146.4 mm(3) ; 95% CI -276.4, -16.4), but not BMI, testosterone, or CRP level. In women, SHBG was positively associated with tibial cartilage volume (β = 0.67 mm(3) ; 95% CI 0.14, 1.20) and Free Androgen Index was negatively associated with lateral tibial cartilage volume (β = -0.04 mm(3) ; 95% CI -0.07, 0.00). Men had 13% more tibial cartilage volume (500 mm(3) ) than women. The magnitude of this association decreased by 38%, 20%, and 37% after adjustment for lean body mass, fat mass, and fibrinogen, respectively., Conclusion: Body composition, sex hormones, and fibrinogen correlate with knee cartilage volume in young adult life. Sex difference in knee cartilage volume is contributed largely by variations in body composition and/or fibrinogen., (© 2016, American College of Rheumatology.)

Objective: To determine the prevalence and burden of pain and activity limitations associated with retaining presurgery self-reported knee instability 6 months after total knee replacement (TKR) surgery and to identify early potentially modifiable risk factors for retaining knee instability in the operated knee after TKR surgery., Methods: A secondary analysis was performed using measures obtained from 390 participants undergoing primary unilateral TKR and participating in a randomized clinical trial. Self-reported knee instability was measured using 2 items from the Activities of Daily Living Scale of the Knee Outcome Survey. Outcome measures were knee pain (range 0-20) and physical function (range 0-68) on the Western Ontario and McMaster Universities Arthritis Index (WOMAC), stair-climb power, 50-foot walk time, knee range of motion, and isometric knee flexion and extension strength., Results: In this study, 72% of participants reported knee instability just prior to surgery, with 32% retaining instability in the operated knee 6 months after surgery. Participants retaining operated knee instability had significantly more knee pain and activity limitations 6 months after surgery, with mean ± SD WOMAC scores of 4.8 ± 3.7 and 17.5 ± 11.1, respectively, compared to participants without knee instability, with 2.9 ± 3.1 and 9.8 ± 9.2. The multivariable predictor model for retained knee instability included a high comorbidity score (>6), low stair-climb power (<150 watts), more pain in the operated knee (>7 of 20), and younger age (<60 years)., Conclusion: Self-reported knee instability is highly prevalent before and after TKR surgery and is associated with a considerable burden of pain and activity limitation in the operated knee. Increasing lower extremity muscle power may reduce the risk of retaining knee instability after TKR surgery., (© 2016, American College of Rheumatology.)

Context: Tick paralysis is a neurotoxic envenoming that mimics polio and primarily afflicts children, especially in hyperendemic regions of the Western United States of America (US) and Eastern Australia., Objective: To compare the epidemiology, clinical and electrodiagnostic manifestations, and outcomes of tick paralysis in the US versus Australia., Methods: A comparative meta-analysis of the scientific literature was conducted using Internet search engines to identify confirmed cases of tick paralysis in the US and Australia. Continuous variables including age, time to tick removal, and duration of paralysis were analyzed for statistically significant differences by unpaired t-tests; and categorical variables including gender, regional distribution, tick vector, tick attachment site, and misdiagnosis were compared for statistically significant differences by chi-square or Fisher exact tests., Results: Tick paralysis following ixodid tick bites occurred seasonally and sporadically in individuals and in more clusters of children than in adults of both sexes in urban and rural locations in North America and Australia. The case fatality rate for tick paralysis was low, and the proportion of misdiagnoses of tick paralysis as Guillain-Barré syndrome (GBS) was greater in the US than in Australia. Although electrodiagnostic manifestations were similar, the neurotoxidromes differed significantly with prolonged weakness and even residual neuromuscular paralysis following tick removal in Australian cases compared with US cases., Discussion: Tick paralysis was a potentially lethal envenoming that occurred in children and adults in a seasonally and regionally predictable fashion. Tick paralysis was increasingly misdiagnosed as GBS during more recent reporting periods in the US. Such misdiagnoses often directed unnecessary therapies including central venous plasmapheresis with intravenous immunoglobulin G that delayed correct diagnosis and tick removal., Conclusion: Tick paralysis should be added to and quickly excluded from the differential diagnoses of acute ataxia with ascending flaccid paralysis, especially in children living in tick paralysis-endemic regions worldwide.

In late 2012, a new screening test for fetal aneuploidy based on circulating cell-free DNA (cfDNA) became available to Australian women. The introduction of this technology in the United States has led to a reduction in invasive diagnostic procedures. Analysis of the number of amniocentesis and chorionic villus sampling (CVS) procedures performed in Australia from 1994 to 2014 shows that the introduction of cfDNA testing has been associated with the most rapid decline in invasive procedures in the last 20 years. This change has important implications for training in, and maintenance of, the procedural skills of amniocentesis and CVS., (© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Globally, rheumatic heart disease (RHD) remains an important cause of heart disease. In Australia it particularly affects younger Indigenous and older non-Indigenous Australians. Despite its impact there is limited understanding of the factors influencing outcome following surgery for RHD., Methods: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed to assess outcomes following surgical procedures for RHD and non-RHD valvular disease. The association with demographics, co-morbidities, pre-operative status, valve(s) affected and operative procedure was evaluated., Results: Outcome of 1384 RHD and 15843 non-RHD valve procedures was analysed. RHD patients had longer ventilation, experienced fewer strokes and had more readmissions to hospital and anticoagulant complications. Mortality following RHD surgery at 30 days was 3.1% (95% CI 2.2 - 4.3), 5 years 15.3% (11.7 - 19.5) and 10 years 25.0% (10.7 - 44.9). Mortality following non-RHD surgery at 30 days was 4.3% (95% CI 3.9 - 4.6), 5 years 17.6% (16.4 - 18.9) and 10 years 39.4% (33.0 - 46.1). Factors independently associated with poorer longer term survival following RHD surgery included older age (OR1.03/additional year, 95% CI 1.01 - 1.05), concomitant diabetes (OR 1.7, 95% CI 1.1 - 2.5) and chronic kidney disease (1.9, 1.2 - 2.9), longer invasive ventilation time (OR 1.7 if greater than median value, 1.1- 2.9) and prolonged stay in hospital (1.02/additional day, 1.01 - 1.03). Survival in Indigenous Australians was comparable to that seen in non-Indigenous Australians., Conclusion: In a large prospective cohort study we have demonstrated survival following RHD valve surgery in Australia is comparable to earlier studies. Patients with diabetes and chronic kidney disease, were at particular risk of poorer long-term survival. Unlike earlier studies we did not find pre-existing atrial fibrillation, being an Indigenous Australian or the nature of the underlying valve lesion were independent predictors of survival.

Background: Prescription sequence symmetry analysis (PSSA) is a signal detection method for adverse drug events. Its capacity to consistently detect adverse drug events across different settings has not been tested. We aimed to determine the consistency of PSSA results for detecting positive and negative control adverse drug events across different settings., Methods: Using a distributed network model, we analyzed prescription dispensing data using PSSA in Australia, Hong Kong, Japan, Korea, and Taiwan. Positive control was amiodarone and thyroxine, as a marker of amiodarone-induced hypothyroidism, a known adverse event with a clear temporal relationship to amiodarone initiation. Negative controls were amiodarone and allopurinol, as a marker of amiodarone-induced gout and thyroxine and allopurinol, as a marker of thyroxine-induced gout. Gout is not recorded as an adverse event in product information for either medicine. Adjusted sequence ratios (ASR) were calculated for each country. Pooled estimates were obtained by using the generic inverse variance method., Results: A positive association was identified between amiodarone and thyroxine in all settings with a pooled ASR 2.63 (95% confidence interval (CI) 1.47-4.72). Temporal analysis showed the effect occurred within the first few weeks of treatment. No significant associations were found for the negative controls in any setting; pooled ASR were 0.76 (95%CI 0.62-0.93) and 0.98 (95%CI 0.85-1.12) for amiodarone-allopurinol and thyroxine-allopurinol, respectively., Conclusion: Despite different health settings, different populations, and different patterns of medicine utilization, PSSA gave consistent estimates across countries for a well-known positive association and two negative control adverse events., (© 2015 The Authors Pharmacoepidemiology and Drug Safety Published by John Wiley & Sons Ltd.)

Aim: To examined the efficacy and safety of treatment with boceprevir, PEGylated-interferon and ribavirin (PR) in hepatitis C virus genotype 1 (HCVGT1) PR treatment-failures in Asia., Methods: The Boceprevir Named-Patient Program provided boceprevir to HCVGT1 PR treatment-failures. Participating physicians were invited to contribute data from their patients: baseline characteristics, on-treatment responses, sustained virological response at week 12 (SVR12), and safety were collected and analysed. Multivariate analysis was performed to determine predictors of response., Results: 150 patients were enrolled from Australia, Malaysia, Singapore and Thailand (Asians = 86, Caucasians = 63). Overall SVR12 was 61% (Asians = 59.3%, Caucasians = 63.5%). SVR12 was higher in relapsers (78%) compared with non-responders (34%). On-treatment responses predicted SVR, with undetectable HCVRNA at week 4, 8 and 12 leading to SVR12s of 100%, 87%, and 82% respectively, and detectable HCVRNA at week 4, 8 and 12, leading to SVR12s of 58%, 22% and 6% respectively. Asian patients were similar to Caucasian patients with regards to on-treatment responses. Patients with cirrhosis (n = 69) also behaved in the same manner with regards to on-treatment responses. Those with the IL28B CC genotype (80%) had higher SVRs than those with the CT/TT (56%) genotype (P = 0.010). Multivariate analysis showed that TW8 and TW12 responses were independent predictors of SVR. Serious adverse events occurred in 18.6%: sepsis (2%), decompensation (2.7%) and blood transfusion (14%). Discontinuations occurred in 30.7%, with 18.6% fulfilling stopping rules., Conclusion: Boceprevir can be used successfully in PR treatment failures with a SVR12 > 80% if they have good on-treatment responses; however, discontinuations occurred in 30% because of virological failure or adverse events.

Background: Polycystic ovary syndrome (PCOS) is a common disorder with metabolic complications, yet the prevalence of hypertension is unclear. We aim to assess hypertension prevalence and the impact of obesity in women reporting PCOS compared to those not reporting PCOS., Methods: This is a cross-sectional analysis of data from a large longitudinal study, the Australian Longitudinal Study on Women's Health (ALSWH). Women from the general community were randomly selected from the national health insurance database. Standardized data collection occurred at 6 survey time points. Data from Survey 4 in 2006 (n = 8,612, age: 28-33 years) were examined for this study. The main outcome measures studied were self-reported PCOS and hypertension., Results: Reported PCOS prevalence was 5.8% (95% confidence interval (CI): 5.3%-6.4%). Women with PCOS had higher body mass index (BMI). Hypertension prevalence was 5.5% (95% CI: 3.3-7.7) in women reporting PCOS and 2.0% (95% CI: 1.6-2.3) in women not reporting PCOS (P < 0.001). Hypertension was associated with BMI (odds ratio: 1.07, 95% CI: 1.05-1.10, P < 0.001) with a trend towards an association with PCOS (P = 0.09). On subgroup analysis, hypertension was not associated with BMI in women reporting PCOS but was associated in those not reporting PCOS., Conclusions: In this large community-based cohort, we note increased prevalence of hypertension and higher BMI in young women reporting PCOS. BMI association with hypertension appeared clear in women not reporting PCOS. Yet in women with PCOS, hypertension appeared to not be associated with BMI, akin to observations on diabetes risk in PCOS, suggesting that metabolic abnormalities in PCOS may be independent of BMI., (© American Journal of Hypertension, Ltd 2014. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background and Objectives: Cinacalcet and vitamin D are often combined to treat secondary hyperparathyroidism (SHPT) in patients on dialysis. Independent effects on fibroblast growth factor-23 (FGF-23) concentrations in patients on hemodialysis administered cinacalcet or vitamin D analogs as monotherapies during treatment of SHPT are evaluated., Design, Setting, Participants, & Measurements: A multicenter, randomized, open-label study to compare the efficacy of cinacalcet versus traditional vitamin D therapy for management of secondary hyperparathyroidism among subjects undergoing hemodialysis (PARADIGM) was a prospective, phase 4, multicenter, randomized, open-label study conducted globally. Participants (n=312) were randomized 1:1 to cinacalcet (n=155) or vitamin D analog (n=157) for 52 weeks. Levels of FGF-23 were measured at baseline and weeks 20 and 52. The absolute and percentage changes from baseline in plasma FGF-23, parathyroid hormone (PTH), calcium (Ca), phosphorus (P), and calcium-phosphorus product (Ca×P) were assessed. Correlations and logistic regression were used to explore relationships between changes in FGF-23 and changes in PTH, Ca, P, and Ca×P from baseline to week 52 by treatment arm., Results: Median (quartiles 1, 3) decrease in FGF-23 concentrations was observed in the cinacalcet arm (-40%; -63%, 16%) compared with median increase in the vitamin D analog arm (47%; 0%, 132%) at week 52 (P<0.001). Changes in FGF-23 in both arms were unrelated to changes in PTH (cinacalcet: r=0.17, P=0.11; vitamin D analog: r=-0.04, P=0.70). Changes in FGF-23 in the vitamin D analog but not the cinacalcet arm were correlated with changes in Ca (cinacalcet: r=0.11, P=0.30; vitamin D analog: r=0.32, P<0.01) and P (cinacalcet: r=0.19, P=0.07; vitamin D analog: r=0.49, P<0.001). Changes in FGF-23 were correlated with changes in Ca×P in both arms (cinacalcet: r=0.26, P=0.01; vitamin D analog: r=0.57, P<0.001). Independent of treatment arm, participants with reductions in P or Ca×P were significantly more likely to show reductions in FGF-23., Conclusions: During treatment of SHPT, cinacalcet use was associated with a decrease in FGF-23 concentrations, whereas vitamin D analogs were associated with an increase. The divergent effects of these treatments on FGF-23 seem to be independent of modification of PTH. It is possible that effects of cinacalcet and vitamin D analogs on FGF-23 may be mediated indirectly by other effects on bone and mineral metabolism., (Copyright © 2015 by the American Society of Nephrology.)

Background: up to 80% of residents in aged care facilities (ACFs) experience pain, and previous studies have found that older patients with pain are often undertreated. Few studies have been conducted in Australia evaluating the use of analgesic therapy in ACF residents., Objective: to explore the use of analgesics among ACF residents, including independent predictors of analgesic use, evaluate analgesic use against pain management guidelines and identify potential medication management issues., Methods: a retrospective analysis of 7,309 medicines reviews conducted on Australian ACF residents was undertaken. Medication use was compared with published guidelines relating to the management of pain in elderly patients or ACF residents. Multiple variable logistic regression was used to identify independent predictors of analgesic use., Results: nearly 91% of residents were prescribed analgesics. Of those, 2,057 residents were taking regular opioids (28.1%). Only 50% of those taking regular opioids received regular paracetamol at doses of 3-4 g/day. The concurrent use of sedatives was high, with 48.4% of those taking regular opioids also taking an anxiolytic/hypnotic., Conclusion: there is a need to optimise the prescribing and administration of regular paracetamol as a first line and continuing therapy for pain management in ACF residents, to potentially improve pain management and reduce opioid requirements. Furthermore, with the risk of falls and fractures increased by concurrent use of opioids and sedatives, the widespread use of these drugs in a population already at high risk was concerning, indicating a need for better education of health professionals in this area., (© The Author 2014. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objectives: To update the Australian System for Cardiac Operative Risk Evaluation (AusSCORE) model for operative estimation of 30-day mortality risk after isolated coronary artery bypass grafting in the Australian population., Methods: Data were collected by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons registry from 2001 to 2011 in 25 hospitals. A total of 31,250 patients underwent isolated coronary artery bypass grafting and the outcome was 30-day mortality. A total of 2154 (6.9%) patients had 1 or multiple missing values. Missing values were estimated assuming missing completely at random and logistic regression with a generalized estimating equation was used to address within-hospital variance. Bootstrapping methods were used to construct and validate the updated model (AusSCORE II). Also the model was validated on an out-of-creation sample of 4700 patients who underwent bypass surgery in 2012., Results: The average age of the patients was 65.6±12.9 years and 78.6% were male. Thirteen variables were selected in the updated model. The bootstrap discrimination and calibration of the AusSCORE II was very good (receiver operating characteristics [ROC], 82.0%; slope calibration, 0.987). The overall observed/AusSCORE II predicted mortality was 1.63% compared with the original AusSCORE predicted mortality of 1.01%. The validation of the AusSCORE II on the out-of-sample data also showed a high performance of the model (ROC, 84.5%; Hosmer-Lemoshow P value, .7654)., Conclusions: The AusSCORE II model provides improved prediction of 30-day mortality and successfully stratifies patient risk. The model will be useful to improve the preoperative consultation regarding risk stratification in terms of 30-day mortality., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Aim: Whilst increasing numbers of elderly people in Australia are commencing dialysis, few Indigenous patients are aged ≥ 65 years and their outcomes are unknown. We compared the long-term survival, mortality hazards and causes of death between elderly Indigenous and elderly non-Indigenous dialysis patients., Methods: This was a retrospective cohort study of adults aged ≥ 65 years who commenced dialysis in Australia from 2001-2011, identified from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Indigenous (n = 263) and non-Indigenous (n = 10,713) patients were followed until death, loss to follow-up, recovery of renal function or 31 December 2011. Mortality was compared using a multivariate Cox proportional-hazards model with age, gender, body mass index, smoking, primary renal disease, comorbidities, late referral and initial treatment modality as predictive variables., Results: Median follow-up was 26.9 months (interquartile range 11.3-48.8 months). Overall 166 Indigenous and 6265 non-Indigenous patients died during the 11-year follow-up period. Mortality rates per 100 patient-years were 23.9 for Indigenous patients and 21.2 for non-Indigenous patients. The overall 1-, 3- and 5-year survival rates were 81%, 49% and 27% for Indigenous patients and 82%, 55% and 35% for non-Indigenous patients respectively. Indigenous patients had a 20% increased risk of mortality compared with non-Indigenous patients (adjusted hazard ratio 1.20, 95% confidence interval, 1.02, 1.41; P = 0.02). 'Social deaths' (predominantly dialysis withdrawal) and cardiac deaths were the main causes of death for both groups., Conclusion: Among elderly dialysis patients in Australia, Indigenous status remains an important factor in predicting survival., (© 2014 Asian Pacific Society of Nephrology.)

Aim: Acute kidney injury (AKI) is associated with increased mortality. While angiotensin-converting enzyme inhibitors (ACEI) are known to slow progression of chronic kidney disease, their role in AKI remains unclear., Methods: The Randomised Evaluation of Normal vs. Augmented Level Replacement Therapy (RENAL) study data were analysed according to ACEI use over time. The primary outcome was all-cause mortality at 90 days following randomisation. Analyses used a multivariate Cox model adjusted for either baseline or for time-dependent covariates, and a sensitivity analysis of patients surviving to at least the median time to ACEI initiation., Results: Of the 1463 participants with available data on ACE inhibitors usage, 142 (9.7%) received ACEI at least once during study data collection. Participants treated with ACEI were older (P = 0.02) and had less sepsis at baseline (P < 0.001). ACEI use was significantly associated with lower mortality at 90 days (HR 0.46, 95% CI 0.30-0.71, P < 0.001), and an increase in renal replacement therapy-free days (P < 0.001), intensive care unit-free days (P < 0.001) and hospital free-days (P < 0.001) after adjusting for baseline covariates. Using the time-dependent analysis, however, the effect of ACEI administration was not significant (HR 0.78, 95% CI 0.51-1.21, P = 0.3). The sensitivity analysis in day 8 survivors produced similar results., Conclusion: In the RENAL study cohort, the use of ACEI during the study was not common and, after adjustment for time-dependent covariates, was not significantly associated with reductions in mortality. Further assessment of the effect of ACEI use in AKI patients is needed., (© 2014 Asian Pacific Society of Nephrology.)

Objectives: To report on sexual behaviors and sexually transmitted infections (STIs) among men who have sex with men (MSM) in their teens, when many MSM engage in their first sexual experiences., Methods: MSM aged 16 to 20 years were recruited via community and other sources. Men completed a questionnaire about their sexual behaviors and were screened for gonorrhea, chlamydia, syphilis, and HIV., Results: Two hundred men were included. The median age was 19 years. The median age at first insertive or receptive anal intercourse was 17 years. Half of men reported sex with mainly older men: these men were more likely to engage in receptive anal intercourse (48% vs. 25%, p < .001) than other men. Most men had engaged in insertive (87%) and receptive (85%) anal intercourse in the prior 12 months with 60% and 53% reporting inconsistent condom use with insertive and receptive anal intercourse partners, respectively. The median number of insertive anal intercourse partners was 3 and 1.5 (p < .001) among men reporting inconsistent and consistent condom use with insertive anal intercourse over the prior 12 months. The median number of receptive anal intercourse partners was 3 and 2 (p = .006) among men reporting inconsistent and consistent condom use with receptive anal intercourse over the prior 12 months. Pharyngeal gonorrhea, rectal gonorrhea, urethral chlamydia, rectal chlamydia, and syphilis were detected in 3.0%, 5.5%, 3.0%, 4%, and 2.0% of men, respectively. All men were HIV negative., Conclusion: Many of the teenage MSM in this study were at risk for STI. Preventative messages and STI screening interventions that are age appropriate need to be developed to reduce HIV and STI risk in this under-recognized group., (Copyright © 2014 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To estimate the influence of prior oral contraceptive pill (OCP) use on future diagnosis of endometriosis in young women., Design: Prospective cohort study, the Australian Longitudinal Study on Women's Health., Setting: Community-based sample., Patient(s): 9,585 women age 18-23 at study onset., Intervention(s): None., Main Outcome Measure(s): Risk of self-reported endometriosis estimated with Cox proportional-hazards regression with time-dependent covariates., Result(s): Compared with never users, endometriosis hazard ratios in nulliparous women with <5 years and ≥ 5 years of OCP use (preceding diagnosis) were 1.8 (95% CI, 1.30-2.53) and 2.3 (95% CI, 1.59-3.40), respectively. Similar risk was seen in both women reporting infertility and unsure fertility. In parous women with <5 years of use, the hazard ratio for endometriosis was 0.41 (95% CI, 0.15-0.56) and for ≥ 5 years of use was 0.45 (95% CI, 0.16-1.23). Women reporting early noncontraceptive OCP use had a twofold higher risk (odds ratio 2.07; 95% CI, 1.72-2.51)., Conclusion(s): Prior OCP exposure reduces the risk of diagnosis of endometriosis in parous women but increases it among nulliparous women; these associations appear unaffected by fertility status. An increased risk of endometriosis diagnosis seen in women reporting early noncontraceptive OCP use may explain some of the positive OCP risk seen in nulliparous women., (Copyright © 2014 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To report procedural characteristics and outcomes from a central venous catheter placement service operated by advanced practice nurses., Design: Single-center observational study., Setting: A tertiary care university hospital in Sydney, Australia., Patients: Adult patients from the general wards and from critical care areas receiving a central venous catheter, peripherally inserted central catheter, high-flow dialysis catheter, or midline catheter for parenteral therapy between November 1996 and December 2009., Interventions: None., Measurements and Main Results: Prevalence rates by indication, site, and catheter type were assessed. Nonparametric tests were used to calculate differences in outcomes for categorical data. Catheter infection rates were determined per 1,000 catheter days after derivation of the denominator. A total of 4,560 catheters were placed in 3,447 patients. The most common catheters inserted were single-lumen peripherally inserted central catheters (n = 1,653; 36.3%) and single-lumen central venous catheters (n = 1,233; 27.0%). A small proportion of high-flow dialysis catheters were also inserted over the reporting period (n = 150; 3.5%). Sixty-one percent of all catheters placed were for antibiotic administration. The median device dwell time (in d) differed across cannulation sites (p < 0.001). Subclavian catheter placement had the longest dwell time with a median of 16 days (interquartile range, 8-26 d). Overall catheter dwell was reported at a cumulative 63,071 catheter days. The overall catheter-related bloodstream infection rate was 0.2 per 1,000 catheter days. The prevalence rate of pneumothorax recorded was 0.4%, and accidental arterial puncture (simple puncture-with no dilation or cannulation) was 1.3% using the subclavian vein., Conclusions: This report has demonstrated low complication rates for a hospital-wide service delivered by advance practice nurses. The results suggest that a centrally based service with specifically trained operators can be beneficial by potentially improving patient safety and promoting organizational efficiencies.

Stigma is a well-documented concern of people living with mental illness. Through the use of novel exploratory structural equation modelling (ESEM) methods, we aimed to elucidate the structure of stigma as measured by two stigma scales (the Depression Stigma Scale and the Social Distance Scale), to establish dimensions of stigma towards a range of disorders and to compare levels on these dimensions between disorders and respondent subgroups. We used data from two Australian national surveys, one of the general community aged 15+ and another of youths aged 15-25. Stigma responses were elicited using a range of mental illness vignettes: depression, schizophrenia, social phobia and post-traumatic stress disorder (PTSD). ESEM revealed that the structure of stigmatizing attitudes in young people and adults is comparable in personally held attitudes and those perceived in others. Personal and perceived stigma formed distinct dimensions with each comprising "Weak-not-sick" and "Dangerous/unpredictable" components. The social distance dimension of stigma was separate from other components of stigma, supporting the appropriateness of the existing Social Distance Scale. Scales reflecting these dimensions had different patterns of association with respondent age and gender, and the type of mental disorder portrayed in the vignette., (Copyright © 2014 John Wiley & Sons, Ltd.)

Background: The incidence of acute kidney injury (AKI) is increasing globally and it is much more common than end-stage kidney disease. AKI is associated with high mortality and cost of hospitalisation. Studies of treatments to reduce this high mortality have used differing renal replacement therapy (RRT) modalities and have not shown improvement in the short term. The reported long-term outcomes of AKI are variable and the effect of differing RRT modalities upon them is not clear. We used the prolonged follow-up of a large clinical trial to prospectively examine the long-term outcomes and effect of RRT dosing in patients with AKI., Methods and Findings: We extended the follow-up of participants in the Randomised Evaluation of Normal vs. Augmented Levels of RRT (RENAL) study from 90 days to 4 years after randomization. Primary and secondary outcomes were mortality and requirement for maintenance dialysis, respectively, assessed in 1,464 (97%) patients at a median of 43.9 months (interquartile range [IQR] 30.0-48.6 months) post randomization. A total of 468/743 (63%) and 444/721 (62%) patients died in the lower and higher intensity groups, respectively (risk ratio [RR] 1.04, 95% CI 0.96-1.12, p = 0.49). Amongst survivors to day 90, 21 of 411 (5.1%) and 23 of 399 (5.8%) in the respective groups were treated with maintenance dialysis (RR 1.12, 95% CI 0.63-2.00, p = 0.69). The prevalence of albuminuria among survivors was 40% and 44%, respectively (p = 0.48). Quality of life was not different between the two treatment groups. The generalizability of these findings to other populations with AKI requires further exploration., Conclusions: Patients with AKI requiring RRT in intensive care have high long-term mortality but few require maintenance dialysis. Long-term survivors have a heavy burden of proteinuria. Increased intensity of RRT does not reduce mortality or subsequent treatment with dialysis., Trial Registration: www.ClinicalTrials.govNCT00221013.

Objectives: To study contemporary popliteal artery aneurysm (PA) repair., Methods: Vascunet is a collaboration of population-based registries in 10 countries: eight had data on PA repair (Australia, Finland, Hungary, Iceland, New Zealand, Norway, Sweden, and Switzerland)., Results: From January 2009 until June 2012, 1,471 PA repairs were registered. There were 9.59 operations per million person years, varying from 3.4 in Hungary to 17.6 in Sweden. Median age was 70 years, ranging from 66 years in Switzerland and Iceland to 74 years in Australia and New Zealand; 95.6% were men and 44% were active smokers. Elective surgery dominated, comprising 72% of all cases, but only 26.2% in Hungary and 39.7% in Finland, (p < .0001). The proportion of endovascular PA repair was 22.2%, varying from 34.7% in Australia, to zero in Switzerland, Finland, and Iceland (p < .0001). Endovascular repair was performed in 12.2% of patients with acute thrombosis and 24.1% of elective cases (p < .0001). A vein graft was used in 87.2% of open repairs, a synthetic or composite graft in 12.7%. Follow-up was until discharge or 30 days. Amputation rate was 2.0% overall: 6.5% after acute thrombosis, 1.0% after endovascular, 1.8% after open repair, and 26.3% after hybrid repair (p < .0001). Mortality was 0.7% overall: 0.1% after elective repair, 1.6% after acute thrombosis, and 11.1% after rupture., Conclusions: Great variability between countries in incidence of operations, indications for surgery, and choice of surgical technique was found, possibly a result of surgical tradition rather than differences in case mix. Comparative studies with longer follow-up data are warranted., (Copyright © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objectives: To assess, in a randomised controlled trial (RCT) and in clinical practice, an association of time to remission and baseline disease activity with both induction of remission and sustained remission in etanercept-treated patients with rheumatoid arthritis (RA)., Methods: Data from an RCT (Trial of Etanercept and Methotrexate with Radiographic Patient Outcomes [TEMPO]; n=682) and an observational registry (Rheumatoid Arthritis DMARD Intervention and Utilization Study [RADIUS II]; n=4341) were used to evaluate disease activity (Clinical Disease Activity Index [CDAI] score) over time in patients initiating etanercept (monotherapy or with methotrexate). CDAI remission (CDAI≤2.8) and sustained remission (≥6 months) were determined through year 3 by treatment group, study, time to remission, and disease severity., Results: Patients from TEMPO and RADIUS II who received etanercept monotherapy showed similar CDAI remission rates (39% and 35%, respectively, at 3 years). Among patients who received etanercept with methotrexate, remission rates were 54% and 36%, respectively. Remission occurred more rapidly in TEMPO than RADIUS II perhaps from differences in compliance, patient populations, or sequence of combination therapy initiation. Generally, more patients with lower baseline CDAI scores achieved remission than those with higher scores. Continued remission appeared more likely in patients achieving remission earlier in the course of their therapy (0-6 months)., Conclusions: Remission by year 3 in etanercept-treated (with and without methotrexate) patients with RA occurred in ≥35% of patients in both an RCT (TEMPO) and a clinical practice setting (RADIUS II), and more frequently in those with lower baseline disease severity. Patients with lower RA disease activity were more likely to reach remission. Continued remission may be more likely in patients who achieved remission earlier.

Aim: To study serological antibodies in Caucasians and Asians, in health and inflammatory bowel disease (IBD), in Australia and Hong Kong (HK)., Methods: Anti-glycan antibodies [anti-chitobioside (ACCA), anti-laminaribioside (ALCA)], and anti-mannobioside (AMCA), anti-Saccharomyces cervisiae (gASCA); and atypical perinuclear anti-neutrophil cytoplasmic antibody (pANCA) were tested in IBD patients, their unaffected relatives, and healthy controls in Australia and HK (China). Antibody status (positive or negative) and titre was compared between subjects of different geography, ethnicity and disease state., Results: Ninety subjects were evaluated: 21 Crohn's disease (CD), 32 ulcerative colitis (UC), 29 healthy controls, and 8 IBD patient relatives. Forty eight subjects were Australian (29 Caucasian and 19 ethnic Han Chinese) and 42 were from HK (all Han Chinese). Caucasian CD patients had a significantly higher antibody prevalence of gASCA (67% vs 3%, P < 0.001), ALCA (44% vs 6%, P = 0.005), and AMCA (67% vs 15%, P = 0.002), whereas HK CD patients had a higher prevalence of only AMCA (58% vs 25%, P = 0.035), when compared with UC and healthy subjects in both countries. Caucasian CD had significantly higher gASCA prevalence (67% vs 0%, P < 0.001) and titre (median 59 vs 9, P = 0.002) than HK CD patients. Prevalence and titres of ALCA, ACCA and AMCA did not differ between CD in the two countries. Presence of at least one antibody was higher in Caucasian than HK CD patients (100% vs 58%, P = 0.045). pANCA did not differ between countries or ethnicity., Conclusion: Serologic CD responses differ between HK Asian and Australian Caucasian patients. Different genetic, environmental or disease pathogenic factors may account for these differences.

Repetitive transcranial magnetic stimulation treatment (rTMS) is an effective treatment for depression but the optimal methods of administration have yet to be determined. Recent studies have produced conflicting results as to whether unilateral rTMS is more or less effective than sequentially applied bilateral rTMS. To address this we conducted a trial comparing sequential bilateral rTMS to right-sided unilateral rTMS using a priming protocol. Patients with treatment-resistant depression (n = 179) were enrolled in a two-arm randomized controlled trial across a 4-wk time period. The primary outcome assessment was the Hamilton Depression Rating Scale. Overall, there was a substantial response rate of >50% (and a 40% remission rate); however, there were no significant differences in clinical response between the two treatment groups. rTMS was well tolerated with a very low discontinuation rate. There was no relationship between response in the current trial and previous response, or non-response, to electroconvulsive therapy. We found no significant differences in clinical response between sequential bilateral rTMS and right-sided unilateral rTMS applied with a priming protocol. The results of this study do not support superior efficacy of bilateral rTMS and instead suggest that other approaches should be explored to increase treatment efficacy.

We present new data on the prevalence and patterning of the maxillary premolar accessory ridge (MxPAR), a common but understudied morphological dental trait that is expressed as a linear elevation extending from the buccal cusp ridge to the medial sulcus of maxillary premolar teeth. A total of 579 sets of dental casts, representing six ethnic groups, were scored using the five-grade system proposed by Burnett et al. (2010). The frequency and distribution of the MxPAR were determined by tooth type, sex, side, locus and ethnicity, and the applicability of the scoring system was assessed. The MxPAR was found in approximately two-thirds of premolar teeth, more often on second than first premolars, and more often on the distal aspect of the occlusal surface than the mesial. There was some evidence that more pronounced forms of the feature occurred more often in males than females, and that there may be some directionality in its expression between sides. Variation was also noted in the frequency of occurrence and degree of expression of the MxPAR between ethnic groups. Intra- and inter-observer concordance rates for scoring the MxPAR were low, confirming that it was difficult to score the trait identically on two different occasions. Our findings have clarified the distribution of the MxPAR within the dentition and between ethnic groups, and highlighted the need for researchers to carry out thorough replicability studies and to decide on an appropriate breakpoint for determining presence or absence of this feature before embarking on genetic studies or bio-distance analyses., (Copyright © 2013 Wiley Periodicals, Inc.)

Objectives: We examined trends in HCV incident infection among injection drug users (IDUs) attending needle and syringe programs (NSPs) in Australia in 1995 to 2010., Methods: We created a passive retrospective cohort of 724 IDUs who tested negative for HCV antibodies by a simple deterministic method linking partial identifiers to find repeat respondents in annual cross-sectional serosurveillance., Results: We identified 180 HCV seroconversions over the study period, for a pooled incidence density of 17.0 per 100 person-years (95% confidence interval [CI] = 14.68, 19.66). Incidence density declined, from a high of 30.8 per 100 person-years (95% CI = 21.3, 44.6) in 2003 to a low of 4.0 (95% CI = 1.3, 12.3) in 2009., Conclusions: A decline in HCV incidence among Australian IDUs attending NSPs coincided with considerable expansion of harm reduction programs and a likely reduction in the number of IDUs, associated with significant changes in drug markets. Our results demonstrate the capacity of repeat cross-sectional serosurveillance to monitor trends in HCV incidence and provide a platform from which to assess the impact of prevention and treatment interventions.

Background and Objectives: Local anesthetic systemic toxicity (LAST) is a potentially life-threatening complication of local anesthetic administration. In this article, the results of the Australian and New Zealand Registry of Regional Anaesthesia were analyzed to determine if ultrasound-guided peripheral nerve blockade (PNB) was associated with a reduced risk of LAST compared with techniques not utilizing ultrasound technology., Methods: The period of study for this multicenter study involving 20 hospitals was from January 2007 through May 2012. The primary outcome was LAST comprising minor, major, and cardiac arrest (due to toxicity) events determined using standardized definitions. Multivariable logistic regression models and propensity score analyses were used to determine significant event predictors., Results: The study population comprised 20,021 patients who received 25,336 PNBs. There were 22 episodes of LAST, resulting in an incidence of LAST of 0.87 per 1000 PNBs (95% confidence interval, 0.54-1.3 per 1000). Ultrasound guidance was associated with a reduced incidence of local anesthetic toxicity. Site of injection, local anesthetic type, dose per weight, dose, and patient weight were all predictors of LAST., Conclusions: This study provides the strongest evidence, to date, that ultrasound guidance may improve safety because it is associated with a reduced risk of LAST following PNB.