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ABSTRACT Background In Australia, lung cancer is the leading cause of cancer‐related deaths. In Victoria, the mortality risk is assumed to vary across Local Government Areas (LGAs) due to variations in socioeconomic advantage, remoteness, and healthcare accessibility. Thus, we applied Bayesian spatial survival models to examine the geographic variation in lung cancer survival in Victoria. Methods Data on lung cancer cases were extracted from the Victorian Lung Cancer Registry (VLCR). To account for spatial dependence and risk factors of survival in lung cancer patients, we employed a Bayesian spatial survival model. Conditional Autoregressive (CAR) prior was assigned to model the spatial dependence. Deviance Information Criterion (DIC), Watanabe Akaike Information Criterion (WAIC), and Log Pseudo Marginal Likelihood (LPML) were used for model comparison. In the final best‐fitted model, the Adjusted Hazard Ratio (AHR) with the 95% Credible Interval (CrI) was reported. The outcome variable was the survival status of lung cancer patients, defined as whether they survived or died during the follow‐up period (death was our interest). Results Our study revealed substantial variations in lung cancer mortality in Victoria. Poor Eastern Cooperative Oncology Group (ECOG) performance status, diagnosed at a regional hospital, Small Cell Lung Cancer (SCLC), advanced age, and advanced clinical stage were associated with a higher risk of mortality, whereas being female, presented at Multidisciplinary Team (MDT) meeting, and diagnosed at a metropolitan private hospital were significantly associated with a lower risk of mortality. Conclusion Identifying geographical disparities in lung cancer survival may help shape healthcare policy to implement more targeted and effective lung cancer care services.

Background: Socioeconomic status (SES) is a well-established determinant of cardiovascular health. However, the relationship between SES and clinical outcomes in long-term out-of-hospital cardiac arrest (OHCA) is less well-understood. The Singapore Housing Index (SHI) is a validated building-level SES indicator. We investigated whether SES as measured by SHI is associated with long-term OHCA survival in Singapore. Methods: We conducted an open cohort study with linked data from the Singapore Pan-Asian Resuscitation Outcomes Study (PAROS), and the Singapore Registry of Births and Deaths (SRBD) from 2010 to 2020. We fitted generalized structural equation models, calculating hazard ratios (HRs) using a Weibull model. We constructed Kaplan–Meier survival curves and calculated the predicted marginal probability for each SHI category. Results: We included 659 cases. In both univariable and multivariable analyses, SHI did not have a significant association with survival. Indirect pathways of SHI mediated through covariates such as Emergency Medical Services (EMS) response time (HR of low-medium, high-medium and high SHI when compared to low SHI: 0.98 (0.88–1.10), 1.01 (0.93–1.11), 1.02 (0.93–1.12) respectively), and age of arrest (HR of low-medium, high-medium and high SHI when compared to low SHI: 1.02 (0.75–1.38), 1.08 (0.84–1.38), 1.18 (0.91–1.54) respectively) had no significant association with OHCA survival. There was no clear trend in the predicted marginal probability of survival among the different SHI categories. Conclusions: We did not find a significant association between SES and OHCA survival outcomes in residential areas in Singapore. Among other reasons, this could be due to affordable healthcare across different socioeconomic classes.

Abstract Little is known about the methods and outcomes of patient-reported outcome measure (PROM) use among high-risk medical device registries. The objective of this scoping review was to assess the utility and predictive ability of PROMs in high-risk medical device registries. We searched Ovid Medline, Embase, APA PsychINFO, Cochrane Library, and Scopus databases for published literature. After searching, 4323 titles and abstracts were screened, and 262 full texts were assessed for their eligibility. Seventy-six papers from across orthopedic (nnnnnn Level of Evidence: 4

Objective: To conduct a pilot randomised controlled trial examining the feasibility, acceptability and efficacy of MEmory Training for Recovery-Adolescent (METRA) in improving psychological symptoms among Afghan adolescent boys following a terrorist attack. Method: A pilot randomised controlled trial compared METRA to a Control Group, with a three-month follow-up. The study occurred in Kabul (June-November 2022). Fifty-eight boys aged 14–19 years (Mage = 16.70, SD = 1.26) with heightened posttraumatic stress disorder (PTSD) symptoms were recruited through a local school that had recently experienced a terrorist attack. Participants were randomised 1:1 to receive METRA (n = 28) (10 session group-intervention) or Control (n = 30) (10 group-sessions of study skills). Primary outcomes were self-reported PTSD symptoms at post-intervention. Secondary outcomes included self-reported anxiety, depression, Afghan-cultural distress symptoms and psychiatric difficulties. Results: There were challenges in youth participation related to security and competing education demands. For those who did complete METRA, METRA was deemed feasible and acceptable. Following the intent-to-treat principle, linear mixed effects models found at posttreatment the METRA group had a 20.89-point (95%CI −30.66, −11.11) decrease in PTSD symptoms, while the Control Group had a 1.42-point (95%CI −8.11, 5.27) decrease, with the group over time interaction being significant (p

Abstract Background People living with diabetes must manage a range of factors for optimal control of glycaemia and to minimise the risk of diabetes-related complications. Diabetes practitioners are expected to follow guidelines for the key process of care and clinical outcomes, to help people living with diabetes achieve clinical targets. In Australia, the performance of diabetes centres against guidelines is evaluated by the Australian National Diabetes Audit, an annual clinical audit and feedback activity. Previous work has identified areas for improvement in the feedback provided to participating diabetes centres and suggested additional educational and support resources to assist in using audit feedback for the development of quality improvement activities. This cluster randomised trial will test the acceptability, utility and impact on selected clinical outcomes of the developed study intervention (audit feedback and a tailored educational and peer support cointervention). Methods Two-armed cluster randomised trial with Australian Diabetes Centres that participated in the Australian National Diabetes Audit in 2021 as the clusters, stratified by location and type of centre. We aim to recruit 35 diabetes centres in each arm. Both the intervention and control arms will receive an augmented feedback report, accompanied by a partially pre-populated slide deck. In addition, the intervention arm will receive a tailored theory-based intervention designed to address identified, modifiable barriers to utilising and implementing the recommendations from diabetes audit feedback. The co-primary outcomes are (1) HbA1c at the patient level, measured at 6 months after delivery of the intervention, and (2) the acceptability and utility of the augmented feedback and cointerventions at the practitioner level, measured at 3 months after delivery of the intervention. Discussion This trial aims to test the effects of systematic development and implementation of theory and evidence-informed changes to the audit feedback delivered to diabetes centres participating in an established national clinical diabetes audit. Potential benefits of improved audit feedback include more optimal engagement with the feedback by end clinical users which, ultimately, may lead to improvements in care for people living with diabetes. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12621000765820. Prospectively registered on June 21, 2021

Abstract Survival statistics, estimated using data from national cystic fibrosis (CF) registries, inform the CF community and monitor disease progression. This study aimed to estimate survival among people with CF in Australia and to identify factors associated with survival. This population-based cohort study used prospectively collected data from 23 Australian CF centres participating in the Australian CF Data Registry (ACFDR) from 2005–2020. Period survival analysis was used to calculate median age of survival estimates for each 5-year window from 2005–2009 until 2016–2020. The overall median survival was estimated using the Kaplan–Meier method. Between 2005–2020 the ACFDR followed 4,601 people with CF, noting 516 (11.2%) deaths including 195 following lung transplantation. Out of the total sample, more than half (52.5%) were male and 395 (8.6%) had undergone lung transplantation. Two thirds of people with CF (66.1%) were diagnosed before six weeks of age or by newborn/prenatal screening. The overall median age of survival was estimated as 54.0 years (95% CI: 51.0–57.04). Estimated median survival increased from 48.9 years (95% CI: 44.7–53.5) for people with CF born in 2005–2009, to 56.3 years (95% CI: 51.2–60.4) for those born in 2016–2020. Factors independently associated with reduced survival include receiving a lung transplant, having low FEV1pp and BMI. Median survival estimates are increasing in CF in Australia. This likely reflects multiple factors, including newborn screening, improvement in diagnosis, refinements in CF management and centre-based multidisciplinary care.

Abstract Anemia is a common health problem for women and under five children in low income countries. According to the WHO, anemia is considered a serious public health problem when the prevalence is greater than 40%. The prevalence of anemia among children under five in Ethiopia changes over time, and is spatially correlated because it is influenced by environmental, socio-economic and other related factors. However, to our knowledge, there is no small area level estimates of anemia among children under five in Ethiopia. Therefore, this study aimed to assess zonal level estimates of anemia using a Bayesian spatio-temporal conditional autoregressive modeling approach. The data for the study was extracted from the Ethiopian Demographic and Health Surveys (EDHS) from 2005 to 2016. A sample of 18,939 children aged 6–59 months were considered for this study. A Bayesian spatio-temporal conditional autoregressive model was implemented to identify the risk of child anemia. Smoothed relative risks along with the 95% credible interval were reported. The queen’s adjacency matrix method was used in spatial smoothing and in estimating the relative risk. The prevalence of anemia among children aged 6–59 months in Ethiopia was 54% in 2005, 44% in 2011 and 57% in 2016. This study showed that low maternal education, low socio-economic status of women, and maternal anemia at zone level were strongly associated with child anemia in Ethiopia. Therefore, enhancing education for women, improving women's socioeconomic status, and mitigating maternal anemia are crucial to reduce the prevalence of childhood anemia in Ethiopia.

Objectives Benchmarking is common in clinical registries to support the improvement of health outcomes by identifying underperforming clinician or health service providers. Despite the rise in clinical registries and interest in publicly reporting benchmarking results, appropriate methods for benchmarking and outlier detection within clinical registries are not well established, and the current application of methods is inconsistent. The aim of this review was to determine the current statistical methods of outlier detection that have been evaluated in the context of clinical registry benchmarking.Design A systematic search for studies evaluating the performance of methods to detect outliers when benchmarking in clinical registries was conducted in five databases: EMBASE, ProQuest, Scopus, Web of Science and Google Scholar. A modified healthcare modelling evaluation tool was used to assess quality; data extracted from each study were summarised and presented in a narrative synthesis.Results Nineteen studies evaluating a variety of statistical methods in 20 clinical registries were included. The majority of studies conducted application studies comparing outliers without statistical performance assessment (79%), while only few studies used simulations to conduct more rigorous evaluations (21%). A common comparison was between random effects and fixed effects regression, which provided mixed results. Registry population coverage, provider case volume minimum and missing data handling were all poorly reported.Conclusions The optimal methods for detecting outliers when benchmarking clinical registry data remains unclear, and the use of different models may provide vastly different results. Further research is needed to address the unresolved methodological considerations and evaluate methods across a range of registry conditions.PROSPERO registration number CRD42022296520.

Abstract Background Clinical quality registries (CQRs) monitor compliance against optimal practice and provide feedback to the clinical community and wider stakeholder groups. Despite a number of CQRs having incorporated the patient perspective to support the evaluation of healthcare delivery, no recommendations for inclusion of patient-reported outcome measures (PROMs) in CQRs exist. The aim of this study was to develop a core set of recommendations for PROMs inclusion of in CQRs. Method An online two-round Delphi survey was performed among CQR data custodians, quality of life researchers, biostatisticians and clinicians largely recruited in Australia. A list of statements for the recommendations was identified from a literature and survey of the Australian registries conducted in 2019. The statements were grouped into the following domains: rationale, setting, ethics, instrument, administration, data management, statistical methods, and feedback and reporting. Eighteen experts were invited to participate, 11 agreed to undertake the first online survey (round 1). Of these, nine experts completed the online survey for round 2. Results From 117 statements presented to the Delphi panel in round 1, a total of 72 recommendations (55 from round 1 and 17 from round 2) with median importance (MI) ≥ 7 and disagreement index (DI)

Summary: Background: Understanding the long-term outcomes and disability-adjusted life years (DALY) after out-of-hospital cardiac arrest (OHCA) is important to understand the overall health and disease burden of OHCA respectively, but data in Asia remains limited. We aimed to quantify long-term survival and the annual disease burden of OHCA within a national multi-ethnic Asian cohort. Methods: We conducted an open cohort study linking the Singapore Pan-Asian Resuscitation Outcomes Study (PAROS) and the Singapore Registry of Births and Deaths from 2010 to 2019. We performed Cox regression, constructed Kaplan–Meier curves, and calculated DALYs and standardised mortality ratios (SMR) for each year of follow-up. Results: We analysed 802 cases. The mean age was 56.0 (SD 17.8). Most were male (631 cases, 78,7%) and of Chinese ethnicity (552 cases, 68.8%). At one year, the SMR was 14.9 (95% CI:12.5–17.8), decreasing to 1.2 (95% CI:0.7–1.8) at three years, and 0.4 (95% CI:0.2–0.8) at five years. Age at arrest (HR:1.03, 95% CI:1.02–1.04, p

Abstract Background Polycystic ovary syndrome (PCOS) is challenging to diagnose. While the 2003 Rotterdam criteria are widely used for adults, the 2018 international PCOS guideline recommended updated Rotterdam criteria with both hyperandrogenism and oligo-anovulation for adolescents based on evidence-informed expert consensus. This study compared the prevalence of PCOS using updated and original Rotterdam criteria in community-based adolescents and explored long-term body mass index (BMI) trajectories across different diagnostic phenotypes. Methods Overall, 227 postmenarchal adolescent females from the prospective cohort Raine Study undertook comprehensive PCOS assessment at age 14–16 years. Detailed anthropometric measurements were collected from birth until age 22 years. Cross-sectional and longitudinal BMI were analyzed using t tests and generalized estimating equations. Results PCOS was diagnosed in 66 (29.1%) participants using original criteria versus 37 (16.3%) participants using updated Rotterdam criteria. Using updated criteria, participants with PCOS had higher BMI than participants without PCOS from prepubertal. Only the phenotype meeting the updated criteria was significantly associated with higher long-term BMI gain whereas other PCOS phenotypes had similar BMI trajectories to participants without PCOS (p

Abstract Background With the rapid development of technologies for type 1 diabetes, economic evaluations are integral in guiding cost-effective clinical and policy decisions. We therefore aimed to review and synthesise the current economic literature for available diabetes management technologies and outline key determinants of cost-effectiveness. Methods A systematic search was conducted in April 2019 that focused on modelling or trial based economic evaluations. Searched databases included Medline, Medline in-process and other non-indexed citations, EMBASE, PubMed, All Evidenced Based Medicine Reviews, EconLit, Cost-effectiveness analysis Registry, Research Papers in Economics, Web of Science, PsycInfo, CINAHL, and PROSPERO from inception. We assessed quality of included studies with the Questionnaire to Assess Relevance and Credibility of Modeling Studies for Informing Health Care Decision Making an ISPOR-AMCP-NPC good practice task force report. Screening of abstracts and full-texts, appraisal, and extraction were performed by two independent researches. Results We identified 16,772 publications, of which 35 were analysed and included 11 health technologies. Despite a lack of consensus, most studies reported that insulin pumps (56%) or interstitial glucose sensors (62%) were cost-effective, although incremental cost-effectiveness ratios ranged widely ($14,266–$2,997,832 USD). Cost-effectiveness for combined insulin pumps and glucose sensors was less clear. Determinants of cost-effectiveness included treatment effects on glycosylated haemoglobin and hypoglycaemia, costing of technologies and complications, and measures of utility. Conclusions Insulin pumps or glucose sensors appeared cost-effective, particularly in populations with higher HbA1c levels and rates of hypoglycaemia. However, cost-effectiveness for combined insulin pumps and glucose sensors was less clear. Registration The study was registered with PROSPERO, number CRD42017077221.

BackgroundIncreasing global diabetes incidence has profound implications for health systems and for people living with diabetes. Guidelines have established clinical targets but there may be variation in clinical outcomes including HbA1c, based on location and practice size. Investigating this variation may help identify factors amenable to systemic improvement interventions. The aims of this study were to identify centre-specific and patient-specific factors associated with variation in HbA1c levels and to determine how these associations contribute to variation in performance across diabetes centres.MethodsThis cross-sectional study analysed data for 5,872 people with type 1 (n = 1,729) or type 2 (n = 4,143) diabetes mellitus collected through the Australian National Diabetes Audit (ANDA). A linear mixed-effects model examined centre-level and patient-level factors associated with variation in HbA1c levels.ResultsMean age was: 43±17 years (type 1), 64±13 (type 2); median disease duration: 18 years (10,29) (type 1), 12 years (6,20) (type 2); female: 52% (type 1), 45% (type 2). For people with type 1 diabetes, volume of patients was associated with increases in HbA1c (p = 0.019). For people with type 2 diabetes, type of centre was associated with reduction in HbA1c (p ConclusionsCentre-level and patient-level factors were associated with variation in HbA1c, but patient-level factors had greater impact. Interventions targeting patient-level factors conducted at a centre level including sick-day management, smoking cessation programs and culturally appropriate diabetes education for and Aboriginal and Torres Strait Islander peoples may be more important for improving glycaemic control than targeting factors related to the Centre itself.

Objectives Adequate risk adjustment for factors beyond the control of the healthcare system contributes to the process of transparent and equitable benchmarking of trauma outcomes. Current risk adjustment models are not optimal in terms of the number and nature of predictor variables included in the model and the treatment of missing data. We propose a statistically robust and parsimonious risk adjustment model for the purpose of benchmarking.Setting This study analysed data from the multicentre Australia New Zealand Trauma Registry from 1 July 2016 to 30 June 2018 consisting of 31 trauma centres.Outcome measures The primary endpoints were inpatient mortality and length of hospital stay. Firth logistic regression and robust linear regression models were used to study the endpoints, respectively. Restricted cubic splines were used to model non-linear relationships with age. Model validation was performed on a subset of the dataset.Results Of the 9509 patients in the model development cohort, 72% were male and approximately half (51%) aged over 50 years . For mortality, cubic splines in age, injury cause, arrival Glasgow Coma Scale motor score, highest and second-highest Abbreviated Injury Scale scores and shock index were significant predictors. The model performed well in the validation sample with an area under the curve of 0.93. For length of stay, the identified predictor variables were similar. Compared with low falls, motor vehicle occupants stayed on average 2.6 days longer (95% CI: 2.0 to 3.1), p

Abstract Background Composite measures combine data to provide a comprehensive view of patient outcomes. Despite composite measures being a valuable tool to assess post-intervention outcomes, the patient perspective is often missing. The purpose of this study was to develop a composite measure for an established cardiac outcome registry, by combining clinical outcomes following percutaneous coronary interventions (PCI) with a patient-reported outcome measure (PROM) developed specifically for this population (MC-PROM). Methods Two studies were undertaken. Study 1: Patients who had undergone a PCI at one of the three participating registry hospital sites completed the 5-item MC-PROM. Clinical outcome data for the patients (e.g. death, myocardial infarction, repeat vascularisation, new bleeding event) were collected 30 days post-intervention as part of routine data collection for the cardiac registry. Exploratory factor analysis of clinical outcomes and MC-PROM data was conducted to determine the minimum number of constructs to be included in a composite measure. Study 2: Clinical experts participated in a Delphi technique, consisting of three rounds of online surveys, to determine the clinical outcomes to be included and the weighting of the clinical outcomes and MC-PROM score for the composite measure. Results Study 1: Routine clinical outcomes and the MC-PROM data were collected from 266 patients 30 days post PCI. The MC-PROM score was not significantly correlated with any clinical outcomes. Study 2: There was a relatively consistent approach to the weighting of the clinical outcomes and MC-PROM items by the expert panel (n = 18) across the three surveys with the exception of the clinical outcome of ‘deceased at 30 days’. The final composite measure included five clinical outcomes within 30 days weighted at 90% (new heart failure, new myocardial infarction, new stent thrombosis, major bleeding event, new stroke, unplanned cardiac rehospitalisation) and the MC-PROM score (comprising 10% of the total weighting). Conclusions A single patient level composite score, which incorporates weighted clinical outcomes and a PROM was developed. This composite score provides a more comprehensive reported measure of individual patient wellbeing at 30 days post their PCI-procedure, and may assist clinicians to further assess and address patient level factors that potentially impact on clinical recovery.

Introduction The burden of injury in the Kingdom of Saudi Arabia (KSA) has increased in recent years, but the country has lacked a consistent methodology for collecting injury data. A trauma registry has been established at a large public hospital in Riyadh from which these data are now available.Objectives We aimed to provide an overview of trauma epidemiology by reviewing the first calendar year of data collection for the registry. Risk-adjusted analyses were performed to benchmark outcomes with a large Australian major trauma service in Melbourne. The findings are the first to report the trauma profile from a centre in the KSA and compare outcomes with an international level I trauma centre.Methods This was an observational study using records with injury dates in 2018 from the registries at both hospitals. Demographics, processes and outcomes were extracted, as were baseline characteristics. Risk-adjusted endpoints were inpatient mortality and length of stay. Binary logistic regression was used to measure the association between site and inpatient mortality.Results A total of 2436 and 4069 records were registered on the Riyadh and Melbourne databases, respectively. There were proportionally more men in the Saudi cohort than the Australian cohort (86% to 69%). The Saudi cohort was younger, the median age being 36 years compared with 50 years, with 51% of injuries caused by road traffic incidents. The risk-adjusted length of stay was 4.4 days less at the Melbourne hospital (95% CI 3.95 days to 4.86 days, p

Introduction Nearly one quarter of a million Australian workers experience a work injury annually and make a benefit claim through one of the nation’s eleven workers’ compensation (WC) systems. The total cost to Australian society has most recently been estimated at $61.8 billion or 4.1% of GDP. The disaggregation of legislative responsibility between jurisdictions has contributed to a lack of common data standards, and thus minimal understanding of the efficiency or effectiveness of service provision in the Australian WC sector. Objectives and Approach This project developed a new multi-jurisdictional work disability database including detailed information on work disability duration, health and social care service provision. Service level payment data contained in structured WC insurance claims datasets held by five large WC jurisdictions with >60% coverage of the Australian labour force was collected for all cases of work-related low back pain, fractures and limb soft tissue disease over between 2010 and 2015. Database development involved creation and coding of harmonised service-level indicators for individual episodes of healthcare provision and weekly periods of wage replacement. Results A total of 253,000 cases and 10.7 million service episodes are included in the database. Initial exploratory analyses focused on the frequency, prevalence, timing, intensity and continuity of General Practitioner (GP) services to each of the injury groups. Regression modelling examined occupational, injury, demographic and jurisdictional factors affecting GP service use outcomes. As anticipated, service patterns varied by injury type, age, gender and occupational group. Significant differences in service use between WC jurisdictions were observed. Conclusion / Implications This exploratory study demonstrates the feasibility of developing a population-based service level database for monitoring health service delivery to injured Australian workers. Future studies will examine the impact of jurisdictional policy differences on service delivery, and the relationship between service delivery and outcomes such as disability duration.

Background Incidence and outcomes of out‐of‐hospital cardiac arrest (OHCA) vary between communities. We aimed to examine differences in patient characteristics, prehospital care, and outcomes in Singapore and Victoria. Methods and Results Using the prospective Singapore Pan‐Asian Resuscitation Outcomes Study and Victorian Ambulance Cardiac Arrest Registry, we identified 11 061 and 32 003 emergency medical services‐attended adult OHCAs between 2011 and 2016 respectively. Incidence and survival rates were directly age adjusted using the World Health Organization population. Survival was analyzed with logistic regression, with model selection via backward elimination. Of the 11 061 and 14 834 emergency medical services‐treated OHCAs (overall mean age±SD 65.5±17.2; 67.4% males) in Singapore and Victoria respectively, 11 054 (99.9%) and 5595 (37.7%) were transported, and 440 (4.0%) and 2009 (13.6%) survived. Compared with Victoria, people with OHCA in Singapore were older (66.7±16.5 versus 64.6±17.7), had less shockable rhythms (17.7% versus 30.3%), and received less bystander cardiopulmonary resuscitation (45.7% versus 58.5%) and defibrillation (1.3% versus 2.5%) (all P

Abstract Background Cardiovascular risk stratification is complex in type 1 diabetes. We hypothesised that traditional and diabetes-specific cardiovascular risk factors were prevalent and strongly associated with cardiovascular disease (CVD) among adults with type 1 diabetes attending Australian diabetes centres. Methods De-identified, prospectively collected data from patients with type 1 diabetes aged ≥ 18 years in the 2015 Australian National Diabetes Audit were analysed. The burden of cardiovascular risk factors [age, sex, diabetes duration, glycated haemoglobin (HbA1c), blood pressure, lipid profile, body mass index, smoking status, retinopathy, renal function and albuminuria] and associations with CVD inclusive of stroke, myocardial infarction, coronary artery bypass graft surgery/angioplasty and peripheral vascular disease were assessed. Restricted cubic splines assessed for non-linearity of diabetes duration and likelihood ratio test assessed for interactions between age, diabetes duration, centre type and cardiovascular outcomes of interest. Discriminatory ability of multivariable models were assessed with area under the receiver operating characteristic (ROC) curves. Results Data from 1169 patients were analysed. Mean (± SD) age and median diabetes duration was 40.0 (± 16.7) and 16.0 (8.0–27.0) years respectively. Cardiovascular risk factors were prevalent including hypertension (21.9%), dyslipidaemia (89.4%), overweight/obesity (56.4%), ever smoking (38.5%), albuminuria (31.1%), estimated glomerular filtration rate 7.0% (53 mmol/mol) (81.0%). Older age, longer diabetes duration, smoking and antihypertensive therapy use were positively associated with CVD, while high density lipoprotein-cholesterol and diastolic blood pressure were negatively associated (p

Abstract Background Technology has been implemented since the 1970s with the hope of improving glycaemic control and reducing the burden of complications for those living with type 1 diabetes. A clinical and cost-effectiveness comparison of all available technologies including continuous subcutaneous insulin infusion (CSII), continuous glucose monitors (CGMs), sensor-augmented pump therapy (including either low-glucose suspend or predictive low-glucose suspend), hybrid closed-loop systems, closed-loop (single-hormone or dual-hormone) systems, flash glucose monitoring (FGM), insulin bolus calculators, and ‘smart-device’ applications is currently lacking. This systematic review, network meta-analysis, and narrative synthesis aims to summarise available evidence regarding the clinical and cost-effectiveness of available technologies in the management of patients with type 1 diabetes. Methods Relevant studies will be searched using a comprehensive strategy through MEDLINE, MEDLINE in-process and other non-indexed citations, EMBASE, PubMed, all evidenced-based medicine reviews, EconLit, Cost-effectiveness Analysis Registry, Research Papers in Economics, Web of Science, PsycInfo, CINAHL, and PROSPERO for randomised controlled trials and economic evaluations. The search strategy will assess if there are combinations of currently available technologies that are superior to each other or to insulin injections and capillary blood glucose testing with regard to glycaemic control, morbidity/mortality, quality of life, and cost-effectiveness. Two reviewers will screen all articles for eligibility and then independently evaluate risk of bias, complete quality assessment, and extract data for included studies. Network meta-analyses will be performed where there is sufficient homogenous clinical data. Narrative synthesis will be performed for heterogeneous clinical data that cannot be pooled for network meta-analysis with critical appraisal of economic evaluations. Discussion This systematic review protocol utilises rigorous methodology and pre-determined eligibility criteria to provide a uniquely comprehensive search for a broad spectrum of clinical and economic outcomes in comparing multiple currently available technologies for managing type 1 diabetes. Evidence on which technologies may be most appropriate for particular patient groups will be examined as well as the economic justification for funding of different technologies. Systematic review registration PROSPERO (CRD42017077221)

Abstract Background Obesity is common in young women, increasing insulin resistance (IR) and worsening pregnancy complications, including gestational diabetes (GDM). Women with polycystic ovary syndrome (PCOS) are commonly obese, which aggravates the severity of PCOS clinical expression. Relationships between these common insulin-resistant conditions, however, remain unclear. Methods We conducted a secondary analysis of the Australian Longitudinal Study on Women’s Health (ALSWH) database, including data from 8009 women aged 18–36 years across six surveys. We used latent-curve growth modelling to identify distinct body mass index (BMI) trajectories and multinomial logistic regression to explore sociodemographic and health variables characterizing BMI group membership. Logistic regression was used to assess independent risk of GDM. Results A total of 662 women (8.29%, 95% CI 7.68–8.89) reported PCOS. Three distinct BMI trajectories emerged, namely low stable (LSG) (63.8%), defined as an average trajectory remaining at ~25 kg/m2; moderately rising (MRG) (28.8%), a curvilinear trajectory commencing in a healthy BMI and terminating in the overweight range; and high-rising (HRG) (7.4%), a curvilinear trajectory starting and terminating in the obese range. A high BMI in early reproductive life predicted membership in higher trajectories. The HRG BMI trajectory was independently associated with GDM (OR 2.50, 95% CI 1.80–3.48) and was a stronger correlate than PCOS (OR 1.89, 95% CI 1.41–2.54), maternal age, socioeconomic status, or parity. Conclusion Our results suggest heterogeneity in BMI change among Australian women of reproductive age, with and without PCOS. Reducing early adult life weight represents an ideal opportunity to intervene at an early stage of reproductive life and decreases the risk of long-term metabolic complications such as GDM.

Abstract Diets high in advanced glycation end products (AGEs) are thought to be detrimental to cardiovascular health. However, there remains uncertainty about the beneficial effect of a low AGE diet on cardiovascular risk factors and inflammatory markers in overweight individuals. We thus performed a randomised, double blind, crossover trial to determine whether consumption of low AGE diets reduce inflammation and cardiovascular risks in overweight and obese otherwise healthy adults. All participants (n = 20) consumed low and high AGE diets alternately for two weeks and separated by a four week washout period. Low AGE diets did not change systolic (p = 0.2) and diastolic blood pressure (p = 0.3), mean arterial pressure (p = 0.8) and pulse pressure (p = 0.2) compared to high AGE diets. Change in total cholesterol (p = 0.3), low-density lipoprotein (p = 0.7), high-density lipoprotein (p = 0.2), and triglycerides (p = 0.4) also did not differ and there was no difference in inflammatory markers: interleukin-6 (p = 0.6), monocyte chemoattractant protein-1 (p = 0.9), tumour necrosis factor α (p = 0.2), C-reactive protein (p = 0.6) and nuclear factor kappa beta (p = 0.2). These findings indicate that consumption of low AGE diets for two weeks did not improve the inflammatory and cardiovascular profiles of overweight and obese adults.

Abstract Background Acute diabetic emergencies are often managed by prehospital Emergency Medical Services (EMS). The projected growth in prevalence of diabetes is likely to result in rising demand for prehospital EMS that are already under pressure. The aims of this study were to model the temporal trends and provide forecasts of prehospital attendances for diabetic emergencies. Methods A time series analysis on monthly cases of hypoglycemia and hyperglycemia was conducted using data from the Ambulance Victoria (AV) electronic database between 2009 and 2015. Using the seasonal autoregressive integrated moving average (SARIMA) modelling process, different models were evaluated. The most parsimonious model with the highest accuracy was selected. Results Forty-one thousand four hundred fifty-four prehospital diabetic emergencies were attended over a seven-year period with an increase in the annual median monthly caseload between 2009 (484.5) and 2015 (549.5). Hypoglycemia (70%) and people with type 1 diabetes (48%) accounted for most attendances. The SARIMA (0,1,0,12) model provided the best fit, with a MAPE of 4.2% and predicts a monthly caseload of approximately 740 by the end of 2017. Conclusions Prehospital EMS demand for diabetic emergencies is increasing. SARIMA time series models are a valuable tool to allow forecasting of future caseload with high accuracy and predict increasing cases of prehospital diabetic emergencies into the future. The model generated by this study may be used by service providers to allow appropriate planning and resource allocation of EMS for diabetic emergencies.

Objectives Prostate cancer is the second most common cause of cancer-related death in males after lung cancer, imposing a significant burden on the healthcare system in Australia. We propose the use of autoregressive integrated moving average (ARIMA) models in conjunction with population forecasts to provide for robust annual projections of prostate cancer.Design Data on the incidence and mortality from prostate cancer was obtained from the Australian Institute of Health and Welfare. We formulated several ARIMA models with different autocorrelation terms and chose one which provided for an accurate fit of the data based on the mean absolute percentage error (MAPE). We also assessed the model for external validity. A similar process was used to model age-standardised incidence and mortality rate for prostate cancer in Australia during the same time period.Results The annual number of prostate cancer cases diagnosed in Australia increased from 3606 in 1982 to 20 065 in 2012. There were two peaks observed around 1994 and 2009. Among the various models evaluated, we found that the model with an autoregressive term of 1 (coefficient=0.45, p=0.028) as well as differencing the series provided the best fit, with a MAPE of 5.2%. External validation showed a good MAPE of 5.8% as well. We project prostate cancer incident cases in 2022 to rise to 25 283 cases (95% CI: 23 233 to 27 333).Conclusion Our study has accurately characterised the trend of prostate cancer incidence and mortality in Australia, and this information will prove useful for resource planning and manpower allocation.

Background Prior studies have demonstrated the association of air pollution with cardiovascular deaths. Singapore experiences seasonal transboundary haze. We investigated the association between air pollution and acute myocardial infarction (AMI) incidence in Singapore. Methods and Results We performed a time‐stratified case‐crossover study on all AMI cases in the Singapore Myocardial Infarction Registry (2010–2015). Exposure on days where AMI occurred (case days) were compared with the exposure on days where AMI did not occur (control days). Control days were chosen on the same day of the week earlier and later in the same month and year. We fitted conditional Poisson regression models to daily AMI incidence to include confounders such as ambient temperature, rainfall, wind‐speed, and Pollutant Standards Index. We assessed relationships between AMI incidence and Pollutant Standards Index in the entire cohort and subgroups of individual‐level characteristics. There were 53 948 cases. Each 30‐unit increase in Pollutant Standards Index was association with AMI incidence (incidence risk ratio [IRR] 1.04, 95% CI 1.03–1.06). In the subgroup of ST‐segment–elevation myocardial infarction the IRR was 1.00, 95% CI 0.98 to 1.03, while for non–ST‐segment–elevation myocardial infarction, the IRR was 1.08, 95% CI 1.05 to 1.10. Subgroup analyses showed generally significant. Moderate/unhealthy Pollutant Standards Index showed association with AMI occurrence with IRR 1.08, 95% CI 1.05 to 1.11 and IRR 1.09, 95% CI 1.01 to 1.18, respectively. Excess risk remained elevated through the day of exposure and for >2 years after. Conclusions We found an effect of short‐term air pollution on AMI incidence, especially non–ST‐segment–elevation myocardial infarction and inpatient AMI. These findings have public health implications for primary prevention and emergency health services during haze.

Background: A new prostate cancer (PCa) prognostic grading system [Gleason groups (GGs)] has been proposed based on the contemporary Gleason scores (GSs), which has five simplified prognostic categories. The objective of this study was to evaluate the agreement between the GGs of prostate biopsy and radical prostatectomy specimens and to identify predictive factors for upgrading GGs. Methods: A total of 5339 cases of RP notified to the Prostate Cancer Outcomes Registry, Victoria, Australia over 6 years (2009–2014) from 46 hospitals, were included. The upgrading was evaluated using the new PCa prognostic grading system, the International Society of Urologic Pathology grade groups, which has five prognostic categories. GG 1 is GS≤6, GG 2 is GS 3+4=7, GG 3 is GS 4 + 3=7, GG 4 is GS 8, and GG 5 is GS 9 and 10. Predictors of upgrading were assessed using univariate and multivariate models. Results: The GG of prostate biopsies and RP specimens were concordant in 54.5% of cases, while 31.1% were upgraded and 14.3% were downgraded. Longer time interval between biopsy and RP [44–99 days: odds ratio (OR)=1.3, 95% confidence interval (CI)=1.1–1.6; > 99 days: OR=3.0, 95% CI=2.4–3.8), and RP performed in a metropolitan hospital (biopsy in a regional hospital: OR=2.2, 95% CI=1.6–3.2, biopsy in a metropolitan hospital: OR=1.7, 95% CI=1.2–2.2) were significant predictors of GG upgrading. Patients who were diagnosed by transperineal biopsy compared to transrectal ultrasound (OR=0.6, 95% CI=0.5–0.8) and higher percentage of positive biopsy cassettes (25–62.5%: OR=0.7, 95% CI=0.6–0.8, > 62.5: OR=0.6, 95% CI=0.5–0.8) were significantly associated with less likelihood of upgrade. Conclusion: The lack of concordance among hospitals may be attributable to the specialist expertise of the pathologist. Expert review of specimens may help to overcome this discordance. Clinicians should consider clinical parameters and potential limitations of the GG at biopsy when making treatment decisions with regard to PCa.

Background: Environmental contexts have been shown to predict health behaviours and outcomes either directly or via interaction with individual risk factors. In this paper, we created indexes of socioeconomic disadvantage (SEDI) and socioeconomic advantage (SAI) in Singapore to test the applicability of these concepts in an Asian context. These indices can be used for health service resource allocation, research and advocacy. Methods: We used principal component analysis (PCA) to create SEDI and SAI using a structured and iterative process to identify and include influential variables in the final index. Data at the master plan geographical level was obtained from the most recent Singapore census 2010. Results: The 3 areas with highest SEDI scores were Outram (120.1), followed by Rochor (111.0) and Downtown Core (110.4). The areas with highest SAI scores were Tanglin, River Valley and Newton. The SAI had 89.6% of variation explained by the final model, as compared to 67.1% for SEDI, and we recommend using both indices in any analysis. Conclusion: These indices may prove useful for policy-makers to identify spatially varying risk factors, and in turn help identify geographically targeted intervention programs, which can be more cost effective to conduct.

This study examines prehospital Emergency Medical Service (EMS) utilisation and patterns of demand for hyperglycaemia management, including characteristics of individuals and factors related to hospital transport.A state-wide, community-based observational study of all patients requiring prehospital EMS for hyperglycaemia during a 7 year study period (Jan 2009-Dec 2015) using electronic data from the Ambulance Victoria data warehouse was conducted. Pre-specified variables related to patient demographics, comorbidities, examination findings, paramedic treatment and transport outcomes were obtained. Logistic regression was used to assess factors associated with transport to hospital.There were 11,417 cases of hyperglycaemia attended by paramedics during the study period, accounting for 0.3-0.4% of the total annual EMS caseload, and equating to 0.54 attendances per 100 people with diabetes in the state of Victoria, Australia, per year. There was a significant increase in annual utilisation, with a rate ratio of 1.62 between 2009 (2.42 cases per 10,000 population) and 2015 (3.91 cases per 10,000 population). Fifty-one percent of cases had type 2 diabetes, 37% had type 1 diabetes, 4% had diabetes with the type unspecified and 8% had no recorded history of diabetes. Ninety percent of cases were transported to hospital. Factors associated with increased odds of transport to hospital included no known history of diabetes, regional/rural locations, case time between 0600 and

BackgroundWe examined the influence of sex, ethnicity, and time on competing cardiovascular and noncardiovascular causes of death following acute myocardial infarction in a multiethnic Asian cohort. Methods and ResultsFor 12 years, we followed a prospective nationwide cohort of 15 151 patients (aged 22–101 years, median age 63 years; 72.3% male; 66.7% Chinese, 19.8% Malay, 13.5% Indian) who were hospitalized for acute myocardial infarction between 2000 and 2005. There were 6463 deaths (4534 cardiovascular, 1929 noncardiovascular). Compared with men, women had a higher risk of cardiovascular death (age‐adjusted hazard ratio [HR] 1.3, 95% CI 1.2–1.4) but a similar risk of noncardiovascular death (HR 0.9, 95% CI 0.8–1.0). Sex differences in cardiovascular death varied by ethnicity, age, and time. Compared with Chinese women, Malay women had the greatest increased hazard of cardiovascular death (HR 1.4, 95% CI 1.2–1.6) and a marked imbalance in death due to heart failure or cardiomyopathy (HR 3.4 [95% CI 1.9–6.0] versus HR 1.5 [95% CI 0.6–3.6] for Indian women). Compared with same‐age Malay men, Malay women aged 22 to 49 years had a 2.5‐fold (95% CI 1.6–3.8) increased hazard of cardiovascular death. Sex disparities in cardiovascular death tapered over time, least among Chinese patients and most among Indian patients; the HR comparing cardiovascular death of Indian women and men decreased from 1.9 (95% CI 1.5–2.4) at 30 days to 0.9 (95% CI 0.5–1.6) at 10 years. ConclusionAge, ethnicity, and time strongly influence the association between sex and specific cardiovascular causes of mortality, suggesting that health care policy to reduce sex disparities in acute myocardial infarction outcomes must consider the complex interplay of these 3 major modifying factors.

We conducted a study among healthcare workers (HCWs) exposed to patients with severe acute respiratory syndrome (SARS) before infection control measures were instituted. Of all exposed HCWs, 7.5% had asymptomatic SARS-positive cases. Asymptomatic SARS was associated with lower SARS antibody titers and higher use of masks when compared to pneumonic SARS.

Severe acute respiratory syndrome (SARS) is an emerging viral infectious disease. One of the largest outbreaks of SARS to date began in Singapore in March 2003. We describe the clinical, laboratory, and radiologic features of the index patient and the patient’s initial contacts affected with probable SARS.

After an outbreak of meningococcal disease caused by Neisseria meningitidis W135, associated with the Hajj pilgrimage in 2001, 15% of returning vaccinated pilgrims carried a single W135 clone, and 55% were still carriers 6 months later. Transmission to 8% of their unvaccinated household contacts occurred within a few weeks, but no late transmission took place. Public health interventions are needed to protect household contacts.

To investigate the independent relationship of individual- and area-level socio-economic status (SES) with the presence and severity of visual impairment (VI) in an Asian population.Cross-sectional data from 9993 Chinese, Malay and Indian adults aged 40-80 years who participated in the Singapore Epidemiology of eye Diseases (2004-2011) in Singapore. Based on the presenting visual acuity (PVA) in the better-seeing eye, VI was categorized into normal vision (logMAR≤0.30), low vision (logMAR>0.30

Introduction: Burnout among nurses is a significant problem in healthcare establishments and has negative implications on clinical outcomes. International studies have shown the prevalence of burnout ranged from 30% to 80%. However, this is unknown amongst nurses in a community hospital in Singapore. Our objectives are to determine the prevalence of burnout among nurses at a community hospital in Singapore as well as explore the factors associated with burnout. Methods: The nurses, from a community hospital with palliative, rehabilitation, chronic sick and nursing home services, self-administered the Professional Quality of Life Scale to determine the level of burnout. An anonymous survey was included to collect demographics and variables that were postulated to be associated with burnout. Results: With a response rate of 51.4%, the prevalence of burnout was found to be 33.3%. Nurses working in the rehabilitation wards had higher odds of burnout (p=0.026). Multivariate analysis indicated increased number of years working as a nurse (p = 0.006) and whether work interferes “sometimes” & “often” with family commitments (p = 0.006 & 0.028 respectively) to be significantly associated with burnout. Conclusion: The prevalence of burnout was found to be comparable to that of a tertiary hospital and this deserves further attention. In conclusion, this research reveals the extent of nursing burnout in intermediate and long term care sector as well as identifies factors associated with burnout.

An improved number of anti-fungal drugs are currently available for the treatment of invasive aspergillosis (IA). While serial galactomannan index (GMI) measurement can be used to monitor response to treatment, the extent to which different anti-fungal regimens can affect galactomannan levels is unknown. In 147 IA patients receiving either voriconazole (VCZ) or conventional amphotericin B (CAB) in a multicentre clinical trial, we performed post-hoc analyses of GMI trends in relation to outcomes. The generalized estimation equations approach was used to estimate changes in the effect size for GMI over time within patients. Patients who received VCZ primary therapy and had good treatment response 12 weeks later showed earlier decreases in GMI values at Week 1 and Week 2 (p = 0.001 and 0.046 respectively) as compared to patients who only received CAB. At end-of-randomized therapy (EORT), which was a pre-set secondary assessment point for all patients who switched from randomized primary (CAB or VCZ) to an alternative anti-fungal drug, treatment failure was associated with increasing GMI at Weeks 1 and 2 in CAB-primary treated patients (p = 0.022 and 0.046 respectively). These distinct trends highlight the variations in GMI kinetics with the use of different anti-fungal drugs and their implications in relation to IA treatment response.

BACKGROUND: Tuberculosis remains common in Singapore, increasing in incidence since 2008. We attempted to determine the molecular epidemiology of Mycobacterium tuberculosis complex (MTC) isolates locally, identifying major circulating genotypes and obtaining a glimpse of transmission dynamics. METHODOLOGY: Non-duplicate MTC isolates archived between 2006 and 2012 at the larger clinical tuberculosis laboratory in Singapore were sampled for spoligotyping and MIRU-VNTR typing, with case data obtained from the Singapore Tuberculosis Elimination Program registry database. Isolates between 2008 and 2012 were selected because of either multidrug-resistance or potential epidemiological linkage, whereas earlier isolates were randomly selected. Separate analyses were performed for the early (2006-2007) and later (2008-2012) study phases in view of potential selection bias. PRINCIPAL FINDINGS: A total of 1,612 MTC isolates were typed, constituting 13.1% of all culture-positive tuberculosis cases during this period. Multidrug-resistance was present in 91 (5.6%) isolates - higher than the national prevalence in view of selection bias. The majority of isolates belonged to the Beijing (45.8%) and EAI (22.8%) lineages. There were 347 (30.7%) and 133 (27.5%) cases clustered by combined spoligotyping and MIRU-VNTR typing from the earlier and later phases respectively. Patients within these clusters tended to be of Chinese ethnicity, Singapore resident, and have isolates belonging to the Beijing lineage. A review of prior contact investigation results for all patients with clustered isolates failed to reveal epidemiological links for the majority, suggesting either unknown transmission networks or inadequate specificity of the molecular typing methods in a country with a moderate incidence of tuberculosis. CONCLUSION: Our work demonstrates that Singapore has a large and heterogeneous distribution of MTC strains, and with possible cross-transmission over the past few years based on our molecular typing results. A universal MTC typing program coupled with enhanced contact investigations may be useful in further understanding the transmission dynamics of tuberculosis locally.