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Fractional exhaled nitric oxide (Feno), used as a biomarker, is influenced by several factors including ethnicity. Normative data are essential for interpretation, and currently single cutoff values are used in children and adults.Accounting for factors that influence Feno, (1) what are appropriate predicted and upper limit of normal (ULN) Feno values in an underserved population (First Nations Australians), (2) how do these values compare with age-based interpretive guidelines, and (3) what factors influence Feno and what is the size of the effect?Feno data of First Nations Australians (age 16 years, n = 862; age ≥ 16 years, n = 348) were obtained. Medical history using participant questionnaires and medical records were used to define healthy participants. Flexible regression using spline functions, as used by the Global Lung Function Initiative, were used to generate predicted and ULN values.Look-up tables for predicted and ULN values using age (4-76 years) and height (100-200 cm) were generated and are supplied with a calculator for clinician use. In healthy First Nations children (age 18 years), ULN values ranged between 25 and 60 parts per billion (ppb) when considering only biologically plausible age and height combinations. For healthy adults, ULN values ranged between 39 and 88 ppb. Neither the current Feno interpretation guidelines, nor the currently recommended cutoff of 50 ppb for First Nations children 16 years of age or younger were appropriate for use in this cohort. Our modelling revealed that predicted and ULN values of healthy participants varied nonlinearly with age and height.Because single pediatric, adult, or all-age Feno cutoff values used by current interpretive guidelines to define abnormality fail to account for factors that modify Feno values, we propose predicted and ULN values for First Nations Australians 4 to 76 years of age. Creating age- and height-adjusted predicted and ULN values could be considered for other ethnicities.

Background Asthma epidemics associated with thunderstorms have had catastrophic impacts on individuals and emergency services. Seasonal allergic rhinitis (SAR) is present in the vast majority of people who develop thunderstorm asthma (TA), but there is little evidence regarding risk factors for TA among the SAR population. Objective We sought to identify risk factors for a history of TA and hospital presentation in a cohort of individuals with SAR. Methods This multi-centre study recruited adults from Melbourne (Australia) with a past diagnosis of TA and/or self-reported SAR. Clinical information, spirometry, white blood-cell count, ryegrass pollen specific IgE (RGP-spIgE) and fractional exhaled nitric oxide (FeNO) were measured to identify risk factors for a history of TA in individuals with SAR. Results From a total of 228 individuals with SAR, 35% (80/228) reported SAR only (I-SAR), 37% (84/228) reported TA symptoms but had not attended hospital for treatment (O-TA) and 28% (64/228) had presented to hospital for TA (H-TA). All H-TA patients reported a previous asthma diagnosis. Logistic regression analysis of factors associated with O-TA and H-TA indicated that lower forced expiratory volume in one second (FEV1) and asthma control questionnaire (ACQ) score >1.5 were associated with H-TA. Higher blood RGP-spIgE, eosinophil counts, and FeNO were significantly associated with both O-TA and H-TA. Receiver-operating curve (ROC) analysis showed RGP-spIgE >10·1 kU/L and pre-bronchodilator FEV1 ≤90% to be biomarkers of increased H-TA risk. Conclusion Clinical tests can identify risk for a history of TA in individuals with SAR and thereby inform patient-specific treatment recommendations.

Psychological distress and alcohol consumption are associated but few studies have focused on the association with problematic drinking in semi-urban and rural settings. In this study, we assessed the role of psychological distress on various measures of problematic drinking in urban, semi-urban and rural settings.Retrospective descriptive study Setting SETTING: National Drug Strategy Household Survey population health survey data PARTICIPANTS: 151,341 Australian residents MAIN OUTCOME MEASURES: Problematic alcohol consumption categorised as either heavy-episodic drinking (defined as drinking 5 or more standard drinks at least once in the last 12 months) or long-term risky drinking (defined as drinking more than 730 standard drinks in the past 12 months) was the outcome variables. Psychological distress was identified from the K10 questionnaire. Participants were grouped into area of residence: urban, semi-urban and rural. Sex differences were also explored.Poor-to-severe psychological distress was associated with higher odds of both long-term and heavy-episodic drinking. Being male alone increased the risk of both long-term and heavy-episodic drinking in all areas. When stratified by sex, being female and severe levels of psychological distress increased the risk of both long-term risky and heavy-episodic drinking. These risks were greater in non-urban environments.Poor mental health outcomes may exacerbate problematic drinking amongst females, especially those living in non-urban environments. Public health campaigns could both target these at-risk groups of females in non-urban settings and also account for the interplay between problematic drinking and mental health.

Background: Days of high asthma admissions (HAADs) or readmissions (HARDs) create substantial acute burdens on hospital systems. An important component of asthma care is understanding potential causes of these admission spikes with potential of mitigation of risk. Crucial to this research is accurately distinguishing these events from background seasonal changes and time trends. To date, classification methods have been based on ad hoc and un-tested definitions which may hamper understanding of causes due to HAADs and HARDs misclassification. The aim of this article is to introduce an easily applied robust statistical approach, demonstrated to have high classification accuracy in other settings. It is referred to as the Seasonal Hybrid Extreme Studentized Deviate (S-H-ESD) method.Methods: We demonstrate S-H-ESD on a time series between 1996 to 2009 of all daily paediatric asthma hospital admissions from the Victorian Admitted Episodes Data set (VAED).Results: The S-H-ESD method clearly identified HAADs and HARDs without applying ad-hoc classification definitions, while appropriately accounting for seasonality and time trend. Furthermore, this was able to be done with statistical testing to provide evidence in support of their identification. Conclusion: The S-H-ESD is useful and statistically appropriate for the accurate classification of HAADs and HARDS. This method removes the need for ad-hoc approaches and presents as a means of systemizing the accurate classification and detection of high asthma admission days. This will strengthen synthesis and efficacy of research in order to understand causes of high asthma hospital admission and readmission.

Pediatric asthma hospital readmission is a burden on the individual and costly for Australian hospitals. Grass pollen's role, a known trigger for asthma admissions, is unexamined in readmissions. We examined the association between grass pollen and pediatric asthma readmission.The Victorian Admitted Episodes Dataset was used to identify all primary admissions with a principal diagnosis of asthma in children aged 2-18 years between 1997 and 2009. Readmissions were defined as subsequent admissions within 28 days of index admission discharge. Generalized additive models were used to assess associations between readmission, grass pollen season, and daily grass pollen counts, lagged and cumulative. Models were further stratified by sex and age group.Mean daily readmission was higher during grass pollen season than other times of the year, incidence rate ratio (IRR) 1.44 (95% CI, 1.03, 2.02) and for children aged 2-5 years, IRR 1.99 (1.26, 3.14). Same day grass pollen was nonlinearly associated with daily readmission for the 13-18 age group between 110 and 256 grains/mGrass pollen exposure was associated with higher readmission rates for pediatric asthma. Treatment plans prior to discharge could be implemented to reduce the likelihood of readmission by younger children during the pollen season.

Adjustment to life with acquired brain injury (ABI) requires self-identity and behaviour to be updated, incorporating injury-related changes. Identifying and enabling new values-consistent behaviours could facilitate this process. We evaluated the feasibility, acceptability, and preliminary efficacy of VaLiANT, a new group intervention that aims to enhance "valued living" following ABI. We used a non-concurrent multiple baseline single-case experimental design (SCED) with an 8-week follow-up phase and randomization to multiple baseline lengths (5-7 weeks). Eight participants (50% women, aged 26-65; 4 Stroke, 3 Traumatic Brain Injury, 1 Epilepsy) attended eight group sessions with assessments before, during, and after the group. Target behaviour was valued living, assessed weekly by the Valued Living Questionnaire. Secondary outcomes included measures of wellbeing, mood, psychological acceptance, self-efficacy regarding ABI consequences, cognitive complaints, and intervention acceptability. Target behaviour was analysed through visual and statistical analysis while secondary outcome data were analysed via reliable change indices and descriptive statistics. Target behaviour data displayed no convincing patterns of improvement. Reliable improvements were found for most participants on secondary outcomes, particularly subjective wellbeing and anxiety. Intervention delivery was feasible with high acceptability ratings. Further investigation of VaLiANT is warranted, based on the feasibility and acceptability of intervention delivery and signals of efficacy identified across adjustment-related secondary outcomes.

Aim This study examined microclimate changes to the skin as a result of pressure over a 1 h period. The results were compared to skin parameter results following brief consecutive off-loading of pressure-prone areas. Design A descriptive-correlational pilot study was undertaken. Method A convenience sample of 41 healthy adults aged 18–60 years was recruited. Participants engaged in four 1 h data collection sessions. The sessions were conducted in both semi-recumbent and supine positions. Measures of erythema, melanin, stratum corneum hydration, and skin temperature were taken at pressure-prone areas at baseline and after 1 h in an uninterrupted method (continuous pressure-loading) and every 10 min in an interrupted method (brief off-loading). The Corneometer and Mexameter (Courage + Khazaka Electronics GMbH, 2013) and Exergen DermaTemp DT-1001 RS Infrared Thermographic Scanner (Exergen Corporation, 2008) provided a digital appraisal of skin parameters. Intraclass correlation coefficients (ICC) were calculated to indicate test-retest reliability and absolute agreement of results between the two methods. Results Strong agreement between the interrupted and uninterrupted method was observed with ICCs ranging from 0.72 to 0.99 (supine) and 0.62–0.99 (semi-recumbent). Endpoint measures tended to be higher compared to baseline measures for all skin parameters. Differences in skin parameters results by anatomical location were evident particularly for erythema and stratum corneum hydration; the elbows and heels yielded lower scores compared to the sacrum. Erythema had the most variation across methods. The supine and semi-recumbent positions had negligible effect on measured skin parameters. Conclusions Minimal variation between skin parameter results indicates that brief off-loading in the interrupted method did not significantly change the outcomes; minor shifts in positioning do not alter changes to the skin from pressure. Skin parameters varied by anatomical location and changed over a 1 h period of pressure-loading. Relevance to clinical practice Biophysical techniques may be able to assist accurate assessment of skin microclimate and skin colour. As brief off-loading (interruptions) to enable skin parameter measurement does not alter skin readings, researchers can proceed with some confidence regarding the use of this protocol in future studies assessing skin parameters. This study data provides a library of cutaneous changes at pressure-prone areas of healthy adults and is expected to inform innovative approaches to pressure injury risk assessment.

Periods when asthma admissions peaks have serious implications for asthma sufferers and hospitals. We assessed the association between aeroallergen exposure and childhood asthma peak periods during two grass pollen seasons using the Melbourne Air Pollen Children and Adolescent Health (MAPCAH) study conducted in Melbourne, Australia. Two peak periods were identified. Effect modifications by atopy and sex were considered. All pollen 2 days prior was associated with increased odds of these peak periods. Same day fungal spores, but not pollen, were important. Grass at lag 2 was associated with increased odds 1.03 (95%CI 1.01, 1.05) as was the same day Alternaria 1.02 (1.00, 1.04) per spore/m3 for boys. In addition to pollen, fungal spores particularly Alternaria may result in days of high exacerbations during pollen seasons. Further guidance is needed to better prepare families/carers with information about the increased risk of asthma attacks in children prior to pollen seasons.

Background: Experimental challenge studies have shown that pollen can have early and delayed effects on the lungs and airways. Here, we qualitatively and quantitatively synthesize the evidence of outdoor pollen exposure on various lung function and airway inflammation markers in community-based studies. Methods: Four online databases were searched: Medline, Web of Science, CINAHL and Google Scholar. The search strategy included terms relating to both exposure and outcomes. Inclusion criteria were human-based studies published in English that were representative of the community. Additionally, we only considered cross-sectional or short-term longitudinal studies which investigated pollen exposure by levels or season. Study quality assessment was performed using the Newcastle-Ottawa scale. Meta-analysis was conducted using random-effects models. Results: We included 27 of 6551 studies identified from the search. Qualitative synthesis indicated associations between pollen exposure and predominantly type-2 inflammation in both the upper and lower airways, but little evidence for lung function changes. People with ever asthma and/or seasonal allergic rhinitis (SAR) were at higher risk of such airway inflammation. Meta-analysis confirmed a positive relationship between pollen season, eosinophilia and eosinophil cationic protein (ECP) in people with ever SAR but the results between studies were highly variable. Heterogeneity was reduced after further subgrouping by age, and the forest plots indicated that eosinophilic airway inflammation to outdoor pollen exposure increased with age. Conclusion: Among people with ever asthma and ever SAR, exposure to increased ambient pollen triggers type-2 upper and lower airway inflammation rather than a non-specific or innate inflammation. These findings can lead to the formulation of specific pollen immunotherapy for susceptible individuals. Future research should be directed towards investigating lagged associations and effect modifications using larger and more generalized populations.

Background Breast hypoplasia is one reason for insufficient milk supply. Case reports use wide intra-mammary width and certain breast appearances as markers of breast hypoplasia. However, the reliability of these variables has not been determined. Research aims To test the (i) interrater and intrarater reliability of intra-mammary width measurement and interrater reliability of categorizing women’s breasts into breast types, and (ii) feasibility and acceptability of study procedures for the participants. Methods This was a prospective, longitudinal, non-experimental design with survey and observational components of a convenience sample of early postpartum women ( N = 31). Interrater and intrarater reliability were measured using intraclass correlation coefficient for agreement for intra-mammary width measurements. Interrater reliability was measured using weighted kappa for agreement for categorizing breast type. Feasibility and acceptability of study procedures were collected 1 month later. Results Excellent intrarater and interrater reliability for the intra-mammary width measurement (ICC = 0.99, 95% CI [0.99, 0.997] and ICC = 0.88, 95% CI [0.74, 0.94], respectively) and fair interrater reliability for breast type categorization (k = 0.35, 95% CI [−0.05, 0.75]) with high level of agreement between raters (97%) were achieved. Proportions of participants agreeing to breast photography and acceptability of study procedures were 68% (21/31) and 100% (28/28) respectively. Conclusion The excellent reliability for the intra-mammary width measurement means it provides a useful measure for future research. Since the “fair” reliability of categorizing breast type was due to lack of breast shape range in our sample, future research could assess the breasts of women with different medical profiles.

While the relationship between pollen and respiratory allergies is well-documented, the role of short-term pollen exposure in food allergy and eczema flares has not previously been explored. We aimed to investigate these associations in a population-based sample of children.We investigated 1- (n = 1108) and 6-year-old (n = 675) children in the grass pollen season from the HealthNuts cohort. Grass pollen concentrations were considered on the day of testing (lag 0), up to three days before (lag 1-lag 3) and cumulatively (lag 0-3). Associations between grass pollen and food skin-prick test reactivity (SPT ≥ 2 mm at age 1 year and ≥ 3 mm at age 6 years), eczema flares, challenge-confirmed food allergy, reaction threshold to oral food challenges (OFC), and serum food-specific IgE levels were analyzed using either logistic or quantile regression models. Atopy and family history of allergic disease were considered as potent effect modifiers.Grass pollen at lag 0-3 (every 20 grains/msup3/supincrease) was associated with an up to 1.2-fold increased odds of food SPT reactivity and eczema flares in 6-year-olds. In 1-year-olds, the associations were only observed for peanut in those with a family history of food allergy. Increasing grass pollen concentrations were associated with a lower reaction threshold to OFC and higher serum IgE levels in peanut-allergic 1-year-olds only.Increasing grass pollen concentration was associated with increased risk of food SPT reactivity and eczema flares in children. The associations in peanut-allergic infants may be related to immune activation and/or peanut and grass pollen cross-reactivity leading to a lower reaction threshold.

Following evidence from randomized controlled trials, patients with bronchiectasis unrelated to cystic fibrosis receive long-term azithromycin to reduce acute respiratory exacerbations. However, the period when azithromycin is effective and which patients are likely to most benefit remain unknown.(i) What is the period after its commencement when azithromycin is most effective? and (ii) Which factors may modify azithromycin effects?A secondary analysis was conducted of our previous randomized controlled trial involving 89 indigenous children with bronchiectasis unrelated to cystic fibrosis. Semi-parametric Poisson regression identified the azithromycin efficacy period. Multivariable Poisson regression identified factors that modify azithromycin effect.Azithromycin was associated with fewer exacerbations per child-week during weeks 4 through 96, with the most effective period observed between weeks 17 and 62. Eleven factors were associated with different azithromycin effects; four were significant at the P .05 level. Compared with their counterparts, higher reduction in exacerbations was observed in children with nasopharyngeal carriage of bacterial pathogens (incidence rate ratio [IRR] = 0.81 [95% CI, 0.57-1.14] vs 0.29 [0.20-0.44]; P .001); New Zealand children (IRR = 0.73 [0.51-1.03] vs 0.39 [0.28-0.55]; P = .012); and those with higher weight-for-height z scores (interaction IRR = 0.82 [0.67-0.99]; P = .044). Compared with their counterparts, lower reduction was observed in those born preterm (IRR = 0.41 [0.30-0.55] vs 0.74 [0.49-1.10]; P = .012).Regular azithromycin is best used for at least 17 weeks and up to 62 weeks, as these periods provide maximum benefit for indigenous children with bronchiectasis unrelated to cystic fibrosis. Several factors modified azithromycin benefits; however, these traits need confirmation in larger studies before being adopted into clinical practice.Australian New Zealand Clinical Trials Registry; ACTRN12610000383066.

Background The association between grass pollen exposure and early markers of asthma exacerbations such as lung function changes and increase in airway inflammation is limited. We investigated the associations between short-term grass pollen exposure and lung function and airway inflammation in a community-based sample, and whether any such associations were modified by current asthma, current hay fever, pollen sensitization, age, and other environmental factors. Methods Cross-sectional and short-term analyses of data from the Melbourne Atopy Cohort Study (MACS) participants (n = 936). Lung function was assessed using spirometry. Airway inflammation was assessed by fractional exhaled nitric oxide (FeNO) and exhaled breath condensate pH and nitrogen oxides (NOx). Daily pollen counts were collected using a volumetric spore trap. The associations were examined by linear regression. Results Higher ambient levels of grass pollen 2 days before (lag 2) were associated with lower mid-forced expiratory flow (FEF25%-75%) and FEV1/FVC ratio (Coef. [95% CI] = −119 [−226, −11] mL/s and −1.0 [−3.0, −0.03] %, respectively) and also 3 days before (lag 3). Increased levels of grass pollen a day before (lag 1) were associated with increased FeNO (4.35 [−0.1, 8.7] ppb) and also at lag 2. Adverse associations between pollen and multiple outcomes were greater in adults with current asthma, hay fever, and pollen sensitization. Conclusion Grass pollen exposure was associated with eosinophilic airway inflammation 1-2 days after exposure and airway obstruction 2-3 days after exposure. Adults and individuals with asthma, hay fever, and pollen sensitization may be at higher risk.

Background Evidence of the influence of water, sanitation and hygiene (WASH) behaviors on childhood nutritional status is inconsistent. Few studies have examined their interactive effects. This study aimed to examine associations and interactions between WASH variables and preschool child undernutrition. Methods Data from a nationally representative sample of 2352 children assessed during the 2016 Nepal Demographic and Health Survey were analyzed by multi-variable linear regression to understand the association between height-for-age (HAZ), weight-for-height (WHZ) and weight-for-age (WAZ) z-scores and WASH variables. Interactions between WASH variables, sex and area of residence on childhood nutritional status were also examined. Results The mean z-score [standard deviation] for children’s WAZ, HAZ and WHZ scores were − 1.33 [1.1], − 1.52 [1.3] and − 0.65 [1.1], respectively. A unit increase in cluster sanitation coverage was associated with an increase of 0.30 (95%CI: 0.12 to 0.48) for WAZ and 0.28 (95%CI: 0.001 to 0.56) for HAZ scores. Household water purification practice was associated with an increase of 0.24 (95%CI: 0.07 to 0.41) in WHZ score. Handwashing practice with water and soap was associated with an increase of 0.15 (95%CI: 0.04 to 0.25) in WAZ and 0.13 (95%CI: 0.01 to 0.24) in WHZ scores. The effect of water purification practice was higher for rural areas compared to urban settings for HAZ scores (p-value for interaction = 0.02). Conclusions Consistent with findings from other countries in the South Asian region, findings of this study highlight the potential importance of good WASH practices, and therefore the potential of WASH interventions, to contribute to improved nutritional status in rural Nepal.

Background: This exploratory observational case–control study investigated the rate of referral to cardiac rehabilitation (CR) among patients hospitalised with heart failure (HF) and identified factors associated with referral. Methods: Patients hospitalised with HF as identified by the Victorian Cardiac Outcomes Registry HF study were included. Factors found to be univariately associated with referral were selected for multivariate logistic regression. Results: Among 1281 patients (mean age: 76.9 years; 32.8% HFrEF and 33.9% HfpEF), 125 (9.8%) were referred to CR. Patients referred were younger (73.6 (2.7, 81.5) vs. 80.2 (71.1, 86.5) p < 0.001) and were more likely to be men (72%, p < 0.001). Factors associated with referral included inpatient percutaneous coronary intervention (OR, 3.31; 95% CI, 1.04–10.48; p = 0.04), an aetiology of ischaemic or rhythm-related cardiomyopathy, and anticoagulants prescribed on discharge. Factors that lowered the likelihood of referral included older age, female, receiving inpatient oxygen therapy, and the presence of chronic obstructive pulmonary disease (COPD) or anaemia. Conclusions: The rate of referral to CR following hospitalisation with HF is low. Shortfalls are particularly evident among females, older patients, and in those with COPD or anaemia. Future studies should focus on improving referral processes and translating proven strategies that increase referrals to CR into practice.

Current alcohol public health policy in Australia is not uniform but is generally focused on restricting access and early prevention of problematic alcohol use. Semi-urban and rural populations are at greater risk of disease and other poor health outcomes due to a variety of factors. Little is known about problematic drinking patterns over time in semi-urban and rural populations. This study aims to assess patterns of problematic drinking defined as both long-term risky and heavy episodic drinking over time by age, sex, and mental health status among urban, semi-urban and rural populations). Four waves (2004 to 2016) of the Australian NDSHS (National Drug Strategy Household Survey) were analyzed to assess problematic drinking of participants over 18 years of age. We used regression models and predictive margins to identify trends in problematic drinking over time based on age, sex, and mental health status. Our results show young adults across all regions, males, and mentally well individuals in urban areas have reductions in the risk of problematic drinking over time. Middle-aged adults across all regions, females, and those with varying mental health presentations in rural areas have some increases in risk of problematic drinking over time. The general conclusion is that targeted alcohol-related public health policy may need to change and focus on females, middle-aged individuals, and those living in rural areas. Programs to support problematic drinking in people with mental health disorders may also need to be a priority.

BackgroundClassifying individuals at high chronic obstructive pulmonary disease (COPD)-risk creates opportunities for early COPD detection and active intervention.ObjectiveTo develop and validate a statistical model to predict 10-year probabilities of COPD defined by post-bronchodilator airflow obstruction (post-BD-AO; forced expiratory volume in 1 s/forced vital capacitySettingGeneral Caucasian populations from Australia and Europe, 10 and 27 centres, respectively.ParticipantsFor the development cohort, questionnaire data on respiratory symptoms, smoking, asthma, occupation and participant sex were from the Tasmanian Longitudinal Health Study (TAHS) participants at age 41–45 years (n=5729) who did not have self-reported COPD/emphysema at baseline but had post-BD spirometry and smoking status at age 51–55 years (n=2407). The validation cohort comprised participants from the European Community Respiratory Health Survey (ECRHS) II and III (n=5970), restricted to those of age 40–49 and 50–59 with complete questionnaire and spirometry/smoking data, respectively (n=1407).Statistical methodRisk-prediction models were developed using randomForest then externally validated.ResultsArea under the receiver operating characteristic curve (AUCROC) of the final model was 80.8% (95% CI 80.0% to 81.6%), sensitivity 80.3% (77.7% to 82.9%), specificity 69.1% (68.7% to 69.5%), positive predictive value (PPV) 11.1% (10.3% to 11.9%) and negative predictive value (NPV) 98.7% (98.5% to 98.9%). The external validation was fair (AUCROC 75.6%), with the PPV increasing to 17.9% and NPV still 97.5% for adults aged 40–49 years with ≥1 respiratory symptom. To illustrate the model output using hypothetical case scenarios, a 43-year-old female unskilled worker who smoked 20 cigarettes/day for 30 years had a 27% predicted probability for post-BD-AO at age 53 if she continued to smoke. The predicted risk was 42% if she had coexistent active asthma, but only 4.5% if she had quit after age 43.ConclusionThis novel and validated risk-prediction model could identify adults aged in their 40s at high 10-year COPD-risk in the general population with potential to facilitate active monitoring/intervention in predicted ‘COPD cases’ at a much earlier age.

Public health movement and social restrictions imposed by the Australian and New Zealand governments in response to the COVID-19 pandemic influenced the working environment and may have affected health behaviours, work ability, and job performance. The aim of this study was to determine the associations between health behaviours and work ability and performance during COVID-19 restrictions and if health behaviours were related to demographic or population factors. A cross-sectional survey was used to gather responses from 433 adult employees in Australia and New Zealand between June and August 2020. The survey requested demographic information and used the International Physical Activity Questionnaire, Work Ability Index, and the World Health Organisation’s Health and Work Performance Questionnaire. Multivariate regression models were used to explore relationships between the identified variables while controlling for several possible confounders. Being sufficiently physically active was associated with higher reported physical (aOR = 2.1; p = 0.001) and mental work abilities (aOR = 1.8; p = 0.007) and self-reported job performance (i.e., lower presenteeism) (median +7.42%; p = 0.03). Part-time employees were 56% less likely (p = 0.002) to report a good or very good mental work ability. Those with existing medical conditions were 14% less likely (p = 0.008) to be sufficiently active and 80% less likely (p = 0.002) to report rather good or very good physical work ability. Being sufficiently active was associated with higher physical and mental work abilities and better job performance during the COVID-19 pandemic. Employers should support opportunities for regular physical activity and provide specific support to individuals with medical conditions or in part-time employment.

Introduction: Patients undergoing hyperbaric oxygen treatments (HBOT) have been shown to experience a reduction in blood glucose (BG) levels during a treatment. This necessitates frequent assessment of BG levels. Continuous glucose monitoring (CGM) may represent an alternative to the current finger prick monitoring method in-chamber, however, continuous sensor glucose (SG) data has not been validated in situ. The aim was to determine the validity of continuous SG and intermittent BG monitoring with serum BG levels in diabetic patients during HBOT. Methods: Measurements were obtained (finger prick [capillary sample], CGM [interstitial fluid], and serum [venous sample]) at baseline, and at 30, 60, 90 and 120 minutes during the hyperbaric treatment. Data were analysed by calculating intraclass correlation coefficients (ICC) and using mixed effects linear regression. Results: The ICC results (n = 10 patients) between the three methods indicated very high and statistically significant absolute agreement at baseline (pre-dive) (ICC = 0.90, 95% CI 0.74-0.97), at 30 minutes (ICC = 0.85, 95% CI 0.61−0.96), 60 minutes (ICC = 0.86, 95% CI 0.58−0.96), 90 minutes (ICC = 0.87, 96% CI 0.63−0.96) and 120 minutes (ICC = 0.90, 95% CI 0.70-0.97). Capillary glucose and CGM SG readings were each within 1 mmol·L-1 on average of the serum glucose reading, with multi-level linear regression finding the average difference between the CGM SG and capillary glucose methods of BG sampling was not statistically significant (P = 0.81). Conclusions: The CGM SG data were comparable with glucose readings from capillary monitoring. Both CGM and capillary data were consistent with serum values.

Background Experimental challenge studies have shown that pollen can affect the lungs and airways. Here, we systematically reviewed community-based studies investigating outdoor pollen exposure, lung function and/or airway inflammation. Methods Four online databases were searched. The search strategy included terms relating to both exposure and outcomes. Inclusion criteria were studies published in English that were representative of the community. We only considered cross-sectional or short-term longitudinal studies which investigated pollen exposure by levels or season. Study quality assessment was performed using the Newcastle-Ottawa scale. Meta-analysis was conducted using random-effects models. Results We included 27 of 6,551 studies identified from the search. Qualitative synthesis indicated associations between pollen exposure and predominantly type-2 inflammation in both the upper and lower airways, but little evidence for lung function changes. People with ever asthma and/or seasonal allergic rhinitis (SAR) were at higher risk of such airway inflammation. Meta-analysis confirmed a positive relationship between pollen season and eosinophilic airway inflammation in people with ever SAR but the results between studies were highly variable. Heterogeneity was reduced after further subgrouping by age and the forest plots indicated that eosinophilic airway inflammation to outdoor pollen exposure increased with age. Conclusion Among people with ever asthma and ever SAR, exposure to increased ambient pollen triggers type-2 airway inflammation rather than a non-specific or innate inflammation. Key messages This review indicates pollen exposure influences predominantly type-2 airway inflammation, but little evidence on lung function.

Background Paediatric asthma-related readmissions significantly challenge public health systems. As evidence suggests readmissions are possibly associated with ambient grass pollen levels, we sought to determine the relationship between grass pollen exposure and the risk of readmission for asthma among children in Victoria, Australia. Methods The Victorian Admitted Episodes Dataset 1st July 1997–30th June 2009 was used to identify primary admissions with a principal diagnosis of asthma for children aged 2-18 years. Total sample size was 48,068 admissions. Readmissions were defined as a subsequent admission within 28 days of index discharge. Multiple semi-parametric Poisson Generalized Additive Models were used to assess associations between the grass pollen season and daily grass pollen counts (lagged and cumulative) with repeat admissions, while controlling for meteorological factors and air pollutants. Results Readmissions totalled to 2,152 (4.47% of all admissions). Mean daily readmissions were 1.44 times higher during the grass pollen season (95%CI 1.03-2.02). Pollen season was associated with readmission only for the youngest age group (2-5), incident rate ratio 1.99 (95%CI 1.26-3.14). Daily readmission was non-linearly associated with same day pollen counts only for the 13-18-year age group. Lag 2 pollen counts were non-linearly associated with all daily readmissions for boys in gender-stratified and younger age groups (2-5, 6-12) in age-stratified analysis. Conclusions Grass pollen exposure was associated with higher readmission rates for paediatric asthma. Key messages Younger children and boys with severe or poorly controlled asthma need to be assessed for preventive therapies before the grass pollen season to reduce the repeat admissions.

Grass pollen exposure is a risk factor for childhood asthma hospital attendances. However, its short-term influence on lung function, especially among those with other allergic conditions, has been less well-studied.To investigate this association in a population-based sample of children.Within the HealthNuts cohort, 641 children performed spirometry during the grass pollen season. Grass pollen concentration was considered on the day of testing (lag 0), up to 3 days before (lag 1-lag 3), and cumulatively (lag 0-3). We used linear regression to assess the relevant associations and examined potential interactions with current asthma, hay fever or eczema, and food allergy.Associations were observed only in children with allergic disease (P value for interaction ≤ 0.1). In children with food allergy, grass pollen concentration was associated with a lower ratio of forced expiratory volume in 1 second to forced vital capacity (FEVA proactive approach needs to be enforced to manage susceptible children, especially those with food allergy, before high-grass pollen days.

Background: We present a systematic review of studies assessing the association between ambient particulate matter (PM) and premature mortality and the results of a Bayesian hierarchical meta-analysis while accounting for population differences of the included studies. Methods: The review protocol was registered in the PROSPERO systematic review registry. Medline, CINAHL and Global Health databases were systematically searched. Bayesian hierarchical meta-analysis was conducted using a non-informative prior to assess whether the regression coefficients differed across observations due to the heterogeneity among studies. Results: We identified 3248 records for title and abstract review, of which 309 underwent full text screening. Thirty-six studies were included, based on the inclusion criteria. Most of the studies were from China (n = 14), India (n = 6) and the USA (n = 3). PM2.5 was the most frequently reported pollutant. PM was estimated using modelling techniques (22 studies), satellite-based measures (four studies) and direct measurements (ten studies). Mortality data were sourced from country-specific mortality statistics for 17 studies, Global Burden of Disease data for 16 studies, WHO data for two studies and life tables for one study. Sixteen studies were included in the Bayesian hierarchical meta-analysis. The meta-analysis revealed that the annual estimate of premature mortality attributed to PM2.5 was 253 per 1,000,000 population (95% CI: 90, 643) and 587 per 1,000,000 population (95% CI: 1, 39,746) for PM10. Conclusion: 253 premature deaths per million population are associated with exposure to ambient PM2.5. We observed an unstable estimate for PM10, most likely due to heterogeneity among the studies. Future research efforts should focus on the effects of ambient PM10 and premature mortality, as well as include populations outside Asia. Key messages: Ambient PM2.5 is associated with premature mortality. Given that rapid urbanization may increase this burden in the coming decades, our study highlights the urgency of implementing air pollution mitigation strategies to reduce the risk to population and planetary health.

BACKGROUND: Allergic rhinitis affects half a billion people globally, including a fifth of the Australian population. As the foremost outdoor allergen source, ambient grass pollen exposure is likely to be altered by climate change. The AusPollen Partnership aimed to standardize pollen monitoring and examine broad-scale biogeographical and meteorological factors influencing interannual variation in seasonality of grass pollen aerobiology in Australia. METHODS: Daily airborne grass and other pollen concentrations in four eastern Australian cities separated by over 1700 km, were simultaneously monitored using Hirst-style samplers following the Australian Interim Pollen and Spore Monitoring Standard and Protocols over four seasons from 2016 to 2020. The grass seasonal pollen integral was determined. Gridded rainfall, temperature, and satellite-derived grassland sources up to 100 km from the monitoring site were analysed. RESULTS: The complexity of grass pollen seasons was related to latitude with multiple major summer-autumn peaks in Brisbane, major spring and minor summer peaks in Sydney and Canberra, and single major spring peaks occurring in Melbourne. The subtropical site of Brisbane showed a higher proportion of grass out of total pollen than more temperate sites. The magnitude of the grass seasonal pollen integral was correlated with pasture greenness, rainfall and number of days over 30 °C, preceding and within the season, up to 100 km radii from monitoring sites. CONCLUSIONS: Interannual fluctuations in Australian grass pollen season magnitude are strongly influenced by regional biogeography and both pre- and in-season weather. This first continental scale, Southern Hemisphere standardized aerobiology dataset forms the basis to track shifts in pollen seasonality, biodiversity and impacts on allergic respiratory diseases.

Background: Some but not all previous studies report that pneumonia in children aged less than five years is associated with lower lung function and elevated risk of respiratory disease. To date, none have explored these associations in at-risk populations such as First Nations Australians, whose incidence of early childhood pneumonia is among the highest reported in the world. Methods: This cross-sectional study included 1276 First Nations Australian children/young adults aged 5–25 years recruited from regional/remote Queensland and Northern Territory communities and schools. Associations between pneumonia and both spirometry values and asthma were investigated using linear and logistic regression. Results: Early childhood pneumonia was associated with lower FEV1 and FVC Z-scores, but not FEV1/FVC% Z-scores, when occurring before age three (FEV1 β = −0.42, [95%CI −0.79, −0.04]; FVC β = −0.62, [95%CI −1.14, −0.09]), and between three and five years (β = −0.50, [95%CI −0.88, −0.12]; β = −0.63, [95%CI −1.17, −0.10]), compared to those who never had pneumonia. Similarly, pneumonia occurring when aged before age three years (OR = 3.68, 95%CI 1.96–6.93) and three to five years (OR = 4.81, 95%CI 1.46–15.8) was associated with increased risk of asthma in later childhood. Conclusions: Early childhood pneumonia is associated with lung function deficits and increased asthma risk in later childhood/early adulthood in First Nations Australians. The disproportionate impact of pneumonia on at-risk children must be addressed as a priority.

Background Elevated cord blood IgE is important on the pathway to allergic disease. The association between season of birth and infant cord blood IgE is not well-established. Study findings differ on which birth season is associated with higher cord blood IgE risk and its magnitude. We conducted a systematic review and meta-analysis of studies on season of birth and cord blood IgE. Methods We searched Medline, Web of Science, Scopus and ProQuest Health databases, and reviewed reference lists of articles that met the inclusion criteria. All included studies measured IgE as a binary variable using various cut-off values. We performed multivariate-random-effects meta-analysis to handle an exposure with multiple categories of Season of Birth. Results Our search identified 275 records and 10 had sufficient data to be included in a meta-analysis. Relative to summer, winter birth had the greatest odds of high IgE (≥ 0.1 IU/ml), meta-analysis OR = 1.24 (95%CI: 1.01–1.52). A similar OR, was found for IgE ≥ 0.5 IU/ml, OR = 1.30 (95%CI: 0.99–1.71). Conclusions A winter season of birth was associated with statistically significant higher odds of elevated cord blood IgE at cut-off ≥ 0.1 IU/ml but borderline at cut-off ≥ 0.5 IU/ml. This winter effect is likely to be a marker for a range of other environmental exposures during specific stages of pregnancy, such as aeroallergen exposures, maternal infections and vitamin D levels. Further research is required to support our finding and to identify the exact mechanisms that lead to the winter season of birth effect on circulating IgE levels, as this may have implications for allergic disease prevention.

Abstract: Background: Evidence of the influence of water, sanitation and hygiene (WASH) behaviors on childhood nutritional status is inconsistent. Few studies have examined their interactive effects. This study aimed to examine associations and interactions between WASH variables and preschool child undernutrition. Methods: Data from a nationally representative sample of 2352 children assessed during the 2016 Nepal Demographic and Health Survey were analyzed by multi-variable linear regression to obtain β-coefficients representing change in height-for-age (HAZ), weight-for-height (WHZ) and weight-for-age (WAZ) z-scores associated with WASH variables. Interactions between WASH variables, sex and area of residence on childhood nutritional status were also examined. Results: The mean z-score [standard deviation] for children’s WAZ, HAZ and WHZ scores were -1.33 [1.1], -1.52 [1.3] and -0.65 [1.1], respectively. A unit increase in cluster sanitation coverage was associated with an increase of 0.30 (95%CI: 0.12, 0.48) for WAZ and 0.28 (95%CI: 0.001, 0.56) for HAZ scores. Household water purification practice was associated with an increase of 0.24 (95%CI: 0.07, 0.41) in WHZ score. Handwashing practice with water and soap was associated with an increase of 0.15 (95%CI: 0.04, 0.25) in WAZ and 0.13 (95%CI: 0.01, 0.24) in WHZ scores. The effect of water purification practice was higher for rural areas compared to urban settings for HAZ scores (p-value for interaction=0.002). Conclusions: Consistent with findings from other countries in the South Asian region, findings of this study highlight the potential importance of good WASH practices, and therefore the potential of WASH interventions, to contribute to improved nutritional status in rural Nepal.

Introduction The development of bedside methods to assess muscularity is an essential critical care nutrition research priority. We aimed to compare ultrasound-derived muscle thickness at 5 landmarks with computed tomography (CT) muscle area at intensive care unit (ICU) admission. Secondary aims were to (1) combine muscle thicknesses and baseline covariates to evaluate correlation with CT muscle area and (2) assess the ability of the best-performing ultrasound model to identify patients with low CT muscle area. Methods Adult patients who underwent CT scanning at the third lumbar area

Objective: Length of hospital stay (LOS) is considered a vital component for successful colorectal surgery treatment. Evidence of an association between hospital surgery volume and LOS has been mixed. Data modelling techniques may give inconsistent results that adversely impact conclusions. This study applied techniques to overcome possible modelling drawbacks. Method: An additive quantile regression model formulated to isolate hospital contextual effects was applied to every colorectal surgery for cancer conducted in Victoria, Australia, between 2005 and 2015, involving 28,343 admissions in 90 Victorian hospitals. The model compared hospitals’ operational efficiencies regarding LOS. Results: Hospital LOS operational efficiencies for colorectal cancer surgery varied markedly between the 90 hospitals and were independent of volume. This result was adjusted for pertinent patient and hospital characteristics. Conclusion: No evidence was found that higher annual surgery volume was associated with lower LOS for patients undergoing colorectal cancer surgery. Our model showed strong evidence that differences in LOS efficiency between hospitals was driven by hospital contextual effects that were not predicted by provider volume. Further study is required to elucidate these inherent differences between hospitals. Implications for public health: Our model indicated improved efficiency would benefit the patient and medical system by lowering LOS and reducing expenditure by more than $3 million per year.

Background Asian infants born in Australia are 3 times more likely to develop nut allergy than non-Asian infants and rates of challenge-proven food allergy in infants have been found to be unexpectedly high in metropolitan Melbourne. To further investigate risk factors for nut allergy we assessed the whole of State prevalence distribution of parent-reported nut allergy in 5 year old children entering school. Methods Using the 2010 School Entrant Health Questionnaire administered to all 5 year old children in Victoria, Australia, we assessed the prevalence of parent-reported nut allergy (tree nut and peanut) and whether this was altered by region of residence, socioeconomic status, country of birth or history of migration. Prevalence was calculated as observed proportion with 95% confidence intervals (CI). Risk factors were evaluated using multivariable logistic regression and adjusted for appropriate confounders. Results Parent-reported nut allergy prevalence was 3.1% (95%CI 2.9-3.2) amongst a cohort of nearly 60,000 children. It was more common amongst children of mothers with higher education and socioeconomic index and less prevalent amongst children in regional Victoria than in Melbourne. While children born in Australia to Asian-born mothers (aOR 2.67 95%CI 2.28, 3.27) were more likely to have nut allergy than non-Asian children, children born in Asia who subsequently migrated to Australia were at decreased risk of nut allergy (aOR 0.1 95%CI 0.03, 0.31). Conclusion Migration from Asia after the early infant period appears protective for the development of nut allergy. Additionally, rural regions have lower rates of nut allergy than urban areas. This article is protected by copyright. All rights reserved.

We demonstrate the utility of predicting the whole distribution of an outcome rather than a marginal change. We overcome inconsistent data modelling techniques in a real world problem. A model based on additive quantile regression and boosting was used to predict the whole distribution of length of hospital stay (LOS) following colorectal cancer surgery. The model also assessed the association of hospital and patient characteristics over the whole distribution of LOS. The model recovered the empirical LOS distribution. A counterfactual simulation quantified change in LOS over the whole distribution if an important associated predictor were to be varied. The model showed that important hospital and patient characteristics were differentially associated across the distribution of LOS. Model insights were much richer than just focusing on a marginal change. This method is novel for public health and epidemiological studies and could be applied in other fields of research.