Search

To investigate the association between the timing and adequacy of antibiotics administered to patients presenting with culture-positive sepsis and septic shock to the ED and in-hospital mortality and/or intensive care unit (ICU) admission.Multicentre retrospective cohort study of ED presentations at four metropolitan hospitals in Sydney, Australia between January 2017 and November 2019. Encounters for patients aged ≥16 years meeting specified criteria for sepsis or septic shock with antibiotic administration within the first 6 h of presentation were included.Of 7611 encounters included in the study, 2328 (31%) were culture positive, and 2228 (29%) met the criteria for septic shock. In culture-positive sepsis encounters, partial or inadequate antibiotic coverage was associated with higher risk of death or ICU admission (adjusted odds ratio [AOR] 1.50, 95% confidence interval [CI] 1.04-2.06 and 1.95, 95% CI 1.28-2.99, respectively). This effect was not significant in septic shock encounters (AOR 1.10, 95% CI 0.64-1.88) with partial coverage and (AOR 1.63, 95% CI 0.81-3.3) inadequate coverage. Time to antibiotics was not significantly associated with the risk of mortality/ICU admission. This inference remained the same when analysis was restricted to cases with adequate antibiotic coverage.In a large multicentre sample of patients with culture-positive sepsis, inadequacy of antibiotics was associated with higher risk of in-hospital mortality or ICU admission.

Medications remain an important contributor to the development of acute kidney injury (AKI). This study aimed to examine associations between (i) administration of medications known to reduce glomerular filtration rate (GFR), that is, GFR modifiers and subsequent hospital-acquired AKI; and (ii) potentially medication-related AKI and patient adverse outcomes.A retrospective cohort study utilising electronic health record data of patients admitted to a tertiary hospital in Australia in 2015. Timing of medication administration was compared with timing of AKI development. AKI cases were identified using an algorithm based on serum creatinine level changes. Multilevel regression models were applied with adjustment for relevant demographic and clinical factors.Among 11 503 admissions, AKI was identified in 955 patients (8.3%) and 637 (66.7% of 955) were preceded by administration of a GFR modifier. Patients without prior AKI were 17% more likely to develop AKI after administration of these medications (adjusted odds ratio 1.17, 95% confidence interval (CI) 1.003-1.37). Older age and comorbidity with diabetes, acute myocardial infarction, peripheral vascular disease, liver cirrhosis and multiple myeloma were also significant predictors. Patients with potentially medication-related AKI were 11.69 times more likely to die in hospital (95% CI 7.84-17.43) and stayed 3.49 times longer in hospital (95% CI 3.26-3.73), compared with those without AKI.Administration of medications contributing to the reduction of GFR is associated with an increased risk of hospital-acquired AKI and worse patient outcomes. Caution is required when prescribing these medications to patients at risk of developing AKI, and monitoring patients for deterioration is needed if administered.

BACKGROUND Sepsis is a severe condition associated with extensive morbidity and mortality worldwide. Pediatric, neonatal, and maternal patients represent a considerable proportion of the sepsis burden. Identifying sepsis cases as early as possible is a key pillar of sepsis management and has prompted the development of sepsis identification rules and algorithms that are embedded in computerized clinical decision support (CCDS) systems. OBJECTIVE This scoping review aimed to systematically describe studies reporting on the use and evaluation of CCDS systems for the early detection of pediatric, neonatal, and maternal inpatients at risk of sepsis. METHODS MEDLINE, Embase, CINAHL, Cochrane, Latin American and Caribbean Health Sciences Literature (LILACS), Scopus, Web of Science, OpenGrey, ClinicalTrials.gov, and ProQuest Dissertations and Theses Global (PQDT) were searched by using a search strategy that incorporated terms for sepsis, clinical decision support, and early detection. Title, abstract, and full-text screening was performed by 2 independent reviewers, who consulted a third reviewer as needed. One reviewer performed data charting with a sample of data. This was checked by a second reviewer and via discussions with the review team, as necessary. RESULTS A total of 33 studies were included in this review—13 (39%) pediatric studies, 18 (55%) neonatal studies, and 2 (6%) maternal studies. All studies were published after 2011, and 27 (82%) were published from 2017 onward. The most common outcome investigated in pediatric studies was the accuracy of sepsis identification (9/13, 69%). Pediatric CCDS systems used different combinations of 18 diverse clinical criteria to detect sepsis across the 13 identified studies. In neonatal studies, 78% (14/18) of the studies investigated the Kaiser Permanente early-onset sepsis risk calculator. All studies investigated sepsis treatment and management outcomes, with 83% (15/18) reporting on antibiotics-related outcomes. Usability and cost-related outcomes were each reported in only 2 (6%) of the 31 pediatric or neonatal studies. Both studies on maternal populations were short abstracts. CONCLUSIONS This review found limited research investigating CCDS systems to support the early detection of sepsis among pediatric, neonatal, and maternal patients, despite the high burden of sepsis in these vulnerable populations. We have highlighted the need for a consensus definition for pediatric and neonatal sepsis and the study of usability and cost-related outcomes as critical areas for future research. INTERNATIONAL REGISTERED REPORT RR2-10.2196/24899

Background Sepsis is a significant cause of morbidity and mortality worldwide. Early detection of sepsis followed promptly by treatment initiation improves patient outcomes and saves lives. Hospitals are increasingly using computerized clinical decision support (CCDS) systems for the rapid identification of adult patients with sepsis. Objective This scoping review aims to systematically describe studies reporting on the use and evaluation of CCDS systems for the early detection of adult inpatients with sepsis. Methods The protocol for this scoping review was previously published. A total of 10 electronic databases (MEDLINE, Embase, CINAHL, the Cochrane database, LILACS [Latin American and Caribbean Health Sciences Literature], Scopus, Web of Science, OpenGrey, ClinicalTrials.gov, and PQDT [ProQuest Dissertations and Theses]) were comprehensively searched using terms for sepsis, CCDS, and detection to identify relevant studies. Title, abstract, and full-text screening were performed by 2 independent reviewers using predefined eligibility criteria. Data charting was performed by 1 reviewer with a second reviewer checking a random sample of studies. Any disagreements were discussed with input from a third reviewer. In this review, we present the results for adult inpatients, including studies that do not specify patient age. Results A search of the electronic databases retrieved 12,139 studies following duplicate removal. We identified 124 studies for inclusion after title, abstract, full-text screening, and hand searching were complete. Nearly all studies (121/124, 97.6%) were published after 2009. Half of the studies were journal articles (65/124, 52.4%), and the remainder were conference abstracts (54/124, 43.5%) and theses (5/124, 4%). Most studies used a single cohort (54/124, 43.5%) or before-after (42/124, 33.9%) approach. Across all 124 included studies, patient outcomes were the most frequently reported outcomes (107/124, 86.3%), followed by sepsis treatment and management (75/124, 60.5%), CCDS usability (14/124, 11.3%), and cost outcomes (9/124, 7.3%). For sepsis identification, the systemic inflammatory response syndrome criteria were the most commonly used, alone (50/124, 40.3%), combined with organ dysfunction (28/124, 22.6%), or combined with other criteria (23/124, 18.5%). Over half of the CCDS systems (68/124, 54.8%) were implemented alongside other sepsis-related interventions. Conclusions The current body of literature investigating the implementation of CCDS systems for the early detection of adult inpatients with sepsis is extremely diverse. There is substantial variability in study design, CCDS criteria and characteristics, and outcomes measured across the identified literature. Future research on CCDS system usability, cost, and impact on sepsis morbidity is needed. International Registered Report Identifier (IRRID) RR2-10.2196/24899

BACKGROUND Sepsis is a significant cause of morbidity and mortality worldwide. Early detection of sepsis followed promptly by treatment initiation improves patient outcomes and saves lives. Hospitals are increasingly using computerized clinical decision support (CCDS) systems for the rapid identification of adult patients with sepsis. OBJECTIVE This scoping review aims to systematically describe studies reporting on the use and evaluation of CCDS systems for the early detection of adult inpatients with sepsis. METHODS The protocol for this scoping review was previously published. A total of 10 electronic databases (MEDLINE, Embase, CINAHL, the Cochrane database, LILACS [Latin American and Caribbean Health Sciences Literature], Scopus, Web of Science, OpenGrey, ClinicalTrials.gov, and PQDT [ProQuest Dissertations and Theses]) were comprehensively searched using terms for sepsis, CCDS, and detection to identify relevant studies. Title, abstract, and full-text screening were performed by 2 independent reviewers using predefined eligibility criteria. Data charting was performed by 1 reviewer with a second reviewer checking a random sample of studies. Any disagreements were discussed with input from a third reviewer. In this review, we present the results for adult inpatients, including studies that do not specify patient age. RESULTS A search of the electronic databases retrieved 12,139 studies following duplicate removal. We identified 124 studies for inclusion after title, abstract, full-text screening, and hand searching were complete. Nearly all studies (121/124, 97.6%) were published after 2009. Half of the studies were journal articles (65/124, 52.4%), and the remainder were conference abstracts (54/124, 43.5%) and theses (5/124, 4%). Most studies used a single cohort (54/124, 43.5%) or before-after (42/124, 33.9%) approach. Across all 124 included studies, patient outcomes were the most frequently reported outcomes (107/124, 86.3%), followed by sepsis treatment and management (75/124, 60.5%), CCDS usability (14/124, 11.3%), and cost outcomes (9/124, 7.3%). For sepsis identification, the systemic inflammatory response syndrome criteria were the most commonly used, alone (50/124, 40.3%), combined with organ dysfunction (28/124, 22.6%), or combined with other criteria (23/124, 18.5%). Over half of the CCDS systems (68/124, 54.8%) were implemented alongside other sepsis-related interventions. CONCLUSIONS The current body of literature investigating the implementation of CCDS systems for the early detection of adult inpatients with sepsis is extremely diverse. There is substantial variability in study design, CCDS criteria and characteristics, and outcomes measured across the identified literature. Future research on CCDS system usability, cost, and impact on sepsis morbidity is needed. INTERNATIONAL REGISTERED REPORT RR2-10.2196/24899

Stepwise escalation of glucose-lowering therapy to more intensive regimens is an integral component of type 2 diabetes management (1). Early blood glucose control is associated with beneficial effects on long-term micro- and macrovascular outcomes (2). Understanding factors associated with time to therapy escalation following an elevated glycated hemoglobin (HbA1c) may inform interventions to facilitate timely control. We used linked real-world data to examine time to therapy escalation following a recorded HbA1c ≥8.0% (64 mmol/mol) and associated factors. The EXamining ouTcomEs in chroNic Disease in the 45 and Up Study (EXTEND45 Study) is an Australian population-based linked data study in which participants of the 45 and Up Study have been linked to the Medicare Benefits Schedule (MBS), providing data on government-subsidized medical services, the Pharmaceutical Benefits Scheme (PBS), providing prescription claims data, and community laboratory databases (among others) (3). The 45 and Up Study comprises 267,153 individuals aged ≥45 years living in New South Wales (NSW), Australia, recruited between July 2006 and December 2009. Ethical approval for the EXTEND45 Study was obtained from the NSW Population & Health Services Research Ethics Committee (HREC/13/CIPHS/49). In EXTEND45, 24,430 individuals with diabetes between 2006 and 2014 have been identified using multiple linked data sources (3). In the current study, therapy escalation was assessed during the 6 months following all linked HbA1c results ≥8.0% occurring in non–treatment-naive, non–insulin-using individuals presumed to have type 2 diabetes. As a result, the unit of analysis was the elevated HbA1c, with individuals able to contribute multiple results to the analysis. A threshold of 8.0% was used to reflect the typically higher HbA1c targets recommended for older people (4). To ensure that all included HbA1c results represented separate instances of an elevated HbA1c in the same individual, those results ≥8.0% that occurred …

BACKGROUND Sepsis is a leading cause of death in hospitals, with high associated costs for both patients and health care systems worldwide. Early detection followed by timely intervention is critical for successful sepsis management and, hence, can save lives. Health care institutions are increasingly leveraging clinical data captured in electronic health records for the development of computerized clinical decision support (CCDS) systems aimed at enhancing the early detection of sepsis. However, a comprehensive evidence base regarding sepsis CCDS systems to inform clinical practice, research, and policy is currently lacking. OBJECTIVE This scoping review aims to systematically describe studies reporting on the use and evaluation of CCDS systems for early detection of sepsis in hospitals. METHODS The methodology for conducting scoping reviews presented by the Joanna Briggs Institute Reviewer’s Manual and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) will be used and adapted as guides. A comprehensive literature search of 10 electronic databases will be conducted to identify all empirical quantitative and qualitative studies that investigate the use of CCDS systems for early detection of sepsis in hospitals. Detailed inclusion and exclusion criteria have been developed. Two reviewers will independently screen all articles based on these criteria. Any discrepancies will be resolved through discussion and further review by a third researcher if required. RESULTS Electronic database searches have retrieved 12,139 references after removing 10,051 duplicates. As of the submission date of this protocol, we have completed the title and abstract screening. A total of 372 references will be included for full-text screening. Only 15.9% (59/372) of these studies were focused on children: 11.0% (41/372) for pediatric and 4.8% (18/372) for neonatal patients. The scoping review and the manuscript will be completed by December 2020. CONCLUSIONS Results of this review will guide researchers in determining gaps and shortcomings in the current evidence base for CCDS system use and evaluation in the early detection of sepsis. The findings will be shared with key stakeholders in clinical care, research, policy, and patient advocacy. INTERNATIONAL REGISTERED REPORT PRR1-10.2196/24899

Stepwise escalation of glucose-lowering therapy to more intensive regimens is an integral component of type 2 diabetes management (1). Early blood glucose control is associated with beneficial effects on long-term micro- and macrovascular outcomes (2). Understanding factors associated with time to therapy escalation following an elevated glycated hemoglobin (HbA1c) may inform interventions to facilitate timely control. We used linked real-world data to examine time to therapy escalation following a recorded HbA1c ≥8.0% (64 mmol/mol) and associated factors.

Background: Multiple regimens for the pharmacological management of diabetes exist. In Australia, new agents have become available in recent years. We examined temporal trends in prescribing patterns of pharmacotherapy regimens in Australia. Methods: The EXTEND45 Study links health information on consenting participants of the 45 and Up Study (2006-2009) with administrative health information from the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) (provided by the Department of Human Services), community pathology providers and other routinely collected health information sources. Linkage was performed by the Centre for Health Record Linkage and the Sax Institute (MBS and PBS). We identified a population-based cohort (2006-2014) of people aged ≥45 years who met a pre-specified definition for diabetes. Treatment episodes amongst our cohort were identified, and defined as the period that a patient adhered to a particular regimen of pharmacotherapy without any changes or treatment breaks of two or more standard coverage days (SCD). Episodes were attributed to the calendar year in which they commenced and were categorized into six patterns of glucose lowering medication use. Results: We identified 24,236 participants with diabetes who experienced 149,532 treatment episodes over a mean follow-up period of 4.97 years. Episodes included: never treated (4.4%), monotherapy (33.1%), dual therapy (17.0%), triple or more therapy (4.0%), insulin-based therapy (21.7%) and treatment break (20.3%). Metformin (a biguanide) accounted for the majority (68.5%) of monotherapy episodes, followed by sulfonlyureas (23.1%). The combination of metformin and a sulfonylurea was the most common dual therapy episode (56.1%) but became less common over the study period (75.5% in 2006 to 41.1% in 2014). Conclusion: Most treatment episodes in our cohort involved a monotherapy regimen. There was a temporal change in the specific drug agents prescribed in dual therapy regimens, likely related to the availability of newer agents. Disclosure T.K. Young: None. C. Hockham: None. L. Sukkar: None. A. Kang: None. M. Jun: Research Support; Self; AstraZeneca. J. Baker: None. K. Rogers: None. A. Cass: None. C.A. Pollock: Advisory Panel; Self; AstraZeneca, Merck Sharp & Dohme Corp., Otsuka Pharmaceutical Co., Ltd., Vifor Pharma. Board Member; Self; Boehringer Ingelheim Pharmaceuticals, Inc. Speaker's Bureau; Self; Amgen Inc., AstraZeneca, Novartis AG, Vifor Pharma. Other Relationship; Self; Janssen Pharmaceuticals, Inc. D. Sullivan: None. G. Wong: None. M.J. Jardine: Advisory Panel; Self; Akebia Therapeutics, Baxter, Boehringer Ingelheim International GmbH, CSL Behring, Vifor Pharma. Research Support; Self; Amgen Inc., Baxter, Eli Lilly and Company, Gambro, Merck Sharp & Dohme Corp. Speaker's Bureau; Self; Janssen Pharmaceuticals, Inc. Other Relationship; Self; Janssen Pharmaceuticals, Inc. Funding National Heart Foundation of Australia (100720); Roche Products Pty Ltd. (FR-MIR-0095); Rebecca L. Cooper Grant (REB002); Eli Lilly Australia Pty Ltd. (PO4100294024); Merck Sharp & Dohme Australia Pty Ltd. (MSD_EXTEND45); Amgen Australia Pty Ltd. (Amgen01)

Background: Comparative, real-world evidence for clinical outcomes of different glucose lowering pharmacotherapy regimens in diabetes is limited. We compared therapy persistence and achieved HbA1c amongst episodes of different pharmacotherapy regimens in a community-based Australian cohort. Methods: The EXTEND45 Study combines baseline questionnaire responses (2006-2009) with data from community pathology providers, the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) (provided by the Department of Human Services) and other routinely collected health databases for participants of the 45 and Up study for the period 2005 to 2014. Linkage of MBS and PBS data was performed by the Sax Institute and all other data sources by the Centre for Health Record Linkage. We identified 24,236 people aged ≥45 years with diabetes. Using treatment episodes as our unit of analysis, the persistence and achieved glycaemic control of episodes was compared according to therapy regimens using Wilcoxon Sum rank tests. Results: Among 149,532 episodes, mean (median) therapy persistence was 163 (76), 175 (84), 132 (54) and 164 (108) days for mono-, dual, multioral-, and insulin-based therapy episodes, respectively. For monotherapy episodes, mean persistence was greatest for metformin (178 days). For dual therapy, mean persistence was longest for combinations that did not involve metformin or a sulfonylurea (195 days). Mean HbA1c was 6.9%, 7.3%, 7.4% and 7.9% for mono-, dual, multioral-, and insulin-based therapy episodes, respectively. For monotherapy episodes, mean HbA1c was lowest for metformin (6.8%) whilst for dual therapy, mean persistence was highest for sulfonylurea combinations that did not involve metformin (7.5%). Conclusion: Persistence with therapy is heterogeneous across different intensities of therapy and is shortest for multioral-agent regimens. Participants requiring insulin therapy have the highest achieved HbA1c, which is likely to reflect disease severity. Disclosure T.K. Young: None. C. Hockham: None. L. Sukkar: None. A. Kang: None. M. Jun: Research Support; Self; AstraZeneca. J. Baker: None. K. Rogers: None. A. Cass: None. C.A. Pollock: Advisory Panel; Self; AstraZeneca, Merck Sharp & Dohme Corp., Otsuka Pharmaceutical Co., Ltd., Vifor Pharma. Board Member; Self; Boehringer Ingelheim Pharmaceuticals, Inc. Speaker's Bureau; Self; Amgen Inc., AstraZeneca, Novartis AG, Vifor Pharma. Other Relationship; Self; Janssen Pharmaceuticals, Inc. D. Sullivan: None. G. Wong: None. M.J. Jardine: Advisory Panel; Self; Akebia Therapeutics, Baxter, Boehringer Ingelheim International GmbH, CSL Behring, Vifor Pharma. Research Support; Self; Amgen Inc., Baxter, Eli Lilly and Company, Gambro, Merck Sharp & Dohme Corp. Speaker's Bureau; Self; Janssen Pharmaceuticals, Inc. Other Relationship; Self; Janssen Pharmaceuticals, Inc. Funding National Heart Foundation of Australia (100720); Roche Products Pty Ltd. (FR-MIR-0095); Rebecca L. Cooper Grant (REB002); Eli Lilly Australia Pty Ltd. (PO4100294024); Merck Sharp & Dohme Australia Pty Ltd. (MSD_EXTEND45); Amgen Australia Pty Ltd. (Amgen01)

Objective Melanoma is on the rise, especially in Caucasian populations exposed to high ultraviolet radiation such as in Australia. This paper examined the psychological components facilitating change in skin cancer prevention or early detection behaviours following a text message intervention. Methods The Queensland-based participants were 18 to 42 years old, from the Healthy Text study (N = 546). Overall, 512 (94%) participants completed the 12-month follow-up questionnaires. Following the social cognitive model, potential mediators of skin self-examination (SSE) and sun protection behaviour change were examined using stepwise logistic regression models. Results At 12-month follow-up, odds of performing an SSE in the past 12 months were mediated by baseline confidence in finding time to check skin (an outcome expectation), with a change in odds ratio of 11.9% in the SSE group versus the control group when including the mediator. Odds of greater than average sun protective habits index at 12-month follow-up were mediated by (a) an attempt to get a suntan at baseline (an outcome expectation) and (b) baseline sun protective habits index, with a change in odds ratio of 10.0% and 11.8%, respectively in the SSE group versus the control group. Conclusions Few of the suspected mediation pathways were confirmed with the exception of outcome expectations and past behaviours. Future intervention programmes could use alternative theoretical models to elucidate how improvements in health behaviours can optimally be facilitated. Copyright © 2015 John Wiley & Sons, Ltd.

Background Malnutrition is common in patients with advanced epithelial ovarian cancer (EOC), and is associated with impaired quality of life (QoL), longer hospital stay and higher risk of treatment-related adverse events. This phase III multi-centre randomised clinical trial tested early enteral feeding versus standard care on postoperative QoL. Methods From 2009 to 2013, 109 patients requiring surgery for suspected advanced EOC, moderately to severely malnourished were enrolled at five sites across Queensland and randomised to intervention (n = 53) or control (n = 56) groups. Intervention involved intraoperative nasojejunal tube placement and enteral feeding until adequate oral intake could be maintained. Despite being randomised to intervention, 20 patients did not receive feeds (13 did not receive the feeding tube; 7 had it removed early). Control involved postoperative diet as tolerated. QoL was measured at baseline, 6 weeks postoperatively and 30 days after the third cycle of chemotherapy. The primary outcome measure was the difference in QoL between the intervention and the control group. Secondary endpoints included treatment-related adverse event occurrence, length of stay, postoperative services use, and nutritional status. Results Baseline characteristics were comparable between treatment groups. No significant difference in QoL was found between the groups at any time point. There was a trend towards better nutritional status in patients who received the intervention but the differences did not reach statistical significance except for the intention-to-treat analysis at 7 days postoperatively (11.8 intervention vs. 13.8 control, p 0.04). Conclusion Early enteral feeding did not significantly improve patients' QoL compared to standard of care but may improve nutritional status.

To examine the association between preoperative quality of life (QoL) and postoperative adverse events in women treated for endometrial cancer.760 women with apparent Stage I endometrial cancer were randomised into a clinical trial evaluating laparoscopic versus open surgery. This analysis includes women with preoperative QoL measurements, from the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire, and who were followed up for at least 6 weeks after surgery (n=684). The outcomes for this study were defined as (1) the occurrence of moderate to severe adverse events within 6 months (Common Toxicology Criteria (CTC) grade≥3); and (2) any serious adverse event (SAE). The association between preoperative QoL and the occurrence of AE was examined, after controlling for baseline comorbidity and other factors.After adjusting for other factors, odds of occurrence of AE of CTC grade≥3 were significantly increased with each unit decrease in baseline FACT-G score (OR=1.02, 95% CI 1.00-1.03, p=0.030), which was driven by physical well-being (PWB) (OR=1.09, 95% CI 1.04-1.13, p=0.0002) and functional well-being subscales (FWB) (OR=1.04, 95% CI 1.00-1.07, p=0.035). Similarly, odds of SAE occurrence were significantly increased with each unit decrease in baseline FACT-G score (OR=1.02, 95% CI 1.01-1.04, p=0.011), baseline PWB (OR=1.11, 95% CI 1.06-1.16, p0.0001) or baseline FWB subscales (OR=1.05, 95% CI 1.01-1.10, p=0.0077).Women with early endometrial cancer presenting with lower QoL prior to surgery are at higher risk of developing a serious adverse event following surgery.Cancer Council Queensland, Cancer Council New South Wales, Cancer Council Victoria, Cancer Council, Western Australia; NHMRC project grant 456110; Cancer Australia project grant 631523; The Women and Infants Research Foundation, Western Australia; Royal Brisbane and Women's Hospital Foundation; Wesley Research Institute; Gallipoli Research Foundation; Gynetech; TYCO Healthcare, Australia; Johnson and Johnson Medical, Australia; Hunter New England Centre for Gynaecological Cancer; Genesis Oncology Trust; and Smart Health Research Grant QLD Health.

Paediatric injuries can lead to long-term functional impairment and reduced health-related quality of life, and are a growing public health issue in India. To date, however, the burden has been poorly characterized. This study assessed the impact of non-fatal injuries on health-related quality of life in a prospective cohort study of 373 children admitted to three hospitals in Chandigarh and Haryana states in India. The Pediatric Quality of Life Inventory (PedsQL) and King’s Outcome Scale for Childhood Head Injury (KOSCHI) were administered at baseline (pre-injury) and at 1, 2, 4, and 12 months post-injury by telephone interview. Follow-up at all-time points was completed for 277 (77%) of all living participants. Less than one percent reported ongoing disability at 4 months, and no disability was reported at 12 months. PedsQL physical health scores were below healthy child norms (83.4) at 1 month in the cohort for ages 8–12 years and 13–16 years. Although injuries are prevalent, ongoing impact on functioning and disability from most childhood injuries at 12 months was reported to be low. The results raise questions about reliability of generic, Western-centric tools in low- and middle-income settings, and highlight the need for local context-specific tools.

Background Effective management of hospital staff time is crucial to quality patient care. Recent years have seen widespread implementation of electronic health record (EHR) systems but the effect of this on documentation time is unknown. This review compares time spent on documentation tasks by hospital staff (physicians, nurses and interns) before and after EHR implementation. Methods A systematic search identified 8153 potentially relevant citations. Studies examining proportion of total workload spent on documentation with ≥40 h of staff observation time were included. Meta-analysis was performed for physicians, nurses and interns comparing pre- and post-EHR results. Studies were weighted by person-hours observation time. Results Twenty-eight studies met selection criteria. Seventeen were pre-EHR, nine post-EHR and two examined both periods. With implementation of EHR, physicians’ documentation time increased from 16% (95% confidence interval (CI) 11–22%) to 28% (95% CI 19–37%), nurses from 9% (95% CI 6–12%) to 23% (95% CI 15–32%) and interns from 20% (95% CI 7–32%) to 26% (95% CI 10–42%). Conclusions There is a lack of long-term follow-up on the effects of EHR implementation. Initial adjustment to EHR appears to increase documentation time but there is some evidence that as staff become more familiar with the system, it may ultimately improve work flow.

Analgesia and early quality of recovery may be improved by epidural analgesia. We aimed to assess the effect of receiving epidural analgesia on surgical adverse events and quality of life after laparotomy for endometrial cancer.Patients were enrolled in an international, multicentre, prospective randomised trial of outcomes for laparoscopic versus open surgical treatment for the management of apparent stage I endometrial cancer (LACE trial). The current analysis focussed on patients who received an open abdominal hysterectomy via vertical midline incision only (n=257), examining outcomes in patients who did (n=108) and did not (n=149) receive epidural analgesia.Baseline characteristics were comparable between patients with or without epidural analgesia. More patients without epidural (34%) ceased opioid analgesia 3-5 days after surgery compared to patients who had an epidural (7%; p0.01). Postoperative complications (any grade) occurred in 86% of patients with and in 66% of patients without an epidural (p0.01) but there was no difference in serious adverse events (p=0.19). Epidural analgesia was associated with increased length of stay (up to 48 days compared to up to 34 days in the non-epidural group). There was no difference in postoperative quality of life up to six months after surgery.Epidural analgesia was associated with an increase in any, but not serious, postoperative complications and length of stay after abdominal hysterectomy. Randomised controlled trials are needed to examine the effect of epidural analgesia on surgical adverse events, especially as the present data do not support a quality of life benefit with epidural analgesia.

BackgroundThe epidemic of Type 2 diabetes is one of the world?s main disablers and killers. Increasing in every country of the world, it is the fastest growing chronic condition globally with enormous social and economic costs. Immediate action is required to manage diabetes early and prevent complications. In 2015, diabetes affected an estimated 415 million people and caused 5.1 million deaths. It is projected to affect 642 million (10% of population) by 2040 with related expenditure exceeding 802 billion USD unless action is taken to reduce the global burden. Type 2 diabetes accounts for 90-95% of diabetic cases and is the leading cause of kidney failure, nontraumatic lower-limb amputation, new cases of blindness, and a major cause of heart disease and stroke. These consequences and subsequent hospitalisation can potentially be mitigated with quality primary care. Thus, it is critical to identify patients at risk of type 2 diabetes complications within a community setting. This study identifies types of patient who are at risk for hospitalisation for type 2 diabetes complications and adverse outcomes during their hospital stay.MethodsModels were fit to five years of hospital data and Census data for the New South Wales North Coast in Australia. Factors associated with hospitalisation for type 2 diabetes complications, multiple admissions, longer length of stay, readmissions within 28 days and admission to intensive care unit (ICU) were examined.ResultsAmong the cohort of 11,293 patients with type 2 diabetes, patients were more likely to be hospitalised for type 2 diabetes complications if older and female, and less likely if comorbid with other chronic conditions. For a range of fourteen general patient profiles, the probability of hospitalisation for a type 2 diabetic complication and the probability for multiple admissions, longer length of stay, readmissions within 28 days and ICU admission were estimated.DiscussionThis discussion will canvass the fourteen patient profiles for whom predictive analytics can direct mitigation efforts of type 2 diabetes-related hospital readmissions. Differing predictive characteristics (e.g. demographics, comorbidities) have been shown to require tailored strategies, and these will be highlighted. Early identification within the community of individuals at high risk for diabetic complications is crucial. Through quality management of these individuals, it is possible to prevent the complications of diabetes and ameliorate the global crisis arising from the diabetic epidemic.

Background Three variant formulations of a spatiotemporal shared component model are proposed that allow examination of changes in shared underlying factors over time. Methods Models are evaluated within the context of a case study examining hospitalisation rates for five chronic diseases for residents of a regional area in New South Wales: type II diabetes mellitus (DMII), chronic obstructive pulmonary disease (COPD), coronary arterial disease (CAD), hypertension (HT) and congestive heart failure (CHF) between 2001–2006. These represent ambulatory care sensitive (ACS) conditions, often used as a proxy for avoidable hospitalisations. Using a selected model, the effects of socio-economic status (SES) as a shared component are estimated and temporal patterns in the influence of the residual shared spatial component are examined. Results Choice of model depends upon the application. In the featured application, a model allowing for changing influence of the shared spatial component over time was found to have the best fit and was selected for further analyses. Hospitalisation rates were found to be increasing for COPD and DMII, decreasing for CHF and stable for CAD and HT. SES was substantively associated with hospitalisation rates, with differing degrees of influence for each disease. In general, most of the spatial variation in hospitalisation rates was explained by disease-specific spatial components, followed by the residual shared spatial component. Conclusion Appropriate selection of a joint disease model allows for the examination of temporal patterns of disease outcomes and shared underlying spatial factors, and distinction between different shared spatial factors.

Melanoma is on the rise, especially in Caucasian populations exposed to high ultraviolet radiation such as in Australia. This paper examined the psychological components facilitating change in skin cancer prevention or early detection behaviours following a text message intervention.The Queensland-based participants were 18 to 42 years old, from the Healthy Text study (N = 546). Overall, 512 (94%) participants completed the 12-month follow-up questionnaires. Following the social cognitive model, potential mediators of skin self-examination (SSE) and sun protection behaviour change were examined using stepwise logistic regression models.At 12-month follow-up, odds of performing an SSE in the past 12 months were mediated by baseline confidence in finding time to check skin (an outcome expectation), with a change in odds ratio of 11.9% in the SSE group versus the control group when including the mediator. Odds of greater than average sun protective habits index at 12-month follow-up were mediated by (a) an attempt to get a suntan at baseline (an outcome expectation) and (b) baseline sun protective habits index, with a change in odds ratio of 10.0% and 11.8%, respectively in the SSE group versus the control group.Few of the suspected mediation pathways were confirmed with the exception of outcome expectations and past behaviours. Future intervention programmes could use alternative theoretical models to elucidate how improvements in health behaviours can optimally be facilitated.

Objectives. We compared postoperative analgesic requirements between women with early stage endometrial cancer treated by total abdominal hysterectomy (TAH) or total laparoscopic hysterectomy (TLH).Methods. 760 patients with apparent stage I endometrial cancer were treated in the international, multicentre, prospective randomised trial (LACE) by TAH (n=353) or TLH (n=407) (2005–2010). Epidural, opioid, and nonopioid analgesic requirements were collected until ten months after surgery.Results. Baseline demographics and analgesic use were comparable between treatment arms. TAH patients were more likely to receive epidural analgesia than TLH patients (33% versus 0.5%,P<0.001) during the early postoperative phase. Although opioid use was comparable in the TAH versus TLH groups during postoperative 0–2 days (99.7% versus 98.5%,P=0.09), a significantly higher proportion of TAH patients required opioids 3–5 days (70% versus 22%,P<0.0001), 6–14 days (35% versus 15%,P<0.0001), and 15–60 days (15% versus 9%,P=0.02) after surgery. Mean pain scores were significantly higher in the TAH versus TLH group one (2.48 versus 1.62,P<0.0001) and four weeks (0.89 versus 0.63,P=0.01) following surgery.Conclusion. Treatment of early stage endometrial cancer with TLH is associated with less frequent use of epidural, lower post-operative opioid requirements, and better pain scores than TAH.

Aims To identify risk factors for major adverse events (AEs) and to develop a nomogram to predict the probability of such AEs in patients who have surgery for apparent early stage endometrial cancer. Methods We used data from 753 patients who were randomised to either total laparoscopic hysterectomy or total abdominal hysterectomy in the LACE trial. Serious adverse events that prolonged hospital stay or postoperative adverse events (using common terminology criteria 3+, CTCAE V3) were considered major AEs. We analysed pre-surgical characteristics that were associated with the risk of developing major AEs by multivariate logistic regression. We identified a parsimonious model by backward stepwise logistic regression. The six most significant or clinically important variables were included in the nomogram to predict the risk of major AEs within 6 weeks of surgery and the nomogram was internally validated. Results Overall, 132 (17.5%) patients had at least one major AE. An open surgical approach (laparotomy), higher Charlson’s medical co-morbidities score, moderately differentiated tumours on curettings, higher baseline Eastern Cooperative Oncology Group (ECOG) score, higher body mass index and low haemoglobin levels were associated with AE and were used in the nomogram. The bootstrap corrected concordance index of the nomogram was 0.63 and it showed good calibration. Conclusions Six pre-surgical factors independently predicted the risk of major AEs. This research might form the basis to develop risk reduction strategies to minimise the risk of AEs among patients undergoing surgery for apparent early stage endometrial cancer.

To compare Total Laparoscopic Hysterectomy (TLH) and Total Abdominal Hysterectomy (TAH) with regard to surgical safety.Between October 2005 and June 2010, 760 patients with apparent early stage endometrial cancer were enroled in a multicentre, randomised clinical trial (LACE) comparing outcomes following TLH or TAH. The main study end points for this analysis were surgical adverse events (AE), hospital length of stay, conversion from laparoscopy to laparotomy, including 753 patients who completed at least 6 weeks of follow-up. Postoperative AEs were graded according to Common Toxicity Criteria (V3), and those immediately life-threatening, requiring inpatient hospitalisation or prolonged hospitalisation, or resulting in persistent or significant disability/incapacity were regarded as serious AEs.The incidence of intra-operative AEs was comparable in either group. The incidence of post-operative AE CTC grade 3+ (18.6% in TAH, 12.9% in TLH, p 0.03) and serious AE (14.3% in TAH, 8.2% in TLH, p 0.007) was significantly higher in the TAH group compared to the TLH group. Mean operating time was 132 and 107 min, and median length of hospital stay was 2 and 5 days in the TLH and TAH group, respectively (p0.0001). The decline of haemoglobin from baseline to day 1 postoperatively was 2g/L less in the TLH group (p 0.006).Compared to TAH, TLH is associated with a significantly decreased risk of major surgical AEs. A laparoscopic surgical approach to early stage endometrial cancer is safe.

Objectives To investigate the efficacy of progestin treatment to achieve pathological complete response (pCR) in patients with complex atypical endometrial hyperplasia (CAH) or early endometrial adenocarcinoma (EC). Methods A systematic search identified 3245 potentially relevant citations. Studies containing less than ten eligible CAH or EC patients in either oral or intrauterine treatment arm were excluded. Only information from patients receiving six or more months of treatment and not receiving other treatments was included. Weighted proportions of patients achieving pCR were calculated using R software. Results Twelve studies met the selection criteria. Eleven studies reported treatment of patients with oral (219 patients, 117 with CAH, 102 with grade 1 Stage I EC) and one reported treatment of patients with intrauterine progestin (11 patients with grade 1 Stage IEC). Overall, 74% (95% confidence interval [CI] 65–81%) of patients with CAH and 72% (95% CI 62–80%) of patients with grade 1 Stage I EC achieved a pCR to oral progestin. Disease progression whilst on oral treatment was reported for 6/219 (2.7%), and relapse after initial complete response for 32/159 (20.1%) patients. The weighted mean pCR rate of patients with grade 1 Stage I EC treated with intrauterine progestin from one prospective pilot study and an unpublished retrospective case series from the Queensland Centre of Gynaecologic Oncology (QCGC) was 68% (95% CI 45–86%). Conclusions There is a lack of high quality evidence for the efficacy of progestin in CAH or EC. The available evidence however suggests that treatment with oral or intrauterine progestin is similarly effective. The risk of progression during treatment is small but longer follow-up is required. Evidence from prospective controlled clinical trials is warranted to establish how the efficacy of progestin for the treatment of CAH and EC can be improved further.

Reduction in length of inpatient stay is an important factor in reducing healthcare costs in many hospital systems. This paper examines trends in hospital stay over time for general surgical patients presenting with abscess, and outlines the potential benefits if a day case service for acute abscess procedures was established.Retrospective review of Otago Surgical Audit data from 1992 to 2007 yielded clinical data for 2475 adult general surgical cases at Auckland City Hospital with a primary or secondary diagnosis of abscess. A subset of patients potentially suitable for day case surgical procedures was analysed.A steady increase in numbers of abscess cases treated by the Department of General Surgery was seen from 1992 to 2007. The most common types of superficial abscess were cutaneous (47%), perianal (40%), and breast (13%). Fifty-nine percent of general surgical hospital admissions in this series could potentially have been treated on a day case basis, but only 6% were actually treated as day cases. A median duration of inpatient stay of two days was required for a mean procedure duration of 16 minutes. A total of 1357 (90%) patients had a total hospital stay of more than 24 hours in the potential day case group. This accounted for 2338 bed days over the 15-year study period, or an average of 359 bed days per annum. For the most recent three-year period, the average total cost of each acute superficial abscess admission for less than seven days was $4440. The average cost for a patient treated as a day case was $1389, indicating a potential saving of $3501 per patient if a day case service had been available.This study identifies a common problem which is being managed suboptimally in our hospital. Day case management of appropriate patients with acute superficial abscess would result in significant cost savings, decrease hospital bed occupancy and improve patient care.

With the rising incidence of type II diabetes mellitus (DM II) worldwide, methods to identify high-risk geographical areas have become increasingly important. In this comprehensive review following Cochrane Collaboration guidelines, we outline spatial methods, outcomes and covariates used in all spatial studies involving outcomes of DM II. A total of 1894 potentially relevant citations were identified. Studies were included if spatial methods were used to explore outcomes of DM II or type I and 2 diabetes combined. Descriptive tables were used to summarize information from included studies. Ten spatial studies conducted in the USA, UK and Europe met selection criteria. Three studies used Bayesian generalized linear mixed modelling (GLMM), three used classic generalized linear modelling, one used classic GLMM, two used geographic information systems mapping tools and one compared case:provider ratios across regions. Spatial studies have been effective in identifying high-risk areas and spatial factors associated with DM II outcomes in the USA, UK and Europe, and would be useful in other parts of the world for allocation of additional services to detect and manage DM II early.

The reported numbers of notifiable sexually transmitted infections in Australia are subject to a myriad of biases and limitations, including demographic, clinical, behavioural, and temporal factors. As such, trends in reported diagnosis rates may not reflect trends in true underlying incidence, thereby confounding any direct interpretation of raw notification data for public health research. The development of new methods to determine the true incidence and prevalence of an infection is a critical step for furthering the understanding of disease in the population. Here we devise a statistical model for chlamydia testing, and apply it to routinely available data to estimate the true incidence and prevalence of chlamydia infection within the Australian population. We preview in-progress work towards a yet more sophisticated methodology and outline how the approach may be extended to provide estimates for a number of other bacterial sexually transmitted infections of public health importance. References T. Vos, A. D. Flaxman, M. Naghavi, R. Lozano, C. Michaud, M. Ezzati, K. Shibuya, J. A. Salomon, and 348 coauthors. Years lived with disability (ylds) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the global burden of disease study 2010. The Lancet , 380(9859):2163–2196, Dec 2012. doi:10.1016/S0140-6736(12)61729-2 Communicable Disease Network Australia. National Notifiable Diseases Surveillance System (NNDSS). http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-surveil-nndss-nndssintro.htm United States Centres for Disease Control and Prevention. The Role of STD Detection and Treatment in HIV Prevention–-CDC Fact Sheet, 2012. http://www.cdc.gov/std/hiv/stdfact-std-hiv.htm Australian Government Department of Health and Ageing. Second National Sexually Transmissible Infections Strategy 2010–2013, 2010. http://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-national-strategies-2010-sti The Kirby Institute. National Blood-borne Virus and Sexually Transmissible Infections Surveillance and Monitoring Report, 2011. The Kirby Institute, The University of New South Wales, Sydney, NSW 2052. The Kirby Institute. HIV, Viral Hepatitis and Sexually Transmissible Infections in Australia Annual Surveillance Report, 2012. The Kirby Institute, The University of New South Wales, Sydney, NSW 2052. M. Y. Chen, M. Karvelas, V. Sundararajan, J. S. Hocking, and C. K. Fairley. Evidence for the effectiveness of a chlamydia awareness campaign: increased population rates of chlamydia testing and detection. International Journal of STD and AIDS , 18(4):239–243, 2007. doi:10.1258/095646207780658854 P. M. Konowitz, G. A. Petrossian, and D N. Rose. The underreporting of disease and physicians' knowledge of reporting requirements. Public Health Reports , 99(1):31–35, 1984. http://www.ncbi.nlm.nih.gov/pubmed/6422492 P. S. Mead, L. S., V. D., L. F. McCaig, J. S. Bresee, C. Shapiro, P. M. Griffin, and R. V. Tauxe. Food-related illness and death in the United States. Emerging Infectious Diseases , 5(5):607–625, 1999. doi:10.3201/eid0505.990502 R. Marier. The reporting of communicable diseases. American Journal of Epidemiology , 105(6):587–590, Jun 1977. http://www.ncbi.nlm.nih.gov/pubmed/868863 M. C. Kaczmarek, L. Valenti, H. A. Kelly, R. S. Ware, H. C. Britt, and S. B. Lambert. Sevenfold rise in likelihood of pertussis test requests in a stable set of Australian general practice encounters, 2000–2011. The Medical Journal of Australia , 198(11):624–628, 2013. doi:10.5694/mja13.10044 D. A. Cohen, M. Nsuami, D. H. Martin, and T. A. Farley. Repeated school-based screening for sexually transmitted diseases: a feasible strategy for reaching adolescents. Pediatrics , 104(6):1281–1285, Dec 1999. doi:10.1542/peds.104.6.1281 Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 8th edition. Royal Australian College of General Practitioners, East Melbourne, Australia, 2012. J. E. van Bergen, J. J. Kerssens, F. G. Schellevis, T. G. Sandfort, T. T. Coenen, and P. J. Bindels. Sexually transmitted infection health-care seeking behaviour in the Netherlands: general practitioner attends to the majority of sexually transmitted infection consultations. International Journal of STD and AIDS , 18(6):374–379, 2007. doi:10.1258/095646207781024883 C. H. Mercer, L. Sutcliffe, A. M. Johnson, P. J. White, G. Brook, J. D. C. Ross, J. Dhar, P. Horner, and 7 coauthors. How much do delayed healthcare seeking, delayed care provision, and diversion from primary care contribute to the transmission of STIs? Sexually Transmitted Infections , 83(5):400–405, 2007. doi:10.1136/sti.2006.024554 J. S. Hocking, M. S. C. Lim, J. Vidanapathirana, T. R. H. Read, and M. Hellard. Chlamydia testing in general practice–-a survey of Victorian general practitioners. Sexual Health , 3(4):241–244, Dec 2006. doi:10.1071/SH06042 R. L. Cook, S. L. Hutchison, L. \T1\O stergaard, R. S. Braithwaite, and R. B. Ness. Systematic review: noninvasive testing for chlamydia trachomatis and neisseria gonorrhoeae. Annals of Internal Medicine , 142(11):914–925, Jun 2005. doi:10.7326/0003-4819-142-11-200506070-00010 S. A. Morre, A. J. C. van den Brule, L. Rozendaal, A. J. P. Boeke, F. J. Voorhorst, S. de Blok, and C. J. L. M. Meijer. The natural course of asymptomatic Chlamydia trachomatis infections: 45% clearance and no development of clinical pid after one-year follow-up. International Journal of STD and AIDS , 13(1):12–18, 2002. doi:10.1258/095646202762226092 Australian Bureau of Statistics. Australian Demographic Statistics . Australian Bureau of Statistics, Canberra, Australia, 2013. http://www.abs.gov.au/ausstats/abs@.nsf/mf/3101.0 R Core Team. R: A Language and Environment for Statistical Computing . R Foundation for Statistical Computing, Vienna, Austria, 2013. http://www.R-project.org

Background Spatial analysis is increasingly important for identifying modifiable geographic risk factors for disease. However, spatial health data from surveys are often incomplete, ranging from missing data for only a few variables, to missing data for many variables. For spatial analyses of health outcomes, selection of an appropriate imputation method is critical in order to produce the most accurate inferences. Methods We present a cross-validation approach to select between three imputation methods for health survey data with correlated lifestyle covariates, using as a case study, type II diabetes mellitus (DM II) risk across 71 Queensland Local Government Areas (LGAs). We compare the accuracy of mean imputation to imputation using multivariate normal and conditional autoregressive prior distributions. Results Choice of imputation method depends upon the application and is not necessarily the most complex method. Mean imputation was selected as the most accurate method in this application. Conclusions Selecting an appropriate imputation method for health survey data, after accounting for spatial correlation and correlation between covariates, allows more complete analysis of geographic risk factors for disease with more confidence in the results to inform public policy decision-making. Electronic supplementary material The online version of this article (doi:10.1186/1476-072X-13-47) contains supplementary material, which is available to authorized users.