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Resistance training (RT) is beneficial for older adults, particularly to support living independently in their home. However, fewer than 25% of older adults in Australia participate in the recommended, twice-weekly sessions. Reasons older adults do not participate in RT include not having anyone to go with or not knowing what to do. Our study linked older adults with a peer (i.e., older person already participating in RT) to help them overcome these barriers. The aim of our study was to determine whether peer support was suitable for older adults participating in RT for the first time in the home or gymnasium setting. Each group (home vs. gymnasium) received a 6 week, twice-weekly program. Twenty-one participants completed the 6 week intervention: 14 in the home group and seven in the gymnasium group. The home group completed significantly more sessions per week (2.7 vs. 1.8) than the gymnasium group. Although both groups significantly improved on many physical assessments, no between-group differences were found. However, it is suitable to link a peer for support with novice older people participating in a RT program for the first time in the home or gymnasium. It is recommended that future studies explore whether peer support improves sustainability.

Background Since the beginning of the COVID-19 pandemic, the Western Australian government imposed multiple restrictions that impacted daily life activities and the social life. The aim of this study was to examine the effects of COVID-19 lockdown on the community’s physical, mental and psychosocial health. Methods Approximately 2 months after a three-month lockdown, a cross-sectional study was opened to Western Australian adults for an 8-week period (25th August – 21 October 2020). Participants competed a 25-min questionnaire adapted from the Western Australia Health and Wellbeing Surveillance system. Participants provided information on their socio-demographic status, lifestyle behaviours, mental health, and psychosocial health during and post-lockdown. Open-ended questions explored key issues in greater detail. Changes between the lockdown and post-lockdown period were assessed using Wilcoxon signed rank test and One-Sample Kolmogorov-Smirnov Normal tests as appropriate. Sex differences were examined using the Mann-Whitney U test. A content analysis approach examined responses to the open-ended questions with frequencies and variations in responses determined using Chi-Square tests. Results A total of 547 complete responses were obtained. Compared to post-lockdown period, lockdown was associated with a significantly lower levels of physical activity, poorer mental well-being and sense of control over one’s life, and a higher level of loneliness. Similarly, during lockdown, there was a significantly higher consumption of junk food, soft drinks and alcoholic drinks but no change in fruit and vegetable intake. Participants recalled health campaigns on hand washing and social distancing and there was a retrospective view that more timely and informative campaigns on physical activity, nutrition and mental well-being should have been available during lockdown. Conclusions While advice on infection control measures were appropriately provided, there is a need for concurrent health promotional information to help combat the changes in physical, mental and psychosocial well-being observed during quarantine to prevent negative health consequences in the community even if there are minimal effects of the pandemic itself.

BackgroundPhysical symptoms, anxiety, depression, fear of recurrence, sexual dysfunction, and social withdrawal are common in women after treatment for ovarian cancer. Most patients would like and need help dealing with these symptoms. The traditional model of follow-up care is unstructured and largely focused on diagnosing recurrent disease, and most oncologists lack skills to identify and manage psychosocial issues. No high quality prospective clinical trials have been conducted to determine the optimal follow-up regimen or the cost effectiveness of ovarian cancer surveillance strategies.Primary Objective(s)To assess emotional wellbeing, acceptability, safety, and cost effectiveness of nurse led follow-up via telehealth for women with ovarian cancer following completion of primary treatment.Study HypothesisWe hypothesize that compared with routine clinic based follow-up, nurse led follow-up via telehealth, including serum CA125 monitoring and completion of a patient reported outcome instrument, the Measure of Ovarian Symptoms and Treatment concerns-Surveillance (MOST-S26), will improve emotional wellbeing in women with ovarian cancer; be feasible, safe, acceptable, and not delay the time to diagnosis of recurrent disease; will result in greater patient satisfaction; will identify more patients with psychological distress, lead to better care, and improved psychological outcomes; and be cost-effective.Trial DesignPhase II multicenter randomized trial comparing 3 monthly nurse led telehealth consultations that include serum CA125 monitoring and completion of the MOST-S26, with routine clinic based follow-up. The allocation ratio will be 1:1.Major Inclusion/Exclusion CriteriaEligible patients will be women with high grade epithelial ovarian cancer who have normalized serum CA125 (to Primary Endpoint(s)Emotional wellbeing at 12 months.Sample Size150 patients.Estimated Dates for Completing Accrual and Presenting ResultsJuly 2023. Results expected in 2025, 24 months after the last participant is enrolled.Trial RegistrationACTRN12620000332921

Aims We investigated long-term mortality associated with changes in left ventricular ejection fraction (LVEF) in a large, real-world patient cohort. Methods and results A total of 117 275 adults (63 ± 16 years, 46% women) had LVEF quantified by the same method ≥6 months apart. This included 17 343 cases (66 ± 15 years, 48% women) being initially investigated for heart failure (HF). During 3.3 [interquartile range (IQR) 1.7–6.0] years from first to last echocardiogram, median change in LVEF was −1 (IQR −8 to +5) units from a baseline of 62% (IQR 54–69%). During subsequent 7.6 (IQR 4.3–10.1) years of follow-up, 11 397 (9.7%) and 34 101 (29.1%) cases died from cardiovascular disease and all causes, respectively. Actual 5-year, all-cause mortality increased from 12% to 29% among those with the smallest to the largest decrease in LVEF (from 30 units); the adjusted risk of cardiovascular-related mortality increased two- to eightfold beyond a >10-unit decline in LVEF (vs. minimal change; P 30-unit increase to >30-unit decline in LVEF (vs. minimal change; P

AIMS We investigated the sex-based risk of mortality across the spectrum of left ventricular ejection fraction (LVEF) in a large cohort of patients in Australia. METHODS AND RESULTS Quantified levels of LVEF from 237 046 women (48.1%) and 256 109 men undergoing first-time, routine echocardiography (2000-2019) were linked to 119 232 deaths (median 5.6 years of follow-up). Overall, 17.6% of men vs. 8.3% of women had an LVEF

Fewer than 20% of older adults participate in strength training (ST). Barriers to ST participation include not knowing where to go or not having someone to go with. To address these barriers, the authors provided older adults with a peer (older person already participating in ST) to support their engagement. The aim of this pilot randomized controlled trial was to determine whether older adults who were provided with a peer when participating in ST were more likely to be participating in ST 4 weeks postintervention, compared with those receiving ST alone. Fifty-one ST participants were recruited; 40 completed the intervention and postintervention data collection (78.4%). Providing peer support with ST did not significantly increase ST participation (p = .775). However, both groups made significant improvements over time in lower-limb strength and mobility. Participants in either group who continued the ST program (55%) had made additional significant improvements in lower-limb strength and mobility.

Objective: This study explored the healthcare needs and barriers to health services in older homeless women in the Perth metropolitan area, Western Australia. Methods: Twenty‐two older women experiencing homelessness completed a questionnaire and semi‐structured interview. Data were analysed using descriptive statistics and thematic analysis. Results: The study highlighted that these women had complex and inter‐related issues that affected their health. The nine major themes that emerged from the interview data consisted of: safe accommodation; financial insecurity; experience of trauma and abuse; stigma, embarrassment and fear of being judged; the health impact of not fulfilling their role as family nurturer; mental health; complex interaction of physical and mental health issues; healthcare costs; and the need for ongoing psychosocial and healthcare support once housed. Conclusion: Provision of safe and secure accommodation is pivotal to women's health, as is the need for greater understanding of the impact of poverty, women's traditional roles, social disconnection and domestic violence, and ongoing access to healthcare and support services. Implications for public health: A structural and systemic approach based on a social determinants of health framework is required to address the health needs of the increasing numbers of older women becoming homeless in this country.

Background Despite all the resourcefulness and efforts in the last 30 years for quality in healthcare, safety and quality considerations are recognized with up to 17% of total hospital activity and expenditure related to adverse events. A knowledge gap is identified in the literature that few studies have reported from a whole hospital perspective on what and how quality activities are being performed, particularly in the Australian context. Objective This study aims to describe the characteristics of quality activities in a tertiary quaternary hospital in Western Australia. Methods Data from the study hospital’s electronic quality management system Governance, Evidence, Knowledge and Outcome between 1 January 2015 and 31 December 2019 was analysed by using descriptive and thematic methods. Results Quality assurance (QA) accounted for 68.3% of all quality activities in the study hospital. Principal investigators of activities were mostly in clinical roles and relatively senior in their profession. Collaboration within the same profession and same team was common, but much less so across departments. The median quality cycle length measured by proposal submission to completion was 202 days, but 190 days when measured by proposal approval to completion. A majority (93.2%) of quality activities were undertaken as part of everyday business. Common issues outlined in activity reports were documentation and compliance 44.8% (n = 100), data and tool limitations 10.8% (n = 24), variation in care 9.9% (n = 22), process 9.4% (n = 21), and knowledge and awareness 9.0% (n = 20). Common recommendations to address the issues were communicating findings to relevant teams and governance committees 26.8% (n = 104), further data collection including re-audit 26.0% (n = 101), education and training 20.4% (n = 79), process review and/or development 13.9% (n = 54), and policy/guidelines review and/or development 4.4% (n = 17). Conclusion Understanding the characteristics of quality activities from a whole hospital perspective provides insights and informs discussions relating to the efficiency and effectiveness of quality activities in hospitals. Embedding quality activities into everyday business is achievable for hospitals but considerations need to occur on how to sustain staff motivation and enthusiasm by helping individuals and teams reach the ultimate goals for improvement and keeping performance monitoring as close to the real time of care as possible. There is a need to transform QA into quality improvement, with the 90-day cycle being a feasible target for QA in hospitals.

Background Historical data suggesting poor survival in patients with aortic stenosis (AS) who do not undergo treatment are largely confined to patients with severe AS. Objectives This study sought to determine the prognostic impact of all levels of native valvular AS. Methods Severity of AS was characterized by convention and by statistical distribution in 122,809 male patients (mean age 61 ± 17 years) and 118,494 female patients (mean age 62 ± 19 years), with measured aortic valve (AV) mean gradient, peak velocity, and/or area. The relationship between AS severity and survival was then examined during median 1,208 days (interquartile range: 598 to 2,177 days) of follow-up. Patients with previous aortic valve intervention were excluded. Results Overall, 16,129 (6.7%), 3,315 (1.4%), and 6,383 (2.6%) patients had mild, moderate, and severe AS, respectively. On an adjusted basis (vs. no AS; 5-year mortality 19%), patients with mild to severe AS had an increasing risk of long-term mortality (adjusted hazard ratio: 1.44 to 2.09; p 50%) and cardiovascular disease was evident from a mean AV gradient >20.0 mm Hg (moderate AS) after adjusting for age, sex, left ventricular systolic or diastolic dysfunction, and aortic regurgitation. Conclusions These data confirm that when left untreated, severe AS is associated with poor long-term survival. Moreover, they also suggest poor survival rates in patients with moderate AS. (National Echocardiographic Database of Australia [NEDA]; ACTRN12617001387314)

There is increasing evidence that current thresholds for diagnosing pulmonary hypertension (PHT) underestimate the prognostic impact of PHT.The aim of this study was to determine the prognostic impact of increasing pulmonary pressures within the National Echocardiography Database of Australia cohort (n = 313,492).The distribution of estimated right ventricular systolic pressure (eRVSP) was examined in 157,842 men and women. All had data linkage to long-term survival during median follow-up of 4.2 years (interquartile range: 2.2 to 7.5 years).The cohort comprised 74,405 men and 83,437 women 65.6 ± 17.7 years of age. Overall, 17,955 (11.4%), 7,016 (4.4%), and 4,515 (2.9%) subjects had eRVSP levels indicative of mild (40 to 49 mm Hg), moderate (50 to 59 mm Hg), or severe (≥60 mm Hg) PHT, respectively, assuming a right atrial pressure of 5 mm Hg. These subjects were more likely to die during long-term follow up (for severe PHT, adjusted hazard ratio: 9.73; 95% confidence interval: 8.60 to 11.0; p 0.001). After adjustment for age, sex, and evidence of left heart disease, those subjects with eRVSP levels within the third (28.05 to 32.0 mm Hg; hazard ratio: 1.410; 95% confidence interval: 1.310 to 1.517) and fourth (32.05 to 38.83 mm Hg; hazard ratio: 1.979; 95% confidence interval: 1.853 to 2.114) quintiles had significantly higher mortality (p 0.001) than those in the lowest quintile. Accordingly, a clear and consistent threshold of increased mortality (including 1- and 5-year actuarial mortality) around an eRVSP of 30.0 mm Hg was evident.In this large and unique cohort, the prognostic impact of clinically accepted levels of PHT was confirmed. Moreover, a distinctly lower threshold for increased risk for mortality (eRVSP30.0 mm Hg) indicative of PHT was identified. (A Longitudinal Cohort Study of Echocardiograms From Public and Private Echocardiography Laboratories From Around Australia, Linked With the National Deaths Index; ACTRN12617001387314).

ObjectiveTo retrospectively assess a cohort of mothers for characteristics of injuries that they have suffered as a result of family and domestic violence (FDV) and which have required admission to a hospital during both the intrapartum and postpartum periods.Design and settingRetrospective, whole-population linked data study of FDV in Western Australia using the Western Australia birth registry from 1990 to 2009 and Hospital Morbidity Data System records from 1970 to 2013.Main outcome measuresNumber of hospitalisations, and mode, location and type of injuries recorded, with particular focus on the head and neck area.ResultsThere were 11 546 hospitalisations for mothers due to FDV. 8193 hospitalisations recorded an injury code to the head and/or neck region. The upper and middle thirds of the face and scalp were areas most likely to receive superficial injuries (58.7% or 4158 admissions), followed by the mouth and oral cavity (9.7% or 687 admissions). Fracture to the mandible accounted for 479 (4.2%) admissions and was almost equal to the sum of the next three most common facial fractures (nasal, maxillary and orbital floor). Mothers more likely to be hospitalised due to a head injury from FDV included those with more than one child (OR=1.17, 95% CI 1.03 to 1.30) and those with infants (ConclusionsFDV is a serious and ongoing problem and front-line clinicians are in need of evidence-based guidelines to recognise and assist victims of FDV. Mothers with children in their care are a particularly vulnerable group.

Sharolin Boban,1 Jenny Downs,2 Jim Codde,3,4 Paul A Cohen,3,4 Caroline Bulsara3 1School of Health Sciences, University of Notre Dame Australia, Fremantle, Western Australia, Australia; 2Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Nedlands, Western Australia, Australia; 3Institute for Health Research, University of Notre Dame Australia, Fremantle, Western Australia, Australia; 4Division of Obstetrics and Gynecology, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, AustraliaCorrespondence: Sharolin BobanSchool of Health Sciences, University of Notre Dame Australia, Fremantle, Western Australia, AustraliaEmail 32009365@my.nd.edu.auPurpose: By directly engaging with women diagnosed with ovarian cancer, this study aimed to explore and identify their view of the health symptoms and outcomes that matter most to them as they traverse their disease pathway.Background: Patient-reported outcome measures in ovarian cancer have tended to focus on physical symptoms rather than the more complex psychosocial aspects of living with the disease. Using a “ground-up approach”, this study sought to comprehensively understand the health concerns that matter most to women with ovarian cancer as a first step in generating items for development into an ovarian cancer–specific patient-reported outcome measure.Patients and Methods: Following an extensive literature review, we sought to capture the “patient voice” through a qualitative descriptive approach including a community conversation with ovarian cancer patients, their carers and clinicians, and interviews and focus groups with women with ovarian cancer. Thirteen women were interviewed individually, and two focus groups were conducted. A template thematic analysis was used to analyze the data.Results: Key themes included challenges related to clinical diagnosis, treatment phase, altered relationships with family/friends, financial issues, relationships with health professionals and coping strategies. Within each key theme, several sub-themes emerged that were identified as various challenges experienced by participants. Diagnostic delay, chemotherapy and surgery-related challenges, negative impact of sexual well-being on partner relationship, communicational challenges with health professionals were among the few issues identified. In addition, self-empowerment was identified as a coping mechanism among participants.Conclusion: By identifying priorities for women diagnosed with ovarian cancer we have highlighted the need for strategies to reduce diagnostic delays and improve quality of life for these women. Data will inform the development of an ovarian cancer–specific patient-reported outcome measure.Keywords: focus groups, health-related quality of life, qualitative descriptive, patient-reported outcome measures, semi-structured interviews

Objective Adenocarcinoma in situ (AIS) of the cervix is a precursor to cervical adenocarcinoma. When AIS is detected by cervical screening an excision biopsy is mandatory to exclude invasion. We aimed to compare margins status, specimen size and fragmentation after loop electrosurgical excision procedure (LEEP) and ‘cold knife cone biopsy’ (CKC). Methods The EXCISE Trial was an investigator-initiated, multicenter, open-label, parallel-group, phase 2, randomized study. Patients were enrolled at seven hospitals in Australia and New Zealand. We randomly assigned women aged ≥18 to ≤45 years with screen detected AIS to LEEP or CKC. Co-primary endpoints were margin status, specimen size and fragmentation. Analysis was by intention-to-treat. Results Between August 2, 2017 and September 6, 2019, 40 patients were randomly assigned 2:1 to LEEP or CKC. Margin status was evaluable in 36 cases. The proportion of patients with involved margins did not differ between groups. 25 of 26 LEEP and all 14 CKC biopsies were excised as single specimens (p = 1·00). There were no differences in specimen dimensions. Patients in the CKC group had more post-operative complications (64.3% compared to 15.4% for LEEP p = ·00). There were no differences in grade three complications (p = ·65). Conclusions LEEP was not associated with a greater likelihood of positive margins, specimen fragmentation or smaller excision compared to CKC when performed according to a standardized protocol. However, the study was not powered to establish non-inferiority of LEEP and a definitive phase 3 trial to compare margin status and rates of treatment failure after LEEP and CKC is warranted.

Background Dementia is a neurological condition that affects the cognitive and functional ability of the brain and is the leading cause of disability among those aged 65 years and above. More effective ways to manage dementia symptoms are needed because current treatment options (antidepressants and antipsychotics) can be ineffective and are associated with substantial side effects, including increased rate of mortality. Cannabinoid-based medicine (CBM) has shown an ability to inhibit some symptoms associated with dementia, and the adverse effects are often minimal; yet, little research has explored the use of CBM among this population. Aim To monitor the safety of a purified dose of CBM oil (3:2 delta-9-tetrahydrocannabinol:cannabidiol) on behaviour symptoms, quality of life and discomfort caused by pain. Methods/design We will carry out an 18-week, randomised, double-blind crossover trial that consists of a 2-week eligibility period, two 6-week treatment cycles, and two 2-week washout periods (between both cycles and after the second treatment cycle). We aim to recruit 50 participants with dementia who are living in residential aged-care facilities. The participants will be randomised into two groups and will receive a dose of either CBM oil or placebo for the first treatment cycle and the opposite medication for the second. Data will be collected using the Neuropsychiatric Inventory Questionnaire, the Cohen-Mansfield Agitation Inventory, the Quality of Life in Alzheimer’s Disease questionnaire, and the Abbey Pain Scale on seven occasions. These will be completed by the participants, aged-care staff, and nominated next of kin or family members. The participants’ heart rate and blood pressure will be monitored weekly, and their body composition and weight will be monitored fortnightly by a research nurse, to assess individual dose response and frailty. In addition, pre- and post-surveys will be administered to aged-care staff and family members to understand their perceptions of CBM and to inform proposed focus groups consisting of the aged-care staff and next of kin. Discussion The study design has been informed by medical professionals and key stakeholders, including those working in the residential aged-care industry to ensure patient safety, collection of non-invasive measures, and methodological rigor and study feasibility. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12619000474156. Registered on 21 March 2019

Background: Adenocarcinoma in situ (AIS) of the cervix is a precursor to cervical adenocarcinoma. When AIS is detected by cervical screening an excision biopsy is mandatory to exclude invasion. Two common procedures are loop electrosurgical excision procedure (LEEP) and ‘cold knife cone biopsy’ (CKC), yet no randomised trials have compared these modalities. We aimed to compare margins status, specimen size and fragmentation after LEEP and CKC. Methods: The EXCISE Trial was an investigator-initiated, multicentre, open-label, parallel-group, phase 2, randomised study. Patients were enrolled at seven hospitals in Australia and New Zealand. We randomly assigned women aged ≥18 to ≤45 years with screen detected AIS to LEEP or CKC by computer generated random numbers. Co-primary endpoints were margin status, specimen size and fragmentation. Analysis was by intention-to-treat. Findings: Between August 2, 2017 and September 6, 2019, 40 patients were randomly assigned 2:1 to LEEP or CKC. All patients were included in the analysis. Margin status was evaluable in 36 cases. The proportion of patients with involved margins did not differ between groups. 25 of 26 LEEP and all 14 CKC biopsies were excised as single specimens (p=1.00). There were no differences in specimen dimensions. Patients in the CKC group had more post-operative complications (64.3% compared to 15.4% for LEEP p=.00). There were no differences in grade three complications (p=.65). Interpretation: LEEP was not associated with a greater likelihood of positive margins, specimen fragmentation or smaller excision compared to CKC when performed according to a standardised protocol. However, the study was not powered to establish non-inferiority of LEEP and a definitive phase 3 trial to compare margin status and rates of treatment failure after LEEP and CKC is warranted. Trial Registration: The study is registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR registration number ACTRN12617000132347). Funding Statement: Australia New Zealand Gynaecological Oncology Group [#FNR2016/03]. Declaration of Interests: PAC and CDHW have received honoraria from Seqirus unrelated to this work. All other authors declare no competing interests. Ethics Approval Statement: Ethical approval for the study was granted by the St John of God Healthcare Human Research Ethics Committee (Reference number #1137) and approvals were obtained at all participating sites.

The National Echocardiography Database Australia (NEDA) is a new echocardiography database collecting digital measurements on both a retrospective and prospective basis. To date, echocardiographic data from 435,133 individuals (aged 61.6 ± 17.9 years) with linkage to 59,725 all-cause deaths during a median of 40 months follow-up have been collected. These data will inform a number of initial analyses focusing on pulmonary hypertension, aortic stenosis and the role of artificial intelligence to facilitate accurate diagnoses of cardiac abnormalities.

Pulmonary hypertension (PH) is common, under diagnosed and associated with a high mortality. There are significant delays in the diagnosis of pulmonary hypertension leading to increased morbidity and delays in the initiation of treatment. Once PH is diagnosed, establishing the degree of pulmonary vascular resistance (PVR) enables clinicians to broadly divide the underlying pathology into pre-capillary or post-capillary causes, a crucial step in tailoring management. Pulmonary hypertension is most commonly due to left heart disease (PH-LHD) and echocardiography (echo) is the most widely accessible investigation in its diagnosis. Regardless of the underlying pathophysiology of LHD, the sequelae lead to pressure overload on the left heart and a reactive increase in pulmonary pressures. In this review article, we will discuss the prevalence of PH, examine the pathophysiology of PH-LHD, establish how echo can be used to identify patients with PH-LHD and discuss surrogate echo markers of PVR.

ObjectiveOur objective was to validate the prognostic role of the chemotherapy response score (CRS), which has been proposed for measuring tumor response to neoadjuvant chemotherapy in patients with high-grade serous tubo-ovarian carcinoma, in predicting progression-free survival (PFS) and overall survival (OS).MethodsA retrospective cohort study was conducted of patients with advanced high-grade serous tubo-ovarian carcinoma diagnosed between January 1, 2010, and December 31, 2014, and treated with neoadjuvant chemotherapy. Treatment-related tumor regression was determined according to the 3-tier CRS, and results were compared with standard clinicopathological variables. Survival analysis was performed using Cox proportional hazards models and the log-rank test.ResultsSeventy-one patients were eligible for analysis. Median OS was 25.5 months. Fifty-eight patients (82%) had disease recurrence and 32 (45%) had died at study census. Of the 71 patients, 19, 29, and 23 patients had a CRS of 1, 2, and 3, respectively. On univariate analysis, the CRS significantly predicted PFS (hazard ratio [HR], 3.77; 95% confidence interval [CI], 1.83–7.78; P = 0.000) and OS (HR, 2.81; 95% CI, 1.16–6.79; P = 0.022). In a multivariate model, the CRS was significantly associated with PFS (HR, 2.81; 95% CI, 1.16–6.79; P = 0.022) but not with OS (HR, 2.39; 95% CI, 0.47–3.08; P = 0.079). Patients with CRS of 1 and 2 combined were twice as likely to progress during the study period compared with patients with a CRS of 3 (HR, 2.0; 95% CI, 1.06–3.78; P = 0.032; median PFS, 16 vs 26 months). No significant association was observed for OS (CRS 1/2 vs 3; HR, 1.57; 95% CI, 0.68–3.65; P = 0.291).ConclusionsIn this study, the CRS showed independent prognostic significance for PFS but not for OS.

Background: Dementia is a neurological condition that affects the cognitive and functional ability of the brain and is the leading cause of disability among those aged 65-years and above. More effective ways to manage dementia symptoms are needed as current treatment options (anti-depressant and antipsychotic) can be ineffective and associated with substantial side-effects, including increased rate of mortality. Cannabinoid-based medicines (CBM) has shown to inhibit some symptoms associated with dementia and the adverse effects are often minimal, yet little research has explored the use of CBM among this population. Aim. To monitor the safety of a purified dose of CBM oil (3:2 THC:CBD) on behaviour symptoms, Quality of life (QOL), and discomfort caused by pain. Methods/Design: We will carry out an 18-week randomised, double-blinded, crossover trial that consists of a 2-week eligibility period, two, 6-week treatment cycles and two, 2-week washout periods (between both cycles, and after the second treatment cycle). We aim to recruit 50 participants with dementia who are living in residential aged-care facilities. The participants will be randomised into two groups, and receive a dose of either CBM oil or placebo for the first treatment cycle and receive the opposite medication for the second. The Neuropsychiatric Inventory Questionnaire, Cohen Mansfield Agitation Inventor, Quality of Life-Alzheimer’s Disease questionnaire, and the Abbey Pain Scale will be collected on seven occasions, and completed by the participants, aged-care staff, and nominated next of kin or family member. The participant’s heart rate and blood pressure will be monitored weekly and their body composition and weight will be monitored fortnightly by a research nurse to assess individual dose response and frailty. In addition, pre- and post-surveys will be administered to aged-care staff and family members to understand their perceptions towards CBM, and to inform proposed focus groups consisting of the aged care staff and next of kin. Discussion: The study design has been informed by medical professionals and key stakeholders including those working in the residential aged-care industry to ensure patient safety, collection of non-invasive measures, and methodological rigor and study feasibility. Trial registration: ACTRN12619000474156 Registered 21 March 2019, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375128&isClinicalTrial=False

There are limited data to describe the relationship between the transvalvular gradient and mortality among patients who undergo aortic valve replacement.Using the National Echo Database Australia, valvular hemodynamics were characterized in 3,943 men (mean age, 62 ± 18 years) and 2,107 women (mean age, 62 ± 19 years) who underwent aortic valve replacement (median follow-up duration, 770 days; interquartile range, 381-1,584 days). The degree of impaired valvular hemodynamics (IVH) was categorized as mild (mean gradient 10.0-19.9 mm Hg, peak velocity 2.0-2.9 m/sec), moderate (mean gradient 20.0-39.9 mm Hg, peak velocity 3.0-3.9 m/sec), or severe (mean gradient ≥ 40.0 mm Hg, peak velocity ≥ 4 m/sec or effective orifice area0.8 cmOverall, 2,175 (36.0%), 2,598 (42.9%), 698 (11.5%), and 579 (9.6%) patients had no, mild, moderate, and severe IVH, respectively. Those with residual moderate or severe IVH had 5-year mortality of 45.5% and 57.3%, respectively, and higher adjusted long-term all-cause mortality (adjusted hazard ratios, 1.44 and 2.02; P .001) compared with "no IVH." Patients with mild IVH had similar mortality rates to those without IVH. A mortality threshold was evident above a mean transvalvular gradient22.5 mm Hg after adjusting for age, sex, stroke volume index, aortic regurgitation, and effective orifice area.After aortic valve replacement, most patients displayed an acceptable aortic valve hemodynamic profile. Moderate to severe IVH, however, was associated with poor long-term survival, with a threshold for increased mortality similar to that of native valvular aortic stenosis evident.

Objective To determine patient satisfaction and experience after robot-assisted radical prostatectomy (RARP) for prostate cancer, using a convergent mixed-method qualitative analysis approach. Patients and methods 412 patients who underwent RARP between January 2014 and June 2016 were mailed questionnaires and invited to participate in focus groups. Qualitative data was thematically analysed using NVivo. Descriptive statistics were obtained from the questionnaire using SPSS. Results 214 patients responded (52% of sample size) of whom 97.6% were satisfied and 91.1% would likely recommend RARP. Key themes from the qualitative data highlighted the psychosocial impacts of the diagnosis and RARP process. The importance of early recovery, the benefits of pelvic floor exercises and educational resources were emphasised. Conclusion Patients were overwhelmingly satisfied with RARP, largely due to relevance and timeliness of the information and support provided both before and after surgery. With an increased understanding of the factors and outcomes that are most important to patients regarding all aspects of hospital care, we can create more targeted care pathways. Key themes will help inform the implementation of an enhanced recovery after surgery (ERAS) protocol to further improve recovery and early return to function.

Objective To compare outcomes of patients with pure AIS and mixed AIS/CIN 2/3 lesions including the incidence of AIS persistence, recurrence and progression to adenocarcinoma. Design Retrospective cohort study. Setting Statewide population in Western Australia. Population Women diagnosed with AIS between 2001 and 2012. Methods We conducted a retrospective, population-based cohort study. Main Outcome Measures De-identified linked data were utilized to ascertain the association between patient age at excisional treatment, margin status, lesion type, lesion size, and risk of persistent AIS (defined as the presence of AIS 30 years (HR 2.1; 95%CI 1.16 – 3.81; p = 0.015), positive endocervical margins (HR 5.8; 95%CI 3.05 – 10.92; p = 8mm (HR 2.5; 95%CI 1.00 – 6.20; p = 0.049). A histologically positive AIS ectocervical margin was not associated with persistence/recurrence. Conclusion In this study, pure AIS was associated with greater risk of persistence/recurrence compared to mixed AIS/CIN 2/3. AIS lesions >8mm and positive endocervical margins were significant predictors for persistent or recurrent disease. This article is protected by copyright. All rights reserved.

The objective of this systematic review and meta-analysis was to evaluate the effectiveness of peers to deliver programs or encourage older people to be physically active and improve physical outcomes. Peer reviewed articles published in English between January 1976 and June 2016, retrieved from six databases according to the predefined inclusion criteria were included. Where possible results were pooled and meta-analyses conducted. Eighteen articles were included in the review, a total of 3,492 intervention participants, average age 66.5 years and 67.1% were female. Overall, study quality was medium to high. Interventions mainly included resistance, flexibility and cardiovascular training, however there was one aquatic exercise group. Eight studies were delivered by peers and five utilised peer support, which included advice and being positive but was not directly linked to an exercise intervention. While 16 of the 18 studies reported improvement in levels of physical activity and/or noted physical benefits by peer involvement, the meta-analyses findings supported the control groups for the six-minute-walk-test and the timed-up-and-go test. Findings from this review suggest exercise programs involving peers can promote and maintain adherence to exercise programs. However, results were inconclusive as to whether peers have a positive effect on improving older people's physical function.

Summary Background Infant simulator-based programmes, which aim to prevent teenage pregnancy, are used in high-income as well as low-income and middle-income countries but, despite growing popularity, no published evidence exists of their long-term effect. The aim of this trial was to investigate the effect of such a programme, the Virtual Infant Parenting (VIP) programme, on pregnancy outcomes of birth and induced abortion in Australia. Methods In this school-based pragmatic cluster randomised controlled trial, eligible schools in Perth, Western Australia, were enrolled and randomised 1:1 to the intervention and control groups. Randomisation using a table of random numbers without blocking, stratification, or matching was done by a researcher who was masked to the identity of the schools. Between 2003 and 2006, the VIP programme was administered to girls aged 13–15 years in the intervention schools, while girls of the same age in the control schools received the standard health education curriculum. Participants were followed until they reached 20 years of age via data linkage to hospital medical and abortion clinic records. The primary endpoint was the occurrence of pregnancy during the teenage years. Binomial and Cox proportional hazards regression was used to test for differences in pregnancy rates between study groups. This study is registered as an international randomised controlled trial, number ISRCTN24952438. Findings 57 (86%) of 66 eligible schools were enrolled into the trial and randomly assigned 1:1 to the intervention (28 schools) or the control group (29 schools). Then, between Feb 1, 2003, and May 31, 2006, 1267 girls in the intervention schools received the VIP programme while 1567 girls in the control schools received the standard health education curriculum. Compared with girls in the control group, a higher proportion of girls in the intervention group recorded at least one birth (97 [8%] of 1267 in the intervention group vs 67 [4%] of 1567 in the control group) or at least one abortion as the first pregnancy event (113 [9%] vs 101 [6%]). After adjustment for potential confounders, the intervention group had a higher overall pregnancy risk than the control group (relative risk 1·36 [95% CI 1·10–1·67], p=0·003). Similar results were obtained with the use of proportional hazard models (hazard ratio 1·35 [95% CI 1·10–1·67], p=0·016). Interpretation The infant simulator-based VIP programme did not achieve its aim of reducing teenage pregnancy. Girls in the intervention group were more likely to experience a birth or an induced abortion than those in the control group before they reached 20 years of age. Funding Western Australian Health Promotion Foundation (Healthway), Lotteries WA, the Western Australian Department of Education and Training, and the Western Australian Department of Health.

Objective: To investigate the relationship between risk of Ross River virus (RRV) infection and proximity to mosquito-breeding habitat surrounding a tidal wetland ecosystem in south-west Australia. Methods: Geographic information systems (GIS) were used to spatially map cases of RRV disease in the Leschenault region between July 1995 and June 1996. Half kilometre buffer zones were constructed around the Leschenault Estuary and associated waterways; RRV disease case counts were calculated for each zone. Results: Different relationships between RRV disease incidence and proximity to saltmarsh mosquito habitat were observed east of the Leschenault Estuary compared with an urban region to the south. Disease incidence showed a decreasing trend away from eastern margins of the Estuary, particularly for the first 2 km. In the urban region, RRV disease risk was low close to the Estuary, but increased further out and remained steady across the remainder of that region. Conclusions: The findings support an increased risk of contracting RRV disease for people residing close to eastern margins of the Leschenault Estuary. Implications: This study highlights how historical data combined with GIS can improve understanding of the epidemiology of RRV disease. This has a valuable role in assessing the risk of mosquito-borne disease for land-use planning.

Background and Purpose— Despite the disproportionate burden of cardiovascular disease among indigenous Australians, information on stroke is sparse. This article documents the incidence and burden of stroke (in disability-adjusted life years) in indigenous and non-indigenous people in Western Australia (1997–2002), a state resident to 15% of indigenous Australians comprising 3.4% of the population of Western Australia. Methods— Indigenous and non-indigenous stroke incidence and excess mortality rates were estimated from linked hospital and mortality data, with adjustment for nonadmitted events. Nonfatal burden was calculated from nonfatal incidence, duration (modeled from incidence, excess mortality, and remission), and disability weights. Stroke death counts formed the basis of fatal burden. Nonfatal and fatal burden were summed to obtain disability-adjusted life years, by indigenous status. Results— The total burden was 55 099 and 2134 disability-adjusted life years in non-indigenous and indigenous Western Australians, respectively. The indigenous to non-indigenous age-standardized stroke incidence rate ratio (≥15 years) was 2.6 in males (95% CI, 2.3–3.0) and 3.0 (95% CI, 2.6–3.5) in females, with similar rate ratios of disability-adjusted life years. The burden profile differed substantially between populations, with rate ratios being highest at younger ages. Conclusions— The differential between indigenous and non-indigenous stroke burden is considerable, highlighting the need for comprehensive intersectoral interventions to reduce indigenous stroke incidence and improve outcomes. Programs to reduce risk factors and increase access to culturally appropriate stroke services are required. The results here provide the quantitative basis for policy development and monitoring of stroke outcomes.

Aim: To describe elderly patient transfers from residential aged care facilities (RACF) to hospital emergency departments (ED), and to estimate the proportion of transfers that may be avoidable with improved primary care service to RACF. Methods: A descriptive study analysing data from a single tertiary hospital ED patient database, medical record reviews from a random sample of RACF patients presenting to ED and previously published reports. Results: Thirty-one per cent of all transfers at our hospital were potentially avoidable. This sits within the range (7% to 48%) found internationally. A small number of simple interventions could potentially reduce unnecessary ED transfer from RACF. Conclusions: Evidence from multiple sources suggests that a meaningful proportion of transfers from RACF to ED may be avoided.

Aim: To assess the impact of an enhanced primary care service for residential aged care facilities (RACF) on the transfer of patients from RACF to a hospital emergency department (ED). Methods: A before–after study of an enhanced primary care service provided by experienced ED-based nurses under the governance of general practitioners. The intervention was analysed comparatively using standardised normal deviates and seasonal autoregressive integrated moving average models, complemented by qualitative assessment. Results: There was a statistically significant reduction (17%, P < 0.001) in the number of transfers during the intervention period. This finding held when adjusting for the seasonality of ED referrals over a 4-year period. The intervention was highly valued by clinicians in RACF and ED. Conclusion: Enhanced primary care services reduce the number of transfers to ED from RACF.

AIM To explore the factors that influence the transfer of patients from residential aged care facilities (RACF) to hospital emergency departments (ED), and describe features of improved primary care in RACF that could result in reduced transfer. METHODS a. Three focus groups conducted with family and carers of RACF residents, along with RACF, ED and general practice staff. b. Semistructured one-on-one interviews with nine residents of RACF. RESULTS Five main themes emerged--staffing and skill mix in RACF, treatment options in RACF, end of life decision-making, communication and bureaucratic requirements. Analysis of the semistructured interviews demonstrated parallel concerns with many of the focus groups indicators. There was a strong but not universal preference among residents to minimise RACF to ED transfer. CONCLUSIONS The transfer of residents from RACF to ED is influenced by multiple interrelated factors, and strategies to reduce transfer should address these.

Introduction CIN2 has a high rate of spontaneous regression in young women and may be managed conservatively in appropriately selected patients. This study aimed to investigate health outcomes in women aged 18–24 years with biopsy-confirmed CIN2. Material and methods A retrospective cohort study of Western Australian women aged 18–24 years diagnosed with CIN2 on cervical biopsy from 1 January 2001 to 31 December 2010. Women who had not received treatment at ≥4 months following CIN2 diagnosis were classified as managed ‘conservatively’. Subsequent cervical cytology and/or biopsy test results were used to report lesion regression (absence of dysplasia or an epithelial lesion of lower grade than CIN2) and disease persistence (CIN2, CIN3 or ACIS). Results Follow-up data were available for 2417 women of whom 924 (38.2%) were ‘conservatively’ managed. In all, 152 (16.4%) conservatively managed women had a lesion more severe than CIN2 detected within 24 months of initial diagnosis, of which 144 were CIN3 and eight were ACIS. There was no statistically significant association between rates of regression and patient age, Socio-economic Indexes for Areas or Accessibility/Remoteness Index of Australia indices. The 2-year regression rate for CIN2 was estimated to be 59.5% (95%CI 0.5–0.6) in this cohort of women. Conclusion In conservatively managed young women with CIN2 there was a high rate of spontaneous disease regression. Thus, excisional or ablative treatments may be avoided in selected patients who receive appropriate counseling and who are able to comply with more intensive and prolonged follow-up requirements.

Patients have an increased risk of persistent/recurrent cervical disease if they received treatment for a high-grade squamous intraepithelial lesion (HSIL). Consequently, understanding whether co-testing (human papillomavirus [HPV] DNA testing and cervical cytology) is fully utilised by general practitioners (GPs) is paramount.After consultation with key stakeholders, an anonymous, self-completion questionnaire was developed and disseminated to GPs who had provided cervical cytology.Responses were received from 745 GPs (30.9% response rate). A significant number (34.3%) of GPs were unaware of the use of co-testing (HPV DNA testing and cervical cytology) for the management of patients after HSIL treatment. Additionally, the majority of GPs reported they did not 'always' receive a clear follow-up plan for patients after treatment of an HSIL.GPs require further support and education to ensure successful adoption of co-testing (HPV DNA testing and cervical cytology), specifically, for patients treated for an HSIL.

To compare the outcomes of patients with cervical adenocarcinoma in situ (ACIS) treated with cold knife cone (CKC) biopsy or loop electrosurgical excision procedure (LEEP) for the treatment of cervical adenocarcinoma in situ (ACIS).This is a retrospective, population-based cohort study of Western Australian patients with ACIS diagnosed between 2001 and 2012. Outcomes included pathological margin status and the incidence of persistent or recurrent endocervical neoplasia (ACIS and adenocarcinoma) during follow-up (12 months) and surveillance (≥12 months) periods.The study group comprised 338 patients including 107 (32%) treated initially by LEEP and 231 (68%) treated by CKC biopsy. The mean age was 33.2 years (range 18 to 76 years) and median follow-up interval was 3.6 years (range1 year to 11.8 years). Overall, 27 (8.0%) patients had ACIS persistence/recurrence while 9 (2.7%) were diagnosed with adenocarcinoma during the follow-up and surveillance periods. No patient died of cervical cancer within the study period. There were no significant differences in the incidence of persistent and/or recurrent endocervical neoplasia according to the type of excisional procedure. Patients with positive biopsy margins were 3.4 times more likely to have disease persistence or recurrence.LEEP and CKC biopsy appear equally effective in the treatment of ACIS for women wishing to preserve fertility. Patients undergoing conservative management for ACIS should be closely monitored, particularly if biopsy margins are positive in initial excision specimens. Patients and their clinicians should be aware of the potential risks of residual and recurrent disease.

Objective: To analyze the incidence of type 1 diabetes in 0- to 14-year olds in Western Australia, from 1985 to 2002, by region and socioeconomic status. Methods: Primary case ascertainment was from the prospective population-based Western Australian Diabetes Register, and secondary case ascertainment was from the Western Australian Hospital Morbidity Data System. The address at diagnosis was used to categorize cases into urban, rural and remote areas and into five socioeconomic groups using the Index of Relative Socioeconomic Disadvantage. Denominator data were obtained from the Australian Bureau of Statistics. Poisson regression was used to analyze the incidence rates by area and socioeconomic status. Results: There were a total of 1143 cases (904 urban, 190 rural and 49 remote). Case ascertainment was estimated to be 99.8% complete. The mean annual age-standardized incidence from 1985 to 2002 was 18.1 per 100 000 person years in urban (95% CI: 16.3–19.9), 14.3 per 100 000 in rural (95% CI: 11.4–7.3) and 8.0 per 100 000 in remote areas (95% CI: 5.8–10.3). The incidence was significantly higher in urban compared with rural (rate ratio 1.27, p = 0.001) and remote (rate ratio 2.28, p

Aims This study compares the hazard of death among opiate and amphetamine using clients who accessed drug treatment with individuals who had no specialist treatment contact between 1985 and 1998. Design, setting, participants This was a retrospective cohort study of 4280 drug-using individuals (2887 opiate users, 1393 amphetamine users) admitted to Perth metropolitan hospitals or Perth psychiatric institutions between 1985 and 1998. Of these, 1469 attended Next Step Specialist Drug and Alcohol Services (928 received methadone and 541 attended counselling or support groups) and 2811 had no contact with this service. Methods Data from two drug treatment programmes were linked with hospital morbidity, psychiatric services and the mortality database using record linkage. Findings The results show that people who were currently in drug treatment had a lower hazard of death compared with non-clients and those who had ceased treatment. Those who had ceased treatment more than 6 months ago had 7.0 times the hazard of all-cause death and 8.4 times the hazard of drug-cause death. Opiate users were at 1.4 times the hazard of all-cause death and 2.4 times the hazard of drug-cause death compared with amphetamine users. Males were at 1.79 times the hazard of all-cause death and, unexpectedly, were found to be at 2.69 times the hazard of drug-cause death compared with females. Conclusions Treatment protected clients from premature death compared with people who did not receive treatment and also those who ceased treatment. While amphetamine users had a lower risk of mortality compared with opiate users, the full extent of the relationship between amphetamine use and mortality needs to be examined further.

IntroductionAdenocarcinoma in situ (AIS) of the uterine cervix is the precursor to invasive endocervical adenocarcinoma. An excisional biopsy such as a cold knife cone biopsy (CKC) should be performed to exclude invasive adenocarcinoma. Loop electrosurgical excision procedure (LEEP) is an alternative modality to CKC but is controversial in AIS. There is a perception that there is a greater likelihood of incomplete excision of AIS with LEEP because the depth of excised tissue tends to be smaller and the tissue margins may show thermal artefact which can interfere with pathology assessment. In the USA, guidelines recommend that any treatment modality can be used to excise AIS, provided that the specimen remains intact with interpretable margins. However, there are no high-quality studies comparing LEEP with CKC and well-designed prospective studies are needed. If such a study were to show that LEEP was non-inferior to CKC for the outcomes of post-treatment persistence, recurrence and adenocarcinoma, LEEP could be recommended as an appropriate treatment option for AIS in selected patients. This would benefit women because, unlike CKC, LEEP does not require general anaesthesia and may be associated with reduced morbidity.Methods and analysisThe proposed exploratory study is a parallel group trial with an allocation ratio of 2:1 in favour of the intervention (LEEP: CKC). Participants are women aged ≥18 to ≤45 years diagnosed with AIS on cervical screening and/or colposcopically directed biopsy in Australia and New Zealand, who are to receive excisional treatment in a tertiary level centre.Ethics and disseminationEthical approval for the study has been granted by the St John of God Healthcare Human Research Ethics Committee (reference number #1137). Results from the study will be presented at conferences and published in a peer-reviewed scientific journal.RegistrationANZCTR registration number ACTRN12617000132347https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372173&isReview=true

Adenocarcinoma in situ of the uterine cervix is a precursor to cervical adenocarcinoma and may coexist with both adenocarcinoma and high-grade squamous dysplasia (cervical intraepithelial neoplasia 2 and 3). Up to 60% of adenocarcinoma in situ lesions are detected incidentally following excisional biopsies performed for the treatment of cervical intraepithelial neoplasia 2/3. To date there are no data regarding risk factors for persisting or progressive cervical neoplasia in these patients.We sought to investigate patient outcomes following incidentally detected cervical adenocarcinoma in situ after loop electrosurgical excision procedure or cold knife cone biopsy performed for the treatment of high-grade cervical intraepithelial neoplasia.We conducted a retrospective, population-based cohort study of Western Australian patients with an incidental diagnosis of adenocarcinoma in situ from 2001 through 2012. Primary outcomes were persistent or recurrent cervical intraepithelial neoplasia 2/3 and or adenocarcinoma in situ, and invasive adenocarcinoma during follow-up (12 months) and surveillance (≥12 months) periods.The cohort comprised 298 patients, with 228 (76.5%) treated initially by loop electrosurgical excision procedure and 70 (23.5%) treated by cold knife cone biopsy. The mean age was 31.2 (range 18-68) years and the median length of follow-up was 2.4 (range 0.3-12.2) years. Overall, 11 (3.7%) patients had cervical intraepithelial neoplasia 2/3, 23 (7.7%) had adenocarcinoma in situ, and 3 (1.0%) had adenocarcinoma diagnosed during the follow-up and surveillance periods. Age30 years, pure adenocarcinoma in situ lesions, and larger lesions (8 mm) were associated with a greater risk of disease persistence or recurrence.Following the incidental detection of adenocarcinoma in situ, age30 years, pure adenocarcinoma in situ lesions, and lesions8 mm were significantly associated with disease persistence/recurrence. In younger women, incidentally detected adenocarcinoma in situ that coexists with cervical intraepithelial neoplasia 2/3 and is8 mm extent with clear margins may not require reexcision.