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Context The plasma aldosterone concentration (PAC), renin, and aldosterone-to-renin ratio (ARR) are used to screen for primary aldosteronism (PA). Substantial intra-individual variability of PAC and ARR using plasma renin activity in the context of usual antihypertensive therapy has been described, but there is no data on ARR variability calculated using direct renin concentration (DRC). Objective To describe the intra-individual variability of PAC, DRC, and ARR in the absence of interfering medications in patients with and without PA. Design Retrospective cohort study. Patients Hypertensive patients referred for investigation of PA, with at least 2 ARR measurements while off interfering medications. Setting Endocrine hypertension service of a tertiary center, from May 2017 to July 2021. Main outcome measures PAC, DRC, and ARR variability was calculated as coefficient of variation (CV) and percent difference (PD). Results Analysis of 223 patients (55% female, median age 52 years), including 162 with confirmed PA, demonstrated high variability with a sample CV of 22-25% in the PAC and sample CV of 41% to 42% in the DRC and ARR in both the PA and non-PA groups. The degree of variability was substantially higher than the assays’ analytical CV. Sixty-two patients (38%) with PA had at least one ARR below 70 pmol/L:mU/L (2.4 ng/dL:mU/L), a cut-off for first-line screening of PA. Conclusions Significant intra-individual variability in PAC, DRC, and hence ARR occurs in a large proportion of patients being investigated for PA. These findings support the need for at least 2 ARR before PA is excluded or further investigated.

Background Failure to rescue (FTR) is increasingly recognised as a measure of the quality care provided by a health service in recognising and responding to patient deterioration. We report the association between a patient’s pre-operative status and FTR following major abdominal surgery. Methods A retrospective chart review was conducted on patients who underwent major abdominal surgery and who suffered Clavien–Dindo (CDC) III-V complications at the University Hospital Geelong between 2012 and 2019. For each patient suffering a major complication, pre-operative risk factors including demographics, comorbidities (Charlson Comorbidity Index (CCI)), American Society of Anaesthesiology (ASA) Score and biochemistry were compared for patients who survived and patients who died. Statistical analysis utilised logistic regression with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). Results There were 2579 patients who underwent major abdominal surgery, of whom 374 (14.5%) suffered CDC III-V complications. Eighty-eight patients subsequently died from their complication representing a 23.5% FTR and an overall operative mortality of 3.4%. Pre-operative risk factors for FTR included ASA score ≥ 3, CCI ≥ 3 and pre-operative serum albumin of Conclusion Identification of patients at high risk of FTR should they develop a complication would inform shared decision-making, highlight the need for optimisation prior to surgery, or in some cases, result in surgery not being undertaken.

Background Splenectomy is an effective intervention in primary immune thrombocytopenia (ITP). Attempts to define pre-clinical predictors of platelet response to splenectomy are inconsistent. Based on international studies defining the likelihood of platelet response using platelet sequestration, patients with relapsed/refractory ITP being considered for splenectomy at a regional Australian hospital were assessed with 111 Indium-labelled autologous platelet sequestration (ILAPS) studies. Aims To audit the use of ILAPS in an Australian setting and define its role in predicting response to splenectomy. Methods A retrospective review of all patients referred for an ILAPS study at a regional hospital was performed. Results for each patient were expressed as an "R" value (spleen/ liver uptake ratio) to quantify the platelet sequestration pattern and outcome post splenectomy, based on platelet counts. Results A total of 45 patients were identified, 13 underwent splenectomy and 32 were medically managed. Patients with favourable ILAPS scans (pure or predominant splenic sequestration) demonstrated a superior response post splenectomy (100% overall response rate (ORR), 83.5% complete remission (CR)) compared to those with unfavourable ILAPS scans (mixed or pure hepatic sequestration) (71.4% ORR, 57.1% CR) over 12 months. Conclusions The use of ILAPS in the Australian setting is feasible and this experience confirms larger international studies demonstrating its utility as a predictor of response to splenectomy in ITP. An unfavourable ILAPS scan could be considered a negative predictor of response prompting consideration for other emerging ITP treatments such as thrombopoietin-receptor agonists (TPO-RAs) or B-cell depleting therapy such as Rituximab. This article is protected by copyright. All rights reserved.

To investigate the factor structure of the Agitated Behavior Scale (ABS) in patients with traumatic brain injury (TBI) in posttraumatic amnesia (PTA).Inpatient TBI rehabilitation ward in Victoria, Australia.A total of 364 patients aged 16 to 92 years meeting diagnostic criteria for TBI and PTA admitted between September 2013 and October 2020.Retrospective cohort study utilizing electronic medical record data.The ABS and the Westmead Post-Traumatic Amnesia Scale (WPTAS).Exploratory factor analysis uncovered 2 moderately correlated underlying factors (0.52), labeled Restlessness and Aggression/Lability. Two items failed to demonstrate sufficiently large loadings on either factor. Both factors demonstrated adequate reliability (Cronbach α = 0.87 and 0.81 for Restlessness and Aggression/Lability, respectively). Linear regression indicated that higher WPTAS scores were associated with lower levels of Restlessness (β = -.14, P.001), supporting construct validity. Conversely, WPTAS scores were not significantly associated with Aggression/Lability (β = -.12, P = .08). Subgroup analysis indicated that a history of mood disorder was associated with greater severity of Aggression/Lability (P = .02). Confirmatory factor analysis indicated superior fit of the identified 2-factor solution when compared with previously explored 1-, 2-, 3-, and 4-factor structures.This study suggests that the latent structure of the ABS is best explained by a single construct of agitation with 2 discrete facets reflecting Restlessness and Aggression/Lability. These subscales may be used in clinical practice to evaluate the severity of different aspects of agitated behavior, inform treatment decisions, and judge the efficacy of interventions over time. Further research is required to explain low factor loadings demonstrated by 2 items.

Like other assisted reproductive technology (ART) procedures, the cost of egg freezing (EF) is significant, presenting a potential barrier to access. Given recent technological advancements and rising demand for EF, it is timely to reassess how EF is funded. An online cross-sectional survey was conducted in Victoria, Australia and was completed by 656 female individuals. Participants were asked their views on funding for both medical and non-medical EF. The median age of participants was 28 years (interquartile range 23–37 years) and most participants were employed (44% full-time, 28% part-time, 33% students). There was very high support for public funding for medical EF (n = 574, 87%), with 302 (46%) participants indicating support for the complete funding of medical EF through the public system. Views about funding for non-medical EF were more divided; 43 (6%) participants supported full public funding, 235 (36%) supported partial public funding, 150 (23%) supported coverage through private health insurance, and 204 (31%) indicated that non-medical EF should be self-funded. If faced with the decision of what to do with surplus eggs, a high proportion of participants indicated that they would consider donation (71% to research, 59% to a known recipient, 52% to a donor programme), indicating that eggs surplus to requirements could be a potential source of donor eggs. This study provides insights that could inform policy review, and suggests revisiting whether the medical/non-medical distinction is a fair criterion to allocate funding to ART.

Objectives The saline suppression test (SST) serves to confirm the diagnosis of primary aldosteronism (PA), while adrenal vein sampling (AVS) is used to subtype PA as unilateral or bilateral. Criteria that can accurately identify those with bilateral PA based on SST results could reduce the need for AVS. We previously demonstrated that a combination of plasma aldosterone concentration (PAC) < 300 pmol L−1 and a reduction in aldosterone-to-renin ratio (ARR) following recumbent SST had high specificity for predicting bilateral PA in an Australian cohort of 92 patients with PA who have undergone AVS. We sought to validate our predictive criteria in larger, independent cohorts of patients with PA. Design An international, multi-centre cohort study. Methods Data from 55 patients at Monash Health, Victoria, Australia, 106 patients from the First Affiliated Hospital of Chongqing Medical University, China, and 105 patients from Nihon University Itabashi Hospital, Japan were analysed. Results A combination of PAC Conclusion In patients undergoing the recumbent SST, a post-saline PAC

Objectives: The health and well-being of older women may be influenced by frailty and low socioeconomic status (SES). This study examined the association between frailty and SES, healthcare utilisation and quality of life (QOL) among older women in regional Australia. Methods: Cross-sectional analysis of the Geelong Osteoporosis Study was conducted on 360 women (ages ≥60yr) in the 15-year follow up. Frailty was identified using modified Fried’s phenotype. Individual SES measures and healthcare utilisation were documented by questionnaire. Area-based SES was determined by cross-referencing residential addresses with the Australian Bureau of Statistics Index of Relative Socio-economic Advantage and Disadvantage (IRSAD). QOL was measured using the Australian World Health Organisation Quality of Life Instrument (WHOQoL-Bref). Multinomial logistic regression was conducted with frailty groupings as outcome. Results: Sixty-two (17.2%) participants were frail, 199 (55.3%) pre-frail and 99 (27.5%) robust. Frail participants were older with higher body mass index. Frailty was associated with lower education but not marital status, occupation or IRSAD. Strong associations with frailty were demonstrated for all WHOQoL-Bref domains. Frailty was associated with more primary care doctor visits (p

BACKGROUND On 29 November 2017, the Victorian Parliament passed the Voluntary Assisted Dying (VAD) Act 2017, which came into effect on 19 June 2019. AIMS To investigate whether staff from a large regional health service support the legalisation of VAD and the implementation of VAD at their workplace. METHODS Staff were invited to complete an anonymous online survey comprising both closed- and open-ended questions. RESULTS Thirty-eight percent of the workforce (n = 1624) responded to the survey. Most participants supported the legalisation of VAD (88%), the provision of eligibility assessment and/or the administration of VAD within the health service (80%). There were negligible differences in support for VAD by role; however, specialist doctors were significantly less supportive (65%). Approximately half of the respondents expressed concern about monitoring (49%) or implementation (53%) of VAD. Concerns were also raised about assessment of eligibility, support for staff involved in VAD and pressure on both patients and staff to participate. Nearly three-quarters (71%) of participants agreed that if the health service offers VAD services, a special unit or facility should be available. CONCLUSIONS This study found that health workers have concerns about the implementation of VAD at their workplace but are generally supportive. This article provides information for health services considering the implementation of VAD, about staff concerns and issues that need to be addressed for the successful introduction of VAD.

Several studies have demonstrated a bidirectional relationship between obstructive sleep apnea and primary aldosteronism (PA); however, many of these studies are limited to patients with known obstructive sleep apnea, hypertension, or PA. We evaluated the role of screening for PA in all patients referred for a diagnostic sleep study without selecting for prior diagnoses with these conditions. Plasma aldosterone and renin concentration were measured after an overnight polysomnography. Blood pressure was measured at the sleep center for all patients, while a proportion underwent 24-hour blood pressure monitoring. Of the 85 participating patients, 2 (2.4%) were identified to have likely PA based on an elevated aldosterone:renin ratio and/or clinical characteristics. Another 10 (11.8%) were identified to have possible PA based on their low or normal plasma renin concentration despite taking antihypertensive medications that are known to elevate renin. In participants with both obstructive sleep apnea and hypertension (n=40), the prevalence of likely or possible PA was 30%. However, there was no correlation between aldosterone, rennin, or aldosterone:renin ratio and the apnea-hypopnea index using multiple regression analysis adjusted for interfering medications and hypertension status. The observed high prevalence of possible PA among those with both hypertension and obstructive sleep apnea suggests that they should be routinely screened for PA.

Purpose To evaluate outcomes for men with biochemically recurrent prostate cancer who were selected for transponder-guided salvage radiotherapy (SRT) to the prostate bed alone by 68Ga-labelled prostate-specific membrane antigen positron emission tomography (68Ga-PSMA-PET). Methods This is a single-arm, prospective study of men with a prostate-specific antigen (PSA) level rising to 0.1–2.5 ng/mL following radical prostatectomy. Patients were staged with 68Ga-PSMA-PET and those with a negative finding, or a positive finding localised to the prostate bed, continued to SRT only to the prostate bed alone with real-time target-tracking using electromagnetic transponders. The primary endpoint was freedom from biochemical relapse (FFBR, PSA > 0.2 ng/mL from the post-radiotherapy nadir). Secondary endpoints were time to biochemical relapse, toxicity and patient-reported quality of life (QoL). Results Ninety-two patients (median PSA of 0.18 ng/ml, IQR 0.12–0.36), were screened with 68Ga-PSMA-PET and metastatic disease was found in 20 (21.7%) patients. Sixty-nine of 72 non-metastatic patients elected to proceed with SRT. At the interim (3-year) analysis, 32 (46.4%) patients (95% CI 34.3–58.8%) were FFBR. The median time to biochemical relapse was 16.1 months. The rate of FFBR was 82.4% for ISUP grade-group 2 patients. Rates of grade 2 or higher gastrointestinal and genitourinary toxicity were 0% and 15.2%, respectively. General health and disease-specific QoL remained stable. Conclusion Pre-SRT 68Ga-PSMA-PET scans detect metastatic disease in a proportion of patients at low PSA levels but fail to improve FFBR. Transponder-guided SRT to the prostate bed alone is associated with a favourable toxicity profile and preserved QoL. Trial registration number ACTRN12615001183572, 03/11/2015, retrospectively registered.

Background Personality disorder (PD) may affect the efficacy of pharmacological interventions for mood disorders, but the extent to which this occurs is uncertain. We aimed to examine the available published evidence concerning the role of PD in pharmacological treatment outcomes of randomised controlled trials (RCTs) for adults with mood disorders (i.e. depressive and bipolar spectrum disorders). Methods A systematic search of Cochrane Central Register of Controlled Clinical Trials, PubMed, EMBASE, PsycINFO, CINAHL Complete, and Google Scholar databases was undertaken to identify studies of interest. Data were independently extracted by two reviewers. The Cochrane Risk of Bias tool was used to assess methodological quality and risk of bias. A random effects model was utilised and statistical heterogeneity was assessed using the I2 statistic. This systematic review was registered with PROSPERO (CRD42018089279) and the protocol is published. Results The search yielded 11,640 studies. Subsequent to removing duplicates, 9657 studies were screened at title and abstract stage and 1456 were assessed at full-text stage. Eighteen studies met criteria for inclusion in this review. Meta-analysis did not reveal a significant difference between groups for treatment outcome (standardised mean difference 0.22 [-0.09, 0.54]; I2: 69%, p=0.17) and remission (risk ratio 0.84 [0.64, 1.11]; I2: 51%, p=0.22). Limitations This review was limited by lack of studies on bipolar disorder. Conclusion PD comorbidity does not appear to affect treatment efficacy of pharmacological interventions for adults with mood disorders.

BACKGROUND: Adrenal vein sampling (AVS) is crucial for accurate lateralization of aldosterone excess but it is technically challenging due to the difficulty of adrenal vein cannulation. The use of adrenocorticotropic hormone (ACTH) to improve cannulation success is controversial and can lead to discordant lateralization outcomes. OBJECTIVE: To evaluate the utility of ACTH in two centres with different levels of AVS expertise and formulate a strategy for interpreting discordant results. DESIGN: A retrospective cross-sectional analysis of AVS results and postoperative patient outcomes. SETTING: Two large tertiary hospitals with harmonized AVS protocols where adrenal venous samples are collected both before and after ACTH stimulation. MEASUREMENTS: Cannulation success (measured by selectivity index, SI), lateralization (measured by lateralization index, LI) and postoperative biochemical cure. RESULTS: Number of AVS procedures judged to have successful bilateral adrenal vein cannulation increased from 53% pre- to 73% post-ACTH. The increase in cannulation success was significantly higher in centre where AVS was performed by multiple radiologists with a lower basal success rate. In both centres, the proportion of cases deemed to display lateralization significantly decreased with the use of ACTH (70% pre- to 52% post-ACTH). Based on postoperative outcomes of patients with discordant results who underwent unilateral adrenalectomy, the combination of LI >3 pre-ACTH and LI >2 post-ACTH was predictive of a biochemical cure. CONCLUSION: Adrenocorticotropic hormone can increase the rate of cannulation success during AVS at the expense of reduced lateralization. The criteria for lateralization should be carefully determined based on local data when ACTH is used.

OBJECTIVE Current Endocrine Society Clinical Practice Guidelines use a specific aldosterone/renin ratio (ARR) threshold to screen for primary aldosteronism (a treatable disease causing up to 15% of hypertension in primary care) in all patients. We sought to characterize demographic variations in the ARR, hypothesizing a need for age- and sex-specific reference ranges to improve the accuracy of the test. DESIGN Retrospective cross-sectional analysis of ARR measurements at a single tertiary hospital from December 2016 to June 2018. PATIENTS A total of 442 patients with clinically indicated ARR were included, after excluding those who were on spironolactone or the oral contraceptive pill, were pregnant or had an existing adrenal condition. MEASUREMENTS Aldosterone, renin and the ARR. RESULTS Among those aged 20-39 years (n = 74), females had significantly higher median aldosterone (369 vs 244 pmol/L, P = .028), lower median renin (17.0 vs 27.6 mIU/L, P = .034) and higher median ARR (20.7 vs 10.3 (pmol/L)/(mIU/L), P = .001) than males, despite having lower systolic (135 vs 145 mmHg, P = .021) and diastolic (89 vs 96.5 mmHg, P = .007) blood pressure. The ≥ 60-year age group (n = 157) also had significant sex differences in the ARR. With increasing age (20-39 vs ≥ 60 years), there was a significant fall in plasma aldosterone in females (369 pmol/L vs 264 pmol/L, P = .005), with no change observed in males. CONCLUSIONS For those 20-39 years old, aldosterone and the ARR are significantly higher in females despite a lower systolic and diastolic BP, highlighting the potential for false-positive results. Our findings indicate the need for prospective studies with a control population to define age- and sex-specific ARR reference ranges.

ObjectiveTo assess the predictive value of bronchial hyper-responsiveness (BHR) for the subsequent development of respiratory symptoms, airflow limitation and decline in lung function among aluminium smelter workers.MethodsAn inception cohort study of new employees at two Australian aluminium smelters was conducted. Participants completed a modified British Medical Research Council respiratory questionnaire, spirometry and a methacholine bronchial challenge test at baseline and at annual follow-up reviews. BHR was defined as PD20 ≤4000 µg. Poisson and mixed effects models were fitted to respiratory symptoms and lung function (forced expiratory volume in 1 s (FEV1) and FEV1/forced vital capacity (FVC)).ResultsBaseline interview and lung function testing were completed by 278 workers, who were followed for a median of 4 years. BHR at baseline, present in 82 workers, was not associated with incident wheeze risk ratio (RR)=1.07 (95% CI 0.74 to 1.55) and cough RR=0.78 (95% CI 0.45, 1.35), but there was some increased risk of chest tightness RR=1.40 (95% CI 0.99, 1.98) after adjustment for age, sex, smoking and atopy. BHR at baseline was associated with lower FEV1 and FVC, although the rate of annual decline in FEV1 or FVC was similar between those with or without BHR. The specificity of BHR was 77% for wheeze, 70% for cough and 77% for chest tightness, but the sensitivity was poor, at 33%, 24% and 39%, respectively.ConclusionMethacholine challenge testing at entry to employment was not sufficiently predictive of later adverse respiratory outcomes, and notwithstanding the study limitations is unlikely to be a useful pre-employment or preplacement screening test in the aluminium smelting industry.

BACKGROUND: The advantages of simultaneous bilateral total knee arthroplasty (sim-BTKA) remain controversial. This study investigated the effects of two-surgeon sim-BTKA compared to separate admission staged BTKA regarding intraoperative and post-operative outcomes and health service costs. METHODS: Patients underwent sim-BTKA or staged BTKA between 1 November 2008 and 30 June 2016. Data were extracted from a joint replacement registry and medical records. Median regression and chi-squared tests were used for between-group comparisons. RESULTS: Median hospital total length of stay was 5 days less for sim-BTKA (n = 122) than staged BTKA group (n = 46) (7 versus 12; 95% confidence interval (CI) 3.9, 6.1), and 9 days less for inpatient rehabilitation (17 versus 26; 95% CI 3.7, 14.3). However, 80% of sim-BTKA patients went to inpatient rehabilitation (versus 27% following staged BTKA), so median total length of stay was 9 days less for staged BTKA (13 versus 22; 95% CI -12.8, -5.2). Total anaesthesia time was 135 min less for sim-BTKA (P

To examine the association between brain magnetic resonance imaging (MRI) characteristics and executive function and bimanual performance in children with unilateral cerebral palsy (CP).Clinical MRI brain scans were classified as: (1) predominant pathological pattern (normal, white matter injury [WMI]; grey matter injury; focal vascular insults [FVI]; malformations; or miscellaneous); and (2) focal lesions (frontal, basal ganglia, and/or thalamus). Assessments included: (1) bimanual performance; (2) unimanual dexterity; and (3) executive function tasks (information processing, attention control, cognitive flexibility, and goal setting) and behavioural ratings (parent).From 131 recruited children, 60 were ineligible for analysis, leaving 71 children (47 males, 24 females) in the final sample (mean age 9y [SD 2y], 6y-12y 8mo). Brain MRIs were WMI (69%) and FVI (31%); and frontal (59%), thalamic (45%), basal ganglia (37%), and basal ganglia plus thalamic (21%). Bimanual performance was lower in FVI versus WMI (p0.003), and with frontal (p=0.36), basal ganglia (p=0.032), and thalamic/basal ganglia lesions (p=0.013). Other than information processing, executive function tasks were not associated with predominant pattern. Frontal lesions predicted attention control (p=0.049) and cognitive flexibility (p=0.009) but not goal setting, information processing, or behavioural ratings.Clinical brain MRI predicts cognitive and motor outcomes when focal lesions and predominate lesion patterns are considered. What this paper adds Early brain magnetic resonance imaging (MRI) predicts bimanual performance and cognitive outcomes. Brain MRI may identify children requiring targeted interventions. Basal ganglia with/without thalamic lesions predicted bimanual performance. Frontal lesions were associated with attention control and cognitive flexibility. Brain MRI predominant patterns predicted motor, not cognitive outcomes, other than information processing.La resonancia magnética cerebral es un predictor del rendimiento bimanual y la función ejecutiva en niños con parálisis cerebral unilateral OBJETIVO: Examinar la asociación entre las características de la resonancia magnética cerebral (RMN) y la función ejecutiva y el rendimiento bimanual en niños con parálisis cerebral unilateral (PC). MÉTODO: Los escáneres cerebrales de resonancia magnética clínica se clasificaron como: (1) patrón patológico predominante (normal, lesión de la sustancia blanca [WMI]; lesión de la materia gris; lesiones vasculares focales [FVI]; malformaciones; o varios); y (2) lesiones focales (ganglios frontales, basales y / o tálamo). Las evaluaciones incluyeron: (1) desempeño bimanual; (2) destreza unimanual; y (3) tareas de funciones ejecutivas (procesamiento de información, control de atención, flexibilidad cognitiva y fijación de objetivos) y calificaciones de comportamiento (padres). RESULTADOS: De 131 niños reclutados, 60 no fueron elegibles para el análisis, dejando 71 niños (47 varones, 24 mujeres) en la muestra final (edad media 9 años [DE 2 años], 6 años - 12 años 8 meses). Las RMN cerebrales fueron WMI (69%) y FVI (31%); y frontal (59%), talámico (45%), ganglios basales (37%) y ganglios basales más talámico (21%). El rendimiento bimanual fue menor en FVI versus WMI (p0,003), y con lesiones frontales (p = 0,36), ganglios basales (p = 0,032) y talámicas / ganglios basales (p = 0,013). Aparte del procesamiento de la información, las tareas de la función ejecutiva no se asociaron con el patrón predominante. Las lesiones frontales predijeron el control de la atención (p = 0,049) y la flexibilidad cognitiva (p = 0,009) pero no el establecimiento de objetivos, el procesamiento de la información o las clasificaciones de comportamiento. INTERPRETACIÓN: La resonancia magnética cerebral clínica predice los resultados cognitivos y motores cuando se consideran las lesiones focales y los patrones de lesiones predominantes.Imagem por ressonância magnética do cérebro como preditora do desempenho bimanual e função executiva de crianças com paralisia cerebral unilateral OBJETIVO: Examinar a associação entre as características do exame de imagem por ressonância magnética (IRM) e a função executiva e desempenho bimanual em crianças com paralisia cerebral (PC) unilateral. MÉTODO: Escaneamentos clínicos de IRM cerebrais foram classificados como: 1) padrão patológico predominante (normal, lesão da substância branca [LSB]; lesão da substância cinzenta; insultos vasculares focais [IVF]; malformações; ou outro); e (2) lesões focais (frontal, gânglios basais, e/ou tálamo). As avaliações incluíram: (1) desempenho bimanual; (2) destreza unimanual; e (3) tarefas de função executiva (processamento de informações, controle da atenção, flexibilidade cognitiva, e estabelecimento de metas) e pontuações comportamentais (pais). RESULTADOS: De 131 crianças recrutadas, 60 eram inelegíveis para análise, restando 71 crianças (47 do sexo masculino, 24 do sexo feminino) na amostra final (média de idade 9a [DP 2a], 6a-12a 8m). IRMs cerebrais eram do tipo LSB (69%) e IVFs (31%); e frontais (59%), talâmicas (45%), de gânglios da base (37%), e de gânglios da base mais talâmicas (21%). O desempenho bimanual foi menor em IVF versus LSB (p0,003), e com lesões frontais (p=0,36), gânglios da base (p=0,032), e talâmicas/gânglios da base (p=0,013). Com exceção do processamento de informações, as tarefas da função executiva não foram associadas com o padrão predominante. Lesões frontais foram preditivas do controle da atenção (p=0,049) e flexibilidade cognitiva (p=,.009) mas não do estabelecimento de metas, processamento de informações, e pontuações comportamentais. INTERPRETAÇÃO: A IRM cerebral clínica prediz resultados cognitivos e motores quando lesões focais e padrões predominantes de lesão são considerados.

ObjectivesPrimary aldosteronism (PA), the most common endocrine cause of hypertension, is associated with a higher risk of cardiovascular disease (CVD) than blood pressure (BP)-matched essential hypertension (EH). We aimed to compare the calculated risks of CVD in patients who had hypertension with PA or EH using CVD risk calculators, hypothesising that they will fail to recognise the increased CVD risk in PA.DesignCross-sectional analysis.SettingAn endocrine hypertension service in Victoria, Australia.ParticipantsPatients who had hypertension without CVD referred for the investigation of hypertension.Outcome measuresCalculated 5-year or 10-year CVD risk as predicted by the National Vascular Disease Prevention Alliance (NVDPA) algorithm, Framingham Risk Score, Pooled Cohort Equations and QRISK3.ResultsThose with PA (n=128) and EH (n=133), did not differ significantly in their calculated CVD risks with the NVDPA algorithm (moderate-to-high 5-year risk 36/100 vs 45/99, p=0.17); the Framingham Risk Score (median 10-year risk 7.72% (4.43%–12.95%) vs 6.84% (3.85%–10.50%), p=0.14); the Pooled Cohort Equations (median 10-year risk 9.45% (4.36%–15.37%) vs 7.90% (2.09%–14.73%), p=0.07); and QRISK3 (median 10-year risk 11.31% (7.22%–20.29%) vs 12.47% (5.10%–19.93%), p=0.51). Similarities persisted on regression analyses accounting for systolic BP.ConclusionsCVD risk algorithms do not reflect the increased risk of CVD in patients with PA, and likely underestimate the true risk of CVD among those with PA. Screening for PA, in addition to using the CVD risk algorithm in patients who had hypertension, may facilitate the targeted treatment of PA and minimisation of cardiovascular risk in affected individuals.

Recent studies have demonstrated the risk of contrast-associated acute kidney injury (CA-AKI) is low post-multimodal computed tomography (MMCT) in the evaluation of acute stroke. We provide a complementary study with long-term renal follow up. A retrospective analysis was performed on all suspected strokes from January 2019 to June 2020 for those who had undergone computed tomography angiography, computed tomography perfusion or both. We identified 776 cases, of which 538 were excluded. The incidence of CA-AKI was 7.6% (n/N = 18/238; 95% confidence interval = 4.2-11.0). All CA-AKI cases had renal confounders. No AKI at30 days was found in 60.5% (n = 144) of all cases studied. The long-term renal outcome post-MMCT in stroke evaluation is favourable at30 days.

Since 2014, many companies have followed the lead of Apple and Facebook and now offer financial support to female employees to access egg freezing. Australian companies may soon make similar offers...

AIM To evaluate the trend in presentation and postoperative outcomes of infants with hypertrophic pyloric stenosis (HPS) over the last decade. METHODS This was a multicentre retrospective study in two tertiary paediatric centres between 2005 and 2015 inclusive. Participants included 626 infants who underwent a pyloromyotomy for HPS. We collected data on presentation features (age, weight, clinical signs, blood gas results, ultrasound findings) and postoperative outcomes (length of stay (LOS), complications, time to first postoperative feed). RESULTS No trend was identified during the study period with regards to age, weight, biochemical findings (pH, chloride, base excess) or pre-operative ultrasound measurements. There was a downtrend in the number of palpated tumours over time, with a mean of 36% of tumours clinically palpated. Pyloric wall thickness had a moderate association with LOS in patients admitted for >8 days (correlation = 0.4752) but had a weak negative association with shorter lengths of stay (≤8 day, correlation = -0.094). Overall, median time to first feed was 7.80 h and improved yearly during the study period (hazard ratio = 1.07). CONCLUSIONS Patients presenting with HPS are not being identified at an earlier age or with fewer biochemical derangements, in contrast to our initial perceptions. Subsequently, biochemical derangements can still play an important role in the diagnosis of HPS, and attention needs to be given to fluid management and electrolyte correction in all patients with HPS.

Despite many interventions aiming to reduce excessive gestational weight gain (GWG), it is currently unclear the impact on infant anthropometric outcomes. The aim of this review was to evaluate offspring anthropometric outcomes in studies designed to reduce GWG. A systematic search of seven international databases, one clinical trial registry and three Chinese databases was conducted without date limits. Studies were categorised by intervention type: diet, physical activity (PA), lifestyle (diet + PA), other, gestational diabetes mellitus (GDM) (diet, PA, lifestyle, metformin and other). Meta-analyses were reported as weighted mean difference (WMD) for birthweight and birth length, and risk ratio (RR) for small for gestational age (SGA), large for gestational age (LGA), macrosomia and low birth weight (LBW). Collectively, interventions reduced birthweight, risk of macrosomia and LGA by 71 g (WMD: −70.67, 95% CI −101.90 to −39.43,PP=0.026) and 19% (RR: 0.81, 95% CI 0.69–0.96,P=0.015), respectively. Diet interventions decreased birthweight and LGA by 99 g (WMD −98.80, 95% CI −178.85 to −18.76,P=0.016) and 65% (RR: 0.35, 95% CI 0.17–0.72,P=0.004). PA interventions reduced the risk of macrosomia by 51% (RR: 0.49, 95% CI 0.26–0.92,P=0.036). In women with GDM, diet and lifestyle interventions reduced birthweight by 211 and 296 g, respectively (WMD: −210.93, 95% CI −374.77 to −46.71,P=0.012 and WMD:−295.93, 95% CI −501.76 to −90.10,P=0.005, respectively). Interventions designed to reduce excessive GWG lead to a small reduction in infant birthweight and risk of macrosomia and LGA, without influencing the risk of adverse outcomes including LBW and SGA.

Background Pseudomonas aeruginosa bacteraemia (PAB) is associated with high mortality. The benefits of infectious diseases consultation (IDC) has been demonstrated in Staphylococcal aureus bacteraemia and other complex infections. Impact of IDC in PAB is unclear. This study aimed to evaluate the impact of IDC on the management and outcomes in patients with PAB. Methods This is a retrospective cohort single-centre study from 1 November 2006 to 29 May 2019, in all adult patients admitted with first episode of PAB. Data collected included demographics, clinical management and outcomes for PAB and whether IDC occurred. In addition, 29 Pseudomonas aeruginosa (PA) stored isolates were available for Illumina whole genome sequencing to investigate if pathogen factors contributed to the mortality. Results A total of 128 cases of PAB were identified, 71% received IDC. Patients who received IDC were less likely to receive inappropriate duration of antibiotic therapy (4.4%; vs 67.6%; p p p = 0.049) and undergo surgical intervention (20.9% vs 5.4%, p = 0.023) for source control. The overall 30-day all-cause mortality rate was 24.2% and was significantly higher in the no IDC group in both unadjusted (56.8% vs 11.0%, odds ratio [OR] = 10.63, p Conclusion Patients who received IDC for PAB had lower 30-day mortality, better source control and management was more compliant with guidelines. Further prospective studies are necessary to determine if these results can be validated in other settings.

Background: Hypertension tracks throughout childhood into adulthood. Aldosterone excess, or primary aldosteronism, has been reported as the most common secondary cause of hypertension in adults. Elevated aldosterone in the setting of low renin predicts incident hypertension in normotensive adults. However, the relationship between aldosterone and blood pressure in adolescents and young adults is unclear. Objectives: To evaluate the relationship between aldosterone, renin and the aldosterone:renin ratio (ARR) and blood pressure (BP) at age 17y as well as BP at age 27y in a community-based population. Methods: This is a prospective birth cohort study. Young adult offspring (Gen2) of women enrolled during pregnancy into the Raine Study, with 1239 at age 17y and 1006 at age 27y, were evaluated. Females taking hormonal contraception and participants without BP data were excluded from the current analysis. A generalised linear model was used to examine the relationship between BP and aldosterone, renin and ARR over time. The median aldosterone, renin and ARR was compared between sexes using quantile regression. Results: At 17y, females had similar aldosterone (349 vs 346 pmol/L, p=0.833) but significantly lower renin (20.6 vs 25.7 mU/L, p

Objective Primary aldosteronism (PA) is a potentially curable cause of hypertension associated with worse cardiovascular prognosis than blood pressure-matched essential hypertension (EH). Effective targeted treatment for PA is available with the greatest benefit seen if treatment is started early, prior to the development of end-organ damage. However, PA is currently substantially under-diagnosed. The standard screening test for PA, the aldosterone-to-renin ratio (ARR), is performed infrequently in both primary and tertiary care. In contrast, ambulatory blood pressure monitoring (ABPM) is frequently utilized in the assessment of hypertension. The aim of this study was to compare ABPM parameters in hypertensive patients with and without PA, in order to identify features of ABPM associated with PA that can prompt screening. Study design Patients with PA (n = 55) were identified from a tertiary clinic specializing in the management of endocrine causes of hypertension whilst the controls (n = 389) were consecutive patients with hypertension but without a known diagnosis of PA who were referred for ABPM. Results In this study, PA patients were younger and had higher 24-h, day, and night-time blood pressure compared with controls despite similar number of antihypertensive medications. However, there was no significant difference in nocturnal dipping or day-night blood pressure variability between the two groups. Conclusions An elevated ambulatory blood pressure in patients on multiple antihypertensives could suggest underlying PA but in the absence of other distinguishing features, ABPM could not reliably differentiate PA from other forms of hypertension. Routine biochemical screening for PA remained the most reliable way of detecting this treatable secondary cause of hypertension.

Background Malnutrition is common in patients with chronic kidney disease (CKD) on dialysis. Oral protein-based nutritional supplements are often provided to patients whose oral intake is otherwise insufficient to meet their energy and protein needs. Evidence for the effectiveness of oral protein-based nutritional supplements in this population is limited. Objectives The aims of this review were to determine the benefits and harms of using oral protein-based nutritional supplements to improve the nutritional state of patients with CKD requiring dialysis. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 12 December 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) of patients with CKD requiring dialysis that compared oral protein-based nutritional supplements to no oral protein-based nutritional supplements or placebo. Data collection and analysis Two authors independently assessed studies for eligibility, risk of bias, and extracted data from individual studies. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference and 95% CI for continuous outcomes. Main results Twenty-two studies (1278 participants) were included in this review. All participants were adults on maintenance dialysis of whom 79% were on haemodialysis (HD) and 21% peritoneal dialysis. The follow-up period ranged from one to 12 months. The majority of studies were at unclear risk of selection, performance, and reporting bias. The detection bias was high for self-reported outcomes. Oral protein-based nutritional supplements probably lead to a higher mean change in serum albumin compared to the control group (16 studies, 790 participants: MD 0.19 g/dL, 95% CI 0.05 to 0.33; moderate certainty evidence), although there was considerable heterogeneity in the combined analysis (I2 = 84%). The increase was more evident in HD participants (10 studies, 526 participants: MD 0.28 g/dL, 95% CI 0.11 to 0.46; P = 0.001 for overall effect) and malnourished participants (8 studies, 405 participants: MD 0.31 g/dL, 95% CI 0.10 to 0.52, P = 0.003 for overall effect). Oral protein-based nutritional supplements also probably leads to a higher mean serum albumin at the end of the intervention (14 studies, 715 participants: MD 0.14 g/dL, 95% CI 0 to 0.27; moderate certainty evidence), however heterogeneity was again high (I2 = 80%). Again the increase was more evident in HD participants (9 studies, 498 participants: MD 0.21 g/dL, 95% CI 0.03 to 0.38; P = 0.02 for overall effect) and malnourished participants (7 studies, 377 participants: MD 0.25 g/dL, 95% CI 0.02 to 0.47; P = 0.03 for overall effect). Compared to placebo or no supplement, low certainty evidence showed oral protein-based nutritional supplements may result in a higher serum prealbumin (4 studies, 225 participants: MD 2.81 mg/dL, 95% CI 2.19 to 3.43), and mid-arm muscle circumference (4 studies, 216 participants: MD 1.33 cm, 95% CI 0.24 to 2.43) at the end of the intervention. Compared to placebo or no supplement, oral protein-based nutritional supplements may make little or no difference to weight (8 studies, 365 participants: MD 2.83 kg, 95% CI -0.43 to 6.09; low certainty evidence), body mass index (9 studies, 368 participants: MD -0.04 kg/m2, 95% CI -0.74 to 0.66; moderate certainty evidence) and lean mass (5 studies, 189 participants: MD 1.27 kg, 95% CI -1.61 to 4.51; low certainty evidence). Due to very low quality of evidence, it is uncertain whether oral protein-based nutritional supplements affect triceps skinfold thickness, mid-arm circumference, C-reactive protein, Interleukin 6, serum potassium, or serum phosphate. There may be little or no difference in the risk of developing gastrointestinal intolerance between participants who received oral protein-based nutritional supplements compared with placebo or no supplement (6 studies, 426 participants: RR 2.81, 95% CI 0.58 to 13.65, low certainty evidence). It was not possible to draw conclusions about cost or quality of life, and deaths were not reported as a study outcome in any of the included studies. Authors' conclusions Overall, it is likely that oral protein-based nutritional supplements increase both mean change in serum albumin and serum albumin at end of intervention and may improve serum prealbumin and mid-arm muscle circumference. The improvement in serum albumin was more evident in haemodialysis and malnourished participants. However, it remains uncertain whether these results translate to improvement in nutritional status and clinically relevant outcomes such as death. Large well-designed RCTs in this population are required.

Background Inappropriate and excessive antimicrobial prescribing can lead to antimicrobial resistance. Antimicrobial Stewardship (AMS) principles are not well established in general practice in Australia despite the relatively high rate of community antimicrobial prescribing. Few interventions have been implemented that have resulted in a significant reduction or improvement in antimicrobial prescribing by General Practitioners (GPs). This study was therefore conducted to assess the impact of a novel GP educational intervention on the appropriateness of antimicrobial prescriptions as well as GP compliance with antimicrobial prescription guidelines. Methods In 2018, a simple GP educational intervention was rolled out in a large clinic with the aim of improving antimicrobial prescribing. It included face-to-face education sessions with GPs on AMS principles, antimicrobial resistance, current prescribing guidelines and microbiological testing. An antibiotic appropriateness audit on prescribing practice before and after the educational intervention was conducted. Data were summarised using percentages and compared across time points using Chi-squared tests and Poisson regression (results reported as risk ratios (RR) with 95% confidence intervals (CI)). Results Data from 376 and 369 prescriptions in July 2016 and July 2018, respectively, were extracted. There were significant improvements in appropriate antimicrobial selection (73.9% vs 92.8%, RR = 1.26; 95% CI = 1.18–1.34), appropriate duration (53.1% vs 87.7%, RR = 1.65; 95% CI = 1.49–1.83) and compliance with guidelines (42.2% vs 58.5%, RR = 1.39, 95% CI = 1.19–1.61) post- intervention. Documentation of antimicrobial duration directions, patient follow-up as well as patient weight significantly increased after the intervention (p p Conclusions Auditing GP antimicrobial prescriptions identified prescribing practices inconsistent with Australian guidelines. However, implementation of a simple education program led to significantly improved antimicrobial prescribing by GPs. These findings indicate the important role of AMS and continued antimicrobial education within general practice.

A common chemical exposure in alumina refining is caustic mist. Although recognized as a strong airways irritant, little is known of the chronic respiratory effects of caustic mist in alumina refining. A suitable metric for caustic mist exposure assessment in alumina refining for epidemiological purposes has not been identified. Peak exposure is likely to be important, but is difficult to assess in epidemiological studies. In this study, we investigate the respiratory effects of caustic mist in an inception cohort (n = 416) of alumina refinery workers and describe the development and use of a peak exposure metric for caustic mist. We then compare the results with a metric based on duration of exposure. Participants were interviewed annually about respiratory symptoms and had a lung function test. Job history data were collected from each interview and levels of caustic mist were measured periodically by air monitoring. We found a weak association between the caustic mist peak exposure metric and reported cough (P for linear trend = 0.079) with the highest peak exposure group odds ratio = 2.32 (95% confidence interval: 1.27, 4.22). For lung function, we found declines in the forced expiratory volume in 1 second and forced vital capacity for changes in annual and absolute lung function for both metrics of exposure, but only the ratio of absolute lung function was statistically associated with an increasing duration of caustic exposure (P for linear trend = 0.011). In this cohort, we did not observe an association with respiratory symptoms or consistent decrements in lung function. There was little difference between the exposure metrics used for investigation of the chronic effects from caustic mist.

Faced with a high likelihood of poor outcome treatment choice is difficult and few people are certain about what they would, or would not, want. Recognising this we sought to explore how individuals react to hypothetical choices made on their behalf by surrogate decision-makers. We used an online survey, using a hypothetical scenario involving a 95% chance of poor outcome and 5% chance of good outcome. There were 510 participants. Most (63%) expressed uncertainty regarding preference for treatment. 37% expressed certainty (12% certainly wanting treatment and 25% certainly not wanting treatment). Seventy seven percent indicated they would be understanding or pleased if the surrogate chose to treat, while 92% were understanding or pleased with a decision not to treat by a surrogate decision maker. Patients who had expressed ‘certain’ wishes when presented with the scenario (either certainly wanting or certainly not wanting treatment) were more likely to be angry/upset when surrogates made the opposite decision. Those who had completed an Advance Care Plan (ACP) were more likely to be angry/upset when these wishes were not followed. This finding suggests it may be unrealistic to expect surrogate decision-makers to identify ‘what the patient would want’ as a binary choice between consenting to treatment or refusing treatment when chances are poor and the decision is difficult. Asking surrogates to identify choices that they believe would be likely to make the person angry or upset might be more appropriate and more effective. Most people were understanding of decisions made by surrogates (whether these matched their preference or not). This finding should be used to reassure surrogates who are required to make difficult decisions. Additionally, factors associated with patient upset/anger at surrogate treatment decisions were identified. This most commonly included those patients who had documented wishes in an Advance Care Plan that was not followed.

Background Information is scarce about the occupational health effects of exposure to alumina dust. This study examines the respiratory effects of inspirable alumina dust exposure in alumina refineries. Methods An inception cohort study at three alumina refineries in Western Australia recruited 416 participants (351 males, 65 females) between 1995 and 2000 who were followed up annually until 2008 or until exit from study. At each health interview a respiratory questionnaire and lung function test was undertaken, measuring forced expiratory volume in one second (FEV1 ) and forced vital capacity (FVC). Participants provided job histories which were combined with air monitoring data to calculate cumulative exposure to inspirable alumina dust (mg/m3 -years). Generalized estimating equations with Poisson distribution and mixed effects models were used to examine the effects of alumina exposure. Results The number of exposed participants was relatively small (n = 82, 19.7%). There was no association between alumina dust exposure and prevalence of cough, wheeze or rhinitis. No associations were found between measures of lung function and tertiles of alumina exposure in the first two follow-ups, or the whole follow-up period, though there was a suggestive dose-response trend across exposed groups for decline in absolute FEV1 (p for trend = .06). For mean annual change in FEV1 and FVC based on the first three follow-ups it was not possible to rule out an effect above a threshold level of exposure. Conclusion There is no evidence of an association between exposure to alumina and the reporting of respiratory symptoms but some evidence for an effect on lung function.

OBJECTIVE To assess the association between the use of a flowchart incorporating Wells score, PERC rule and age-adjusted D-dimer and subsequent imaging and yield rates of computed tomography pulmonary angiogram and nuclear medicine ventilation perfusion scans being ordered in the ED for the assessment of pulmonary embolism. METHODS A flowchart governing ED pulmonary embolism investigation was introduced across three EDs in Melbourne, Australia for a 12 month period. Comparison of pulmonary embolism imaging rates and yield with the preceding 12 months was performed. RESULTS A total of 1815 pre-implementation scans were performed compared with 1116 scans post-implementation. Because of growth in patient attendances over this time, this equated to an imaging rate of 14.5 per 1000 presentations pre-implementation and 8.6 per 1000 presentations post-implementation (P < 0.001). Overall pulmonary embolism imaging yield rates rose from 9.9% to 16.5% (P < 0.001). A total of 179 pre-implementation pulmonary embolisms were identified, with an incidence of 1.4 per 1000 presentations. This compared to 184 pulmonary embolisms post-implementation, with an incidence of 1.4 per 1000 presentations (P = 0.994). CONCLUSION The introduction of a clinical flowchart incorporating Wells score, PERC rule and age-adjusted D-dimer was associated with an increase in ED computed tomography pulmonary angiogram and nuclear medicine ventilation perfusion yield rate from 9.9% to 16.5% across the three enrolment hospitals when investigating possible pulmonary embolism. This corresponded to a 40% relative reduction in pulmonary embolism imaging. Diagnosis rates remained unchanged and no cases of missed pulmonary embolism attributable to the flowchart were identified.

KEY POINTS: Approximately 5–10% pregnancies are affected by fetal growth restriction. Preterm infants affected by fetal growth restriction have a higher incidence of bronchopulmonary dysplasia. The present study is the first to measure pulmonary artery thickness and stiffness. The findings show that impaired vasculogenesis may be a contributory factor in the higher incidence of bronchopulmonary dysplasia in preterm growth restricted infants. The study addresses the mechanistic link between fetal programming and vascular architecture and mechanics. ABSTRACT: Bronchopulmonary dysplasia is the most common respiratory sequelae of prematurity and histopathologically features fewer, dysmorphic pulmonary arteries. The present study aimed to characterize pulmonary artery mechanics and cardiac function in preterm infants with fetal growth restriction (FGR) compared to those appropriate for gestational age (AGA) in the early neonatal period. This prospective study reviewed 40 preterm infants between 28 to 32 weeks gestational age (GA). Twenty infants had a birthweight

Background Enhanced recovery after surgery programs may improve recovery and reduce duration of hospital stay after joint replacement surgery. However, uptake is incomplete, and the relative importance of program components is unknown. This before-and-after quality improvement study was designed to determine whether adding ‘non-surgical’ components, to pre-existing ‘surgical’ components, in an Australian private healthcare setting, would improve patient recovery after total hip replacement. Methods We prospectively collected data regarding care processes and health outcomes of 115 consecutive patients undergoing hip replacement with a single surgeon in a private hospital in Melbourne, Australia. Based on this data, a multidisciplinary team (surgeon, anesthetists, nurse unit managers, physiotherapists, perioperative physician) chose and implemented 12 ‘non-surgical’ program components. Identical data were collected from a further 115 consecutive patients. The primary outcome measure was Quality of Recovery-15 score at 6 weeks postoperatively; the linear regression model was adjusted for baseline group differences. Results The majority of health outcomes, including the primary outcome measure, were similar in pre- and post-implementation groups (quality of recovery score, pain rating and disability score, at time-points up to six weeks postoperatively). The proportion of patients with zero oral morphine equivalent consumption at six weeks increased from 57 to 80% (RR 1.34, 95% CI 1.13, 1.58). Mean (SD) length of hospital stay decreased from 5.94 (5.21) to 5.02 (2.46) days but was not statistically significant once adjusted for baseline group differences. Four of ten measurable program components were successfully implemented. Antiemetic prophylaxis increased by 53% (risk ratio [RR] 95% confidence interval [CI] 1.16, 2.02). Tranexamic acid use increased by 41% (RR 95% CI 1.18, 1.68). Postoperative physiotherapy treatment on the day of surgery increased by 87% (RR 95% CI 1.36, 2.59). Postoperative patient mobilisation ≥ three metres on the day of surgery increased by 151% (RR 95% CI 1.27, 4.97). Conclusions Implementation of a full enhanced recovery after surgery program, and optimal choice of program components, remains a challenge. Improved implementation of non-surgical components of a program may further reduce duration of acute hospital stay, while maintaining quality of recovery. Trial registration Australian New Zealand Clinical Trials Registry (ACTRN12615001170516), 2.11.2015 (retrospective).

Diverticular disease is a common, chronic inflammatory disease of the bowel. This study investigates the differences in body composition between patients with diverticular disease and those without. Appropriate patients were identified using a search of the radiology database. Demographic and disease information was gathered using scanned medical records. Body composition analysis was performed at level L3 using single-slice computed tomography techniques. Two hundred seventy-one patients were included in this study: 83 controls, 93 with diverticulosis and 95 with diverticulitis. Diverticulitis and diverticulosis were associated with a significantly higher visceral fat area (VFA), than the control group (p

Objective The aim of this study was to investigate prevalence of type 2 diabetes (diabetes) and cardiovascular disease (CVD) risk in occupational and industry groups in a large, diverse working population. Methods Five hundred thousand Victorian workers undertook health checks, including lifestyle, anthropometric, and biomedical cardiovascular risk factor assessment. Five-year diabetes (AUSDRISK) and absolute CVD risk were estimated. Results High diabetes and CVD risk was increased in many occupational groups and industries relative to managers and Professional/Scientific/Technical Services, respectively. Significantly more blue-collar workers had high diabetes risk [males prevalence ratio (PR) 1.19 (95% confidence interval, 95% CI 1.17 to 1.20); females 1.34 (95% CI 1.30 to 1.38)], high CVD risk [males 1.45 (95% CI 1.37 to 1.53); females 1.48 (95% CI 1.17 to 1.88], and risk factors including smoking [males 2.26 (95% CI 2.22 to 2.30); females 2.20 (95% CI 2.13 to 2.27)], compared with white-collar workers. Conclusion Targeting occupational and industry groups within sustainable workplace programs could assist in reducing chronic diseases, lowering sickness absence, and improving productivity.

Background Implantable cardiac electronic device (ICED) infections are associated with significant morbidity, mortality and cost. The aim of this study was to perform the first analysis for the cost of ICED infection in Australia. Secondary aims were to provide an update on the incidence, burden and outcomes of ICED infections and an analysis of the hospital ICD-10 codes used for ICED infection admissions. Methods We performed a retrospective study of ICED implantations and infections in the Barwon Health region (BH) and the state of Victoria (Vic) from January 2010 to December 2015 inclusive. Results Sensitivity of ICD-10 code T82.7 was 63.4% (95% CI 46.9–77.8) and specificity was 14.5% (95% CI 9.9–21.1). Infection rates were 1.4 admissions/100,000 persons/year (SD 0.7) in BH and estimated to be 7.9 admissions/100,000 persons/year (95% CI 6.8–9.0) in Vic. Average cost of infection was $670,334/year in BH and estimated to be $14,879,979/year in Vic. Conclusion Rates of ICED infection are decreasing in Victoria. Infections are associated with significant morbidity and cost.

Background: The Monash Lupus Clinic, based at Monash Health in Melbourne, is Australia’s first multi-disciplinary specialist lupus clinic that services a broad community and acts as a research hub, particularly as the foundation site and headquarters of the Australian Lupus Registry and Biobank (ALRB). Since its inception in 2007, the clinic has been co-run by rheumatologists and nephrologists. A carefully curated clinical dataset has been collected since clinic inception. Objectives: We provide an overview of the characteristics and longitudinal outcomes of adult lupus patients treated at the Monash Lupus Clinic over the last ten years. Methods: A ten-year-long dataset from the original Monash Lupus Clinic cohort, of patients subsequently enrolled in the Australian Lupus Registry and Biobank, was used for the analysis. The dataset included information on patient demographics, lupus diagnosis, serological profile, treatments, disease activity, damage accrual and other medical outcomes such as renal failure, adverse pregnancy outcomes and hospitalisations. Descriptive statistics were used to summarise the characteristics of the study population. Bivariate tests and regression analyses were used for comparisons between inception cohort patients, enrolled in the registry within 15 months of their Systemic Lupus Erythematosus (SLE) diagnosis, and existing SLE patients enrolled later in their disease course. Results: Of the 329 enrolled patients, the median age at enrolment was 38.0 years and 87.8% of were female. Most patients were either of Caucasian (48.6%) or Asian (36.5%) ethnicity. Patients were enrolled a median of 4.0 years after their SLE diagnosis; 31.0% of patients were inception cohort patients. Most patients (95.4%) had an abnormal titre of anti-nuclear antibodies; 65.0% of the cohort were positive for anti-dsDNA autoantibodies. Included patients were observed for a median observation period of 3.9 years. The median adjusted mean SLEDAI score over the observation period was 4.0; 49.1% of the cohort spent ≥50% of the observation period in the Lupus Low Disease Activity State and 43.5% had ever had a SLEDAI score ≥10. Just over half (57.4%) had accrued damage at the end of the observation period; however, pleasingly only a very small minority had an adverse pregnancy outcome (2.7%), developed renal failure (2.4%) or died (2.4%) during the observation period. Inception cohort patients did not appear to be different to existing SLE patients except for being a population of patients earlier in their disease course. Conclusion: Running a multi-disciplinary clinic alongside research activity is both feasible and worthwhile. Systematic collection of longitudinal data on SLE patients has shown that adverse outcomes such as end-stage renal disease and death are rare; however, with more than half of the cohort having damage present at the end of the observation period, there is still work to be done to improve outcomes for SLE patients in Australia. Expansion of the Australian Lupus Registry and Biobank beyond the Monash Lupus Clinic will provide further insight into the characteristics and outcomes of SLE patients in Australia and provide a beneficial framework for future studies. Disclosure of Interests: Rachel Koelmeyer Grant/research support from: AstraZeneca, UCB, GSK, Sumanpreet Toor: None declared, StellaMay Gwini: None declared, Vera Golder: None declared, Eric F. Morand Grant/research support from: AstraZeneca, Bristol Myers Squibb, Janssen, Merck Serono, and UCB, Consultant for: AstraZeneca, Eli Lilly, Janssen, and Merck Serono, Speakers bureau: AstraZeneca, Alberta Hoi Grant/research support from: GSK, AstraZeneca, UCB and Merck Serono, Consultant for: Janssen Steering Committee, Speakers bureau: Novartis

Stereotactic body radiotherapy (SBRT) can delay escalation to systemic treatment in men with oligometastatic prostate cancer (PCa). However, large, prospective studies are still required to evaluate the efficacy of this approach in different patient groups. This is the interim analysis of a prospective, single institution study of men relapsing with up to five synchronous lesions following definitive local treatment for primary PCa. Our aim was to determine the proportion of patients not requiring treatment escalation following SBRT. In total, 199 patients were enrolled to receive fractionated SBRT (50 Gray in 10 fractions) to each visible lesion. Fourteen patients were castration resistant at enrolment. The proportion of patients not requiring treatment escalation 2 years following SBRT was 51.7% (95% CI: 44.1-59.3%). The median length of treatment escalation-free survival over the entire follow-up period was 27.1 months (95% CI; 21.8-29.4 months). Prior androgen deprivation therapy (ADT) predicted a significantly lower rate of freedom from treatment escalation at 2 years compared to no prior ADT (odds ratio = 0.21, 95% CI: 0.08-0.54, p = 0.001). There was no difference in the efficacy of SBRT when treating 4-5 vs. 1-3 initial lesions. A prostate-specific antigen (PSA) decline was induced in 75% of patients, with PSA readings falling to an undetectable level in six patients. No late grade three toxicities were observed. These interim results suggest that SBRT can be used to treat up to five synchronous PCa oligometastases to delay treatment escalation.

Background: Primary aldosteronism (PA) has a reported prevalence of up to 30% in cases of resistant hypertension and is associated with worse cardiovascular outcomes than BP-matched essential hypertension (EH), but is substantially under-diagnosed due to the lack of specific symptoms and signs. Ambulatory blood pressure monitoring (ABPM) provides a non-invasive method for evaluating circadian BP variations, offers valuable prognostic information and may help to differentiate PA from EH in patients referred with non-specific hypertension for investigation. Aims: To compare AMBP parameters in hypertensive patients with established PA and those without, and correlate these parameters with cardiovascular outcomes. Methods: AMBP readings were evaluated retrospectively in 453 patients assessed at Monash Heart (the largest cardiology service in Victoria, Australia). Patient demographics, screening aldosterone and renin concentrations and medications were retrieved from medical records. 414 hypertensive patients with presumed EH and 39 PA patients were identified and their cardiovascular events (myocardial infarction, left ventricular hypertrophy, coronary artery disease, atrial fibrillation) were recorded. All parameters are reported as the median [interquartile range], unless stated otherwise. Statistical significance was set at p

Objectives Previously we established that symptoms reported by 1990–1991 Gulf War veterans were correlated and exhibited a pattern with 3 factors (psychophysiological distress, somatic distress and arthroneuromuscular distress), and this pattern was similar to that observed in a military comparison group. In this follow-up study, we examined whether the patterns of symptomatology have changed over time. Methods Using data on 56 symptoms that was collected in 2000–2003 (wave 1) and 2011–2012 (wave 2) from an Australian cohort of Gulf War veterans (veterans) and a military comparison group, exploratory factor analysis was conducted and Tucker9s Congruence Coefficient (TCC) was used to determine factor structure similarity across study groups and waves. Results The results showed that the 3 factors observed at wave 1 were still present at wave 2, and factor structures across study groups and study waves were fairly similar, with TCC ranging 0.86–0.92. Veterans consistently reported more symptoms across all 3 factors. Veterans’ symptomatology specific to psychophysiological distress increased between waves 1 and 2 (ratio of means 1.15; 95% CI 1.07 to 1.25) but psychophysiological distress symptomatology was constant in the comparison group (ratio of means 0.97; 95% CI 0.89 to 1.06). Somatic and arthroneuromuscular distress symptomatology significantly increased over time for both study groups, although at a similar rate. Conclusions While the symptom groupings (measured by the 3 factors) remained unchanged at 10 years of follow-up, and remained comparable between Gulf War and comparison group, symptomatology continued to be elevated in Gulf War veterans than in the comparison group, and was most evident for psychophysiological distress.

Egg freezing (EF) technology has improved significantly over the last decade, giving women more choice over their reproductive futures. Despite this advance, EF brings forth contentious ethical and regulatory issues. Policies controlling access to EF vary around the world and there is a lack of consensus about who should have access and what criteria are relevant in making these decisions. This study aimed to identify views of women about access to EF for both “medical” and “non-medical” risks to infertility. An online survey was administered to women aged between 18 and 60 years in Victoria, Australia between April and May 2018. A total of 1,066 individuals initiated the survey. The median age of the participants was 28 years and 81% were

Background: Anhedonia is a commonly reported symptom among substance-dependent populations that appears to diminish with sustained abstinence. However, previous research has not determined whether anhedonia is dynamically linked to changing patterns of drug use, nor whether it predicts subsequent drug use. Aims: We aimed to test whether changes in illicit opioid use would predict changes in anhedonia, and whether increases in anhedonia would predict further opioid use. Methods: We conducted a longitudinal, observational study, with a convenience sample of 121 participants with current or past-year Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR) opioid dependence recruited from substance use treatment and related services and from pharmacies administering opioid substitution pharmacotherapy. Anhedonia was assessed with the Temporal Experience of Pleasure Scale and frequency of illicit opioid use was assessed using timeline follow-back interviews. Results: There was a significant within-subject effect (β=−0.015; 95% CI −0.02 to −0.01; p=0.001), indicating that participants’ Temporal Experience of Pleasure Scale scores typically declined (i.e. anhedonia increased) following a month with above-average opioid use and Temporal Experience of Pleasure Scale scores rose (i.e. anhedonia reduced) following a month with below-average opioid use. However, Temporal Experience of Pleasure Scale scores did not significantly predict opioid use in the subsequent month (β=−0.04, 95% CI −0.20 to 0.12; p=0.651). Conclusions: Changes in illicit opioid use predict self-reported anhedonia, suggesting a possible causal relationship whereby anhedonia is likely to worsen with frequent drug use and diminish with prolonged abstinence. However, anhedonia does not appear to drive further drug use.

Excessive maternal gestational weight gain (GWG) contributes to generational obesity. Our aim was to explore efficacy and intervention characteristics (trimester, duration, frequency, intensity, and delivery method) of interventions to prevent excessive GWG. CINAHL, Cochrane, EMBASE, LILACS, MEDLINE, PsycINFO, and Scopus were searched up to May 2018 (no date or language restrictions). Keywords and MeSH terms for diet, GWG, intervention, lifestyle, maternal, physical activity, and pregnancy were used to locate randomized-controlled trials (RCTs). The Cochrane Collaboration tool for assessing risk of bias was applied. Eighty-nine RCTs were included. Meta-analysis (60 trials) estimated that women in diet only (WMD: −3.27; 95% CI: −4.96, −1.58, p < 0.01), physical activity (PA) (WMD: −1.02; 95% CI: −1.56, −0.49, p < 0.01), and lifestyle interventions (combining diet and PA) (WMD: −0.84; 95% CI: −1.29, −0.39, p < 0.01) gained significantly less weight than controls. The three eHealth interventions favored neither intervention nor control (WMD: −1.06; 95% CI: −4.13, 2.00, p = 0.50). Meta-regression demonstrated no optimal duration, frequency, intensity, setting, or diet type. Traditional face to face delivery of weight management interventions during pregnancy can be successful. Delivery via eHealth has potential to extend its reach to younger women but needs further evaluation of its success.

© 2018 John Wiley & Sons Ltd Background: The saline suppression test (SST) serves to confirm the diagnosis of primary aldosteronism (PA) whilst adrenal vein sampling (AVS) is used to determine whether the aldosterone hypersecretion is unilateral or bilateral. An accurate prediction of bilateral PA based on SST results could reduce the need for AVS. Aim: We sought to identify SST parameters that reliably predict bilateral PA. Methods: The results from 121 patients undergoing SSTs at Monash Health from January 2010 to January 2018 including screening blood tests, imaging, AVS and histopathology results were evaluated. Patients were subtyped into unilateral or bilateral PA based on AVS and surgical outcomes. Results: Of 113 patients with confirmed PA, 33 had unilateral disease whilst 42 had bilateral disease. In those with bilateral disease, plasma aldosterone concentration (PAC) was significantly lower post-SST, together with a significant fall in the aldosterone-renin ratio (ARR). The combination of PAC

Background Following the 1990–1991 Gulf War, Gulf War veterans (veterans) reported health symptoms more commonly than non-deployed groups. This article examines symptom persistence, incidence and prevalence 20 years on. Methods In 2000–2003 and 2011–2012, a 63-item symptom checklist was administered to 697 veterans and 659 comparison group. Symptomatology was compared using log-binomial regression. Results Both veterans and comparison group reported significantly increased prevalence (3–52%) over time in more than half the symptoms, with a similar overall rate of increase. Half the symptoms had higher incidence (risk-ratios ranged 1.43–1.50) and a quarter were more persistent (risk-ratios ranged 1.12–1.20) in veterans than the comparison group. Conclusions Symptomatology increased in both groups over time, but persisted to a similar extent and had higher incidence among veterans than the comparison group. The gap in symptom prevalence between the two groups remained unchanged. These findings suggest enduring health consequences of Gulf War service. Am. J. Ind. Med. 58:1246–1254, 2015. © 2015 Commonwealth of Australia. American Journal of Industrial Medicine © 2015 Wiley Periodicals, Inc.

Aims: To (i) evaluate the global impact of interventions designed to prevent excessive gestational weight gain (eGWG) on the incidence of gestational diabetes (GDM), and (ii) examine whether the effects differ by pre-conception body mass index (BMI) or ethnicity.Methods: A systematic search of randomised controlled trials (RCTs) with a primary or secondary aim to reduce eGWG was conducted in seven international and three Chinese databases without date limits. Meta-analysis data are reported as relative risk (RR) for GDM incidence for interventions including: diet, physical activity (PA), and lifestyle (diet and PA).Results: Forty-five studies were included, 37 in the meta-analyses. Diet and PA interventions reduced GDM risk by 44% (RR: 0.56, 95% CI: 0.36-0.87) and 38% (RR: 0.62, 95% CI: 0.50-0.78), respectively. Lifestyle interventions and BMI didn't significantly alter GDM risk. PA interventions from Southern-Europe reduced GDM risk by 37% (RR: 0.63, 95% CI: 0.50-0.80). Whereas, diet and lifestyle interventions conducted in Asia reduced GDM risk by 62% (RR: 0.38, 95% CI: 0.24-0.59) and 32% (RR: 0.68, 95% CI: 0.54-0.86), respectively.Conclusion: Diet and PA interventions designed to reduce GWG are more effective than standard care in reducing the incidence of GDM, although the effect varies by region and BMI. The 'one size fits all' approach is not supported. (C) 2018 Elsevier B.V. All rights reserved.

Background Ten years after the 1990–1991 Gulf War (GW), Australian veterans were found to have significantly poorer psychological health and some indicators of poorer physical health. Methods A cohort of GW veterans and matched military comparison group were assessed at baseline (2000–2002) and follow-up (2011–2012), including a 63-item symptom checklist, modified CDC definition of multisymptom illness (MSI), doctor-diagnosed medical conditions since 2001, chronic fatigue and neurological symptom questionnaires. Additional measures e.g. irritable bowel syndrome (IBS) were included at follow-up. Results From baseline, 715/1,330 veterans (54%) and 675/1,449 comparison group (47%) participated at follow-up. Relative to comparison group, GW veterans reported a higher average number of symptoms (ratio of means 1.36, 95% CI 1.24–1.48), higher prevalence of MSI (risk ratio RR 1.60; 1.31–1.95), chronic fatigue RR 1.41 (1.02–1.96), IBS RR 1.64 (1.18–2.27) and 6/40 medical conditions. GW veterans were significantly more likely to report ≥1 RR 1.13 (1.03–1.25) or ≥4 RR 1.32 (1.07–1.64) neuropathic symptoms. From baseline to follow-up, overall, symptom prevalence and MSI increased and remained higher in GW veterans; the gap between GW veterans’ and comparison group symptomatology remained unchanged; chronic fatigue prevalence more than doubled in both groups, and there was a non-significantly greater incidence of chronic fatigue in GW veterans. Conclusions These finding indicate enduring increased health symptoms and longer term adverse physical health outcomes associated with GW service, and highlight the importance of effective detection and management of chronic physical conditions and improved awareness among health practitioners of conditions occurring more commonly in veterans.