Low thyroid function is not associated with an accelerated deterioration in renal function.

BACKGROUND: Chronic kidney disease (CKD) is frequently accompanied by thyroid hormone dysfunction. It is currently unclear whether these alterations are the cause or consequence of CKD. This study aimed at studying the effect of thyroid hormone alterations on renal function in cross-sectional and longitudinal analyses in individuals from all adult age groups. METHODS: Individual participant data (IPD) from 16 independent cohorts having measured thyroid stimulating hormone, free thyroxine levels and creatinine levels were included. Thyroid hormone status was defined using clinical cut-off values. Estimated glomerular filtration rates (eGFR) were calculated by means of the four-variable Modification of Diet in Renal Disease (MDRD) formula. For this IPD meta-analysis, eGFR at baseline and eGFR change during follow-up were computed by fitting linear regression models and linear mixed models in each cohort separately. Effect estimates were pooled using random effects models. RESULTS: A total of 72 856 individuals from 16 different cohorts were included. At baseline, individuals with overt hypothyroidism (n = 704) and subclinical hypothyroidism (n = 3356) had a average (95% confidence interval) -4.07 (-6.37 to -1.78) and -2.40 (-3.78 to -1.02) mL/min/1.73 m2 lower eGFR as compared with euthyroid subjects (n = 66 542). In (subclinical) hyperthyroid subjects (n = 2254), average eGFR was 3.01 (1.50-4.52) mL/min/1.73 m2 higher. During 329 713 patient years of follow-up, eGFR did not decline more rapidly in individuals with low thyroid function compared with individuals with normal thyroid function. CONCLUSIONS: Low thyroid function is not associated with a deterioration of renal function. The cross-sectional association may be explained by renal dysfunction causing thyroid hormone alterations.

The Effect of Media Campaigns, Patient Characteristics, and Presenting Symptoms on Prehospital Delay in Myocardial Infarction Patients: A Prospective Cohort Study.

BACKGROUND: Delays in reperfusion therapy for myocardial infarction (MI) are associated with increased mortality and morbidity, and most of this delay is due to delay in patients initiating contact with emergency services. This study assesses the impact of the Australian National Heart Foundation media campaign and identifies patient characteristics and presenting symptoms that may contribute to delay. METHODS: This prospective cohort study identified patients with a diagnosis of MI admitted to a single tertiary metropolitan hospital in Perth, Western Australia from July 2013 to January 2014. Patients were interviewed and responses were categorised to determine their reasons for delaying treatment and the impact of mass media campaigns. Delay times were analysed using multivariable linear regression models for the Whole Cohort (all patients admitted to the tertiary hospital, including patients from rural and peripheral hospitals) and the Direct Admission Cohort (patients admitted directly to the tertiary hospital). RESULTS: Of 376 patients, 255 patients provided consent, and symptom onset-time was available for 175 patients. While almost two thirds of the cohort was aware of media campaigns, awareness was not associated with decreased prehospital delay. Median delay was 3.9hours for the Whole Cohort and 3.5hours for the Direct Admission Cohort. Delay was associated with being widowed, symptom onset on a weekday compared with weekend, past medical history of MI and coronary artery bypass graft, private compared with ambulance transport to hospital, and lack of symptoms of sweating and weakness. In addition, for the Direct Admission Cohort, age and income were also associated with delay. CONCLUSIONS: This study did not find an association between awareness of media campaigns and delay. This study identified important characteristics and presenting symptoms that are associated with delay, and possibly relevant to future media campaigns.

The Relation Between Thyroid Function and Anemia: A Pooled Analysis of Individual Participant Data.

Context: Anemia and thyroid dysfunction often co-occur, and both increase with age. Human data on relationships between thyroid disease and anemia are scarce. Objective: To investigate the cross-sectional and longitudinal associations between clinical thyroid status and anemia. Design: Individual participant data meta-analysis. Setting: Sixteen cohorts participating in the Thyroid Studies Collaboration (n = 42,162). Main Outcome Measures: Primary outcome measure was anemia (hemoglobin <130 g/L in men and <120 g/L in women). Results: Cross-sectionally, participants with abnormal thyroid status had an increased risk of having anemia compared with euthyroid participants [overt hypothyroidism, pooled OR 1.84 (95% CI 1.35 to 2.50), subclinical hypothyroidism 1.21 (1.02 to 1.43), subclinical hyperthyroidism 1.27 (1.03 to 1.57), and overt hyperthyroidism 1.69 (1.00 to 2.87)]. Hemoglobin levels were lower in all groups compared with participants with euthyroidism. In the longitudinal analyses (n = 25,466 from 14 cohorts), the pooled hazard ratio for the risk of development of anemia was 1.38 (95% CI 0.86 to 2.20) for overt hypothyroidism, 1.18 (1.00 to 1.38) for subclinical hypothyroidism, 1.15 (0.94 to 1.42) for subclinical hyperthyroidism, and 1.47 (0.91 to 2.38) for overt hyperthyroidism. Sensitivity analyses excluding thyroid medication or high levels of C-reactive protein yielded similar results. No differences in mean annual change in hemoglobin levels were observed between the thyroid hormone status groups. Conclusion: Higher odds of having anemia were observed in participants with both hypothyroid function and hyperthyroid function. In addition, reduced thyroid function at baseline showed a trend of increased risk of developing anemia during follow-up. It remains to be assessed in a randomized controlled trial whether treatment is effective in reducing anemia.

Initial evaluation of thyroid dysfunction - Are simultaneous TSH and fT4 tests necessary?

OBJECTIVE: Guidelines for thyroid function evaluation recommend testing TSH first, then assessing fT4 only if TSH is out of the reference range (two-step), but many clinicians initially request both TSH and fT4 (one-step). Given limitations of previous studies, we aimed to compare the two-step with the one-step approach in an unselected community-dwelling study population, and develop a prediction score based on clinical parameters that could identify at-risk patients for thyroid dysfunction. DESIGN: Cross-sectional analysis of the population-based Busselton Health Study. METHODS: We compared the two-step with the one-step approach, focusing on cases that would be missed by the two-step approach, i.e. those with normal TSH, but out-of-range fT4. We used likelihood ratio tests to identify demographic and clinical parameters associated with thyroid dysfunction and developed a clinical prediction score by using a beta-coefficient based scoring method. RESULTS: Following the two-step approach, 93.0% of all 4471 participants had normal TSH and would not need further testing. The two-step approach would have missed 3.8% of all participants (169 of 4471) with a normal TSH, but a fT4 outside the reference range. In 85% (144 of 169) of these cases, fT4 fell within 2 pmol/l of fT4 reference range limits, consistent with healthy outliers. The clinical prediction score that performed best excluded only 22.5% of participants from TSH testing. CONCLUSION: The two-step approach may avoid measuring fT4 in as many as 93% of individuals with a very small risk of missing thyroid dysfunction. Our findings do not support the simultaneous initial measurement of both TSH and fT4.

Declining rates of sterilisation reversal procedures in western Australian women from 1990 to 2008: the relationship with age, hospital type and government policy changes.

BACKGROUND: Female sterilisation is usually performed on an elective basis at perceived family completion, however, around 1-3% of women who have undergone sterilisation elect to undergo sterilisation reversal (SR) at a later stage. The trends in SR rates in Western Australia (WA), proportions of SR procedures between hospital types (public and private), and the effects of Federal Government policies on these trends are unknown. METHODS: Using records from statutory state-wide data collections of hospital separations and births, we conducted a retrospective descriptive study of all women aged 15-49 years who underwent a SR procedure during the period 1st January 1990 to 31st December 2008 (n = 1868 procedures). RESULTS: From 1991 to 2007 the annual incidence rate of SR procedures per 10,000 women declined from 47.0 to 3.6. Logistic regression modelling showed that from 1997 to 2001 the odds of women undergoing SR in a private hospital as opposed to all other hospitals were 1.39 times higher (95% CI 1.07-1.81) and 7.51 times higher (95% CI 5.46-10.31) from 2002 to 2008. There were significant decreases in SR rates overall and among different age groups after the Federal Government interventions. CONCLUSION: Rates of SR procedures in WA have declined from 1990 to 2008, particularly following policy changes such as the introduction of private health insurance (PHI) policies. This suggests decisions to undergo SR may be influenced by Federal Government interventions.

Thyroid Function Within the Normal Range, Subclinical Hypothyroidism, and the Risk of Atrial Fibrillation.

BACKGROUND: Atrial fibrillation (AF) is a highly prevalent disorder leading to heart failure, stroke, and death. Enhanced understanding of modifiable risk factors may yield opportunities for prevention. The risk of AF is increased in subclinical hyperthyroidism, but it is uncertain whether variations in thyroid function within the normal range or subclinical hypothyroidism are also associated with AF. METHODS: We conducted a systematic review and obtained individual participant data from prospective cohort studies that measured thyroid function at baseline and assessed incident AF. Studies were identified from MEDLINE and EMBASE databases from inception to July 27, 2016. The euthyroid state was defined as thyroid-stimulating hormone (TSH) 0.45 to 4.49 mIU/L, and subclinical hypothyroidism as TSH 4.5 to 19.9 mIU/L with free thyroxine (fT4) levels within reference range. The association of TSH levels in the euthyroid and subclinical hypothyroid range with incident AF was examined by using Cox proportional hazards models. In euthyroid participants, we additionally examined the association between fT4 levels and incident AF. RESULTS: Of 30 085 participants from 11 cohorts (278 955 person-years of follow-up), 1958 (6.5%) had subclinical hypothyroidism and 2574 individuals (8.6%) developed AF during follow-up. TSH at baseline was not significantly associated with incident AF in euthyroid participants or those with subclinical hypothyroidism. Higher fT4 levels at baseline in euthyroid individuals were associated with increased AF risk in age- and sex-adjusted analyses (hazard ratio, 1.45; 95% confidence interval, 1.26-1.66, for the highest quartile versus the lowest quartile of fT4; P for trend ≤0.001 across quartiles). Estimates did not substantially differ after further adjustment for preexisting cardiovascular disease. CONCLUSIONS: In euthyroid individuals, higher circulating fT4 levels, but not TSH levels, are associated with increased risk of incident AF.

Thyroid Function Tests in the Reference Range and Fracture: Individual Participant Analysis of Prospective Cohorts.

Context: Hyperthyroidism is associated with increased fracture risk, but it is not clear if lower thyroid-stimulating hormone (TSH) and higher free thyroxine (FT4) in euthyroid individuals are associated with fracture risk. Objective: To evaluate the association of TSH and FT4 with incident fractures in euthyroid individuals. Design: Individual participant data analysis. Setting: Thirteen prospective cohort studies with baseline examinations between 1981 and 2002. Participants: Adults with baseline TSH 0.45 to 4.49 mIU/L. Main Outcome Measures: Primary outcome was incident hip fracture. Secondary outcomes were any, nonvertebral, and vertebral fractures. Results were presented as hazard ratios (HRs) with 95% confidence interval (CI) adjusted for age and sex. For clinical relevance, we studied TSH according to five categories: 0.45 to 0.99 mIU/L; 1.00 to 1.49 mIU/L; 1.50 to 2.49 mIU/L; 2.50 to 3.49 mIU/L; and 3.50 to 4.49 mIU/L (reference). FT4 was assessed as study-specific standard deviation increase, because assays varied between cohorts. Results: During 659,059 person-years, 2,565 out of 56,835 participants had hip fracture (4.5%; 12 studies with data on hip fracture). The pooled adjusted HR (95% CI) for hip fracture was 1.25 (1.05 to 1.49) for TSH 0.45 to 0.99 mIU/L, 1.19 (1.01 to 1.41) for TSH 1.00 to 1.49 mIU/L, 1.09 (0.93 to 1.28) for TSH 1.50 to 2.49 mIU/L, and 1.12 (0.94 to 1.33) for TSH 2.50 to 3.49 mIU/L (P for trend = 0.004). Hip fracture was also associated with FT4 [HR (95% CI) 1.22 (1.11 to 1.35) per one standard deviation increase in FT4]. FT4 only was associated with any and nonvertebral fractures. Results remained similar in sensitivity analyses. Conclusions: Among euthyroid adults, lower TSH and higher FT4 are associated with an increased risk of hip fracture. These findings may help refine the definition of optimal ranges of thyroid function tests.

Radiographic Analysis of Feet With and Without Morton's Neuroma.

BACKGROUND: The aim of this research was to investigate the association of various structural measurements of the forefoot with Morton's neuroma (MN). METHODS: Weightbearing anteroposterior and lateral foot radiographs of subjects attending the University of Western Australia (UWA) Podiatry Clinic and the first author's private practice were included in this study. A single assessor measured the following angles: lateral intermetatarsal angle (LIMA), intermetatarsal angle (IMA), hallux valgus angle (HVA), digital divergence between the second and third digits (DD23), digital divergence between the third and fourth digits (DD34) and relative metatarsal lengths of the first to fifth metatarsals (Met1-5), and the effect of MN size as measured by ultrasonograph on digital divergence. Intratester reliability of all radiographic measurements was assessed on all radiographic measurements. The study included 101 subjects, of whom 69 were diagnosed with MN and 32 were control subjects without MN. The mean (± standard deviation) age of MN subjects was 52 (±15) years and for control subjects, 48 (±12) years. RESULTS: When comparing all feet, there were no significant differences in the LIMA, HVA, IMA, digital divergence angles and the relative metatarsal distances between subjects with MN and control subjects. No relationship between MN size and digital divergence was found in either foot, or in either neuroma location. CONCLUSION: We were unable to demonstrate any relationship in this study between radiographic metatarsal length and angular measurements in a symptomatic MN group compared to a control group. In addition, we did not find any correlation between the size of MN as measured from ultrasonographic images and radiographic evidence of digital divergence. LEVEL OF EVIDENCE: Level III, case control study.

The relationship between foot posture index, ankle equinus, body mass index and intermetatarsal neuroma.

BACKGROUND: The main purpose of this study was to investigate the presence of an association between intermetatarsal neuroma and foot type, as measured by the Foot Posture Index. The study also examined whether there was a relationship between foot type and the interspace affected with intermetatarsal neuroma, and whether ankle equinus or body mass index had an effect. METHODS: In total, 100 participants were recruited from The University of Western Australia's Podiatry Clinic, 68 of whom were diagnosed with inter-metatarsal neuroma from 2009 to 2015. There were 32 control participants recruited from 2014 to 2015. The age of subjects was recorded, as were weight and height, which were used to calculate body mass index. The foot posture index and ankle dorsiflexion were measured using standard technique. Independent t-tests and Kruskal-Wallis tests were used to compare differences in foot posture index, body mass index and ankle dorsiflexion between the inter-metatarsal neuroma and control groups. Multivariable logistic regression was also used to model relationships for outcome. RESULTS: The 68 intermetatarsal neuroma subjects had a mean age of 52 years (range 20 to 74 years) and comprised of 56 females and 12 males. The 32 control subjects had a mean age of 49 years (range 24 to 67 years) with 26 females and six males. There were no significant differences between the control and the intermetatarsal neuroma groups with respect to the mean foot posture index scores of the left and right foot (p = 0.21 and 0.87, respectively). Additionally no significant differences were detected between the affected intermetatarsal neuroma interspace and foot posture index (p = 0.27 and 0.47, respectively). There was no significant difference in mean body mass index between the intermetatarsal neuroma (26.9 ± 5.7) and control groups (26.5 ± 4.1) (p = 0.72). There was, however, a significant difference in mean ankle dorsiflexion between the intermetatarsal neuroma and control groups (p < 0.001 for both feet). Logistic regression models, adjusted for age, sex, foot posture index and body mass index estimated that the odds of having an intermetatarsal neuroma in the right foot increased by 61% (OR 1.61; 95% CI 1.32-1.96) with each one degree reduction of ankle dorsiflexion, and in the left foot by 43% (OR 1.43; 95% CI 1.22-1.69). CONCLUSION: No relationships were found between foot posture index and body mass index with intermetatarsal neuroma, or between foot posture index and the interspaces affected. However, a strong association was demonstrated between the presence of intermetatarsal neuroma and a restriction of ankle dorsiflexion.

Thyroid Function Within the Reference Range and the Risk of Stroke: An Individual Participant Data Analysis.

CONTEXT: The currently applied reference ranges for thyroid function are under debate. Despite evidence that thyroid function within the reference range is related with several cardiovascular disorders, its association with the risk of stroke has not been evaluated previously. DESIGN AND SETTING: We identified studies through a systematic literature search and the Thyroid Studies Collaboration, a collaboration of prospective cohort studies. Studies measuring baseline TSH, free T4, and stroke outcomes were included, and we collected individual participant data from each study, including thyroid function measurements and incident all stroke (combined fatal and nonfatal) and fatal stroke. The applied reference range for TSH levels was between 0.45 and 4.49 mIU/L. RESULTS: We collected individual participant data on 43 598 adults with TSH within the reference range from 17 cohorts, with a median follow-up of 11.6 years (interquartile range 5.1-13.9), including 449 908 person-years. Age- and sex-adjusted pooled hazard ratio for TSH was 0.78 (95% confidence interval [CI] 0.65-0.95 across the reference range of TSH) for all stroke and 0.83 (95% CI 0.62-1.09) for fatal stroke. For the free T4 analyses, the hazard ratio was 1.08 (95% CI 0.99-1.15 per SD increase) for all stroke and 1.10 (95% CI 1.04-1.19) for fatal stroke. This was independent of cardiovascular risk factors including systolic blood pressure, total cholesterol, smoking, and prevalent diabetes. CONCLUSION: Higher levels of TSH within the reference range may decrease the risk of stroke, highlighting the need for further research focusing on the clinical consequences associated with differences within the reference range of thyroid function.

Which patients should be transported to the emergency department? A perpetual prehospital dilemma.

OBJECTIVE: To examine the ability of paramedics to identify patients who could be managed in the community and to identify predictors that could be used to accurately identify patients who should be transported to EDs. METHODS: Lower acuity patients who were assessed by paramedics in the Perth metropolitan area in 2013 were studied. Paramedics prospectively indicated on the patient care record if they considered that the patient could be treated in the community. The paramedic decisions were compared with actual disposition from the ED (discharge and admission), and the occurrence of subsequent events (ambulance request, ED visit, admission and death) for discharged patients at the scene was investigated. Decision tree analysis was used to identify predictors that were associated with hospital admission. RESULTS: In total, 57 183 patients were transported to the ED, and 10 204 patients were discharged at the scene by paramedics. Paramedics identified 2717 patients who could potentially be treated in the community among those who were transported to the ED. Of these, 1455 patients (53.6%) were admitted to hospital. For patients discharged at the scene, those who were indicated as suitable for community care were more likely to experience subsequent events than those who were not. The decision tree found that two predictors (age and aetiology) were associated with hospital admission. Overall discriminative power of the decision tree was poor; the area under the receiver operating characteristic curve was 0.686. CONCLUSION: Lower acuity patients who could be treated in the community were not accurately identified by paramedics. This process requires further evaluation.

Declining rates of sterilization procedures in Western Australian women from 1990 to 2008: the relationship with age, hospital type, and government policy changes.

OBJECTIVE: To describe trends in age-specific incidence rates of female sterilization (FS) procedures in Western Australia and to evaluate the effects of the introduction of government-subsidized contraceptive methods and the implementation of the Australian government's baby bonus policy on FS rates. DESIGN: Population-based retrospective descriptive study. SETTING: Not applicable. PATIENT(S): All women ages 15-49 undergoing an FS procedure during the period January 1, 1990, to December 31, 2008 (n = 47,360 procedures). INTERVENTION(S): Records from statutory statewide data collections of hospitals separations and births were extracted and linked. MAIN OUTCOME MEASURE(S): Trends in FS procedures and the influence on these trends of the introduction of government policies: subsidization of long-acting reversible contraceptives (Implanon and Mirena) and the Australian baby bonus initiative. RESULT(S): The annual incidence rate of FS procedures declined from 756.9 per 100,000 women in 1990 to 155.2 per 100,000 women in 2008. Compared with the period 1990-1994, women ages 30-39 years were 47% less likely (rate ratio [RR] = 0.53; 95% confidence interval [CI], 0.39-0.72) to undergo sterilization during the period 2005-2008. Adjusting for overall trend, there were significant decreases in FS rates after government subsidization of Implanon (RR = 0.89; 95% CI, 0.82-0.97) and Mirena (RR = 0.81; 95% CI, 0.73-0.91) and the introduction of the baby bonus (RR = 0.70; 95% CI, 0.61-0.81). CONCLUSION(S): Rates of female sterilization procedures in Western Australia have declined substantially across all age groups in the last two decades. Women's decisions to undergo sterilization procedures may be influenced by government interventions that increase access to long-term reversible contraceptives or encourage childbirth.

The log TSH-free T4 relationship in a community-based cohort is nonlinear and is influenced by age, smoking and thyroid peroxidase antibody status.

BACKGROUND: The TSH-T4 relationship was thought to be inverse log-linear, but recent cross-sectional studies of selected populations report a complex, nonlinear relationship. The TSH-T4 relationship has not been evaluated in an unselected, community-based cohort, and there are limited data regarding clinical factors which affect it. OBJECTIVE: To analyse the TSH-free T4 relationship in a community-based cohort. DESIGN, PARTICIPANTS AND METHODS: In a cross-sectional, retrospective study, we analysed serum TSH and free T4 concentrations from 4427 participants (55% female) in the 1994 Busselton Health Study who were not taking thyroxine. Simple linear, segmented-linear and nonlinear regression models of log10 TSH on free T4 were compared for goodness of fit. RESULTS: All 5 log TSH-free T4 models tested (separate lines, segmented conterminal line, quartic, error function, double-sigmoid curve) fitted significantly better than a simple linear model (each P < 0·01 by Vuong test). Ranking by Akaike information criterion indicated that the segmented conterminal line and double-sigmoid models provided best fit, followed by the error function, quartic and separate lines models. From multiple regression analysis, age tertile, current smoking and TPOAb status each significantly influenced the TSH-free T4 relationship, whereas BMI category and diabetes did not. A sex difference in the TSH-free T4 relationship was apparent only in the lower part of the free T4 reference range. CONCLUSION: In a community-based setting, the relationship between log TSH and free T4 is complex, nonlinear and influenced by age, smoking and TPOAb status.

Paramedic Checklists do not Accurately Identify Post-ictal or Hypoglycaemic Patients Suitable for Discharge at the Scene.

OBJECTIVES: The objective of this study was to assess the accuracy and safety of two pre-defined checklists to identify prehospital post-ictal or hypoglycemic patients who could be discharged at the scene. METHODS: A retrospective cohort study of lower acuity, adult patients attended by paramedics in 2013, and who were either post-ictal or hypoglycemic, was conducted. Two self-care pathway assessment checklists (one each for post-ictal and hypoglycemia) designed as clinical decision tools for paramedics to identify patients suitable for discharge at the scene were used. The intention of the checklists was to provide paramedics with justification to not transport a patient if all checklist criteria were met. Actual patient destination (emergency department [ED] or discharge at the scene) and subsequent events (eg, ambulance requests) were compared between patients who did and did not fulfill the checklists. The performance of the checklists against the destination determined by paramedics was also assessed. RESULTS: Totals of 629 post-ictal and 609 hypoglycemic patients were identified. Of these, 91 (14.5%) and 37 (6.1%) patients fulfilled the respective checklist. Among those who fulfilled the checklist, 25 (27.5%) post-ictal and 18 (48.6%) hypoglycemic patients were discharged at the scene, and 21 (23.1%) and seven (18.9%) were admitted to hospital after ED assessment. Amongst post-ictal patients, those fulfilling the checklist had more subsequent ambulance requests (P=.01) and ED attendances with seizure-related conditions (P=.04) within three days than those who did not. Amongst hypoglycemic patients, there were no significant differences in subsequent events between those who did and did not meet the criteria. Paramedics discharged five times more hypoglycemic patients at the scene than the checklist predicted with no significant differences in the rate of subsequent events. Four deaths (0.66%) occurred within seven days in the hypoglycemic cohort, and none of them were attributed directly to hypoglycemia. CONCLUSIONS: The checklists did not accurately identify patients suitable for discharge at the scene within the Emergency Medical Service. Patients who fulfilled the post-ictal checklist made more subsequent health care service requests within three days than those who did not. Both checklists showed similar occurrence of subsequent events to paramedics' decision, but the hypoglycemia checklist identified fewer patients who could be discharged at the scene than paramedics actually discharged. Reliance on these checklists may increase transportations to ED and delay initiation of appropriate treatment at a hospital. Tohira H , Fatovich D , Williams TA , Bremner A , Arendts G , Rogers IR , Celenza A , Mountain D , Cameron P , Sprivulis P , Ahern T , Finn J . Paramedic checklists do not accurately identify post-ictal or hypoglycaemic patients suitable for discharge at the scene. Prehosp Disaster Med. 2016;31(3):282-293.

Determining the Superior Technique for Living-donor Nephrectomy: the Laparoscopic Intraperitoneal Versus the Retroperitoneoscopic Approach.

OBJECTIVES: Laparoscopic living-donor nephrectomy is now widely used because of its many beneficial features. Currently, there are 2 major techniques: the laparoscopic intraperitoneal approach and the retroperitoneoscopic approach. There is no evidence to support one particular approach over another. Therefore, in this study, we conducted a systematic literature review with the aim of defining which technique is superior. MATERIALS AND METHODS: The Embase, PubMed, and Cochrane literature databases were searched for English language articles published between January 1994 and January 2013 using the terms "laparoscopic donor nephrectomy," "retroperitoneoscopic donor nephrectomy," and "live donor nephrectomy." A meta-analysis was undertaken, and I(2) statistical analyses were used to describe the percentage of variation across studies due to heterogeneity rather than chance. RESULTS: With the use of our selection criteria, 55 papers on the laparoscopic intraperitoneal approach and 6 papers on the retroperitoneoscopic approach were included in this study. We found significantly lower transfusion rate, fewer patients with delayed graft functions, less vessel injuries, and less conversion to open surgical procedure with the retroperitoneoscopic approach than with the laparoscopic intraperitoneal approach. CONCLUSIONS: From this review, a high degree of study heterogeneity was identified, suggesting an urgent need for consistency in reporting laparoscopic living-donor nephrectomy. Results of the meta-analyses may define a better technique for the future. The retroperitoneoscopic approach may be better than the laparoscopic intraperitoneal approach with fewer complications and fewer patients with delayed graft function. Further study of laparoscopic living-donor nephrectomy is recommended to define a standard and thus to minimize the surgical morbidities.

Use of serum lactate levels to predict survival for patients with out-of-hospital cardiac arrest: A cohort study.

OBJECTIVES: We examined the association of serum lactate levels and early lactate clearance with survival to hospital discharge for patients suffering an out-of-hospital cardiac arrest (OHCA). METHODS: A retrospective cohort analysis was performed of patients with OHCA transported by ambulance to two adult tertiary hospitals in Perth, Western Australia. Exclusion criteria were traumatic cardiac arrest, return of spontaneous circulation prior to the arrival of the ambulance, age less than 18 years and no serum lactate levels recorded. Serum lactate levels recorded for up to 48 h post-arrest were obtained from the hospital clinical information system, and lactate clearance over 48 h was calculated. Descriptive and logistic regression analyses were conducted. RESULTS: There were 518 patients with lactate values, of whom 126 (24.3%) survived to hospital discharge. Survivors and non-survivors had different mean initial lactate levels (mean ± SD 6.9 ± 4.7 and 12.2 ± 5.5 mmol/L, respectively; P < 0.001). Lactate clearance was higher in survivors. Lactate levels for non-survivors did not decrease below 2 mmol/L until at least 30 h after the ambulance call. CONCLUSION: In OHCA patients who had serum lactate levels measured, both lower initial serum lactate and early lactate clearance in the first 48 h following OHCA were associated with increased likelihood of survival. However, the use of lactate in isolation as a predictor of survival or neurological outcome is not recommended. Prospective studies that minimise selection bias are required to determine the clinical utility of serum lactate levels in OHCA patients.

Is it Appropriate for Patients to be Discharged at the Scene by Paramedics?

BACKGROUND: Outcomes of patients who are discharged at the scene by paramedics are not fully understood. OBJECTIVE: We aimed to describe the risk of re-presentation and/or death in prehospital patients discharged at the scene. METHODS: We conducted a retrospective cohort study using linked ambulance, emergency department (ED), and death data. We compared outcomes in patients who were discharged at the scene by paramedics with those who were transported to ED by paramedics and then discharged from ED between January 1 and December 31, 2013 in metropolitan Perth, Western Australia. Occurrences of subsequent ambulance requests, ED attendance, hospital admission and death were compared between those discharged at the scene and those discharged from ED. RESULTS: There were 47,330 patients during the study period, of whom 19,732 and 27,598 patients were discharged at the scene and from ED, respectively. Compared to those discharged from ED, those discharged at the scene were more likely to subsequently: request an ambulance (6.1% vs. 1.8%, adjusted odds ratio [adj OR] 3.4; 95% confidence interval [CI] 3.0-3.9), attend ED (4.6% vs. 1.4%, adj OR 3.3; 95% CI 2.8-3.8), be admitted to hospital (3.3% vs. 0.8%, adj OR 4.2; 95% CI 3.4-5.1). Those discharged at the scene tended towards an increased likelihood of death (0.2% vs. 0.1%, adj OR 1.8; 95% CI 0.99-3.2) within 24 hours of discharge compared to those discharged from ED. CONCLUSION: Patients attended by paramedics who were discharged at the scene had more subsequent events than those who were transported to and discharged from ED. Further consideration needs to be given to who is suitable to be discharged at the scene by paramedics.

Regular Fat and Reduced Fat Dairy Products Show Similar Associations with Markers of Adolescent Cardiometabolic Health.

Reduced fat dairy products are generally recommended for adults and children over the age of two years. However, emerging evidence suggests that dairy fat may not have detrimental health effects. We aimed to investigate prospective associations between consumption of regular versus reduced fat dairy products and cardiometabolic risk factors from early to late adolescence. In the West Australian Raine Study, dairy intake was assessed using semi-quantitative food frequency questionnaires in 860 adolescents at 14 and 17-year follow-ups; 582 of these also had blood biochemistry at both points. Using generalized estimating equations, we examined associations with cardiometabolic risk factors. Models incorporated reduced fat and regular fat dairy together (in serves/day) and were adjusted for a range of factors including overall dietary pattern. In boys, there was a mean reduction in diastolic blood pressure of 0.66 mmHg (95% CI 0.23-1.09) per serve of reduced fat dairy and an independent, additional reduction of 0.47 mmHg (95% CI 0.04-0.90) per serve of regular fat dairy. Each additional serve of reduced fat dairy was associated with a 2% reduction in HDL-cholesterol (95% CI 0.97-0.995) and a 2% increase in total: HDL-cholesterol ratio (95% CI 1.002-1.03); these associations were not observed with regular fat products. In girls, there were no significant independent associations observed in fully adjusted models. Although regular fat dairy was associated with a slightly better cholesterol profile in boys, overall, intakes of both regular fat and reduced fat dairy products were associated with similar cardiometabolic associations in adolescents.

Mothers' group participation: associations with social capital, social support and mental well-being.

AIM: To investigate the relationships between participation in mothers' groups and social capital, social support and mental well-being measures for mothers whose oldest child was 0-5 years. BACKGROUND: Evaluations of facilitated mothers' groups have found positive benefits for information sharing and support. Mothers' groups often continue as parent-led groups; however, little is known about the potential benefits of ongoing participation compared with non-participation. DESIGN: Cross-sectional survey. METHODS: Data were collected through a survey from March 2013-January 2014 in Perth, Western Australia. The data from a subgroup of mothers (N = 313) whose oldest child was 0-5 years of age were analysed using multivariable regression. Participation in mothers' groups in the previous 12 months was investigated for associations with social capital {Neighbourhood Cohesion Index (NCI); Families, Social Capital and Citizenship Survey (FSCCS) and Reciprocity}; social support {Medical Outcomes Study-Social Support Survey (MOS-SSS) and Parent Support Outside Home Scale (PSOHS)}; and mental well-being {Warwick Edinburgh Mental Well-Being Scale (WEMWBS)}. Participation was measured as three groups - locally, outside area of residence and non-participation. RESULTS: Mothers who participated in mothers' groups locally scored significantly higher than those who had not participated in mothers' group for 'social capital' (NCI, FSCCS, Reciprocity), 'social support' (MOS-SSS, PSOHS) and 'mental well-being' (WEMWBS). Mothers who participated in mothers' group outside the area scored significantly higher than those who had not participated in mothers' groups for one measure of 'social support' (PSOHS). CONCLUSIONS: Participation in mothers' group locally may provide support and social capital benefits for mothers of children aged 0-5 years, which may influence mental well-being.

Live delivery outcome after tubal sterilization reversal: a population-based study.

OBJECTIVE: To determine the cumulative incidence of live delivery in women who underwent reversal of tubal sterilization. DESIGN: Population-based retrospective cohort study. SETTING: Hospitals in Western Australia. PATIENT(S): All women aged 20-44 years, with a history of hospital admission for tubal sterilization, who subsequently underwent reversal of sterilization during the period 1985 to 2009 in Western Australia (n = 1,898). INTERVENTION(S): Data regarding reversal of sterilization and prior tubal sterilization were extracted from routinely collected administrative hospital separation records, until commencement of IVF treatment. MAIN OUTCOME MEASURE(S): First live-delivery rates. RESULT(S): There were 969 first live deliveries observed during the study period. The overall cumulative live-delivery rate was 20% (95% confidence interval [CI] 18-23) within the first year after reversal, 40% (95% CI 38-42) at 2 years, 51% (95% CI 48-53) at 5 years, and 52% (95% CI 50-55) at 10 years. The 5-year cumulative live-delivery rate was significantly lower in women who were aged 40-44 years (26%) compared with younger women (aged 20-29, 30-34, and 35-39 years) (50%, 56%, and 51%, respectively). CONCLUSION(S): Women undergoing reversal of sterilization before they reach age 40 years have at least a 50% chance of delivering a live baby within the next 5 years. Up to that age, there is no significant difference in live deliveries. The live-delivery rate halves after the age of 40 years.