What care do people with dementia receive at the end of life? Lessons from a retrospective clinical audit of deaths in hospital and other settings.

BACKGROUND: The need for better end-of-life care for people with dementia has been acknowledged. Existing literature suggests that people dying with dementia have less access to palliative care, yet little is known about the care provided to people with dementia at the end of life. This study aimed to establish evidence related to end-of-life care for people dying with dementia in hospital compared to other settings. METHODS: A retrospective clinical audit of people who had a diagnosis of dementia and had accessed services within a local health district, who died between 2015 and 2019, was conducted. A total of 705 people were identified, and a subset of 299 people randomly selected for manual audit. Chi-square p-values were used to compare the place of death, and a t-test or non-parametric test was used to assess the significance of the difference, as appropriate. Measures of functional decline within one month of death were assessed using mixed effects logistic regression models. RESULTS: The characteristics of people differed by place of death, with people who died in hospital more likely to be living at home and to not have a spouse. Less than 1 in 5 people had advance care directives or plans. Many were still being actively treated at the time of death: almost half of people who died in hospital had an investigation in their final 72 hours, less than half of people were coded as receiving palliative care at death, and more than 2 in 3 people did not get access to specialist palliative care. Declining function was associated with the terminal phase. CONCLUSION: This study provides novel insights for those providing end-of-life care for people with dementia. Healthcare professionals and policy makers should consider how demographic characteristics relate to the places people with dementia receive end-of-life care. The care provided to people with dementia in the last year of their life highlights the need for more support to prepare advance care documentation and timely consideration for palliative care. Changes in markers of nutritional status and function in people with advanced dementia may help with identification of terminal phases.

Trajectories and Predictors of Raised State Anxiety Among Outpatients Who Have Undergone Medical Imaging Procedures.

PURPOSE: The aim of this study was to examine the prevalence of raised state anxiety before and after medical imaging procedures, the prevalence of state anxiety trajectories, and factors associated with postprocedural raised state anxiety. METHODS: A prospective survey was administered to outpatients undergoing elective medical imaging procedures (CT, radiography, MRI, ultrasound, angiography, or fluoroscopy) recruited from one center. Participants completed a self-report survey preprocedure (time 1) and postprocedure (time 2). State anxiety was measured using the six-item State-Trait Anxiety Inventory. The point prevalence of raised state anxiety (State-Trait Anxiety Inventory score ≥33.16) at time 1 and time 2 was calculated, as was the prevalence of four state anxiety trajectories over time: persistent low anxiety, decreasing anxiety, increasing anxiety, and persistent raised anxiety. Factors predictive of raised state anxiety at time 2 were examined using logistic regression analysis. RESULTS: Three hundred fifteen participants completed both surveys. The prevalence of raised state anxiety at time 1 (50%) and time 2 (51%) was similar. Most patients reported persistent raised anxiety (36%) and persistent low anxiety (34%) over time. Fewer patients reported increasing anxiety (15%) and decreasing anxiety (14%). Raised state anxiety (odds ratio, 4.84; 95% confidence interval, 2.48-9.48) and lower reported health status (odds ratio, 2.48; 95% confidence interval, 1.11-5.51) at time 1 were significantly associated with greater odds of raised anxiety at time 2. CONCLUSIONS: Raised state anxiety related to medical imaging procedures is common among outpatients. Half of patients either developed or continued to experience raised anxiety after their procedures. Outpatients may benefit from evidence-based methods of alleviating anxiety before their procedures.

The Effectiveness of Strategies to Improve User Engagement With Digital Health Interventions Targeting Nutrition, Physical Activity, and Overweight and Obesity: Systematic Review and Meta-Analysis.

BACKGROUND: Digital health interventions (DHIs) are effective in improving poor nutrition, physical inactivity, overweight and obesity. There is evidence suggesting that the impact of DHIs may be enhanced by improving user engagement. However, little is known about the overall effectiveness of strategies on engagement with DHIs. OBJECTIVE: This study aims to assess the overall effectiveness of strategies to improve engagement with DHIs targeting nutrition, physical activity, and overweight or obesity and explore associations between strategies and engagement outcomes. The secondary aim was to explore the impact of these strategies on health risk outcomes. METHODS: The MEDLINE, Embase, PsycINFO, CINAHL, CENTRAL, Scopus, and Academic Source Complete databases were searched up to July 24, 2023. Eligible studies were randomized controlled trials that evaluated strategies to improve engagement with DHIs and reported on outcomes related to DHI engagement (use or user experience). Strategies were classified according to behavior change techniques (BCTs) and design features (eg, supplementary emails). Multiple-variable meta-analyses of the primary outcomes (usage and user experience) were undertaken to assess the overall effectiveness of strategies. Meta-regressions were conducted to assess associations between strategies and use and user experience outcomes. Synthesis of secondary outcomes followed the "Synthesis Without Meta-Analysis" guidelines. The methodological quality and evidence was assessed using the Cochrane risk-of-bias tool, and the Grading of Recommendations Assessment, Development, and Evaluation tool respectively. RESULTS: Overall, 54 studies (across 62 publications) were included. Pooled analysis found very low-certainty evidence of a small-to-moderate positive effect of the use of strategies to improve DHI use (standardized mean difference=0.33, 95% CI 0.20-0.46; P<.001) and very low-certainty evidence of a small-to-moderate positive effect on user experience (standardized mean difference=0.29, 95% CI 0.07-0.52; P=.01). A significant positive association was found between the BCTs social support (effect size [ES]=0.40, 95% CI 0.14-0.66; P<.001) and shaping knowledge (ES=0.39, 95% CI 0.03-0.74; P=.03) and DHI use. A significant positive association was found among the BCTs social support (ES=0.70, 95% CI 0.18-1.22; P=.01), repetition and substitution (ES=0.29, 95% CI 0.05-0.53; P=.03), and natural consequences (ES=0.29, 95% CI 0.05-0.53; P=.02); the design features email (ES=0.29, 95% CI 0.05-0.53; P=.02) and SMS text messages (ES=0.34, 95% CI 0.11-0.57; P=.01); and DHI user experience. For secondary outcomes, 47% (7/15) of nutrition-related, 73% (24/33) of physical activity-related, and 41% (14/34) of overweight- and obesity-related outcomes reported an improvement in health outcomes. CONCLUSIONS: Although findings suggest that the use of strategies may improve engagement with DHIs targeting such health outcomes, the true effect is unknown because of the low quality of evidence. Future research exploring whether specific forms of social support, repetition and substitution, natural consequences, emails, and SMS text messages have a greater impact on DHI engagement is warranted. TRIAL REGISTRATION: PROSPERO CRD42018077333; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=77333.

Oestradiol implants for gender-affirming hormone therapy: an observational study of serum oestradiol levels and consumer survey.

BACKGROUND: Custom-compounded subcutaneous implants are being used widely in Australia for gender-affirming hormone therapy. However, there is no published literature regarding their use for this purpose. METHODS: Electronic medical records were audited for consecutive clients who received oestradiol implants April 2019-November 2022 in gender clinics held within Hunter New England Health District in New South Wales, Australia. Serum oestradiol levels were analysed for implant doses 50-200mg, and predicted oestradiol level was modelled following 100mg implant insertion. An electronic consumer survey was sent to a convenience sample of implant recipients. RESULTS: A total of 38 clients received 88 implants, with 100mg oestradiol implants being the most frequently used (68%). The median interval between insertion procedures was 270 (IQR 186-399) days. The median serum oestradiol levels following implant insertion, for all implants combined, were within the target range of 250-600pmol/L at 1-, 3-, 6-, 9- and 12-month time points. Following insertion of a 100mg implant, the estimated time to reach a predicted serum oestradiol of ≤250pmol/L was 4months after an initial implant, and 13months after subsequent implants. Seventeen consumer surveys were received from 28 invitations. All respondents had previous experience of oral and/or transdermal oestradiol use. Oestradiol implants were preferred due to ease of use, perceived effectiveness, and the belief that other methods were less safe or associated with intolerance and side effects. CONCLUSIONS: Oestradiol implants are effective in achieving target serum oestradiol levels over a sustained period. Further research with larger cohorts could identify the optimal dosage regimen.

Cone beam computed tomography image guidance within a magnetic resonance imaging-only planning workflow.

Background and purpose: Magnetic Resonance Imaging (MRI)-only planning workflows offer many advantages but raises challenges regarding image guidance. The study aimed to assess the viability of MRI to Cone Beam Computed Tomography (CBCT) based image guidance for MRI-only planning treatment workflows. Materials and methods: An MRI matching training package was developed. Ten radiation therapists, with a range of clinical image guidance experience and experience with MRI, completed the training package prior to matching assessment. The matching assessment was performed on four match regions: prostate gold seed, prostate soft tissue, rectum/anal canal and gynaecological. Each match region consisted of five patients, with three CBCTs per patient, resulting in fifteen CBCTs for each match region. The ten radiation therapists performed the CBCT image matching to CT and to MRI for all regions and recorded the match values. Results: The median inter-observer variation for MRI-CBCT matching and CT-CBCT matching for all regions were within 2 mm and 1 degree. There was no statistically significant association in the inter-observer variation in mean match values and radiation therapist image guidance experience levels. There was no statistically significant association in inter-observer variation in mean match values for MRI experience levels for prostate soft tissue and gynaecological match regions, while there was a statistically significant difference for prostate gold seed and rectum match regions. Conclusion: The results of this study support the concept that with focussed training, an MRI to CBCT image guidance approach can be successfully implemented in a clinical planning workflow.

Understanding Attrition in Text-Based Health Promotion for Fathers: Survival Analysis.

BACKGROUND: Web-based interventions targeting parents with health and parenting support frequently report high rates of attrition. The SMS4dads text messaging program, developed in Australia, has delivered texts to over 10,000 fathers. The brief text messages, which are sent 3 times per week from 16 weeks of gestation to 48 weeks after birth, include regular reminders that participants can leave the program by texting back "STOP" to any message. Although acceptance of the program is high, almost 1 in 5 ask it to be removed. Analyzing the factors influencing attrition from digital parenting programs such as SMS4dads may assist in developing more effective interventions. OBJECTIVE: This study aimed to examine factors associated with attrition in a text-based intervention targeting fathers. METHODS: Demographic characteristics, requests to complete a psychological scale, individual message content, participant feedback, and automatically collected data registering clicks on links embedded in the texts were examined to identify attrition factors among 3261 participants enrolled in SMS4dads from 4 local health districts in New South Wales, Australia, between September 2020 and December 2021. RESULTS: Participants who were smokers, recorded risky alcohol consumption, had a lower education level, or signed up prenatally had 30% to 47% higher hazard of dropout from the program, whereas participant age, Aboriginal or Torres Strait Islander status, rurality, and psychological distress score (as Kessler Psychological Distress Scale [K10] category) were not associated with dropout. Primary reasons for dropping out reported by 202 of 605 respondents included "other reasons" (83/202, 41.1%), followed by "not helpful" (47/202, 23.3%) and "too busy" (44/202, 21.8%). Program features such as repeated requests to complete a psychological scale (K10) and the content of individual messages were not linked to increased dropout rates. Analysis of a sample (216/2612) of inactive participants who had not engaged (clicked on any embedded links) for at least 10 weeks but who had not opted out identified a further 1.5% of participants who would opt to leave the program if asked. CONCLUSIONS: Identifying which features of the participant population and of the program are linked to dropout rates can provide guidance for improving program adherence. However, with limited information from feedback surveys of those exiting early, knowing which features to target does not, by itself, suggest ways to increase engagement. Planning ahead to include robust measures of attrition, including more detailed feedback from participants, could provide more effective guidance. A novel element in this study was seeking feedback from inactive participants to estimate dropout from this group and thereby provide an overall dropout rate of 20%. The retention rate of 80%, relatively high compared with other web-based parenting programs for fathers, suggests that tailoring the content to specifically address fathers' role may be an important consideration in reducing fathers' disengagement.

Long-term exposure to low concentrations of air pollution and decline in lung function in people with idiopathic pulmonary fibrosis: Evidence from Australia.

BACKGROUND AND OBJECTIVE: Little is known about the association between ambient air pollution and idiopathic pulmonary fibrosis (IPF) in areas with lower levels of exposure. We aimed to investigate the impact of air pollution on lung function and rapid progression of IPF in Australia. METHODS: Participants were recruited from the Australian IPF Registry (n = 570). The impact of air pollution on changes in lung function was assessed using linear mixed models and Cox regression was used to investigate the association with rapid progression. RESULTS: Median (25th-75th percentiles) annual fine particulate matter (<2.5 µm, PM2.5 ) and nitrogen dioxide (NO2 ) were 6.8 (5.7, 7.9) µg/m3 and 6.7 (4.9, 8.2) ppb, respectively. Compared to living more than 100 m from a major road, living within 100 m was associated with a 1.3% predicted/year (95% confidence interval [CI] -2.4 to -0.3) faster annual decline in diffusing capacity of the lungs for carbon monoxide (DLco). Each interquartile range (IQR) of 2.2 µg/m3 increase in PM2.5 was associated with a 0.9% predicted/year (95% CI -1.6 to -0.3) faster annual decline in DLco, while there was no association observed with NO2 . There was also no association between air pollution and rapid progression of IPF. CONCLUSION: Living near a major road and increased PM2.5 were both associated with an increased rate of annual decline in DLco. This study adds to the evidence supporting the negative effects of air pollution on lung function decline in people with IPF living at low-level concentrations of exposure.

Online mental health screening for rural fathers over the perinatal period.

OBJECTIVE: To determine the feasibility of identifying distressed fathers in rural areas of NSW via a 'light touch' support program (SMS4dads). DESIGN: A retrospective observational study using self-reported distress and routinely captured help-seeking behaviour over a 14-month period (September 2020-December 2021) comparing rural and urban fathers. SETTING: Rural and urban Local Health Districts in NSW. PARTICIPANTS: A total of 3261 expectant and new fathers enrolled in a text-based information and support service (SMS4dads). MAIN OUTCOME MEASURES: Registrations, K10 score, program engagement, attrition, escalation and referral to online mental health services. RESULTS: Rural (13.3%) and urban (13.2%) enrolments were equivalent. Rural fathers had higher rates of distress than urban fathers (rural 19%; urban 16%) and were more likely to be smokers, consume alcohol at risky levels and report lower education levels. Rural fathers were more likely to exit the program early (HR = 1.32; 95% CI 1.08-1.62; p = 0.008); however, once adjusted for demographic factors aside from rurality, this increased likelihood was nonsignificant (HR = 1.10; 95% CI 0.88-1.38; p = 0.401). Although engagement with psychological support during the program was equivalent, a greater proportion of rural participants were escalated to online mental health support (7.7%) than urban participants (6.1%); however, this was nonsignificant (p = 0.222). CONCLUSION: Digital platforms offering text-based parenting information in a 'light touch' format may be an effective way to screen rural fathers for mental distress and connect them to online support.

Engagement over telehealth: comparing attendance between dialectical behaviour therapy delivered face-to-face and via telehealth for programs in Australia and New Zealand during the Covid-19 pandemic.

BACKGROUND: While the COVID-19 crisis has had numerous global negative impacts, it has also presented an imperative for mental health care systems to make digital mental health interventions a part of routine care. Accordingly, through necessity, many Dialectical Behaviour Therapy (DBT) programs transitioned to telehealth, despite little information on clinical outcomes compared with face-to-face treatment delivery. This study examined differences in client engagement (i.e. attendance) of DBT: delivered face-to-face prior to the first COVID-19 lockdown in Australia and New Zealand; delivered via telehealth during the lockdown; and delivered post-lockdown. Our primary outcomes were to compare: [1] client attendance rates of DBT individual therapy delivered face-to-face with delivery via telehealth, and [2] client attendance rates of DBT skills training delivered face-to-face compared with delivery via telehealth. METHODS: DBT programs across Australia and New Zealand provided de-identified data for a total of 143 individuals who received DBT treatment provided via telehealth or face-to-face over a six-month period in 2020. Data included attendance rates of DBT individual therapy sessions; attendance rates of DBT skills training sessions as well as drop-out rates and First Nations status of clients. RESULTS: A mixed effects logistic regression model revealed no significant differences between attendance rates for clients attending face-to-face sessions or telehealth sessions for either group therapy or individual therapy. This result was found for clients who identified as First Nations persons and those who didn't identify as First Nations persons. CONCLUSIONS: Clients were as likely to attend their DBT sessions over telehealth as they were face-to-face during the first year of the Covid-19 pandemic. These findings provide preliminary evidence that providing DBT over telehealth may be a viable option to increase access for clients, particularly in areas where face-to-face treatment is not available. Further, based on the data collected in this study, we can be less concerned that offering telehealth treatment will compromise attendance rates compared to face-to-face treatment. Further research is needed comparing clinical outcomes between treatments delivered face-to-face compared delivery via telehealth.

The impact of organisational factors on treatment outcomes for those seeking alcohol or other drug treatment: A systematic review.

INTRODUCTION: Organisational factors have been found to be associated with health outcomes in a number of health-care settings. Despite likely being an important influence on the quality of care provided within alcohol and other drug (AOD) treatment centres, the impact of organisational factors on AOD treatment outcomes have not been extensively explored. This systematic literature review examines the characteristics, methodological quality and findings of published studies exploring the association between organisational factors and client AOD treatment outcomes. METHODS: Medline, Embase, PsycINFO and the Cochrane database were searched from 2010 to March 2022 for relevant papers. Studies meeting the inclusion criteria underwent quality assessment using the Joanna Brigg's Institute critical appraisal tool for cross-sectional studies, followed by data extraction of key variables pertaining to the aims. A narrative summary was used to synthesise the data. RESULTS: Nine studies met the inclusion criteria. Organisational factors examined included cultural competency, organisational readiness for change, directorial leadership, continuity of care practices, service access, service to needs ratios, dual diagnosis training, therapeutic optimism and the funding model/health-care system that treatment was delivered in. Outcome measures included duration, completion or continuation of treatment; AOD use; and patient perceptions of treatment outcomes. Seven out of nine papers found a significant interaction between at least one organisational variable and AOD treatment outcomes. DISCUSSION AND CONCLUSIONS: Organisational factors are likely to impact treatment outcomes for patients seeking treatment for AOD. Further examination of the organisational factors that influence AOD outcomes is needed to inform systemic improvements to AOD treatment.

Genitourinary Quality-of-Life Comparison Between Urethral Sparing Prostate Stereotactic Body Radiation Therapy Monotherapy and Virtual High-Dose-Rate Brachytherapy Boost.

PURPOSE: Although radiation dose escalation improves prostate cancer disease control, it can cause increased toxicity. Genitourinary (GU) symptoms after prostate radiation therapy affect patient health-related quality of life (QoL). We compared patient-reported GU QoL outcomes following 2 alternative urethral sparing stereotactic body radiation therapy regimens. METHODS AND MATERIALS: Expanded Prostate Cancer Index Composite (EPIC)-26 GU scores were compared between 2 urethral sparing stereotactic body radiation therapy trials. The SPARK trial prescribed a "Monotherapy" dose of 36.25 Gy in 5 fractions to the prostate. The PROMETHEUS trial prescribed 2 phases: a 19- to 21-Gy in 2 fractions "Boost" to the prostate, followed by 46 Gy in 23 fractions or 36 Gy in 12 fractions. The biological effective dose (BED) for urethral toxicity was 123.9 Gy for Monotherapy and 155.8 to 171.2 Gy for Boost. Mixed effects logistic regression models were utilized to estimate the difference in the odds of a minimal clinically important change from baseline EPIC-26 GU score between regimens at each follow-up. RESULTS: 46 Monotherapy and 149 Boost patients completed baseline EPIC-26 scoring. Mean EPIC-26 GU scores revealed statistically superior urinary incontinence outcomes for Monotherapy at 12 months (mean difference, 6.9; 95% confidence interval [CI], 1.6-12.1; P = .01) and 36 months (mean difference, 9.6; 95% CI, 4.1-15.1; P < .01). Monotherapy also revealed superior mean urinary irritative/obstructive outcomes at 12 months (mean difference, 6.9; 95% CI, 2.0-12.9; P < .01) and 36 months (mean difference, 6.3; 95% CI, 1.9-10.8; P < .01). For both domains and at all time points, the absolute differences were <10%. There were no significant differences in the odds of reporting a minimal clinically important change between regimens at any time point. CONCLUSIONS: Even in the presence of urethral sparing, the higher BED delivered in the Boost schedule may have a small adverse effect on GU QoL compared with Monotherapy. However, this did not translate to statistically significant differences in minimal clinically important changes. Whether the higher BED of the boost arm offers an efficacy advantage is being investigated in the Trans Tasman Radiation Oncology Group 18.01 NINJA randomized trial.

Topical Lidocaine or Lidocaine/Diltiazem Ointment Following Rubber Band Ligation of Hemorrhoids: A Prospective 3-Armed Randomized Controlled Trial.

BACKGROUND: Rubber band ligation of hemorrhoids causes less pain than excisional hemorrhoidectomy, but many patients still experience significant postprocedure discomfort. OBJECTIVE: This study aimed to determine whether topical lidocaine, with or without diltiazem, is more effective than placebo for analgesia after hemorrhoid banding. DESIGN: This is a prospective, randomized, double-blinded, placebo-controlled trial. Patients were randomly assigned to 2% lidocaine, 2% lidocaine with 2% diltiazem, or a placebo ointment. SETTINGS: This study was performed at 2 university public teaching hospitals and 2 private hospitals in Australia. PATIENTS: Consecutive patients aged ≥18 years undergoing hemorrhoid banding were selected. INTERVENTIONS: Topical ointments were applied postprocedure 3× daily for 5 days. MAIN OUTCOME MEASURES: Visual analog pain score, opiate analgesia usage, and patient satisfaction were the main outcome measures. RESULTS: Of 159 eligible patients, 99 were randomly assigned (33 in each group). Pain scores were reduced at 1 hour for the lidocaine (OR 4.15 [1.12-15.41]; p = 0.03) and lidocaine/diltiazem groups (OR 3.85 [1.05-14.11]; p = 0.04) compared with placebo. Patients in the lidocaine/diltiazem group had improved satisfaction (OR 3.82 [1.28-11.44]; p = 0.02) and were more likely to recommend the procedure to others (OR 9.33 [1.07-81.72]; p = 0.04). Patients in the lidocaine/diltiazem group required approximately 45% less total and in-hospital analgesia compared with the placebo. There was no difference in complications between any of the groups. LIMITATIONS: A cost/benefit analysis was not performed. Analgesic efficacy appeared to be short term and the procedures were performed only in the hospital/nonambulatory setting. CONCLUSIONS: Topical lidocaine reduced short-term analgesia use, whereas combination lidocaine/diltiazem was associated with both improved analgesia and patient satisfaction after hemorrhoid banding. LIDOCANA TPICA O UNGENTO DE LIDOCANA/DILTIAZEM DESPUS DE LA LIGADURA HEMORROIDAL CON BANDA ELSTICA UN ENSAYO PROSPECTIVO CONTROLADO Y ALEATORIZADO DE TRES BRAZOS: ANTECEDENTES:La ligadura de hemorroides con banda elástica causa menos dolor que la hemorroidectomía escisional, pero muchos pacientes siguen experimentando molestias significativas tras el procedimiento.OBJETIVO:Este estudio tiene como objetivo determinar si la lidocaína tópica, con o sin diltiazem, es más eficaz que el placebo para la analgesia tras la ligadura hemorroidal.DISEÑO:Este es un ensayo prospectivo, aleatorizado, doble ciego, controlado con placebo. Los pacientes fueron aleatorizados para recibir lidocaína al 2 %, lidocaína al 2 % con diltiazem al 2 % o ungüento de placebo.AJUSTES:Este estudio se realizó en dos hospitales públicos con docencia universitaria y dos hospitales privados en Australia.PACIENTES:Se seleccionaron pacientes consecutivos de ≥18 años sometidos a ligadura para hemorroides.INTERVENCIONES:Se aplicaron ungüentos tópicos tras el procedimiento tres veces al día durante 5 días.PRINCIPALES MEDIDAS DE RESULTADO:La puntuación analógica visual del dolor, el uso de analgésicos opiáceos y la satisfacción del paciente fueron las principales medidas de resultado.RESULTADOS:De 159 pacientes elegibles, 99 fueron aleatorizados (33 en cada grupo). Las puntuaciones de dolor se redujeron a la hora para los grupos de lidocaína (OR 4,15 (1,12-15,41); p = 0,03) y lidocaína/diltiazem (OR 3,85 (1,05-14,11), p = 0,04) en comparación con el placebo.Los pacientes del grupo de lidocaína/diltiazem mejoraron su satisfacción (OR 3,82 (1,28-11,44), p = 0,02) y eran más propensos de recomendar el procedimiento a otros (OR 9,33 (1,07-81,72), p = 0,04). Los pacientes del grupo de lidocaína/diltiazem requirieron aproximadamente un 45 % menos de analgesia total e intrahospitalaria en comparación con el grupo de placebo. No hubo diferencia en las complicaciones entre ninguno de los grupos.LIMITACIONES:No se realizó un análisis de costo/beneficio. La eficacia analgésica pareció ser a corto plazo y los procedimientos solo se realizaron en el hospital/entorno no ambulatorio.CONCLUSIÓN:La lidocaína tópica mejora la analgesia a corto plazo, mientras que la combinación de lidocaína/diltiazem se asocia tanto con una mejor analgesia como con la satisfacción del paciente tras la colocación de bandas para hemorroides. (Traducción-Dr Osvaldo Gauto ).

The importance of anaesthesia in atrial fibrillation ablation: Comparing conscious sedation with general anaesthesia.

BACKGROUND: General anaesthesia (GA) for atrial fibrillation (AF) ablation is often preferred over conscious sedation (CS) to minimize patient discomfort and reduce the risk of map disruption from patient movement but may pose an additional risk to some patients with significant comorbidity or poor cardiac function. METHODS: We extracted data for 300 patients who underwent AF ablation between the years 2017 and 2019 and compared the outcomes of AF ablation with CS and GA. RESULTS: Compared to the GA group, patients were younger in the CS group (63 versus 66 years, p = 0.02), had less persistent AF (34% versus 46%, p = 0.048) and the left atrial dimension was smaller (41 versus 45 mm, p = 0.01). More patients had cryoballoon ablation (CBA) than radiofrequency (RFA) ablation in the CS than the GA group (88% CB with CS and 56% RF with GA, p < 0.01), frequency of ASA score 3-4 (higher anaesthetic risk) was less for CS than for GA (45% versus 75%, p < 0.01), and procedural duration was shorter for patients who had CS (110 versus 139 min, p < 0.001). Of the patients receiving CS, 127/182 (70%) were planned for same day discharge (SDD) and this occurred in 120 (94%) of those patients. There were no significant differences in complication rates between the groups (5.1% in GA and 6% in CS, p = 0.8). AF type was the only significant predictor of freedom from AF recurrence on multivariate analysis (HR 0.33, 0.13-0.82, p = 0.018). CONCLUSION: In this study, the use of CS compared with GA for AF ablation was associated with similar outcomes and complication rates.

Exposure to other people's gambling and gambling behaviors in Australian secondary school students.

OBJECTIVE: This study explored associations between exposure to other people's gambling and the prevalence of gambling in the last month, engagement in hard gambling activities (defined as those which occur more frequently, with a quicker determination of outcomes, and/or high payout ratios), and the prevalence of at risk and problem gambling, among a large sample of Australian adolescent school students. METHOD: In 2017, 6,377 students from Victoria and Queensland answered gambling questions as part of the cross-sectional triennial Australian Secondary Students' Alcohol and Drug Survey. Students reported on gambling behaviors (gambling in the last month, types of gambling activities), were assessed for problem gambling using the Diagnostic Statistical Manual IV adapted for Juveniles (DSM-IV-[MR]-J), and reported whether people they knew (parents, siblings, other relatives, best friend, or someone else) had gambled in the last month. Logistic regressions explored the relationship between other people's gambling and student gambling behaviors in the last month. RESULTS: Approximately, one in five students reported that someone from their household gambled in the last month. Overall, 6% of students reported they had gambled, and 4% gambled on a hard gambling activity, in the previous month; 10% were classified as potentially at risk or problem gamblers. Having a parent, sibling, best friend, another relative, or someone else who gambled in the last month were each significantly associated with the three gambling outcomes. CONCLUSIONS: There is a need to address the modeling of gambling behaviors by young people's friends, family, and others, in order to reduce gambling behaviors and problem gambling among Australian adolescents. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Impact of Education and Lifestyle Factors on Disability-Free Life Expectancy From Mid-Life to Older Age: A Multi-Cohort Study.

Objectives: Low education and unhealthy lifestyle factors such as obesity, smoking, and no exercise are modifiable risk factors for disability and premature mortality. We aimed to estimate the individual and joint impact of these factors on disability-free life expectancy (DFLE) and total life expectancy (TLE). Methods: Data (n = 22,304) were from two birth cohorts (1921-26 and 1946-51) of the Australian Longitudinal Study on Women's Health and linked National Death Index between 1996 and 2016. Discrete-time multi-state Markov models were used to assess the impact on DFLE and TLE. Results: Compared to the most favourable combination of education and lifestyle factors, the least favourable combination (low education, obesity, current/past smoker, and no exercise) was associated with a loss of 5.0 years TLE, 95% confidence interval (95%CI): 3.2-6.8 and 6.4 years DFLE (95%CI: 4.8-7.8) at age 70 in the 1921-26 cohort. Corresponding losses in the 1946-51 cohort almost doubled (TLE: 11.0 years and DFLE: 13.0 years). Conclusion: Individual or co-ocurrance of lifestyle risk factors were associated with a significant loss of DFLE, with a greater loss in low-educated women and those in the 1946-51 cohort.

Optimising a multi-strategy implementation intervention to improve the delivery of a school physical activity policy at scale: findings from a randomised noninferiority trial.

BACKGROUND: To maximise their potential health benefits, school-based physical activity policies need to be implemented at scale. This paper describes the third in a sequence of trials that sought to optimise an effective strategy (PACE) to assist schools' implementation of a physical activity policy. Specifically, it aimed to determine the probability that a multi-strategy intervention adapted to reduce in-person contact (Adapted PACE) was "as good as" the original intervention (PACE) in increasing the weekly minutes of structured physical activity implemented by classroom teachers. METHODS: A noninferiority cluster randomised controlled trial was undertaken with 48 primary schools in New South Wales, Australia. Schools were randomised to receive PACE or a model with adaptations made to the delivery modes (Adapted PACE). Teachers' scheduled minutes of weekly physical activity was assessed at baseline (Oct 2018-Feb 2019) and 12-month follow-up (Oct-Dec 2019). The noninferiority margin was set at - 16.4 minutes based on previous data and decision panel consensus. A linear mixed model analysed within a Bayesian framework was used to explore noninferiority between the two PACE models. A cost minimisation analysis was conducted from the health service provider perspective, using the Australian dollar (AUD). RESULTS: The posterior estimate for the between group difference at follow-up was - 2.3 minutes (95% credible interval = - 18.02, 14.45 minutes). There was an estimated 96% probability of Adapted PACE being considered noninferior (only 4% of the posterior samples crossed the noninferiority margin of - 16.4 minutes). That is, the minutes of physical activity implemented by teachers at Adapted PACE schools was not meaningfully less than the minutes of physical activity implemented by teachers at PACE schools. The mean total cost was AUD$25,375 (95% uncertainty interval = $21,499, $29,106) for PACE and AUD$16,421 (95% uncertainty interval = $13,974, $19,656) for Adapted PACE; an estimated reduction of AUD$373 (95% uncertainty interval = $173, $560) per school. CONCLUSIONS: It is highly probable that Adapted PACE is noninferior to the original model. It is a cost-efficient alternative also likely to be a more suitable approach to supporting large scale implementation of school physical activity policies. TRIAL REGISTRATION: Retrospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619001229167).

Exposure to gambling promotions and gambling behaviours in Australian secondary school students.

Background: Young people's gambling behaviours are associated with a range of individual, interpersonal and community factors. This study explored the association between exposure to types of gambling advertising and promotions and adolescent gambling behaviours. Methods: Students from two states answered gambling questions as part of the 2017 Australian Secondary Students' Alcohol and Drug (ASSAD) Survey. Students reported gambling behaviours (gambling in the last month, types of gambling activities), exposure to gambling promotions during the last 30 days (e.g. ads for gambling on TV, online, live studio crosses), and were assessed for problem gambling. Principal Component Analysis suggested four groups of gambling promotion exposure. Logistic regression analyses examined the association between gambling promotion exposure and student gambling, engagement in hard gambling activities in the last month, and problem or at risk gambling, controlling for a range of student characteristics. Results: Most students (81%) had been exposed to some form of gambling promotion or advertisement in the last month, most commonly TV, social media and sporting event advertisements. Exposure to online gambling ads (including websites, pop-ups on websites, and social media) in the last month was significantly associated with gambling in the last month, and being classified as an at risk or problem gambler; but not with participating in hard gambling activities. After adjusting for exposure to gambling advertising across categories, no other advertising exposure types were associated with adolescent gambling behaviours. Conclusions: Study findings point to the need to impose restrictions on gambling advertisements and promotions, particularly those presented online.

Smoking and other health factors in patients with head and neck cancer.

BACKGROUND: Information on smoking and other health factors in head and neck cancer (HNC) patients throughout treatment, follow-up and survivorship is limited. This study explores patterns of multiple health factors during radiotherapy (RT) and naturalistic long-term follow-up in a convenience sample of patients with HNC. METHODS: Smoking, alcohol use and depression were measured at baseline, 4 and 12 weeks post RT for a sub-group of 99 patients who participated in a randomised controlled trial and completed long-term follow-up. These factors plus healthy eating, physical activity and fatigue are also reported from the long-term follow-up component. Smoking was measured by self-report and biochemically, whilst all other variables were by self-report. Where variables were assessed at multiple time points logistic mixed effects regression models determined within-person changes over time. RESULTS: There were important discrepancies between self-reported (4-7%) and biochemically verified (13-29%) rates of smoking. Rates of smoking and hazardous alcohol intake were significantly increased at follow-up compared to baseline. Depression rates were observed to be higher at end of RT compared to baseline. At long-term follow-up, fatigue was common and co-occurred with suboptimal healthy eating and hazardous alcohol use. CONCLUSION: Clinically important levels of smoking and alcohol consumption post RT in this sample suggest possible targets for intervention beyond treatment into long-term follow-up of patients.

Do P2Y12 receptor inhibitors prescribed poststroke modify the risk of cognitive disorder or dementia? Protocol for a target trial using multiple national Swedish registries.

INTRODUCTION: The target of a class of antiplatelet medicines, P2Y12R inhibitors, exists both on platelets and on brain immune cells (microglia). This protocol aims to describe a causal (based on a counterfactual model) approach for analysing whether P2Y12R inhibitors prescribed for secondary prevention poststroke may increase the risk of cognitive disorder or dementia via their actions on microglia, using real-world evidence. METHODS AND ANALYSIS: This will be a cohort study nested within the Swedish National Health and Medical Registers, including all people with incident stroke from 2006 to 2016. We developed directed acyclic graphs to operationalise the causal research question considering potential time-independent and time-dependent confounding, using input from several experts. We developed a study protocol following the components of the target trial approach described by Hernan et al and describe the data structure that would be required in order to make a causal inference. We also describe the statistical approach required to derive the causal estimand associated with this important clinical question; that is, a time-to-event analysis for the development of cognitive disorder or dementia at 1, 2 and 5-year follow-up, based on approaches for competing events to account for the risk of all-cause mortality. Causal effect estimates and the precision in these estimates will be quantified. ETHICS AND DISSEMINATION: This study has been approved by the Ethics Committee of the University of Gothenburg and Confidentiality Clearance at Statistics Sweden with Dnr 937-18, and an approved addendum with Dnr 2019-0157. The analysis and interpretation of the results will be heavily reliant on the structure, quality and potential for bias of the databases used. When we implement the protocol, we will consider and document any biases specific to the dataset and conduct appropriate sensitivity analyses. Findings will be disseminated to local stakeholders via conferences, and published in appropriate scientific journals.