Obstetric admissions to intensive care units in Australia and New Zealand: a registry-based cohort study.

OBJECTIVE: Describe the epidemiology of obstetric patients admitted to an Intensive Care Unit (ICU). DESIGN: Registry-based cohort study. SETTING: One hundred and eighty-three ICUs in Australia and New Zealand. POPULATION: Women aged 15-49 years, admitted to ICU between 2008 and 2017, classified as pregnant, postpartum or with an obstetric-related diagnosis. METHODS: Data were extracted from the Australia and New Zealand Intensive Care Society (ANZICS) Adult Patient Database and national agencies. MAIN OUTCOME MEASURES: Incidence of ICU admission, cohort characteristics, maternal outcomes and changes over time. RESULTS: The cohort comprised 16 063 patients. The annual number of obstetric ICU admissions increased, whereas their proportion of total ICU admissions (1.3%) did not change (odds ratio 1.02, 95% CI 0.99-1.04, P = 0.14). There were 10 518 (65%) with an obstetric-related ICU diagnosis, and 5545 (35%) with a non-obstetric ICU diagnosis. Mean (SD) age was 31 (6.4) years, 1463 (9.1%) were Indigenous, 2305 (14%) were transferred from another hospital, and 3008 (19%) received mechanical ventilation. Median [IQR] length of stay in hospital was 5.2 [3.1-7.9] days, which included 1.1 [0.7-1.8] days in ICU. There were 108 (0.7%) maternal deaths, most (n = 97, 90%) having a non-obstetric diagnosis. There was no change in risk-adjusted length of stay or mortality over time. CONCLUSIONS: Obstetric patients account for a stable proportion of ICU admissions in Australia and New Zealand. These patients typically have a short length of ICU stay and low hospital mortality. TWEETABLE ABSTRACT: Obstetric patients in Australia/New Zealand ICUs have a short length of ICU stay and low mortality.

Describing the resource utilisation and costs associated withvertebral fractures: the Build Better Bones with Exercise (B3E) Pilot Trial.

This analysis examined costs/resources of 141 women with vertebral fractures, randomised to a home exercise programme or control group. Total, mean costs and the incremental cost-effectiveness ratio (ICER) were calculated. Quality of life was collected. Cost drivers were caregiver time, medications and adverse events (AEs). Results show adding an exercise programme may reduce the risk of AEs. INTRODUCTION: This exploratory economic analysis examined the health resource utilisation and costs experienced by women with vertebral fractures, and explored the effects of home exercise on those costs. METHODS: Women ≥ 65 years with one or more X-ray-confirmed vertebral fractures were randomised 1:1 to a 12-month home exercise programme or equal attention control group. Clinical and health system resources were collected during monthly phone calls and daily diaries completed by participants. Intervention costs were included. Unit costs were applied to health system resources. Quality of life (QoL) information was collected via EQ-5D-5L at baseline, 6 and 12 months. RESULTS: One hundred and forty-one women were randomised. Overall total costs (CAD 2018) were $664,923 (intervention) and $614,033 (control), respectively. The top three cost drivers were caregiver time ($250,269 and $240,811), medications ($151,000 and $122,145) and AEs ($58,807 and $71,981). The mean cost per intervention participant of $9365 ± $9988 was higher compared with the mean cost per control participant of $8772 ± $9718. The mean EQ-5D index score was higher for the intervention participants (0.81 ± 0.11) compared with that of controls (0.79 ± 0.13). The differences in quality-adjusted life year (QALY) (0.02) and mean cost ($593) were used to calculate the ICER of $29,650. CONCLUSIONS: Women with osteoporosis with a previous fracture experience a number of resources and associated costs that impact their care and quality of life. Caregiver time, medications and AEs are the biggest cost drivers for this population. The next steps would be to expand this feasibility study with more participants, longer-term follow-up and more regional variability.

Accuracy of contrast-enhanced CT and predictive factors for extracapsular spread in unknown primary head and neck squamous cell cancer.

AIM: To determine the accuracy of contrast-enhanced computed tomography (CECT) for nodal extracapsular spread (ECS) and identify predictive radiological signs and clinicopathological features for ECS in unknown-primary head and neck squamous cell cancer (UPHNSCC). MATERIALS AND METHODS: The CECT imaging of patients who underwent primary neck dissection for UPHNSCC during 2011-2015 was analysed. The largest pathological-looking node at each radiologically involved level was evaluated in consensus by two head and neck radiologists. Parameters included longest diameter, margin sharpness, haziness in adjacent fat, necrosis, and loss of fat plane with adjacent structures. Independent assessment was also made regarding the presence/absence of ECS. Findings and clinicopathological parameters were correlated with histopathology. RESULTS: Thirty-one patients with 39 neck levels had metastatic nodal involvement determined on CECT. Confirmed ECS was found at 26 levels in 23 patients. Sensitivity of radiological assessment for ECS by nodal level was 81-85% (95% confidence interval [CI]=65-93%) and specificity 46-54% (95% CI=19-81%); kappa 0.87. On univariate analysis based on the largest involved node per patient, longest diameter being ≥30 mm (p=0.007), haziness in adjacent fat (p=0.023), increasing age (p=0.006), and more advanced pathological nodal status (p=0.027) were statistically significantly associated with ECS. Haziness and increasing age were independent predictors on multivariate analysis (odds ratio [OR]=26.4 and 1.24). CONCLUSION: Expert assessment of ECS on CECT had good sensitivity with excellent interobserver agreement. A longest nodal diameter of ≥30 mm, haziness in the surrounding fat on CECT, advanced pathological nodal status, and advancing patient age were significantly associated with ECS in UPHNSCC patients, findings not previously reported.

Build better bones with exercise (B3E pilot trial): results of a feasibility study of a multicenter randomized controlled trial of 12 months of home exercise in older women with vertebral fracture.

We pilot-tested a trial of home exercise on individuals with osteoporosis and spine fracture. Our target enrollment was met, though it took longer than expected. Participants stayed in the study and completed the exercise program with no safety concerns. Future trials should expand the inclusion criteria and consider other changes. PURPOSE: Osteoporotic fragility fractures create a substantial human and economic burden. There have been calls for a large randomized controlled trial examining the effect of exercise on fracture incidence. The B3E pilot trial was designed to evaluate the feasibility of a large trial examining the effects of home exercise on individuals at high risk of fracture. METHODS: Community-dwelling women ≥ 65 years with radiographically confirmed vertebral compression fractures were recruited at seven sites in Canada and Australia. We randomized participants in a 1:1 ratio to a 12-month home exercise program or equal attention control group, both delivered by a physiotherapist (PT). Participants received six PT home visits in addition to monthly phone calls from the PT and a blinded research assistant. The primary feasibility outcomes of the study were recruitment rate (20 per site in 1 year), retention rate (75% completion), and intervention adherence rate (60% of weeks meeting exercise goals). Secondary outcomes included falls, fractures and adverse events. RESULTS: One hundred forty-one participants were recruited; an average of 20 per site, though most sites took longer than anticipated. Retention and adherence met the criteria for success: 92% of participants completed the study; average adherence was 66%. The intervention group did not differ significantly in the number of falls (IRR 0.97, 95% CI 0.58 to 1.63) or fragility fractures (OR 1.11, 95% CI 0.60 to 2.05) compared to the control group. There were 18 serious adverse events in the intervention group and 12 in the control group. CONCLUSION: An RCT of home exercise in women with vertebral fractures is feasible but recruitment was a challenge. Suggestions are made for the conduct of future trials.

"Left to my own devices, I don't know": using theory and patient-reported barriers to move from physical activity recommendations to practice.

Knowledge exchange with community-dwelling individuals across Ontario revealed barriers to implementation of physical activity recommendations that reflected capability, opportunity, and motivation; barriers unique to individuals with osteoporosis include fear of fracturing, trust in providers, and knowledge of exercise terminology. Using the Behaviour Change Wheel, we identified interventions (training, education, modeling) and policy categories (communication/marketing, guidelines, service provision). INTRODUCTION: Physical activity recommendations exist for individuals with osteoporosis; however, to change behavior, we must address barriers and facilitators to their implementation. The purposes of this project are (1) to identify barriers to and facilitators of uptake of disease-specific physical activity recommendations (2) to use the findings to identify behavior change strategies using the Behaviour Change Wheel (BCW). METHODS: Focus groups and semi-structured interviews were conducted with community-dwelling individuals attending osteoporosis-related programs or education sessions in Ontario. They were stratified by geographic area, urban/rural, and gender, and transcribed verbatim. Two researchers coded data and identified emerging themes. Using the Behaviour Change Wheel framework, themes were categorized into capability, opportunity, and motivation, and interventions were identified. RESULTS: Two hundred forty community-dwelling individuals across Ontario participated (mean ± SD age = 72 ± 8.28). Barriers were as follows: capability: disease-related symptoms hinder exercise and physical activity participation, lack of exercise-related knowledge, low exercise self-efficacy; opportunity: access to exercise programs that meet needs and preferences, limited resources and time, physical activity norms and preferences; motivation: incentives to exercise, fear of fracturing, trust in exercise providers. Interventions selected were training, education, and modeling. Policy categories selected were communication/marketing, guidelines, and service provision. CONCLUSIONS: Barriers unique to individuals with osteoporosis included the following: lack of knowledge on key exercise concepts, fear of fracturing, and trust in providers. Behavior change techniques may need tailoring to gender, age, or presence of comorbid conditions.

"I do not have time. Is there a handout I can use?": combining physicians' needs and behavior change theory to put physical activity evidence into practice.

Guidelines for physical activity exist and following them would improve health. Physicians can advise patients on physical activity. We found barriers related to physicians' knowledge, a lack of tools and of physician incentives, and competing demands for limited time with a patient. We discuss interventions that could reduce these barriers. INTRODUCTION: Uptake of physical activity (PA) guidelines would improve health and reduce mortality in older adults. However, physicians face barriers in guideline implementation, particularly when faced with needing to tailor recommendations in the presence of chronic disease. We performed a behavioral analysis of physician barriers to PA guideline implementation and to identify interventions. The Too Fit To Fracture physical activity recommendations were used as an example of disease-specific PA guidelines. METHODS: Focus groups and semi-structured interviews were conducted with physicians and nurse practitioners in Ontario, stratified by type of physician, geographic area, and urban/rural, and transcribed verbatim. Two researchers coded data and identified emerging themes. Using the behavior change wheel framework, themes were categorized into capability, opportunity and motivation, and interventions were identified. RESULTS: Fifty-nine family physicians, specialists, and nurse practitioners participated. Barriers were as follows: Capability-lack of exercise knowledge or where to refer; Opportunity-pragmatic tools, fit within existing workflow, available programs that meet patients' needs, physical activity literacy and cultural practices; Motivation-lack of incentives, not in their scope of practice or professional identity, competing priorities, outcome expectancies. Interventions selected: education, environmental restructuring, enablement, persuasion. Policy categories: communications/marketing, service provision, guidelines. CONCLUSIONS: Key barriers to PA guideline implementation among physicians include knowledge on where to refer or what to say, access to pragmatic programs or resources, and things that influence motivation, such as competing priorities or lack of incentives. Future work will report on the development and evaluation of knowledge translation interventions informed by the barriers.

Mycobacterium tuberculosis resistance in pulmonary TB patients in Cameroon: a phenotypic susceptibility assay.

OBJECTIVE: To determine the resistance of Mycobacterium tuberculosis to first- and second-line agents in adult pulmonary tuberculosis (TB) patients in Cameroon using a novel phenotypic assay. SETTING: Samples were collected from TB patients at Bamenda Hospital in Bamenda, Cameroon. DESIGN: Samples were collected consecutively from adult pulmonary TB patients over a 2-month period. TREK Sensititre(TM) MYCOTB panels were used to perform phenotypic drug susceptibility testing (DST). Susceptibility/resistance was determined by comparing minimum inhibitory concentrations to standard critical concentrations established for first- and second-line anti-tuberculosis drugs. RESULTS: Of 103 sputum samples processed, growth on Löwenstein-Jensen media was confirmed in 78 samples, 65 of which were suitable for DST. Thirty-nine strains (60%) were susceptible to all first- and second-line drugs. Five strains (8%) were categorized as multidrug-resistant TB. Two strains (3%) were classified as pre-extensively drug-resistant TB. Of those isolates susceptible to first-line drugs, 20% were resistant to at least one second-line drug. CONCLUSION: Antimicrobial resistance may be higher than assumed in TB strains in Cameroon, especially with regard to second-line drugs. There remains a need for rapid, comprehensive DST.

Stress ulcer prophylaxis in the intensive care unit: an international survey of 97 units in 11 countries.

BACKGROUND: Stress ulcer prophylaxis (SUP) may decrease the incidence of gastrointestinal bleeding in patients in the intensive care unit (ICU), but the risk of infection may be increased. In this study, we aimed to describe SUP practices in adult ICUs. We hypothesised that patient selection for SUP varies both within and between countries. METHODS: Adult ICUs were invited to participate in the survey. We registered country, type of hospital, type and size of ICU, preferred SUP agent, presence of local guideline, reported indications for SUP, criteria for discontinuing SUP, and concerns about adverse effects. Fisher's exact test was used to assess differences between groups. RESULTS: Ninety-seven adult ICUs in 11 countries participated (eight European). All but one ICU used SUP, and 64% (62/97) reported having a guideline for the use of SUP. Proton pump inhibitors were the most common SUP agent, used in 66% of ICUs (64/97), and H2-receptor antagonists were used 31% (30/97) of the units. Twenty-three different indications for SUP were reported, the most frequent being mechanical ventilation. All patients were prescribed SUP in 26% (25/97) of the ICUs. Adequate enteral feeding was the most frequent reason for discontinuing SUP, but 19% (18/97) continued SUP upon ICU discharge. The majority expressed concern about nosocomial pneumonia and Clostridium difficile infection with the use of SUP. CONCLUSIONS: In this international survey, most participating ICUs reported using SUP, primarily proton pump inhibitors, but many did not have a guideline; indications varied considerably and concern existed about infectious complications.

Characterisation of macrocyclic lactone resistance in two field-derived isolates of Cooperia oncophora.

The anthelmintic sensitivity of two field-derived isolates (designated FI001 and FI004) of cattle nematodes from beef farms in Scotland were investigated in a controlled efficacy test (CET). Efficacies of ivermectin pour-on (IVM-PO), IVM injectable (IVM-INJ) and moxidectin pour-on (MOX-PO) formulations were assessed. In each group, five helminth-naïve calves were infected experimentally with 50,000 third stage larvae from either isolate and administered with anthelmintic at the manufacturers' recommended dose rate 28 days later. For each isolate, nematode burdens were compared between treatment and control groups to determine efficacy. Nematode species composition, based on data derived from the untreated control groups' burden estimations, were 39 and 14% Cooperia oncophora and 61 and 86% Ostertagia ostertagi for isolates FI001 and FI004, respectively. Macrocyclic lactone resistance in C. oncophora was confirmed for both FI001 and FI004 isolates. Efficacies (as determined by nematode burden analysis) of 4, 21 and 31% for FI001, and 10, 1 and 74% for FI004, were obtained for IVM-INJ, IVM-PO and MOX-PO, respectively. Efficacy based on faecal egg count reduction at seven days post anthelmintic administration were 8, 99 and 100% for FI001, and 37, 20 and 100% for FI004 for IVM-INJ, IVM-PO and MOX-PO, respectively. In summary, this study details two macrocyclic lactone resistant isolates of C. oncophora obtained from cattle from two distinct geographical locales in the UK.

Current and potential renal applications of contrast-enhanced ultrasound.

The combination of microbubble technology and complementary ultrasound techniques has resulted in the development of contrast-enhanced ultrasound (CEUS) and, although initial clinical applications largely focussed on the liver, these are now becoming more diverse. With regard to the kidney, it is a safe, well-tolerated, and reproducible technique, and in selected cases, can obviate the need for computed tomography or magnetic resonance imaging. A clear advantage is the absence of nephrotoxicity. With respect to the current and potential renal applications, it is a useful technique in the evaluation of pseudotumours, acute pyelonephritis, renal tumours, cystic lesions, vascular insults, and renal transplantation. It may also be of value for monitoring the kidney following anti-angiogenic treatment or nephron-sparing interventional techniques for renal tumours. Assessment of microvascular perfusion using time-intensity curves is also likely to have further far-reaching applications in the kidney as well as other organs.

Changing the referral criteria for bone scan in newly diagnosed prostate cancer patients.

OBJECTIVES: The aim of this study was to correlate the prostate-specific antigen (PSA) level and Gleason score with staging bone scan result in patients with a new diagnosis of prostate cancer in order to establish the feasibility of implementing the European Association Urology guidelines, which state that a bone scan may not be indicated when PSA <20 in well-moderately differentiated tumours. METHODS: We identified 633 patients retrospectively and 186 patients prospectively with a new diagnosis of prostate cancer undergoing a staging bone scan between March 2005 and January 2010. Patients were excluded if there was no Gleason score available or if the PSA level was checked over 3 months prior to bone scan. Bone scan results were analysed with respect to age, PSA level and Gleason score. In the case of an equivocal result, subsequent imaging was taken into consideration or the initial bone scan was re-reviewed. In persistently equivocal cases, all relevant imaging was assessed by a blinded panel of radiologists to allow a final decision to be made. RESULTS: Of 672 patients aged 39-93 years (median 71 years), who fulfilled the inclusion criteria, 54 (8%) had evidence of bony metastases. PSA level and Gleason score were both independent predictors of bone scan positivity and their predictive value was additive p<0.01. None of the 357 patients with a PSA level of <20 and a Gleason score of <8 had a positive bone scan. CONCLUSION: Staging bone scans in newly diagnosed prostate cancer patients with a PSA level of <20 and a Gleason score of <8 can be safely omitted, with these criteria having a negative predictive value of 100% in our series.

Applications of cerebral SPECT.

Single-photon emission computed tomography (SPECT) can provide three-dimensional functional images of the brain following the injection of one of a series of radiopharmaceuticals that crosses the blood--brain barrier and distributes according to cerebral perfusion, neurotransmitter, or cell density. Applications include differentiating between the dementias, evaluating cerebrovascular disease, preoperative localization of epileptogenic foci, diagnosing movement disorders, and evaluation of intracerebral tumours, while also proving a useful research tool. Unlike positronemission tomography (PET), SPECT imaging is widely available and can be performed in any department that has access to a rotating gamma camera. The purpose of this review is to demonstrate the utility of cerebral SPECT and increase awareness of its role in the investigation of neurological and psychiatric disorders.

Ovarian cancer stem-like side-population cells are tumourigenic and chemoresistant.

BACKGROUND: Ovarian cancer is the most lethal gynaecological malignancy. Although ovarian cancer patients often respond initially to chemotherapy, they usually develop chemoresistance. We hypothesised that a small portion of ovarian cancer cells have stem-like cell properties that contribute to tumourigenesis and drug resistance. METHODS: Flow cytometry and Hoechst 33342 efflux isolated side-population (SP) cells from ascites derived from ovarian cancer patients and from mice inoculated with human ovarian cancer cell lines. The SP cells were examined for stem cell markers OCT4, NANOG, STELLAR, and ABCG2/BCRP1 by immunocytochemistry and RT-PCR. The SP cells and non-SP cells were studied for tumourigenesis and chemoresistance in vitro and in vivo. RESULTS: The SP cells expressed ABCG2/BCRP1, OCT4, STELLAR, and NANOG, detected by immunocytochemistry and RT-PCR. ABCG2/BCRP1 expression was higher in SP than in non-SP cells. Xenogeneic mice inoculated with SP cells yielded more tumours than did mice inoculated with non-SP cells. In parallel, SP cell culture resulted in extensive cell proliferation, which was markedly more than in non-SP cells. SP cells resisted chemotherapy compared with non-SP cells, both in vivo and in vitro. CONCLUSION: Ovarian cancer SP cells are tumourigenic and chemoresistant. ABCG2/BCRP1 has an important role in chemoresistance, which has implications for new therapeutic approaches.

International albumin use: 1995 to 2006.

Over the last ten years more reliable information regarding the risks and benefits of the use of albumin for fluid resuscitation has emerged. To determine what influence this has had on clinical practice, we sought to document albumin use (from mass of albumin supplied to hospitals) in 16 industrialised countries between 1995 and 2006. Data on national albumin and synthetic colloid use was sought from independent intensive care researchers and albumin issuers. The mass of albumin supplied per 10,000 persons on an annual basis by country and aggregated across the study countries was calculated. Volumes of synthetic colloid supplied per 10,000 persons were calculated. Data were obtained for 15 countries. Albumin use varied significantly between countries and throughout the observation period. Overall, aggregate albumin use decreased from a peak of 2.54 kg per 10,000 persons in 1995 to 1.40 kg per 10,000 persons in 1999; use has remained relatively constant since. Data on supply of synthetic colloids was available in only three countries and varied from 11.7 litres per 10,000 persons in Canada in 1995, to 231.8 litres per 10,000 persons in Denmark in 2004. Between 1995 and 1999 albumin use decreased and has been materially constant since; where data were available, use of synthetic colloids increased. Whether these practice changes have resulted in a net health gain or in harm requires further research.

Pandemic influenza A(H1N1)v in New Zealand: the experience from April to August 2009.

Following the detection of imported cases of pandemic influenza A(H1N1)v on 25 April 2009, New Zealand implemented containment measures that appeared to slow establishment of the pandemic during May. The pandemic accelerated markedly in June, reaching a peak within four to six weeks, and has been declining since mid-July. By 23 August there had been 3,179 recorded cases (97.8% reported as confirmed), including 972 hospitalisations, 114 intensive care admissions, and 16 deaths. Influenza-like illness (ILI) surveillance in general practice suggests that 7.5% (95% CI: 3.4-11.2) of the population of New Zealand had symptomatic infection, giving a case fatality ratio of 0.005%. Hospitalisations were markedly higher for Maori (age standardised relative risk (RR)=3.0, 95% CI: 2.9-3.2) and Pacific peoples (RR=6.7, 95% CI: 6.2-7.1) compared with Europeans and others. The apparent decline of the pandemic (shown by all surveillance systems) cannot be fully explained. New Zealand remains in the middle of its traditional influenza season, the influenza A(H1N1)v virus appears relatively infectious, and we estimate that only about 11% of the population have been infected by this novel agent.

Experimental infection studies of UK Culicoides species midges with bluetongue virus serotypes 8 and 9.

This paper describes a rapid, standardised method for testing the susceptibility to bluetongue virus (BTV) of northern Palaearctic Culicoides species midges that can be used to assess the competence of both field-caught and laboratory-infected midges. The method has been used to show that Culicoides scoticus can replicate btv serotype 8 and BTV serotype 9 strains to more than 3 log(10) TCID50/midge, the first evidence of the potential of this species to transmit BTV.

[HIV seroprevalence in ophthalmologic patients of Cameroon]. / HIV-Prävalenz bei ophthalmologischen Patienten in Kamerun.

BACKGROUND: It is difficult to estimate the exact HIV infection rates in countries such as Cameroon because of diagnostic and statistical problems. The majority of people seek help from traditional healers outside the health system. PATIENTS AND METHODS: A screening for human immunodeficiency virus type 1 (HIV-1) and type 2 (HIV-2) was performed on 2452 patients of the western province of Cameroon. All data were evaluated regarding HIV seroprevalence and ophthalmological findings in HIV-seropositive patients. The test covered all patients who came for cataract surgery (group 1), all outpatients with suspicious ophthalmological findings (group 2), and all remarkable patients of the collaborating department of general medicine (group 3) between 20 September 2000 and 20 September 2001. RESULTS: Of the 2452 screened patients, 467 (19.0%) were HIV seropositive. A positive test result was obtained in 29 (5.5%) of the 525 patients in group 1, 154 (35.6%) of the 433 patients in group 2, and 284 (19.0%) of the 1494 patients in group 3. The main ocular manifestations of the 154 HIV-seropositive patients in group 2 were uveitis (17.6%), squamous cell carcinoma of the conjunctiva (14.9%), zoster ophthalmicus (14.9%), and corneal ulcers (11.0%). CONCLUSIONS: This study shows that the seroprevalence of the screened population of Cameroon lies between 5.5% (results of group 1) and 19.0% (results of group 3).