RESUMO
BACKGROUND: Studies exploring early life-course BMI trajectories and subsequent mental health outcomes are limited but may provide important insights for early intervention. We investigated associations between BMI trajectories from 0 to 18 years and mental health outcomes in emerging adulthood. METHODS: Data were obtained from 434 participants in the Melbourne Atopy Cohort Study (MACS). Anthropometric data were collected across 26 timepoints from infancy to age 25 and group-based trajectory modelling was used to develop BMI trajectories from 0.1 to 18 years. Moderate-to-severe psychological distress (MSPD) and likely depression were assessed at age 18 and 25 years. Associations between BMI trajectories and mental health at 25 years and change in mental health between 18 and 25 years were estimated using logistic regression. History of asthma, hay fever or eczema were independently examined as potential effect modifiers. RESULTS: Five BMI trajectories were identified from 1 month to 18 years. When compared to the stable average BMI trajectory, we found an increased risk of MSPD (OR = 2.97; 95%CI: 1.09,8.06) and likely depression (3.56; 1.39,9.12) at age 25 in the average increasing-to-high trajectory. This group also had a greater likelihood of new-onset depression (4.82; 1.54,15.0) from 18 to 25 years of age. LIMITATIONS: MACS participants are not representative of the general population and mental health data was not available before 18 years of age. CONCLUSION: Excessive weight gain across the childhood transition was associated with poorer mental health in emerging adulthood, highlighting the importance of monitoring growth to allow for early identification and stratification of individuals at risk of poor mental health.
RESUMO
BACKGROUND AND AIMS: Accurate biomarkers to predict outcomes following discontinuation of nucleos(t)ide analogue (NA) therapy are needed. We evaluated serum hepatitis B core-related antigen (HBcrAg) level as a biomarker for predicting outcomes after NA discontinuation. METHODS: Patients with HBeAg-negative chronic hepatitis B (CHB) without cirrhosis were enrolled in a prospective trial evaluating clinical outcomes until 96 weeks after NA discontinuation. End of treatment (EOT) and off-treatment levels of serum HBcrAg, HBsAg, HBV RNA and HBV DNA were used to predict key clinical outcomes including hepatitis flare (ALT ≥5 × ULN and HBV DNA > 2000 IU/mL). The SCALE-B score was calculated for the purposes of model validation. RESULTS: HBcrAg was tested amongst 65 participants. The median age was 54 years, 54% were male and 83% were Asian. HBcrAg was detectable in 86% patients. HBcrAg level ≥4 log U/mL at EOT was predictive of hepatitis flare [8/10 (80%) vs. 17/55 (31%), p = .001]. The presence of either HBcrAg ≥4 log U/mL or detectable HBV RNA at EOT predicted for both biochemical relapse and hepatitis flare. The SCALE-B model at EOT predicted for virological relapse, biochemical relapse, hepatitis flare and HBsAg loss in this cohort. An increase in the serum HBcrAg level off-treatment was also associated with hepatitis flare. No participant with EOT HBcrAg level ≥4 log U/mL achieved HBsAg loss. CONCLUSIONS: High levels of serum HBcrAg predict for hepatitis flare after stopping NA therapy and low likelihood of HBsAg loss at week 96. People with high levels of serum HBcrAg are not suitable candidates for NA discontinuation.
Assuntos
Antivirais , Biomarcadores , DNA Viral , Antígenos do Núcleo do Vírus da Hepatite B , Vírus da Hepatite B , Hepatite B Crônica , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Antígenos do Núcleo do Vírus da Hepatite B/sangue , Antivirais/uso terapêutico , Estudos Prospectivos , Hepatite B Crônica/tratamento farmacológico , Hepatite B Crônica/sangue , Biomarcadores/sangue , DNA Viral/sangue , Adulto , Vírus da Hepatite B/genética , Antígenos de Superfície da Hepatite B/sangue , RNA Viral/sangue , Suspensão de Tratamento , Exacerbação dos Sintomas , IdosoRESUMO
ObjectiveThe causal effect of successive population-wide lockdowns in response to increased COVID-19 cases on mental health has yet to be examined using robust methods. A natural experiment design underpinned by objective data can improve our understanding surrounding the definitive impact of social distancing restrictions.MethodsThe study employed a natural experiment design underpinned by objective data. Health service cost for visits to general practitioners and psychologists and medication dispensing costs served as objective measures of mental health. Difference-in-difference (DID) estimators, which in this study quantify differences in spending changes between groups over time, were produced based on three comparisons: Victoria 2020 lockdown comparison, Victoria 2021 lockdown comparison, and New South Wales (NSW) 2021 lockdown comparison. Specifically, differences in public health service spending during lockdown periods and the same timeframe in 2019 for Victoria and NSW, and control groups (remaining states and territories), were compared.ResultsPositive estimator values indicate that public health service spending for Victoria and NSW increased more during lockdown periods compared to control states and territories. The Victorian lockdowns of 2020 and 2021, but not the NSW lockdown of 2021, resulted in increased public spending for general practitioner mental health consults (2020 DID estimator: $8498.96 [95% CI $4012.84, $12,373.57], 2021 DID estimator: $6630.06 [95% CI $41.27, $13,267.20], all monetary values in AUD$) and short visits to psychologists (2020 DID estimator: $628.82 [95% CI $466.25, $796.00], 2021 DID estimator: $230.11 [95% CI $47.52, $373.98]). The first Victorian lockdown in 2020 and the NSW lockdown in 2021 resulted in greater spending on short visits to clinical psychologists. Spending on long visits to psychologists and clinical psychologists and medication spending did not change.ConclusionsStrict lockdowns can have an adverse impact on population mental health. The impact is particularly evident in those who have a history of previous mental health concerns but does not necessitate extra use of medications, suggesting that psychological care can address the adverse impact of the lockdowns.
RESUMO
Older adults with type 1 diabetes may face challenges driving safely. Glucose "above-5-to-drive" is often recommended for insulin-treated diabetes to minimize hypoglycemia while driving. However, the effectiveness of this recommendation among older adults has not been evaluated. Older drivers with type 1 diabetes were assessed while using sensor-augmented insulin pumps during a 2-week clinical trial run-in. Twenty-three drivers (median age 69 years [interquartile range; IQR 65-72]; diabetes duration 37 years [20-45]) undertook 618 trips (duration 10 min [5-21]). Most trips (n = 535; 87%) were <30 min duration; 9 trips (1.5%) exceeded 90 min and 3 trips (0.5%) exceeded 120 min. Pre-trip continuous glucose monitoring (CGM) was >5.0 mmol/L for 577 trips (93%) and none of these had CGM <3.9 mmol/L during driving (including 8 trips >90 min and 3 trips >120 min). During 41 trips with pre-trip CGM ≤5.0 mmol/L, 11 trips had CGM <3.9 mmol/L. Seventy-one CGM alerts occurred during 60 trips (10%), of which 54 of 71 alerts (76%) were unrelated to hypoglycemia. Our findings support a glucose "above-5-to-drive" recommendation to avoid CGM-detected hypoglycemia among older drivers, including for prolonged drives, and highlight the importance of active CGM low-glucose alerts to prevent hypoglycemia during driving. Driving-related CGM usability and alert functionality warrant investigation. Clinical trial ACTRN1261900515190.
Assuntos
Condução de Veículo , Automonitorização da Glicemia , Glicemia , Diabetes Mellitus Tipo 1 , Hipoglicemia , Hipoglicemiantes , Sistemas de Infusão de Insulina , Insulina , Humanos , Diabetes Mellitus Tipo 1/tratamento farmacológico , Diabetes Mellitus Tipo 1/sangue , Idoso , Masculino , Feminino , Glicemia/análise , Hipoglicemia/prevenção & controle , Hipoglicemiantes/uso terapêutico , Hipoglicemiantes/administração & dosagem , Insulina/administração & dosagem , Insulina/uso terapêutico , Pessoa de Meia-IdadeRESUMO
INTRODUCTION: Little is known about the cost-effectiveness of government policies that support primary care physicians to provide comprehensive chronic disease management (CDM). This paper aimed to estimate the potential cost-effectiveness of CDM policies over a lifetime for long-time survivors of stroke. METHODS: A Markov model, using three health states (stable, hospitalised, dead), was developed to simulate the costs and benefits of CDM policies over 30 years (with 1-year cycles). Transition probabilities and costs from a health system perspective were obtained from the linkage of data between the Australian Stroke Clinical Registry (cohort n = 12,368, 42% female, median age 70 years, 45% had CDM claims) and government-held hospital, Medicare, and pharmaceutical claims datasets. Quality-adjusted life years (QALYs) were obtained from a comparable cohort (n = 512, 34% female, median age 69.6 years, 52% had CDM claims) linked with Medicare claims and death data. A 3% discount rate was applied to costs in Australian dollars (AUD, 2016) and QALYs beyond 12 months. Probabilistic sensitivity analyses were used to understand uncertainty. RESULTS: Per-person average total lifetime costs were AUD 142,939 and 8.97 QALYs for those with a claim, and AUD 103,889 and 8.98 QALYs for those without a claim. This indicates that these CDM policies were costlier without improving QALYs. The probability of cost-effectiveness of CDM policies was 26.1%, at a willingness-to-pay threshold of AUD 50,000/QALY. CONCLUSION: CDM policies, designed to encourage comprehensive care, are unlikely to be cost-effective for stroke compared to care without CDM. Further research to understand how to deliver such care cost-effectively is needed.
Assuntos
Análise Custo-Benefício , Anos de Vida Ajustados por Qualidade de Vida , Acidente Vascular Cerebral , Humanos , Feminino , Masculino , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/terapia , Idoso , Austrália , Doença Crônica , Gerenciamento Clínico , Pessoa de Meia-Idade , Cadeias de Markov , Política de Saúde , Idoso de 80 Anos ou maisRESUMO
Background: Previous studies have suggested that females experiencing out-of-hospital cardiac arrest (OHCA) receive lower rates of both bystander cardiopulmonary resuscitation (CPR) and defibrillation compared to males. Whether this disparity has improved over time is unknown. Methods: A state-wide OHCA registry in Victoria, Australia collected data over twenty years (2002-2021) regarding rates of bystander interventions in OHCA. Characteristics and outcomes of each OHCA were compared with logistic regression according to sex and time (defined in two-year periods). Results: 32,502 OHCAs were included (69.7% male). Both bystander CPR and defibrillation rates increased for females over time (p < 0.0001). There was no sex disparity in receipt of bystander CPR after adjustment for baseline differences. Females were less likely than males to receive bystander defibrillation, with sex disparity increasing from 2010 onwards (adjOR 0.26 (95%CI 0.09-0.80) in 2020-21 for females compared to males). Conclusion: Initiatives to increase bystander CPR and defibrillation have resulted in higher overall rates of bystander interventions in the last two decades and no significant sex differences in provision of bystander CPR. However, females receive less bystander defibrillation than males, and sex disparity is increasing. Strategies to promote bystander defibrillation in females experiencing OHCA with a shockable rhythm should be a priority.
RESUMO
AIMS: To examine the psychometric properties of the Diabetes Management Experiences Questionnaire (DME-Q). Adapted from the validated Glucose Monitoring Experiences Questionnaire, the DME-Q captures satisfaction with diabetes management irrespective of treatment modalities. METHODS: The DME-Q was completed by adults with type 1 diabetes as part of a randomized controlled trial comparing hybrid closed loop (HCL) to standard therapy. Most psychometric properties were examined with pre-randomization data (n = 149); responsiveness was examined using baseline and 26-week follow-up data (n = 120). RESULTS: Pre-randomization, participants' mean age was 44 ± 12 years, 52% were women. HbA1c was 61 ± 11 mmol/mol (7.8 ± 1.0%), diabetes duration was 24 ± 12 years and 47% used an insulin pump prior to the trial. A forced three-factor analysis revealed three expected domains, that is, 'Convenience', 'Effectiveness' and 'Intrusiveness', and a forced one-factor solution was also satisfactory. Internal consistency reliability was strong for the three subscales ( α range = 0.74-0.84) and 'Total satisfaction' ( α = 0.85). Convergent validity was demonstrated with moderate correlations between DME-Q 'Total satisfaction' and diabetes distress (PAID: rs = -0.57) and treatment satisfaction (DTSQ; rs = 0.58). Divergent validity was demonstrated with a weak correlation with prospective/retrospective memory (PRMQ: rs = -0.16 and - 0.13 respectively). Responsiveness was demonstrated, as participants randomized to HCL had higher 'Effectiveness' and 'Total satisfaction' scores than those randomized to standard therapy. CONCLUSIONS: The 22-item DME-Q is a brief, acceptable, reliable measure with satisfactory structural and construct validity, which is responsive to intervention. The DME-Q is likely to be useful for evaluation of new pharmaceutical agents and technologies in research and clinical settings.
Assuntos
Diabetes Mellitus Tipo 1 , Adulto , Humanos , Feminino , Pessoa de Meia-Idade , Masculino , Diabetes Mellitus Tipo 1/tratamento farmacológico , Automonitorização da Glicemia , Satisfação do Paciente , Psicometria , Reprodutibilidade dos Testes , Estudos Retrospectivos , Estudos Prospectivos , Glicemia , Inquéritos e QuestionáriosRESUMO
CONTEXT: Specialist palliative care services must balance provision of needs-based care within resource restraints. The Responding to Urgency of Need in Palliative Care (RUN-PC) Triage Tool is a novel, evidence-based, 7-item prioritization tool, with recommended response times for any given score. OBJECTIVES: To investigate the acceptability and appropriateness of the RUN-PC Triage Tool implemented into clinical practice. METHODS: A single-arm, multisite, prospective implementation pilot conducted at 12 community/inpatient palliative care services, using Quality Improvement methodology with Plan-Do-Study-Act cycles. Data collected for each triage episode included demographics, scoring, user feedback and clinical outcomes. Group differences were tested by chi-squared, Wilcoxon Rank Sum or Kruskal Wallis tests. RESULTS: A total of 5418 triage episodes were captured, 1509 with outcome data. Referrals to inpatient services were of higher acuity than those to community (median score 24 vs. 14). Whilst high numerical scores were unusual, a significant proportion of cases were clinically urgent. Admissions occurred within recommended response times in over 80% of triage episodes; 5.8% of referred patients died before being admitted. Users reported the tool was easy to complete (99.3% of applications), rarely requiring additional time (0.07%), and appropriate in its triage determination (96.0% of applications). CONCLUSION: The RUN-PC Triage Tool is feasible to implement, with high clinician acceptability and virtually no additional time required. The recommended response times are feasible and highlight target areas for improvement. Implementation of the tool enables palliative care services to better characterize their referral population and, in turn, improve transparency around access to care.
Assuntos
Cuidados Paliativos , Triagem , Humanos , Cuidados Paliativos/métodos , Triagem/métodos , Estudos Prospectivos , Pacientes InternadosRESUMO
INTRODUCTION: Survivors of stroke are at risk of experiencing subsequent major adverse cardiovascular events (MACE). We aimed to determine the incidence of, and risk factors for, MACE after first-ever ischemic stroke, by age group (18-64 years vs. ≥65 years). METHODS: Observational cohort study using patient-level data from the Australian Stroke Clinical Registry (2009-2013), linked with hospital administrative data. We included adults with first-ever ischemic stroke who had no previous acute cardiovascular admissions and followed these patients for 2 years post-discharge, or until the first post-stroke MACE event. A Fine-Gray sub-distribution hazard model, accounting for the competing risk of non-cardiovascular death, was used to determine factors for incident post-stroke MACE. RESULTS: Among 5,994 patients with a first-ever ischemic stroke (median age 73 years, 45% female), 17% were admitted for MACE within 2 years (129 events per 1,000 person-years). The median time to first post-stroke MACE was 117 days (89 days if aged <65 years vs. 126 days if aged ≥65 years; p = 0.025). Among patients aged 18-64 years, receiving intravenous thrombolysis (sub-distribution hazard ratio [SHR] 0.51 [95% CI, 0.28-0.92]) or being discharged to inpatient rehabilitation (SHR 0.65 [95% CI, 0.46-0.92]) were associated with a reduced incidence of post-stroke MACE. In those aged ≥65 years, being unable to walk on admission (SHR 1.33 [95% CI 1.15-1.54]), and history of smoking (SHR 1.40 [95% CI 1.14-1.71]) or atrial fibrillation (SHR 1.31 [95% CI 1.14-1.51]) were associated with an increased incidence of post-stroke MACE. Acute management in a large hospital (>300 beds) for the initial stroke event was associated with reduced incidence of post-stroke MACE, irrespective of age group. CONCLUSIONS: MACE is common within 2 years of stroke, with most events occurring within the first year. We have identified important factors to consider when designing interventions to prevent MACE after stroke, particularly among those aged <65 years.
Assuntos
AVC Isquêmico , Acidente Vascular Cerebral , Idoso , Feminino , Humanos , Masculino , Assistência ao Convalescente , Austrália/epidemiologia , AVC Isquêmico/epidemiologia , Alta do Paciente , Sistema de Registros , Fatores de Risco , Acidente Vascular Cerebral/complicaçõesRESUMO
Hypoglycaemia during sleep is a common and clinically important issue for people living with insulin-treated diabetes. Continuous glucose monitoring devices can help to identify nocturnal hypoglycaemia and inform treatment strategies. However, sleep is generally inferred, with diabetes researchers and physicians using a fixed-overnight period as a proxy for sleep-wake status when analysing and interpretating continuous glucose monitoring data. No study to date has validated such an approach with established sleep measures. Continuous glucose monitoring and research-grade actigraphy devices were worn and sleep diaries completed for 2 weeks by 28 older adults (mean age 67 years [SD 5]; 17 (59%) women) with type 1 diabetes. Using continuous glucose monitoring data from a total of 356 nights, fixed-overnight (using the recommended period of 00:00â hours-06:00â hours) and objectively-measured sleep periods were compared. The fixed-overnight period approach missed a median 57 min per night (interquartile range: 49-64) of sleep for each participant, including five continuous glucose monitoring-detected hypoglycaemia episodes during objectively-measured sleep. Twenty-seven participants (96%) had at least 1â night with continuous glucose monitoring time-in-range and time-above-range discrepancies both ≥ 10 percentage points, a clinically significant discrepancy. The utility of fixed-overnight time continuous glucose monitoring as a proxy for sleep-awake continuous glucose monitoring is inadequate as it consistently excludes actual sleep time, obscures glycaemic patterns, and misses sensor hypoglycaemia episodes during sleep. The use of validated measures of sleep to aid interpretation of continuous glucose monitoring data is encouraged.
RESUMO
BACKGROUND: Fractures are a serious consequence following stroke, but it is unclear how these events influence health-related quality of life (HRQoL). We aimed to compare annualized rates of fractures before and after stroke or transient ischemic attack (TIA), identify associated factors, and examine the relationship with HRQoL after stroke/TIA. METHODS: Retrospective cohort study using data from the Australian Stroke Clinical Registry (2009-2013) linked with hospital administrative and mortality data. Rates of fractures were assessed in the 1-year period before and after stroke/TIA. Negative binomial regression, with censoring at death, was used to identify factors associated with fractures after stroke/TIA. Respondents provided HRQoL data once between 90 and 180 days after stroke/TIA using the EuroQoL 5-dimensional 3-level instrument. Adjusted logistic regression was used to assess differences in HRQoL at 90 to 180 days by previous fracture. RESULTS: Among 13 594 adult survivors of stroke/TIA (49.7% aged ≥75 years, 45.5% female, 47.9% unable to walk on admission), 618 fractures occurred in the year before stroke/TIA (45 fractures per 1000 person-years) compared with 888 fractures in the year after stroke/TIA (74 fractures per 1000 person-years). This represented a relative increase of 63% (95% CI, 47%-80%). Factors associated with poststroke fractures included being female (incidence rate ratio [IRR], 1.34 [95% CI, 1.05-1.72]), increased age (per 10-year increase, IRR, 1.35 [95% CI, 1.21-1.50]), history of prior fracture(s; IRR, 2.56 [95% CI, 1.77-3.70]), and higher Charlson Comorbidity Scores (per 1-point increase, IRR, 1.18 [95% CI, 1.10-1.27]). Receipt of stroke unit care was associated with fewer poststroke fractures (IRR, 0.67 [95% CI, 0.49-0.93]). HRQoL at 90 to 180 days was worse among patients with prior fracture across the domains of mobility, self-care, usual activities, and pain/discomfort. CONCLUSIONS: Fracture risk increases substantially after stroke/TIA, and a history of these events is associated with poorer HRQoL at 90 to 180 days after stroke/TIA.
Assuntos
Fraturas Ósseas , Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Humanos , Feminino , Masculino , Ataque Isquêmico Transitório/epidemiologia , Estudos Retrospectivos , Qualidade de Vida , Austrália/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Fraturas Ósseas/epidemiologia , Fatores de RiscoRESUMO
BACKGROUND AND AIMS: HBV RNA in peripheral blood reflects HBV cccDNA transcriptional activity and may predict clinical outcomes. The prospective Melbourne HBV-STOP trial studied nucleot(s)ide analog discontinuation in HBeAg-negative non-cirrhotic participants with long-term virological suppression. Ninety-six weeks after stopping treatment, the proportion of participants with virological relapse (HBV DNA > 2000 IU/mL), biochemical relapse (ALT > 2 × ULN and HBV DNA > 2000 IU/mL), or hepatitis flare (ALT > 5 × ULN and HBV DNA > 2000 IU/mL) was 89%, 58%, and 38%, respectively. We evaluated the ability of serum HBV RNA levels to predict these outcomes. APPROACH RESULTS: HBV RNA levels were measured using the Roche cobas 6800/8800 HBV RNA Investigational Assay. Sixty-five participants had baseline and longitudinal off-treatment specimens available for RNA testing. HBV RNA was detectable at baseline in 25% of participants and was associated with a higher risk of biochemical relapse (81% vs. 51%, p value 0.04) and hepatitis flare (63% vs. 31%, p value 0.04). Participants who had undetectable serum HBV RNA as well as HBsAg ≤ 100 IU/mL at baseline were less likely to experience virological relapse (4 of 9, 44%) than participants with detectable HBV RNA and HBsAg level > 100 IU/mL (15/15, 100%; p value 0.0009). Off-treatment levels of HBV RNA were correlated with HBV DNA and were associated with the risk of hepatitis flare. CONCLUSIONS: Serum HBV RNA may be a useful biomarker for guiding clinical decision-making before stopping nucleot(s)ide analog therapy. Baseline HBV RNA and HBsAg levels are associated with the risk of clinical relapse, hepatitis flare, and disease remission off-treatment.
Assuntos
Hepatite B Crônica , Nucleosídeos , Humanos , Antivirais/uso terapêutico , DNA Viral , Antígenos E da Hepatite B , Antígenos de Superfície da Hepatite B , Vírus da Hepatite B/genética , Hepatite B Crônica/tratamento farmacológico , Nucleosídeos/uso terapêutico , Estudos Prospectivos , RNA , Exacerbação dos SintomasRESUMO
BACKGROUND: Despite global support, there remain gaps in the integration of early palliative care into cancer care. The methods of implementation whereby evidence of benefits of palliative care is translated into practice deserve attention. AIM: To identify implementation frameworks utilised in integrated palliative care in hospital-based oncology services and to describe the associated enablers and barriers to service integration. DESIGN: Systematic review with a narrative synthesis including qualitative, mixed methods, pre-post and quasi experimental designs following the guidance by the Centre for Reviews and Dissemination (PROSPERO registration CRD42021252092). DATA SOURCES: Six databases searched in 2021: EMBASE, EMCARE, APA PsycINFO, CINAHL, Cochrane Library and Ovid MEDLINE searched in 2023. Included were qualitative or quantitative studies, in English language, involving adults >18 years, and implementing hospital-based palliative care into cancer care. Critical appraisal tools were used to assess the quality and rigour. RESULTS: Seven of the 16 studies explicitly cited the use of frameworks including those based on RE-AIM, Medical Research Council evaluation of complex interventions and WHO constructs of health service evaluation. Enablers included an existing supportive culture, clear introduction to the programme across services, adequate funding, human resources and identification of advocates. Barriers included a lack of communication with the patients, caregivers, physicians and palliative care team about programme goals, stigma around the term 'palliative', a lack of robust training, or awareness of guidelines and undefined staff roles. CONCLUSIONS: Implementation science frameworks provide a method to underpin programme development and evaluation as palliative care is integrated within the oncology setting.
RESUMO
Background: Governments are investing in primary care policies that support chronic disease management. Large scale population-based evaluations are lacking. We aim to determine the effectiveness of government-funded chronic disease management policies to improve long-term outcomes (survival, hospital presentations, and preventive medication adherence) following stroke/Transient Ischemic Attack (TIA). Methods: Using a population-based cohort we utilized the target trial methodology. Participants were identified through the Australian Stroke Clinical Registry (January 2012-December 2016) from 42 hospitals in the states of Victoria and Queensland and linked with state and national hospital, primary care, pharmaceutical, aged care, and death datasets. Registrants living in the community, not receiving palliative care and who survived to 18 months following stroke/TIA were included. The comparison was a Medicare claim for policy-supported chronic disease management, 7-18 months following stroke/TIA versus usual care. Outcomes were modelled using multi-level, mixed-effects inverse probability of treatment weighted regression. Findings: 12,368 registrants were eligible (42% female, median age 70 years, 26% TIA), 45% had a chronic disease management claim. The difference in mean outcomes for participants with a claim, compared to those without, showed a 26% lesser mortality rate (adjusted hazard ratio [aHR]: 0.74, 95% confidence interval [CI]: 0.62, 0.87) and a greater adjusted Odds Ratio [aOR] of being adherent with preventive medications: antithrombotics (aOR: 1.16, 95% CI: 1.07, 1.26); lipid-lowering (aOR: 1.23, 95% CI: 1.13, 1.33). Impacts on hospital presentations were variable. Interpretation: Government policies that financially support primary care physicians to provide structured chronic disease management improve survival in the long-term following stroke/TIA. Funding: National Health and Medical Research Council Australia.
RESUMO
BACKGROUND AND AIMS: Surveillance after complete remission of intestinal metaplasia (CRIM) is essential. Current recommendations are to sample visible lesions first, followed by random 4-quadrant biopsy sampling of the original Barrett's esophagus (BE) length. To inform post-CRIM surveillance protocols, we aimed to identify the anatomic location, appearance, and histology of BE recurrences. METHODS: We performed an analysis of 216 patients who achieved CRIM after endoscopic eradication therapy for dysplastic BE at a Barrett's Referral Unit between 2008 and 2021. The anatomic location, recurrence histology, and endoscopic appearance of dysplastic recurrences were evaluated. RESULTS: After a median of 5.5 years (interquartile range, 2.9-7.2) of follow-up after CRIM, 57 patients (26.4%) developed nondysplastic BE (NDBE) recurrence and 18 patients (8.3%) developed dysplastic recurrence. From 8158 routine surveillance biopsy samplings of normal-appearing tubular esophageal neosquamous epithelium, the yield for recurrent NDBE or dysplasia was 0%. One hundred percent of dysplastic tubular esophageal recurrences were visible and in BE islands, whereas 77.8% of gastroesophageal junction dysplastic recurrences were nonvisible. Four distinct endoscopic features suspicious for recurrent advanced dysplasia or neoplasia were identified: buried or subsquamous BE, irregular mucosal pattern, loss of vascular pattern, and nodularity or depression. CONCLUSIONS: The yield of routine surveillance biopsy sampling of normal-appearing tubular esophageal neosquamous epithelium was zero. BE islands with indistinct mucosal or loss of vascular pattern, nodularity or depression, and/or signs of buried BE should raise clinician suspicion for advanced dysplasia or neoplasia recurrence. We suggest a new surveillance biopsy sampling protocol with a focus on meticulous inspection, followed by targeted biopsy sampling of visible lesions and random 4-quadrant biopsy sampling of the gastroesophageal junction.
RESUMO
This study examined correlations between continuous glucose monitoring (CGM)-based composite metrics and standard glucose metrics within CGM data sets from individuals with recent-onset and long-duration type 1 diabetes. First, a literature review and critique of published CGM-based composite metrics was undertaken. Second, composite metric results were calculated for the two CGM data sets and correlations with six standard glucose metrics were examined. Fourteen composite metrics met selection criteria; these metrics focused on overall glycemia (n = 8), glycemic variability (n = 4), and hypoglycemia (n = 2), respectively. Results for the two diabetes cohorts were similar. All eight metrics focusing on overall glycemia strongly correlated with glucose time in range; none strongly correlated with time below range. The eight overall glycemia-focused and two hypoglycemia-focused composite metrics were all sensitive to automated insulin delivery therapeutic intervention. Until a composite metric can adequately capture both achieved target glycemia and hypoglycemia burden, the current two-dimensional CGM assessment approach may offer greatest clinical utility.
Assuntos
Diabetes Mellitus Tipo 1 , Hipoglicemia , Humanos , Diabetes Mellitus Tipo 1/tratamento farmacológico , Glicemia , Automonitorização da Glicemia/métodos , Benchmarking , Hipoglicemia/diagnósticoRESUMO
BACKGROUND: People experiencing homelessness have an increased risk of mortality. The association between being at risk of homelessness and premature mortality is unclear. We aimed to determine all-cause and cause-specific mortality in patients who were homeless, at risk of homelessness (marginally housed), or housed. METHODS: This retrospective longitudinal cohort study compared mortality patterns in adult patients identified in 2003/04 by linking data from an Australian metropolitan emergency department to national mortality data. We used Cox proportional hazards models to estimate associations between housing status and mortality. To address competing risks, cause-specific hazards were modelled and transformed into stacked cumulative incidence functions. FINDINGS: Data from 6290 patients (homeless deceased = 382/1050, marginally housed deceased = 259/518, housed deceased = 1204/4722) found increased risk of mortality in homeless [hazard ratio (HR) = 4.0, 95% confidence interval (CI) = 2.0-3.3) and marginally housed (HR = 2.6, 95% CI = 3.4-4.8) patients. Homeless patients had an excess risk from external causes (HR = 6.1, 95% CI = 4.47-8.35), cardiovascular disease (HR = 4.9, 95% CI = 2.78-8.70) and cancer (HR = 1.5, 95% CI = 1.15-2.09). Marginally housed patients had increased risk from external causes (HR = 3.6, 95% CI = 2.36-5.40) and respiratory diseases (HR = 4.7, 95% CI = 1.82-12.05). Taking account of competing risk, marked inequality was observed, with homeless, marginally housed and housed patients having probabilities of death by 55 years of 0.2, 0.1 and 0.02, respectively. CONCLUSIONS: Mortality rates were elevated in patients who were homeless or at risk of homelessness. Increasing numbers of people are at risk of homelessness, and the effect of this on mortality is relatively unrecognized. Marginal housing may assuage some risk of premature mortality associated with homelessness; however, it is not equivalent to stable housing.
Assuntos
Pessoas Mal Alojadas , Mortalidade Prematura , Humanos , Adulto , Estudos Longitudinais , Estudos Retrospectivos , Austrália/epidemiologia , Habitação , Serviço Hospitalar de EmergênciaRESUMO
AIM: To explore the lived experience of older adults with type 1 diabetes using closed-loop automated insulin delivery, an area previously receiving minimal attention. METHODS: Semi-structured interviews were conducted with adults aged 60 years or older with long-duration type 1 diabetes who participated in a randomised, open-label, two-stage crossover trial comparing first-generation closed-loop therapy (MiniMed 670G) versus sensor-augmented pump therapy. Interview recordings were transcribed, thematically analysed and assessed. RESULTS: Twenty-one older adults participated in interviews after using closed-loop therapy. Twenty were functionally independent, without frailty or major cognitive impairment; one was dependent on caregiver assistance, including for diabetes management. Quality of life benefits were identified, including improved sleep and reduced diabetes-related psychological burden, in the context of experiencing improved glucose levels. Gaps between expectations and reality of closed-loop therapy were also experienced, encountering disappointment amongst some participants. The cost was perceived as a barrier to continued closed-loop access post-trial. Usability issues were identified, such as disruptive overnight alarms and sensor inaccuracy. CONCLUSIONS: The lived experience of older adults without frailty or major cognitive impairment using first-generation closed-loop therapy was mainly positive and concordant with glycaemic benefits found in the trial. Older adults' lived experience using automated insulin delivery beyond trial environments requires exploration; moreover, the usability needs of older adults should be considered during future device development.
Assuntos
Diabetes Mellitus Tipo 1 , Fragilidade , Humanos , Idoso , Insulina/uso terapêutico , Diabetes Mellitus Tipo 1/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , Qualidade de Vida , Resultado do Tratamento , Sistemas de Infusão de Insulina , Automonitorização da Glicemia , Estudos Cross-Over , GlicemiaRESUMO
OBJECTIVE: Using a strength-based framework, we aimed to describe and compare First Nations patients who completed care in an ED to those who took their own leave. METHODS: Routinely collected adult patient data from a metropolitan ED collected over a 5-year period were analysed. RESULTS: A total of 6446 presentations of First Nations patients occurred from 2016 to 2020, constituting 3% of ED presentations. Of these, 5589 (87%) patients waited to be seen and 857 (13%) took their own leave. Among patients who took their own leave, 624 (73%) left not seen and 233 (27%) left at own risk after starting treatment. Patients who were assigned a triage category of 4-5 were significantly more likely to take their own leave (adjusted odds ratio [OR] 3.17, 95% confidence interval [CI] 2.67-3.77, P < 0.001). Patients were significantly less likely to take their own leave if they were >60 years (adjusted OR 0.69, 95% CI 1.01-1.36, P = 0.014) and had private health insurance (adjusted OR 0.61, 95% CI 0.45-0.84, P < 0.001). Patients were more likely to leave if they were women (adjusted OR 1.17, 95% CI 1.01-1.36, P = 0.04), had an unknown housing status (adjusted OR 1.76, 95% CI 1.44-2.15, P < 0.001), were homeless (adjusted OR 1.50, 95% CI 1.22-1.93, P < 0.001) or had a safety alert (adjusted OR 1.60, 95% CI 1.35-1.90, P < 0.001). CONCLUSION: A lower triage category is a strong predictor of First Nations patients taking their own leave. It has been documented that First Nations patients are under-triaged. One proposed intervention in the metropolitan setting is to introduce practices which expediate the care of First Nations patients. Further qualitative studies with First Nations patients should be undertaken to determine successful approaches to create equitable access to emergency healthcare for this population.
Assuntos
Serviço Hospitalar de Emergência , Triagem , Adulto , Humanos , Feminino , Masculino , Fatores de Tempo , Pacientes , Estudos RetrospectivosRESUMO
BACKGROUND: Stroke is a high-cost condition. Detailed patient-level assessments of the costs of care received and outcomes achieved provide useful information for organisation and optimisation of the health system. OBJECTIVES: To describe the costs of hospital care for stroke and transient ischaemic attack (TIA) and investigate factors associated with costs. METHODS: Retrospective cohort study using data from the Australian Stroke Clinical Registry (AuSCR) collected between 2009 and 2013 linked to hospital administrative data and clinical costing data in Queensland. Clinical costing data include standardised assignment of costs from hospitals that contribute to the National Hospital Costing programme. Patient-level costs for each hospital admission were described according to the demographic, clinical and treatment characteristics of patients. Multivariable median regression with clustering by hospital was used to determine factors associated with greater costs. RESULTS: Among 22 hospitals, clinical costing data were available for 3909 of 5522 patient admissions in the AuSCR (71%). Compared to those without clinical costing data, patients with clinical costing data were more often aged <65 years (30% with cost data vs 24% without cost data, p < 0.001) and male (56% with cost data vs 49% without cost data, p < 0.001). Median cost of an acute episode was $7945 (interquartile range $4176 to $14970) and the median length of stay was 5 days (interquartile range 2 to 10 days). The most expensive cost buckets were related to medical (n = 3897, median cost $1577), nursing (n = 3908, median cost $2478) and critical care (n = 434, median cost $3064). Factors associated with greater total costs were a diagnosis of intracerebral haemorrhage, greater socioeconomic position, in-hospital stroke and prior history of stroke. CONCLUSION: Medical and nursing costs were incurred by most patients admitted with stroke or TIA, and were relatively more expensive on average than other cost buckets such as imaging and allied health. IMPLICATIONS: Scaling this data linkage to national data collections may provide valuable insights into activity-based funding at public hospitals. Regular report of these costs should be encouraged to optimise economic evaluations.