Increased diagnosis of attention-deficit hyperactivity disorder despite stable hyperactive/inattentive behaviours: evidence from two birth cohorts of Australian children.

BACKGROUND: Globally, ADHD diagnoses have increased substantially and there is concern that this trend does not necessarily reflect improved detection of cases but that overdiagnosis may be occurring. We directly compared ADHD diagnoses with ADHD-related behaviours and looked for changes across time among Australian children in a large, population-based prospective cohort study. METHODS: We conducted a secondary analysis of the Longitudinal Study of Australian Children, including 4,699 children born 1999/2000 (cohort 1) and 4,425 children born 2003/2004 (cohort 2), followed from 4 to 13 years of age. We compared pre-diagnosis parent-reported hyperactive/inattentive behaviour scores between newly diagnosed (incident cases) and undiagnosed children and fitted Cox's proportional hazards regression models to examine the relationship between birth cohorts 1 and 2 and the risk of incident ADHD diagnosis. RESULTS: Cumulative incident ADHD diagnoses increased from 4.6% in cohort 1 (born in 1999/2000) to 5.6% in cohort 2 (born in 2003/2004), while hyperactive/inattentive behaviour scores remained steady. Among ADHD diagnosed children, 26.5% (88/334) recorded pre-diagnosis behaviours in the normal range, 27.6% (n = 92) had borderline scores and 45.8% (n = 153) scored within the clinical range. Children born in 2003/2004 were more likely to be diagnosed with ADHD compared with those born in 1999/2000 (aHR = 1.33, 95% CI = 1.06-1.67, p = .012), regardless of their ADHD behaviour score (p = .972). CONCLUSIONS: Diagnostic increases were not driven by rises in hyperactive/inattentive behaviours. A quarter of all children with an ADHD diagnosis recorded pre-diagnosis behaviours within the normal range. The increased likelihood of being diagnosed with ADHD for children from the later birth cohort was observed for children across the full range of ADHD-related behaviours.

Carer preparedness improved by providing a supportive educational intervention for carers of patients with high-grade glioma: RCT results.

BACKGROUND: High-grade glioma (HGG) is a rapidly progressing and debilitating disease. Family carers take on multiple responsibilities and experience high levels of distress. We aimed to deliver a nurse-led intervention (Care-IS) to carers to improve their preparedness to care and reduce distress. METHODS: We conducted a randomised controlled trial (ACTRN:12612001147875). Carers of HGG patients were recruited during patients' combined chemoradiation treatment. The complex intervention comprised four components: (1) initial telephone assessment of carer unmet needs; (2) tailored hard-copy resource folder; (3) home visit; and, (4) monthly telephone support for up to 12 months. Primary outcomes included preparedness for caregiving and distress at 2, 4, 6 and 12 months. Intervention effects were estimated using linear mixed models which included a time by group interaction. Secondary outcomes included anxiety, depression, quality of life, carer competence and strain. RESULTS: We randomised 188 carers (n = 98 intervention, n = 90 control). The intervention group reported significantly higher preparedness for caregiving at 4 months (model ß = 2.85, 95% CI 0.76-4.93) and all follow-up timepoints including 12 months (model ß = 4.35, 95% CI 2.08-6.62), compared to the control group. However, there was no difference between groups in carer distress or any secondary outcomes. CONCLUSIONS: This intervention was effective in improving carer preparedness. However, carer distress was not reduced, potentially due to the debilitating/progressive nature of HGG and ongoing caring responsibilities. Future research must explore whether carer interventions can improve carer adjustment, self-efficacy and coping and how we support carers after bereavement. Additionally, research is needed to determine how to implement carer support into practice.

Using health administrative data to model associations and predict hospital admissions and length of stay for people with eating disorders.

BACKGROUND: Eating disorders are serious mental illnesses requiring a whole of health approach. Routinely collected health administrative data has clinical utility in describing associations and predicting health outcome measures. This study aims to develop models to assess the clinical utility of health administrative data in adult eating disorder emergency presentations and length of stay. METHODS: Retrospective cohort study on health administrative data in adults with eating disorders from 2014 to 2020 in Sydney Local Health District. Emergency and admitted patient data were collected with all clinically important variables available. Multivariable regression models were analysed to explore associations and to predict admissions and length of stay. RESULTS: Emergency department modelling describes some clinically important associations such as decreased odds of admission for patients with Bulimia Nervosa compared to Anorexia Nervosa (Odds Ratio [OR] 0.31, 95% Confidence Interval [95%CI] 0.10 to 0.95; p = 0.04). Admitted data included more predictors and therefore further significant associations including an average of 0.96 days increase in length of stay for each additional count of diagnosis/comorbidities (95% Confidence Interval [95% CI] 0.37 to 1.55; p = 0.001) with a valid prediction model (R2 = 0.56). CONCLUSIONS: Health administrative data has clinical utility in adult eating disorders with valid exploratory and predictive models describing associations and predicting admissions and length of stay. Utilising health administrative data this way is an efficient process for assessing impacts of multiple factors on patient care and predicting health care outcomes.

Impact of policy changes of Medicare-rebated telehealth services on medical abortions provided at a family planning service during the coronavirus (COVID-19) pandemic.

This study reviewed data on the mode of delivery of medical abortion care (via face-to-face or telehealth) at a Family Planning service during the coronavirus (COVID-19) pandemic; April 2020 to March 2022. This was considered over time, in the context of changing eligibility criteria for Medicare-rebated telehealth services as well as patient demographic data. The study demonstrated that when Medicare rebates for telehealth are available for all those requiring abortion care, telehealth contributes to care provision alongside face-to-face services, and is more likely to be utilised by people living in regional and remote areas.

Who is responsible for postpartum contraception advice and provision? The perspective of hospital-based maternity clinicians in New South Wales, Australia.

Access to postpartum contraception is critical for the health of the mother and subsequent pregnancies. However, the differential roles and responsibilities of maternity care providers in contraception discussions and provision are often unclear. Our study, part of a larger study on midwifery provision of contraceptive implants, presents the perspectives of hospital-based maternity clinicians. Participants suggested that contraception discussions and provision are a shared responsibility of maternity care providers but identified inconsistencies and issues with current approaches. Access to contraception could be improved through more routine discussions antenatally and postnatally and greater collaboration between maternity care providers in hospital, community and primary care settings.

Sexual Difficulties, Problems, and Help-Seeking in a National Representative Sample: The Second Australian Study of Health and Relationships.

The Australian Study of Health and Relationships is a large national population-representative survey of sexual behavior and attitudes conducted every decade. We describe experiences of sexual difficulties lasting at least a month among Australians surveyed in 2012-2013 and identify changes since the previous survey in 2001-2002. Computer-assisted telephone interviews were completed by 20,091 people aged 16-69 years (participation rate 66%) of whom 16,897 people had had sex with a partner in the previous year. We asked how long each difficulty lasted, whether it was a problem, and whether they sought treatment. Half (48%) the men and 68% of women reported at least one difficulty. Lack of interest in having sex was common (28% men, 52% women); 21% of men reported coming to orgasm "too quickly" and women reported inability to reach orgasm (25%) and trouble with vaginal dryness (22%). Women were more likely than men not to find sex pleasurable and to have physical pain during intercourse. Some differences by age group were also apparent. Many difficulties were not seen as problems, especially lacking interest and reaching orgasm too quickly. People with erection/dryness problems, or with pain in intercourse, were more likely to seek treatment, as were people with multiple difficulties. Between 2001-2002 and 2012-2013, there was little change for men, but among women rates of all sexual difficulties fell by 4-10 percentage points. This change accompanied a drop in frequency of sex among people in ongoing relationships and an increase in masturbation and use of pornography. One explanation might be that, over time, fewer women were agreeing to "service sex" when they were not in the mood. Overall, the drop in prevalence of women's sexual difficulties since a decade earlier suggests a change towards more egalitarian sexual relations.

The preferences of women in Australia for the features of long-acting reversible contraception: results of a discrete choice experiment.

PURPOSE: Long-acting reversible contraceptives (LARC), such as intrauterine devices (IUD) and implants, are highly effective. However, the uptake of LARC in Australia has been slow and the oral contraceptive pill (OC) remains the best known and most widely used contraceptive. Our aim was to investigate women's preferences for the features of LARC. METHODS: We used a discrete choice experiment (DCE) in which each respondent completed 12 choice tasks. We recruited a general population sample of 621 women in Australia aged 18-49 using an online survey panel. A mixed logit model was used to analyse DCE responses; a latent class model explored preference heterogeneity. RESULTS: Overall, 391 (63%) of women were currently using contraception; 49.3% were using an OC. About 22% of women were using a LARC. Women prefer products that are more effective in preventing pregnancy, have low levels of adverse events (including negative effects on mood), and which their general practitioner (GP) recommends or says is suitable for them. CONCLUSIONS: Women have strong preferences for contraceptive products that are effective, safe, and recommended by their GP. The results indicate which characteristics of LARCs need to be front and centre in information material and in discussions between women and healthcare professionals.

A hospital-based cohort study of gender and gestational age-specific body fat percentage at birth.

BACKGROUND: Birthweight is the most commonly used proxy marker but does not adequately define true nutritional status. Modalities like DXA (dual energy x-ray absorptiometry) and TOtal Body Electric Conductivity (TOBEC) have been validated to assess body composition but their accuracy in neonates has not been established. The PEAPOD (COSMED, Rome Italy) has been validated as an accurate tool for measuring percentage body fat (%BF) in newborns. The study aim was to determine the gender-specific %BF percentiles at different gestations (35-41 weeks) for a healthy population of newborn infants. A secondary aim was to determine whether there is any relationship between %BF and neonatal condition at birth (cord gas measurement). METHODS: %BF was measured using air displacement plethysmography (PEAPOD) within 6 h of birth. RESULTS: There is an increase in the mean %BF with increasing gestation for female and males from 36 weeks' gestation in the 7667 infants who underwent assessment. Females have a higher %BF than their male equivalents. There was no correlation between %BF and cord pH. CONCLUSION: Gender and gestation are both important in determining the quantiles and mean %BF at birth. There was no correlation between low cord pH and %BF. IMPACT: Measuring the percentage body fat (PEAPOD) at birth is a useful marker of an infant's nutritional status. This is the largest hospital-based cohort of gestational age and gender-specific %BF in healthy newborns. The normative graphs from this study will help to accurately determine high-risk infants with low %BF so they can be monitored appropriately.

Early medical abortion services provided in Australian primary care.

OBJECTIVES: To examine primary care provision of early medical abortion services in Australia. DESIGN: Cross-sectional study; analysis of Pharmaceutical Benefits Scheme (PBS) dispensing data. SETTING, PARTICIPANTS: Women of child-bearing age (15-54 years), Australia, 2015-2019. MAIN OUTCOME MEASURES: Age-standardised rates of MS-2 Step prescriptions dispensed by year for 2015-2019, and age-standardised rates by state, remoteness area, and level 3 statistical areas (SA3s) for 2019. Numbers and proportions of SA3s in which MS-2 Step was not prescribed by a GP or dispensed by a community pharmacy during 2019 (unweighted and weighted by number of women of reproductive age), by state and remoteness area. RESULTS: During 2015-2019, 91 643 PBS prescriptions for MS-2 Step were dispensed; the national age-standardised rate increased from 1.63 in 2015 to 3.79 prescriptions per 1000 women aged 15-54 years in 2019. In 2019, rates were higher in outer regional Australia (6.53 prescriptions per 1000 women aged 15-54 years) and remote Australia (6.02 per 1000) than in major cities (3.30 per 1000). However, about 30% of women in Australia lived in SA3s in which MS-2 Step had not been prescribed by a GP during 2019, including about 50% of those in remote Australia. CONCLUSIONS: The rate of early medical abortion is greater among women in remote, outer regional, and inner regional Australia than in major cities, but a considerable proportion of women live in areas in which MS-2 Step was not locally prescribed or dispensed during 2019. Supporting GPs in the delivery of early medical abortion services locally should be a focus of health policy.

Outcomes of routine screening for reproductive coercion in a family planning service.

Background Reproductive coercion (RC) occurs when a person's autonomous decision-making regarding reproductive health is compromised by another. RC screening, that is, the use of routine, non-invasive screening questions asked of service users/clients, is one strategy that can be used to assess for RC. Routine screening for RC was implemented within Family Planning NSW clinical consultations in December 2018. A cross-sectional study was undertaken to review the outcomes of screening to better understand the situation of RC among women accessing family planning services. Methods A retrospective review of clinical consultation data of eligible women attending Family Planning NSW clinics in 2019 was undertaken. Descriptive analysis was conducted and modified Poisson regression was used to estimate prevalence ratios and assess associations between binary outcomes and client characteristics. Results Of 7943 women eligible for RC screening, 5497 were screened (69%) and 127 women (2.3%) disclosed RC. RC was more likely to be disclosed among clients who were unemployed, had a disability or had more than one visit within 1 year. Conclusions Sexual and reproductive health clinicians, in particular, are well placed to conduct RC screening. However, they must have adequate training and access to resources to implement screening and respond to women who disclose RC.

A systematic review and meta-analysis of the prevalence of left ventricular non-compaction in adults.

AIMS: To assess the reported prevalence of left ventricular non-compaction (LVNC) in different adult cohorts, taking in to consideration the role of diagnostic criteria and imaging modalities used. METHODS AND RESULTS: A systematic review and meta-analysis of studies reporting LVNC prevalence in adults. Studies were sourced from Pre-Medline, Medline, and Embase and assessed for eligibility according to inclusion criteria. Eligible studies provided a prevalence of LVNC in adult populations (≥12 years). Studies were assessed, and data extracted by two independent reviewers. Fifty-nine eligible studies documenting LVNC in 67 unique cohorts were included. The majority of studies were assessed as moderate or high risk of bias. The pooled prevalence estimates for LVNC were consistently higher amongst cohorts diagnosed on cardiac magnetic resonance (CMR) imaging (14.79%, n = 26; I2 = 99.45%) compared with echocardiogram (1.28%, n = 36; I2 = 98.17%). This finding was unchanged when analysis was restricted to studies at low or moderate risk of bias. The prevalence of LVNC varied between disease and population representative cohorts. Athletic cohorts demonstrated high pooled prevalence estimates on echocardiogram (3.16%, n = 5; I2 = 97.37%) and CMR imaging (27.29%, n = 2). CONCLUSION: Left ventricular non-compaction in adult populations is a poorly defined entity which likely encompasses both physiological adaptation and pathological disease. There is a higher prevalence with the introduction of newer imaging technologies, specifically CMR imaging, which identify LVNC changes more readily. The clinical significance of these findings remains unclear; however, there is significant potential for overdiagnosis, overtreatment, and unnecessary follow-up.

To what extent do postpartum contraception policies or guidelines exist in Australia and New Zealand: A document analysis study.

Women are susceptible to unintended, rapid repeat pregnancies in the first 12 months postpartum. Access to postpartum contraception, specifically long-acting reversible contraception, enables better planning of pregnancy timing and spacing and allows optimisation of health before the next conception. Clinical Practice Guidelines (CPG), and implementation policies, supported by consumer input, can improve such access. We searched publicly available Australian and New Zealand guidelines and policy documents addressing postpartum contraception. One CPG detailed specific information about postpartum contraception and, although of high quality, requires modification to local contexts to support implementation and policy development.

Women's satisfaction with and ongoing use of hormonal long-acting methods compared to the oral contraceptive pill: Findings from an Australian general practice cluster randomised trial (ACCORd).

BACKGROUND: The Australian Contraceptive ChOice pRoject (ACCORd) aimed to assess the impact of a complex general practice intervention on the uptake of long-acting reversible contraceptives (LARC). AIMS: Using survey data from enrolled women, we aimed to compare the ongoing use and satisfaction of women who chose one of the hormonal LARC methods including the levonorgestrel intrauterine system (LNG-IUS) or levonorgestrel implant compared to the oral contraceptive pill (OCP). MATERIALS AND METHODS: We used the data from participants' baseline, six and 12-month surveys to identify new users of implants, LNG-IUS or OCP. We included demographic information, ongoing use of the contraceptive method, reasons for dissatisfaction and discontinuation and experience of side-effects. Proportions were compared using χ2 tests. RESULTS: Of the 740 women enrolled in ACCORd, 176 started using a hormonal LARC or OCP in the study's first six months with 76 using the IUS (43%), 60 the implant (34%) and 40 (23%) the OCP. Twelve-month continuation rates for the LNG-IUS, implant and OCP were 93, 83 and 65% respectively (P < 0.001). Satisfaction was highest among the LNG-IUS users; 86% were very/somewhat satisfied compared to 75% of implant users and 61% of OCP users (P < 0.001). Main reasons for method dissatisfaction were irregular bleeding and mood changes which were similar for all methods. CONCLUSIONS: This study provides further evidence that hormonal LARC methods have higher continuation and satisfaction rates compared to the OCP with similar side-effects. Since hormonal LARC methods have the highest contraceptive efficacy, these should be offered first-line to women.

Effectiveness of a peer education gender and health project for men in Timor-Leste.

ISSUE ADDRESSED: In response to high rates of gender-based violence and poor sexual and reproductive health indicators in Timor-Leste, a 'Men's Health Project' was implemented in two rural communities in 2013. A peer education model was utilised to engage men in issues regarding health, relationships and well-being. METHODS: Community-based baseline and endline surveys were undertaken to evaluate the project in the two communities. RESULTS: In 2013, 401 men and boys completed a baseline survey, and 400 completed an endline survey in 2016. Significant differences were found in a number of areas, with more men in the endline survey aware of the negative impacts of alcohol, safe pregnancy practices, family planning and sexually transmitted infections. Many men reported making the major decisions in their family in both surveys. CONCLUSIONS: The peer education approach engaged men in health awareness and contributed to increasing knowledge of sexual and reproductive health and other health issues. However, while education and positive attitudes are an important foundation for change, other enabling mechanisms including vital infrastructure, services and health personnel must be in place to facilitate change and increase access to information and healthcare. Findings highlight the importance of engaging both women and men in processes of challenging behaviours and structures that reinforce gender inequalities. SO WHAT?: Peer education appears to be an effective model for engaging community members in gender and health issues in Timor-Leste. The Men's Health Project enabled men to participate in health awareness and issues regarding health, relationships and well-being.

Increasing long-acting reversible contraceptives: the Australian Contraceptive ChOice pRoject (ACCORd) cluster randomized trial.

BACKGROUND: Long-active reversible contraceptives reduce unintended pregnancy and abortions, but uptake is low. Interventions to increase uptake in family medicine settings are untested. OBJECTIVE: The Australian Contraceptive ChOice pRoject, which was adapted from the successful US Contraceptive CHOICE study, aimed to evaluate whether a complex intervention in family medicine practices resulted in increased long-active reversible contraceptive uptake. STUDY DESIGN: This cluster randomized controlled trial was set in family practices in metropolitan Melbourne, Australia. From April 2016 to January 2017, we recruited 57 family physicians by mail invitation. Each family physician aimed to recruit at least 14 female patients. Eligible family physicians worked ≥3 sessions per week in computerized practices. Eligible women were English-speaking, sexually active, not pregnant, not planning a pregnancy in the next year, 16-45 years old, and interested in discussing contraception or in starting a new, reversible method. With the use of a randomization sequence with permuted blocks that were stratified by whether the family physician performed long-active reversible contraceptive insertion or not, family physicians were assigned randomly to a complex intervention that involved training to provide structured effectiveness-based contraceptive counselling and access to rapid referral to long-active reversible contraceptive insertion clinics. The 6-hour, online educational intervention was based on the US Contraceptive CHOICE Project and adapted for the Australian context. The control family physicians received neither the educational intervention nor access to the long-active reversible contraceptive rapid referral clinics and conducted their usual contraception counselling. We used the chi-square test, which was adjusted for clustering and stratification by whether the family physician inserted long-active reversible contraceptives, and binary regression models with generalized estimating equations and robust standard errors to compare, between the intervention and control groups, the proportions of women who had a long-active reversible contraceptive inserted. The primary outcome was the proportion of women with long-active reversible contraceptives that were inserted at 4 weeks. Secondary outcomes included women's choice of contraceptive method, quality of life, and long-active reversible contraceptive use at 6 and 12 months. Analyses were performed according to intention-to-treat. RESULTS: A total of 25 intervention and 32 control family physicians recruited 307 and 433 women, respectively (N=740). Within 4 weeks, 19.3% of women in the intervention group and 12.9% of women in the control group had long-active reversible contraceptive inserted (relative risk, 2.0; 95% confidence interval, 1.1-3.9; P=.033). By 6 months, this number had risen to 44.4% and 29.3%, respectively (relative risk, 1.6; 95% confidence interval, 1.2-2.17; P=.001); by 12 months, it had risen to 46.6% and 32.8%, respectively (relative risk, 1.5; 95% confidence interval, 1.2-2.0; P=.0015). The levonorgestrel intrauterine system was the most commonly chosen long-active reversible contraceptive by women in the intervention group at all time points. Differences between intervention and control groups in mean quality-of-life scores across all domains at 6 and 12 months were small. CONCLUSION: A complex intervention combination of family physician training on contraceptive effectiveness counselling and rapid access to long-active reversible contraceptive insertion clinics resulted in greater long-active reversible contraceptive uptake and has the potential to reduce unintended pregnancies.

Cesarean delivery: Trend in indications over three decades within a major city hospital network.

INTRODUCTION: The cesarean delivery rate has been increasing globally in recent decades. The reasons for this are complex and subject to ongoing debate. Investigation of the indications for cesarean delivery and how these have changed over an extended period of time could provide insight into the reasons for changing obstetric practice. Our objective was to explore contributing factors to the increasing rate of cesarean delivery by examining the incidence of and indications for cesarean delivery over the past three decades at our institutions. MATERIAL AND METHODS: We conducted a retrospective observational study of all cesarean deliveries, from 24 weeks' gestational age onwards, within an inner-city hospital network in Sydney, Australia, between August 1989 and December 2016. The primary outcome measures were the rates of and indications for emergency and planned cesarean delivery. We also examined our data within the Robson 10-Group Classification system. RESULTS: There were 147 722 births over the study period, with 37 309 cesarean deliveries for an overall rate of 25.3%. The rate of cesarean delivery increased from 18.7% in 1989-1994 (8.7% emergency, 10% planned) to 30.4% in 2010-2016 (11.4% emergency, 19% planned). Emergency cesarean delivery for slow progress increased from 3.4% to 5.5% of all births (a relative increase of 62%) and other emergency cesareans mainly performed for suspected intrapartum fetal compromise increased from 5.2% to 5.6% (a relative increase of 8%). Previous uterine surgery (predominantly cesarean section) was the largest contributor to the increase in planned procedures from 3.8% to 9.0% of all births, and 29% of all cesarean deliveries. Primary cesarean delivery for planned antenatal fetal indications, previous pregnancy problems, multiple gestation and maternal choice all increased substantially in combined rate from 0.7% to 4.9%. Cesarean rates in Robson groups 6, 7 and 8 (term breech and multiple gestations) increased most over time. CONCLUSIONS: The increased rate of cesarean delivery is mainly attributable to a greater number of procedures performed for slow progress in labor, breech presentation or repeat cesarean section.

Provision of immediate postpartum intrauterine contraception after vaginal birth within a public maternity setting: Health services research evaluation.

INTRODUCTION: Expanding access to postpartum intrauterine contraception (PPIUC) can reduce unintended pregnancies and short inter-pregnancy intervals; however, provision across Europe is limited. Our aim was to determine the feasibility, clinical outcomes and patient satisfaction of providing immediate PPIUC after vaginal birth using a health services research model. MATERIAL AND METHODS: Phased introduction of PPIUC across two Lothian maternity hospitals; all women intending vaginal birth during the study period without a contraindication to use of the method were eligible to receive PPIUC. Midwives and obstetric doctors were trained in vaginal PPIUC insertion using Kelly forceps. Women received information antenatally and had PPIUC insertion of either a levonorgestrel intrauterine system or a copper intrauterine device within 48 hours of vaginal birth. Follow-up was conducted in-person at 6 weeks postpartum and by telephone at 3, 6 and 12 months. Primary outcomes were: uptake, complications (infection, uterine perforation), expulsion and patient satisfaction at 6 weeks; and method of continuation up to 12 months. Secondary outcomes included hazard ratio for expulsion adjusted for demographic and insertion-related variables. RESULTS: Uptake of PPIUC was 4.6% of all vaginal births; 465/447 (96.1%) of those requesting PPIUC successfully received it and most chose a levonorgestrel intrauterine system (73%). At 6 weeks postpartum, the infection rate was 0.8%, there were no perforations and 98.3% of women said they would recommend the service. The complete expulsion rate was 29.8% (n = 113) and most had symptoms (n = 79). Of the additional 121 devices removed, 118 were because of partial expulsion. The rate of complete/partial expulsion was higher for insertions by midwives compared with those by doctors. The re-insertion rate after expulsion/removal was 87.6% and method continuation at 12 months was 79.6%. CONCLUSIONS: Routine PPIUC at vaginal birth is feasible. Complications were extremely rare. High expulsion rates may be observed in early stages of service introduction and with inexperienced providers. Re-insertion and therefore longer-term continuation rates of intrauterine contraception were very high. In settings with low rates of attendance for interval postpartum intrauterine contraception insertion, PPIUC could be a useful intervention to prevent unintended and closely spaced pregnancies.

Quality of life among caregivers of people with end-stage kidney disease managed with dialysis or comprehensive conservative care.

BACKGROUND: To measure health-related and care-related quality of life among informal caregivers of older people with end-stage kidney disease (ESKD), and to determine the association between caregiver quality of life and care recipient's treatment type. METHODS: A prospective cross-sectional study was conducted. Three renal units in the UK and Australia were included. Informal caregivers of people aged ≥75 years with ESKD managed with dialysis or comprehensive conservative non-dialytic care (estimated glomerular filtration (eGFR) ≤10 mL/min/1.73m2) participated. Health-related quality of life (HRQoL) was assessed using Short-Form six dimensions (SF-6D, 0-1 scale) and care-related quality of life was assessed using the Carer Experience Scale (CES, 0-100 scale). Linear regression assessed associations between care-recipient treatment type, caregiver characteristics and the SF-6D utility index and CES scores. RESULTS: Of 63 caregivers, 49 (78%) were from Australia, 26 (41%) cared for an older person managed with dialysis, and 37 (59%) cared for an older person managed with comprehensive conservative care. Overall, 73% were females, and the median age of the entire cohort was 76 years [IQR 68-81]. When adjusted for caregiver sociodemographic characteristics, caregivers reported significantly worse carer experience (CES score 15.73, 95% CI 5.78 to 25.68) for those managing an older person on dialysis compared with conservative care. However, no significant difference observed for carer HRQoL (SF-6D utility index - 0.08, 95% CI - 0.18 to 0.01) for those managing an older person on dialysis compared with conservative care. CONCLUSIONS: Our data suggest informal caregivers of older people on dialysis have significantly worse care-related quality of life (and therefore greater need for support) than those managed with comprehensive conservative care. It is important to consider the impact on caregivers' quality of life when considering treatment choices for their care recipients.

Personalized melanoma risk assessments and tailored prevention advice: a pragmatic randomized controlled trial in Australian general practice.

BACKGROUND: Personalized risk assessments using prediction models that incorporate several melanoma risk factors may promote melanoma-prevention behaviours. OBJECTIVES: To evaluate the effect on short-term melanoma-prevention behaviours of web-based, real-time, model-generated personalized melanoma risk information and tailored prevention advice, and its feasibility and clinician acceptability. METHODS: Between February and April 2016, in an open randomized controlled trial across four general medical practices in New South Wales, Australia, 272 patients were randomly allocated to receive (i) real-time model-generated personalized melanoma risk assessment and tailored melanoma-prevention advice or (ii) generic melanoma-prevention advice. We measured self-reported melanoma-prevention behaviours at baseline and 6 weeks and the intervention's feasibility and acceptability. RESULTS: Follow-up questionnaires were completed by 185 patients at 6 weeks: 174 assessed as average risk and 11 as high or very high risk. There were no statistically significant differences between intervention and control patients in sun protection, sun exposure or early diagnosis behaviours. When stratified by melanoma risk, average risk patients in the intervention group appeared to show greater sun protection at 6 weeks (mean difference = 0.23, on a scale of 1-5; 95% confidence interval: 0.01 to 0.45; P = 0.04) than patients in the control group; the P value for interaction between intervention and risk category was 0.10. There was favourable feedback from patients and general practitioners. CONCLUSIONS: Web-based delivery in general practice of real-time, model-generated personalized melanoma risk prediction and tailored melanoma-prevention advice is feasible and acceptable. An apparent increase in sun protection behaviour in average risk patients warrants further evaluation in different risk groups.

The association between induction of labour at 38 to 39 weeks pregnancy and indication for caesarean delivery: An observational study.

BACKGROUND: Induction of labour is associated with a reduction in caesarean delivery, but the mechanism of action and which groups of women might benefit remain unknown. AIMS: To assess the association between induction of labour at 38-39 weeks pregnancy, and caesarean delivery: (i) overall; (ii) for slow progress in labour; and (iii) for suspected fetal compromise. MATERIAL AND METHODS: Retrospective observational study in two Sydney hospitals from 2009 to 2016, among nulliparous women with induction of labour at 38 or 39 completed weeks pregnancy and a singleton, cephalic presenting fetus. The comparator was all planned vaginal births beyond 39(+1/7) weeks, whether or not labour was induced. Binary and multinomial multiple logistic regressions adjusting for multiple confounders were performed. RESULTS: There were 2388 and 15 259 women in the study and comparison groups respectively. Induction of labour was associated with caesarean delivery overall only for women <25 years of age (adjusted odds ratio 1.63; 95% CI 1.17-2.27) and was not associated with caesarean delivery for slow progress. Induction of labour was positively associated with increased caesarean delivery for suspected fetal compromise among young women (<30 years), with the association weakening as maternal age increased. The association between induction of labour and caesarean delivery was different for slow progress compared with suspected compromise (P = 0.005). CONCLUSIONS: Induction of labour has different effects on the likelihood of caesarean delivery for slow progress and for suspected fetal compromise. Women <30 years of age are at higher risk of caesarean delivery for suspected fetal compromise, potentially due to uterine hyperstimulation.