Descriptive characteristics and in-hospital mortality of critically bleeding patients requiring massive transfusion: results from the Australian and New Zealand Massive Transfusion Registry.

BACKGROUND AND OBJECTIVES: Critically bleeding patients requiring massive transfusion (MT) are clinically challenging, and limited data exist to support management decisions. This study describes patient characteristics, transfusion support and clinical outcomes from the Australian and New Zealand (NZ) Massive Transfusion Registry (ANZ-MTR). MATERIALS AND METHODS: Retrospective, cohort study of all adult patients receiving MT (≥5 units red blood cells [RBC] in 4 h) at participating ANZ-MTR hospitals, 2011-2015. Mortality information was collected from the Australian National Death Index and NZ Ministry of Health. Associations between patient characteristics and outcomes were modelled using logistic regression. RESULTS: A total of 3560 MT cases were identified. For in-hospital deaths, cardiothoracic surgery was the most frequent bleeding context (24·5%) followed by trauma (18·3%). Age (OR = 1·03; 95% CI: 1·02-1·04), more comorbidities (OR = 1·14; 95% CI: 1·09-1·21), larger volume of RBC in first 24 h from MT onset (OR = 1·04; 95% CI: 1·02-1·06), higher platelet to RBC ratio at 4 h (OR = 2·76; 95% CI: 1·14-6·65) and higher activated partial thromboplastin time (OR = 1·02; 95% CI: 1·01-1·03) were associated with in-hospital mortality. CONCLUSION: Patients with more comorbidities, older age, traumatic or surgical bleeding or requiring more blood components had higher in-hospital mortality. These findings provide a basis to evaluate and monitor practice relating to optimal use of blood products, variation in transfusion practices and patient outcomes, and also enable benchmarking of hospital performance for management of MT in specific patient groups.

The impact of intensive care in a private hospital on patients aged 80 and over: health-related quality of life, functional status and burden versus benefit.

BACKGROUND: Greater numbers of persons aged over 80 years are admitted to intensive care units (ICU) compared with 15 years ago. Outcomes other than death such as physical dependence and cognitive impairment and treatment burden are important to older people. AIMS: The aims of this study were to determine the long-term outcomes of functional impairment, health-related quality of life (HRQoL) and the self-reported burden of treatment in a sample of patients aged 80 years and above admitted to ICU. Half of the cohort were admitted for elective cardiac surgery, the rest for non-cardiac surgery and medical conditions. METHODS: In this longitudinal cohort study, in a tertiary level ICU, we measured HRQoL using the SF-36 and functional status using the modified Barthel Index at several time points over a 2-year follow-up period. We also assessed treatment burden by asking participants whether they thought the episode of care was worthwhile. RESULTS: A total of 348 patients was recruited into the study. One-fifth of the cohort had died by the 2-year follow-up data collection point. There was an improvement in physical functioning in the cardiac surgery group at 6 months which was not sustained. There was no change in HRQoL at 2 years in either group. The majority valued the episode of care. CONCLUSION: We demonstrated that HRQoL and previous lifestyle is preserved in the majority following ICU admission, associated with a high level of patient valuation of the episode of care.

How receptive are patients to medical students in Australian hospitals? A cross-sectional survey of a public and a private hospital.

BACKGROUND: Medical student numbers in Australian universities have more than doubled since 2000. There are concerns about the ability for existing clinical training sites to accommodate this increase in student numbers, and there have been calls to increase training in private hospitals. The receptiveness of patients in private hospitals will influence the success of such placements. AIMS: We aimed to evaluate whether patients in a private hospital are as receptive to medical students as patients in a public hospital. METHODS: Cross-sectional survey of patients conducted at a private and a public teaching hospital in Melbourne, Australia. Main outcome measures were willingness to allow a medical student to participate in an interview, physical examination and procedures (electrocardiogram, venepuncture and digital rectal examination), and patient attitudes towards medical students as assessed by a series of 20 attitude statements and a summative attitude score. RESULTS: Patients at the private hospital were more willing than patients at the public hospital to allow a medical student to take their history unsupervised (112/146, 76.7% vs 90/141, 63.8%; P = 0.02). The distribution of patient willingness did not otherwise differ between hospitals for physical examination or procedures. There was no difference in the mean attitude score between hospitals (15.3 ± 0.8 private vs 15.4 ± 1.2 public, P = 0.38), and responses differed between hospitals for only four of the 20 attitude statements. CONCLUSIONS: Our findings suggest that patients in a private hospital are at least as receptive to medical students as patients in a public hospital.

Improving outcomes for hospital patients with critical bleeding requiring massive transfusion: the Australian and New Zealand Massive Transfusion Registry study methodology.

BACKGROUND: The Australian and New Zealand (ANZ) Massive Transfusion (MT) Registry (MTR) has been established to improve the quality of care of patients with critical bleeding (CB) requiring MT (≥ 5 units red blood cells (RBC) over 4 h). The MTR is providing data to: (1) improve the evidence base for transfusion practice by systematically collecting data on transfusion practice and clinical outcomes; (2) monitor variations in practice and provide an opportunity for benchmarking, and feedback on practice/blood product use; (3) inform blood supply planning, inventory management and development of future clinical trials; and (4) measure and enhance translation of evidence into policy and patient blood management guidelines. The MTR commenced in 2011. At each participating site, all eligible patients aged ≥18 years with CB from any clinical context receiving MT are included using a waived consent model. Patient information and clinical coding, transfusion history, and laboratory test results are extracted for each patient's hospital admission at the episode level. RESULTS: Thirty-two hospitals have enrolled and 3566 MT patients have been identified across Australia and New Zealand between 2011 and 2015. The majority of CB contexts are surgical, followed by trauma and gastrointestinal haemorrhage. Validation studies have verified that the definition of MT used in the registry correctly identifies 94 % of CB events, and that the median time of transfusion for the majority of fresh products is the 'product event issue time' from the hospital blood bank plus 20 min. Data linkage between the MTR and mortality databases in Australia and New Zealand will allow comparisons of risk-adjusted mortality estimates across different bleeding contexts, and between countries. Data extracts will be examined to determine if there are differences in patient outcomes according to transfusion practice. The ratios of blood components (e.g. FFP:RBC) used in different types of critical bleeding will also be investigated. CONCLUSIONS: The MTR is generating data with the potential to have an impact on management and policy decision-making in CB and MT and provide benchmarking and monitoring tools for immediate application.

Diabetes and ethnic minorities.

The global prevalence of diabetes for all age groups is estimated to be 2.8%. Type 2 diabetes accounts for at least 90% of diabetes worldwide. Diabetes incidence, prevalence, and disease progression varies by ethnic group. This review highlights unique aspects of the risk of developing diabetes, its overwhelming vascular complications, and their management mainly using data among South Asians and African-Caribbeans in the UK but also using non-UK data. It is concluded that although the origin of the ethnic differences in incidence need further clarification, many factors should be amenable to prevention and treatment in all ethnic groups worldwide.

Randomised controlled trial evaluating the effectiveness of behavioural interventions to modify cardiovascular risk factors in men and women with impaired glucose tolerance: outcomes at 6 months.

AIMS: To evaluate the efficacy of interventions to promote a healthy diet and physical activity in people with impaired glucose tolerance (IGT). METHODS: A randomised controlled trial in Newcastle upon Tyne, UK, 1995-98. Participants included 67 adults (38 men; 29 women) aged 24-75 years with IGT. The intervention consisted of regular diet and physical activity counselling based on the stages of change model. Main outcome measures were changes between baseline and 6 months in nutrient intake; physical activity; anthropometric and physiological measurements including serum lipids; glucose tolerance; insulin sensitivity. RESULTS: The difference in change in total fat consumption was significant between intervention and control groups (difference -21.8 (95% confidence interval (CI) -37.8 to -5.8) g/day, P=0.008). A significantly larger proportion of intervention participants reported taking up vigorous activity than controls (difference 30.1, (95% CI 4.3--52.7)%, P=0.021). The change in body mass index was significantly different between groups (difference -0.95 (95% CI -1.5 to -0.4) kg/m(2), P=0.001). There was no significant difference in change in mean 2-h plasma glucose between groups (difference -0.19 (95% CI -1.1 to 0.71) mmol/l, NS) or in serum cholesterol (difference 0.02 (95% CI -0.26 to 0.31) mmol/l, NS). The difference in change in fasting serum insulin between groups was significant (difference -3.4 (95% CI -5.8 to -1.1) mU/l, P=0.005). CONCLUSIONS: After 6 months of intensive lifestyle intervention in participants with IGT, there were changes in diet and physical activity, some cardiovascular risk factors and insulin sensitivity, but not glucose tolerance. Further follow-up is in progress to investigate whether these changes are sustained or augmented over 2 years.

Prevalence of malnutrition on admission to four hospitals in England. The Malnutrition Prevalence Group.

AIMS: The primary objective was to estimate prevalence of malnutrition on admission to four hospitals. Secondary objectives included assessing the relationship between nutritional status and length of hospital stay, numbers of new prescriptions, new infections and disease severity. METHODS: We entered eligible patients according to predefined quotas for elective and emergency admissions to 23 specialties. We measured height, weight, Body Mass Index and anthropometrics, and recorded history of unintentional weight loss. Patients who had lost > or = 10% of their body weight, had a Body Mass Index <20, or had a Body Mass Index <20 with one anthropometric measurement <15th centile were considered malnourished. RESULTS: Of 1611 eligible patients, 761 did not participate; 269 were too ill; 256 could not be weighed; and 236 refused consent. Eight hundred and fifty were subsequently evaluated. Prevalence of malnutrition on admission was 20%. Length of stay, new prescriptions and infections and disease severity were significantly higher in the malnourished. CONCLUSIONS: One patient in every five admitted to hospital is malnourished. Although this figure is unacceptably high, it may underestimate true prevalence. Malnutrition was associated with increased length of stay, new prescriptions and infections. Malnutrition may also have contributed to disease severity.

Inflammatory markers and growth in South Asian and European origin infants in Britain: the Manchester Children's Growth and Vascular Health Study.

OBJECTIVE: Given the high risk of cardiovascular disease in South Asians and the importance of inflammation in coronary heart disease we tested the hypothesis that circulating C-reactive protein (CRP) and interleukin 6 (IL-6) would be higher in healthy British born infants of South Asian origin than in infants of European origin in the first 2 years of life. STUDY DESIGN AND SETTING: Infants of South Asian (n=74) and European (n=129) origin were followed prospectively from birth. Anthropometry and fasting CRP and IL-6 concentrations were measured at one or more of 3, 6, 12 and 24 months of age. RESULTS: South Asian infants had a significantly lower circulating CRP compared with European infants (beta=0.63, 95% CI 0.41-0.98 mg/l, P=0.040). There was no significant change in CRP from birth to 2 years in either ethnic group so that neither infant weight nor weight gain were associated with CRP during follow-up. IL-6 concentrations were low or undetectable during follow-up in all participants. CONCLUSION: In our cohort, South Asian origin infants had significantly lower markers of inflammation compared with European infants. Infant growth to age 2 years was not associated with CRP or IL-6. Inflammatory markers are not useful indices of CVD risk at this age, with such markers not being elevated as expected in South Asian infants. The timing of the rise of such markers to the levels found in adult South Asian populations needs longer prospective study.

Over and undernutrition in the children of Australian immigrants: Assessing the influence of birthplace of primary carer and English language use at home on the nutritional status of 4-5-year-olds.

OBJECTIVE: To document the relationship between childhood nutrition status and ethnicity (defined as the birthplace of primary carer and English language use at home) using a nationally representative sample of 4- to 5-year-old children. DESIGN AND PARTICIPANTS: Cross-sectional population survey of 4 983 4- to 5-year-old children (2 537 boys and 2 446 girls) as part of Wave 1 (2004) of the Longitudinal Study of Australian Children. MAIN OUTCOME MEASURES: Overweight/obesity and thinness using the newly published body mass index cut-off points of Cole (2007). RESULTS: In total, 20.6% (95%CI 19.5, 21.7) of children aged 4 to 5 years were estimated to be overweight or obese, while 1.0% (95%CI 0.8, 1.3) was thin. Unadjusted analyses showed a significant relationship between childhood overweight/obesity and primary carer's country of birth (chi2=15.9, p<0.01), but the significance became minimal after adjusting for socio-economic and demographic factors. The adjusted model suggests that boys of primary carer's born in Europe (excluding UK and Ireland) were less likely to be overweight/obese than boys whose primary carers were born in Australia, but the overall effect size was negligible. No difference was found for girls. In addition, boys who mainly spoke English at home were less likely to be overweight/obese (OR=0.49; 95%CI 0.27, 0.88; p=0.017) and thin (OR=0.27; 95%CI 0.12, 0.62; p=0.002) than boys who spoke a language other than English at home. No difference was found for girls. CONCLUSIONS: There is a relationship between main language spoken at home and nutritional status in 4-5-year-old boys but not girls. The use of English language at home may be a protective factor for normal weight in young boys. After adjustment for socio-economic and demographics characteristics, there was a negligible relationship between overweight/obesity in children and their primary carer's country of birth.

The effectiveness of nutrition interventions on dietary outcomes by relative social disadvantage: a systematic review.

OBJECTIVE: To determine whether nutrition interventions widen dietary inequalities across socioeconomic status groups. DESIGN: Systematic review of interventions that aim to promote healthy eating. DATA SOURCES: CINAHL and MEDLINE were searched between 1990 and 2007. REVIEW METHODS: Studies were included if they were randomised controlled trials or concurrent controlled trials of interventions to promote healthy eating delivered at a group level to low socioeconomic status groups or studies where it was possible to disaggregate data by socioeconomic status. RESULTS: Six studies met the inclusion criteria. Four were set in educational setting (three elementary schools, one vocational training). The first found greater increases in fruit and vegetable consumption in children from high-income families after 1 year (mean difference 2.4 portions per day, p<0.0001) than in children in low-income families (mean difference 1.3 portions per day, p<0.0003). The second did not report effect sizes but reported the nutrition intervention to be less effective in disadvantaged areas (p<0.01). The third found that 24-h fruit juice and vegetable consumption increased more in children born outside the Netherlands ("non-native") after a nutrition intervention (beta coefficient = 1.30, p<0.01) than in "native" children (beta coefficient = 0.24, p<0.05). The vocational training study found that the group with better educated participants achieved 34% of dietary goals compared with the group who had more non-US born and non-English speakers, which achieved 60% of dietary goals. Two studies were conducted in primary care settings. The first found that, as a result of the intervention, the difference in consumption of added fat between the intervention and the control group was -8.9 g/day for blacks and -12.0 g/day for whites (p<0.05). In the second study, there was greater attrition among the ethnic minority participants than among the white participants (p<0.04). CONCLUSIONS: Nutrition interventions have differential effects by socioeconomic status, although in this review we found only limited evidence that nutrition interventions widen dietary inequalities. Due to small numbers of included studies, the possibility that nutrition interventions widen inequalities cannot be excluded. This needs to be considered when formulating public health policy.