Can screening 4-5 year olds accurately identify children who will have teacher-reported mental health problems when children are aged 6-7 years?

OBJECTIVE: To assess the screening accuracy of information obtained from parents of 4-5-year-old children for the purpose of identifying the children who have teacher-reported mental health problems when they are aged 6-7 years. METHOD: The study used data from the Longitudinal Study of Australian Children (LSAC) obtained when children were aged 4-5 years and 6-7 years. The level of children's mental health problems was assessed using the Strengths and Difficulties Questionnaire (SDQ) completed by parents when children were aged 4-5 years and by teachers when children were aged 6-7 years (n=2163). When children were aged 4-5 years, parenting skills were assessed using three questionnaires developed for the parent-completed LSAC questionnaire and maternal mental health was assessed using the Kessler Psychological Distress Scale (K6). RESULTS: When the level of parent-reported childhood mental health problems at 4-5 years old was used to identify children with teacher-reported mental health problems (i.e. a score in the "abnormal" range of the teacher-reported SDQ Total Difficulties Scale) when the children were aged 6-7 years, sensitivity was 26.8%, positive predictive value was 22.8%, and specificity was 92.9%. The addition of further information about the characteristics of children and their parents made only a small improvement to screening accuracy. CONCLUSIONS: Targeted interventions for preschool children may have the potential to play an important role in reducing the prevalence of mental health problems during the early school years. However, current capacity to accurately identify preschoolers who will experience teacher-reported mental health problems during the early school years is limited.

The association between increasing maternal age at first birth and decreased rates of spontaneous vaginal birth in South Australia from 1991 to 2009.

BACKGROUND: Caesarean section rates in Australia rose over the period 1999-2009, as did maternal age at first birth. The contribution of the rise of maternal age to the rise in caesarean sections remains unclear. AIMS: To estimate the effect of increasing maternal age on the incidence of emergency caesarean section or instrumental delivery in term singleton first births in South Australia. METHODS: We undertook a population-based study of 117 981 term singleton first births, which followed labour during the period 1991-2009, using data from the South Australian Perinatal Statistics Collection. The main outcome measures were deliveries other than spontaneous vaginal births (SVB) (emergency caesarean section or instrumental birth) and emergency caesarean section alone. Logistic regression analysis was performed. RESULTS: Increasing maternal age at first birth was found to be associated with delivery other than SVB and emergency caesarean section. The adjusted odds of delivery other than SVB increased multiplicatively by approximately 1.49 (95% CI, 1.47-1.51) per five-year rise in maternal age, and the odds of emergency caesarean section increased multiplicatively by approximately 1.39 (95% CI, 1.37-1.42) per five-year rise. Although there are likely to be many reasons for the effect, increases in maternal age at first birth made a contribution in up to 75% of the observed increase in delivery other than SVB from 44.0% to 49.6% over the study period. CONCLUSIONS: Rising maternal age at first birth appeared to contribute to a large proportion of the increase in deliveries other than SVB in South Australia.

Vascular function and glucose variability improve transiently following initiation of continuous subcutaneous insulin infusion in children with type 1 diabetes.

OBJECTIVE: The effect of continuous subcutaneous insulin infusion (CSII) and glucose variability on vascular health in type 1 diabetes (T1D) is not known. We aimed to determine whether initiation of CSII improves vascular function and reduces glucose variability, independent of changes in HbA1c. METHODS: Twenty-two children with T1D (12.5 ± 2.9 yr) were reviewed immediately prior, 3 wk, and 12 months after initiation of CSII. Vascular function [flow-mediated dilatation (FMD), glyceryl trinitrate-mediated dilatation (GTN)], glucose variability [mean of daily differences (MODD), mean amplitude of glycaemic excursions (MAGE) and continuous overlapping net glycaemic action (CONGA)], and clinical and biochemical data were measured at each visit. Results for the first two visits were compared to a previously studied cohort of 31 children with T1D who remained on multiple daily injections (MDI). RESULTS: FMD, GTN, blood pressure, HbA1c, fructosamine, and glucose variability significantly improved 3 wk after CSII commencement (all p < 0.05), but there was no change in the MDI control group. At 3 wk, vascular function related to glucose variability [(FMD: MODD, r = -0.62, p = 0.002) and (GTN: MAGE, r = -0.59, p = 0.004; CONGA-4, r = -0.51, p = 0.01; MODD, r = -0.62, p = 0.002)] but not to blood pressure, HbA1c, or fructosamine. At 12 months, FMD, GTN, blood pressure, and glucose variability returned to baseline levels, while HbA1c deteriorated. Carotid intima media thickness was unchanged over 12 months. CONCLUSIONS: Initiation of CSII rapidly improves vascular function in association with decreased glucose variability; however, the effects are not sustained with deterioration of metabolic control and glucose variability.

Genetic and clinical contributions to cerebral palsy: a multi-variable analysis.

AIM: This study aims to examine single nucleotide polymorphism (SNP) associations with cerebral palsy in a multi-variable analysis adjusting for potential clinical confounders and to assess SNP-SNP and SNP-maternal infection interactions as contributors to cerebral palsy. METHODS: A case control study including 587 children with cerebral palsy and 1154 control children without cerebral palsy. Thirty-nine candidate SNPs were genotyped in both mother and child. Data linkage to perinatal notes and cerebral palsy registers was performed with a supplementary maternal pregnancy questionnaire. History of known maternal infection during pregnancy was extracted from perinatal databases. RESULTS: Both maternal and fetal carriage of inducible nitric oxide synthase SNP rs1137933 were significantly negatively associated with cerebral palsy in infants born at less than 32 weeks gestation after adjustment for potential clinical confounders and correction for multiple testing (odds ratio 0.55, 95% confidence interval 0.38-0.79; odds ratio 0.57, 95% confidence interval 0.4-0.82, respectively). Analysis did not show any statistically significant SNP-SNP or SNP-maternal infection interactions after correction for multiple testing. CONCLUSIONS: Maternal and child inducible nitric oxide synthase SNPs are associated with reduced risk of cerebral palsy in infants born very preterm. There was no evidence for statistically significant SNP-SNP or SNP-maternal infection interactions as modulators of cerebral palsy risk.

Healthcare providers' knowledge, experience and challenges of reporting adverse events following immunisation: a qualitative study.

BACKGROUND: Healthcare provider spontaneous reporting of suspected adverse events following immunisation (AEFI) is central to monitoring post-licensure vaccine safety, but little is known about how healthcare professionals recognise and report to surveillance systems. The aim of this study was explore the knowledge, experience and attitudes of medical and nursing professionals towards detecting and reporting AEFI. METHODS: We conducted a qualitative study, using semi-structured, face to face interviews with 13 Paediatric Emergency Department consultants from a tertiary paediatric hospital, 10 General Practitioners, 2 local council immunisation and 4 General Practice nurses, recruited using purposive sampling in Adelaide, South Australia, between December 2010 and September 2011. We identified emergent themes related to previous experience of an AEFI in practice, awareness and experience of AEFI reporting, factors that would facilitate or impede reporting and previous training in vaccine safety. Thematic analysis was used to analyse the data. RESULTS: AEFI reporting was infrequent across all groups, despite most participants having reviewed an AEFI. We found confusion about how to report an AEFI and variability, according to the provider group, as to the type of events that would constitute a reportable AEFI. Participants' interpretation of a "serious" or "unexpected" AEFI varied across the three groups. Common barriers to reporting included time constraints and unsatisfactory reporting processes. Nurses were more likely to have received formal training in vaccine safety and reporting than medical practitioners. CONCLUSIONS: This study provides an overview of experience and beliefs of three healthcare professional groups in relation to identifying and reporting AEFI. The qualitative assessment reveals differences in experience and awareness of AEFI reporting across the three professional groups. Most participants appreciated the importance of their role in AEFI surveillance and monitoring the ongoing safety of vaccines. Future initiatives to improve education, such as increased training to health care providers, particularly, medical professionals, are required and should be included in both undergraduate curricula and ongoing, professional development.

The case for retaining severe perineal tears as an indicator of the quality of obstetric care.

BACKGROUND: The incidence of severe perineal tears acquired during vaginal childbirth varies considerably across hospitals but its use as a safety and quality indicator is in jeopardy because of problems associated with accurate detection and recording. AIM: To understand and interpret time trends in the incidence of third- and fourth-degree perineal tears among women giving birth vaginally in 18 public maternity hospitals in South Australia, taking into account individualised risk factors for each birth. METHODS: The risk-adjusted probability of a third- and fourth-degree tear was estimated for each of 65,598 singleton vaginal births (2002-2008), using a previously published regression model. The risk factors for each birth included maternal age; parity and ethnicity; assistance with instruments and episiotomy; shoulder dystocia; and infant birthweight. Plots of 'excess' tears were generated to help identify maternity services where the observed incidence of severe trauma differed from the expectation estimated from the risk profiles. RESULTS: Three hospitals were identified at which there were systematically more tears than expected (given their risk profiles), and five hospitals were identified at which there were fewer tears. However, increased tearing at two hospitals coincided closely with improved advocacy for better detection and treatment of perineal tears (especially partial third-degree tears). CONCLUSION: Statistical process control methods provide a powerful means of investigating temporal variations in the incidence of outcomes like severe perineal tears. Third- or fourth- degree tears should be retained as a quality indicator of maternity services, but it is likely that many third-degree tears currently go undetected.

Risk models for benchmarking severe perineal tears during vaginal childbirth: a cross-sectional study of public hospitals in South Australia, 2002-08.

BACKGROUND: The incidence of third- and fourth-degree perineal tears during vaginal childbirth is being increasingly used as an indicator of the safety and quality of maternity health care services. In order to make fair comparisons across hospitals it may be necessary to estimate a probability of severe perineal tears for every woman, taking into account her risk profile. METHODS: Logistic regression analysis was used to estimate the probabilities of third- and fourth-degree tears (n = 1582; 2.4%) in 65 598 vaginal births in publicly funded hospitals in South Australia, 2002-08. RESULTS: Maternal age ≥25 years, primiparity, instrument assistance, Asian or African ethnicity, shoulder dystocia and increasing birthweight were all identified as factors that are associated with an increased risk of perineal tears. In parous women, episiotomy, with or without instrument assistance, was associated with more tears; but among nulliparous women, episiotomy was associated with significantly fewer tears when forceps assistance was required, and showed little or no association with tearing in vacuum-assisted or unassisted (spontaneous) births. CONCLUSION: The probabilities of severe perineal tears in first-time mothers giving birth to a term singleton with cephalic presentation, may range from under 1% to over 40%, according to a minimalist model containing only predictors unrelated to clinical management. If instrument assistance and episiotomy are also incorporated into the modelling, the estimated probability of tearing may exceed 50% in high risk individuals. Such variation highlights the need for risk adjustment when comparing hospitals with respect to their incidence of third or fourth degree perineal tears.

The IDEAL study: investigation of dietary advice and lifestyle for women with borderline gestational diabetes: a randomised controlled trial - study protocol.

BACKGROUND: The Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) showed that treatment of pregnant women with mild gestational diabetes mellitus is beneficial for both women and their infants. It is still uncertain whether there are benefits of similar treatment for women with borderline gestational diabetes.This trial aims to assess whether dietary and lifestyle advice and treatment given to pregnant women who screen for borderline gestational diabetes reduces neonatal complications and maternal morbidities. DESIGN: Multicentre, randomised controlled trial. INCLUSION CRITERIA: Women between 240 and 346 weeks gestation with a singleton pregnancy, a positive oral glucose challenge test (venous plasma glucose ≥7.8 mmol/L) and a normal oral 75 gram glucose tolerance test (fasting venous plasma glucose <5.5 mmol/L and a 2 hour glucose <7.8 mmol/L) with written, informed consent.Trial entry and randomisation: Women with an abnormal oral glucose tolerance test (fasting venous plasma glucose ≥5.5 mmol/L or 2 hour glucose ≥7.8 mmol/L) will not be eligible and will be offered treatment for gestational diabetes, consistent with recommendations based on results of the ACHOIS trial. Eligible women will be randomised into either the 'Routine Care Group' or the 'Intervention Group'.Study groups: Women in the 'Routine Care Group' will receive routine obstetric care reflecting current clinical practice in Australian hospitals. Women in the 'Intervention Group' will receive obstetric care, which will include dietary and lifestyle advice, monitoring of blood glucose and further medical treatment for hyperglycaemia as appropriate.Primary study outcome: Incidence of large for gestational age infants. SAMPLE SIZE: A sample size of 682 women will be sufficient to show a 50% reduction in the risk of large for gestational age infants (alpha 0.05 two-tailed, 80% power, 4% loss to follow up) from 14% to 7% with dietary and lifestyle advice and treatment. DISCUSSION: A conclusive trial outcome will provide reliable evidence of relevance for the care of women with borderline glucose intolerance in pregnancy and their infants. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry - ACTRN12607000174482.

Precise mid-trimester placenta localisation: does it predict adverse outcomes?

BACKGROUND: A low-lying placenta detected at the mid-pregnancy ultrasound is commonly reported to warn against potential morbidity associated with placenta praevia. There is no information on what distance away from the internal cervical os is safe. AIMS: We examined whether a low-lying placenta not overlapping the cervical os in the second trimester increases the risk of obstetric complications and whether there is a cut-off point at which that increase occurs. METHODS: Adverse perinatal outcomes were examined prospectively in a cohort of women with a placenta 0-30 mm from the internal cervical os ('low-lying') at the routine mid-trimester ultrasound and compared to those with a placenta further away. Two composite outcomes of 'major' and 'minor' adverse events were predefined as primary outcome measures, requiring a sample size of 480 women with a low-lying placenta. Chi-square and Fisher's exact tests were used for statistical analysis. RESULTS: In 1662 pregnancies ('low-lying': n = 484; 'normal': n = 1178), there was no increase in composite adverse outcomes with a low-lying placenta and no cut-off distance within 30 mm from the cervical os at which risks increased. Postpartum haemorrhage ≥ 1000 mL was more frequent with a low-lying placenta (7.6% vs 4.7%, P < 0.05). CONCLUSIONS: Women with a low-lying placenta, not overlapping the cervical os, in mid-pregnancy are at no higher risk of adverse outcomes than those with a normally located placenta, except postpartum haemorrhage. This suggests that the high-risk label can be removed from pregnancies with a low-lying placenta not overlapping the cervical os in mid-pregnancy, reducing anxiety and resource utilisation.

Depressive symptomatology and service utilisation among refugee children and adolescents living in South Australia.

BACKGROUND: Young refugees resettled in Western countries are at increased risk of mental health problems. However, most research has centred on post traumatic stress disorder (PTSD), with depression, other mental health disorders, and problems receiving comparatively less attention. METHOD: Depressive symptomatology was assessed using the Children's Depression Inventory (CDI) in a multiethnic community sample of 348 refugee children (n = 180) and adolescents (n = 168) aged 7-17 years living in South Australia. RESULTS: According to parent reports, 7.1% of children and adolescents had depressive symptomatology for which services were available and yet only 21.5% of these accessed services. CONCLUSIONS: Young refugees need improved access to culturally appropriate mental health care.

Stressful life events, social health issues and low birthweight in an Australian population-based birth cohort: challenges and opportunities in antenatal care.

BACKGROUND: Investment in strategies to promote 'a healthy start to life' has been identified as having the greatest potential to reduce health inequalities across the life course. The aim of this study was to examine social determinants of low birthweight in an Australian population-based birth cohort and consider implications for health policy and health care systems. METHODS: Population-based survey distributed by hospitals and home birth practitioners to >8000 women six months after childbirth in two states of Australia. Participants were women who gave birth to a liveborn infant in Victoria and South Australia in September/October 2007. Main outcome measures included stressful life events and social health issues, perceived discrimination in health care settings, infant birthweight. RESULTS: 4,366/8468 (52%) of eligible women returned completed surveys. Two-thirds (2912/4352) reported one or more stressful life events or social health issues during pregnancy. Women reporting three or more social health issues (18%, 768/4352) were significantly more likely to have a low birthweight infant (< 2500 grams) after controlling for smoking and other socio-demographic covariates (Adj OR = 1.77, 95% CI 1.1-2.8). Mothers born overseas in non-English speaking countries also had a higher risk of having a low birthweight infant (Adj OR = 1.85, 95% CI 1.2-2.9). Women reporting three or more stressful life events/social health issues were more likely to attend antenatal care later in pregnancy (OR = 2.06, 95% CI 1.3-3.1), to have fewer antenatal visits (OR = 2.17, 95% CI 1.4-3.4) and to experience discrimination in health care settings (OR = 2.69, 95% CI 2.2-3.3). CONCLUSIONS: There is a window of opportunity in antenatal care to implement targeted preventive interventions addressing potentially modifiable risk factors for poor maternal and infant outcomes. Developing the evidence base and infrastructure necessary in order for antenatal services to respond effectively to the social circumstances of women's lives is long overdue.

The mental health and wellbeing of adolescents on remand in Australia.

OBJECTIVE: To compare the nature and prevalence of mental health problems, prevalence of suicidal ideation and behaviour, and health-related quality of life of 13-17-year-olds on remand with that of 13-17-year-olds in the general community. METHOD: Self reported questionnaires completed by 13-17-year-olds who were remanded in South Australia in 2008/9 (N = 159), 13-17-year-olds who participated in the Child and Adolescent Component of the National Survey of Mental Health and Well-being in Australia (N = 1283), and 13-17-year-olds who participated in the Western Australian Aboriginal Child Health Survey (N = 1100). Mental health problems were identified using the Youth Self-Report and the Strength and Difficulties Questionnaire. Health-related quality of life was assessed using the Child Health Questionnaire. RESULTS: A total of 50.0% (95% CI, 42.3-58.3) of adolescents on remand versus 18.9% of adolescents in the community scored above the recommended cut-off score on the Youth Self-Report. Among Indigenous adolescents, 55.8% (95% CI, 41.3-69.5) on remand versus 32.1% in the community scored above the recommended cut-off score on the Strength and Difficulties Questionnaire. Among those on remand, 19.1% (95% CI, 13.2-26.2) reported making a suicide attempt during the previous 12 months compared to 4.3% in the community. Health-related quality of life was significantly worse among adolescents on remand than adolescents in the community. These differences remained after adjusting for differences in the demographic characteristics of the two groups of adolescents. CONCLUSIONS: Compared with adolescents in the community, both Indigenous and non-Indigenous adolescents on remand experience a wide range of problems, including poorer mental and physical health, a higher prevalence of suicidal ideation and behaviour, greater family adversity, and poorer school attendance. This broad range of problems needs to be effectively addressed to enable adolescents on remand to become active and productive members of their communities.

The trouble with clinical indicators: Intact lower genital tract following childbirth in NSW Hospitals, 2003-2005.

BACKGROUND: The federal government wants outcomes of hospital care to be made publicly available. League tables based on single clinical indicators are misleading, largely because of their inability to take case-complexity into account. AIM: To demonstrate the application of a graphical tool (the risk-adjusted funnel plot) to the comparison of clinical outcomes across hospitals; and its advantages over league tables. METHODS: We looked at publicly available data on intact lower genital tract (ILGT), for all hospitals in New South Wales at which more than 200 births occurred in 2005. The 'excess' percentage of women at each hospital with an ILGT following a vaginal birth, was calculated after adjustment for instrumental assistance, the use of epidural analgesia/anaesthesia, the use of induction/augmentation, and the number of births per annum. RESULTS: In 2005, ILGT ranged from 13.1 to 55.8%. A plot of ILGT against vaginal births per annum (a funnel plot) revealed huge heterogeneity among hospitals, and an inverse association with the number of births per annum. A residual funnel plot, constructed from the differences between observed and expected ILGT identified four hospitals (three public and one private) with consistently better ILGT than expected - and four public hospitals with ILGT consistently worse than expected. Some of these hospitals were not located at the extremes of the league table. CONCLUSION: The risk-adjusted funnel plot is a useful graphical tool which may overcome the shortcomings of league tables. We need to become more sophisticated in our use of clinical indicators for comparing hospital performances.

Assessing glycemic variation: why, when and how?

In the post-Diabetes Control and Complications Trial (DCCT) and Epidemiology of Diabetes Interventions and Complications (EDIC) era of type 1 diabetes mellitus (T1DM) care, glycosylated hemoglobin (A1C) has enjoyed primacy as the clinical outcome variable (1). Metabolic control as defined by A1C, however, only defines approximately 25% of the risk of subsequent microvascular pathology (2) and, hence, other glycemic outcome variables are also being canvassed as being of potential significance. Transcription-regulating actions of glucose and the phenomenon of "metabolic memory" have recently become recognized (3,4). Simultaneously, ambulant continuous glucose monitoring (CGM) technologies have become available. The convergence of these factors has increased the interest in the impacts of fluctuations in glycemia, otherwise known as glycemic variation (GV). Initially, this interest was focused upon the effects of post-prandial glycemic excursions (5), but more recently, associations of GV and oxidative stress, microvascular pathology (6), and GV prediction associated with closedloop insulin delivery (7) have evolved. Notwithstanding this emerging interest in GV, there still remains a lack of consensus as to the importance of GV, in what circumstances it can be measured, and what GV metrics are best suited for various purposes. The aim of this review is to discuss these 3 key areas: Why measure GV? When can GV be meaningfully assessed?; How to measure to GV?.

Parents Need More Support: A Qualitative Study of the Experiences of Australian Parents Who Are Waiting for Surgical Intervention for Their Children With Otitis Media.

OBJECTIVE: To explore the experiences, expectations, and motivations of parents/caregivers of children with otitis media who were booked to undergo tympanostomy tube insertion. METHOD: A cross-sectional cohort study was conducted using semistructured interviews with 39 parents. Interviews were conducted via telephone and analyzed for key themes. RESULTS: Three themes emerged that incorporated a range of subthemes: (1) the impact of the child's underlying condition on the family, (2) the cues and prompts that influenced parents to seek intervention, and (3) the parents' expectations of the health-care system. The child's otitis media disrupted the day-to-day functioning of the family and the child's well-being, but despite this, the families found ways to adapt and cope. Parents were influenced by their friends, family, and medical practitioners when making treatment decisions and had differing expectations of the health-care system. CONCLUSION: Parents need support during their child's illness to help with pressures placed on the family and also in making health-care decisions for their child. Clinicians should consider these issues when discussing treatment options with parents.

Gallbladder disease, cholecystectomy, and pancreatic cancer risk in the International Pancreatic Cancer Case-Control Consortium (PanC4).

BACKGROUND: The association among gallbladder disease, cholecystectomy, and pancreatic cancer is unclear. Moreover, time interval between gallbladder disease or cholecystectomy and pancreatic cancer diagnosis is not considered in most previous studies. AIM: To quantify the association among gallbladder disease, cholecystectomy, and pancreatic cancer, considering time since first diagnosis of gallbladder disease or cholecystectomy. METHODS: We used data from nine case-control studies within the Pancreatic Cancer Case-Control Consortium, including 5760 cases of adenocarcinoma of the exocrine pancreas and 8437 controls. We estimated pooled odds ratios and the corresponding 95% confidence intervals by estimating study-specific odds ratios through multivariable unconditional logistic regression models, and then pooling the obtained estimates using fixed-effects models. RESULTS: Compared with patients with no history of gallbladder disease, the pooled odds ratio of pancreatic cancer was 1.69 (95% confidence interval, 1.51-1.88) for patients reporting a history of gallbladder disease. The odds ratio was 4.90 (95% confidence interval, 3.45-6.97) for gallbladder disease diagnosed <2 years before pancreatic cancer diagnosis and 1.11 (95% confidence interval, 0.96-1.29) when ≥2 years elapsed. The pooled odds ratio was 1.64 (95% confidence interval, 1.43-1.89) for patients who underwent cholecystectomy, as compared to those without cholecystectomy. The odds ratio was 7.00 (95% confidence interval, 4.13-11.86) for a surgery <2 years before pancreatic cancer diagnosis and 1.28 (95% confidence interval, 1.08-1.53) for a surgery ≥2 years before. CONCLUSIONS: There appears to be no long-term effect of gallbladder disease on pancreatic cancer risk, and at most a modest one for cholecystectomy. The strong short-term association can be explained by diagnostic bias and reverse causation.

Menstrual and reproductive factors and pancreatic cancer in the SEARCH program of the IARC.

We conducted a population-based case-control study on the relation of menstrual and reproductive factors and hormone use with pancreatic cancer risk among female participants of the SEARCH program study. We evaluated 367 cases of ductal adenocarcinoma and 821 controls for associations between pancreatic cancer and age at menarche, age at menopause, number of pregnancies, exogenous hormone use, and history of gynaecologic surgery. Among directly interviewed and proxy participants, we found a statistically significant association for having age of menarche at 11 years or younger compared with menarche at ages 12-13 years (OR = 1.8, 95% CI = 1.1-3.1). This result was consistent, but not statistically significant, among three of the four studies analyzed, and when the data were analyzed separately by response status (direct vs. proxy interviews). No other menstrual or reproductive factors were associated with pancreatic cancer risk in this study. In conclusion, earlier age at menarche may be weakly associated with pancreatic cancer, but it seems unlikely that menstrual and reproductive factors play more than only a minor role in pancreatic cancer. Additional analyses in large prospective study populations and in pooled studies may help to clarify remaining inconsistencies.

Placental position and late stillbirth: a case-control study.

AIMS AND OBJECTIVES: The aim of this study was to determine whether there is a relationship between placental position and stillbirth with the objective of establishing if placental position impacted on stillbirth risk. BACKGROUND: Whilst there has been extensive research on low placental implantation because of the importance of detecting placenta praevia, little research has been undertaken on other aspects of placental position and possible impact on pregnancy outcome. DESIGN: A matched case-control study of stillbirth and placental position was conducted using case-notes from two tertiary obstetric referral centres. METHODS: Notes were retrospectively examined and Placental position as documented in the case-notes at the routine mid-trimester (20 week) ultrasound was identified. Placental position for a total of 124 pregnancies culminating in stillbirth was compared with placental position in 243 (matched) pregnancies resulting in a live born baby. RESULTS: Women who had a posterior located placenta were statistically more likely to suffer a stillbirth than women who had a placenta in any other position OR 1.64 (95%CI 1.02-2.65 p = 0.04). CONCLUSION: Posterior located placenta may be a contributory risk factor for stillbirth. Further research is warranted. Implications for practice. Nurses and midwives should be aware of this potential risk factor to monitor foetal well-being closely.

The application of risk-adjusted control charts using the Paediatric Index of Mortality 2 for monitoring paediatric intensive care performance in Australia and New Zealand.

OBJECTIVE: To assess the applicability of risk-adjusted sequential control charts using the Paediatric Index of Mortality version 2 for monitoring of the quality of paediatric intensive care. DESIGN: Observational study. SETTING: A registry of patient admissions to paediatric intensive care units (PICUs) in Australia and New Zealand. PATIENTS: A total of 10,710 patients admitted to eight PICUs during a 24-month period. MEASUREMENTS AND RESULTS: A series of risk-adjusted control charts was created for each PICU. Modified sequential probability ratio tests were used to test the hypothesis that the PICUs being monitored were 'out of control', where loss of control was arbitrarily defined as the odds of death exceeding twice the odds of dying as estimated by PIM2. In 24 months of monitoring, there was one alarm signal, suggesting the odds of deaths had doubled, and there was one signal, in another PICU, suggesting the odds of death had halved. CONCLUSIONS: The major advantage of risk-adjusted sequential control charts is that the technique allows unit performance to be monitored continuously over time, rather than intermittently, with the aim of rapidly detecting a change in performance as soon as possible after it occurs. This technique is suitable for continuously screening for a change in outcome within a PICU over time and complements other methods of monitoring the quality of paediatric intensive care.

Baby Friendly Hospital Initiative practices and breast feeding duration in a cohort of first-time mothers in Adelaide, Australia.

OBJECTIVE: to investigate the relationship between adherence to six of the Baby Friendly Hospital Initiative (BFHI) Ten steps to successful breast feeding and the duration of breast feeding in first-time mothers. DESIGN: a prospective study to assess the duration of breast feeding up to 6 months postpartum. Survival analysis techniques (Kaplan-Meier curves and Cox proportional hazard models) were used to interpret the data. PARTICIPANTS: 317 women who had given birth to their first baby (at term) in a large teaching maternity hospital in Adelaide, South Australia, during the period March to November 2003. FINDINGS: ignoring all other factors, we found that women whose babies received a bottle feed, used a pacifier or dummy, or who used a nipple shield during their postnatal stay, were at significantly greater risk of weaning (p0.05). After adjusting for socio-demographic variables, self-efficacy, intended duration of breast feeding, and method of delivery, the results unexpectedly showed that the only significant predictor of early weaning was breast feeding on demand. However, a composite variable indicating use of one or more of nipple shields, a dummy or bottle feeds while in hospital resulted in a significantly greater risk of weaning (p=0.05). IMPLICATIONS FOR PRACTICE: socio-demographic and cultural factors may be more important determinants of the duration of breast feeding than some of the very specific hospital practices targeted in the Ten steps to successful breast feeding. From a public health perspective, we may influence the duration of breast feeding through better post-discharge support services, or through interventions that improve attitudes to breast feeding in specific socio-cultural and economic groups.