Trends in cesarean birth rates in Iceland over a 19-year period.

BACKGROUND: Cesarean birth (CB) rates have increased in high-resource countries during the past two decades, yet it is not known whether CB rates have changed according to maternal age and/or gestational age. METHODS: All singleton live births in Iceland between 1997 and 2015 were identified from the Icelandic Medical Birth Registry (80 130). Rates of cesarean births (intrapartum and prelabor) were calculated overall and separately for maternal age groups and gestational age groups and by parity. Logit binomial regression was used to calculate odds ratios (ORs) and confidence intervals (CIs) for annual change in cesarean birth rates adjusted for maternal characteristics and clinical indication groups. RESULTS: The overall CB rate was 15.7% in 1997 and 15.8% in 2015; the CB rate did not change significantly during the study period. The overall CB rate for early-term deliveries (37-38 weeks) decreased for multiparas (annual aOR = 0.99 [95% CI = 0.98-0.99]), and the preterm (<37 weeks) prelabor cesarean rate increased significantly (1.11 [1.09-1.14]) for both primiparas and multiparas. For multiparas only, the intrapartum CB rate decreased (0.97 [0.97-0.98]), whereas the prelabor CB rate increased, predominantly for women aged over 35 years (1.03 [1.02-1.04]). Adjustment for clinical indication groups did not change these results. CONCLUSIONS: Findings indicate a rise in prelabor cesarean for preterm births and women aged over 35 years (multiparas only). As adjustment for clinical indications did not affect these results, changes in obstetric practice are more likely to have affected these rate changes rather than changes in clinical indications.

Providing mentorship support to general surgery residents: a model for structured group facilitation.

SUMMARY: Mentorship is foundational to surgical training, with recognized benefits for both mentees and mentors. The University of Ottawa General Surgery Mentorship Program was developed as a module-based group facilitation program to support inclusive personal and professional development of junior general surgery residents. The group format provided an opportunity for both vertical and horizontal mentorship relationships between staff mentors and resident mentees. Perceived benefits of program participants were evaluated at the conclusion of the first year of the program. The program was well-received by staff and resident participants and may provide a time-efficient and inclusive mentorship structure with the additional benefit of peer support. We review the development and implementation of the program to date and share our mentorship experience to encourage the growth of formal mentorship opportunities within general surgery training programs.

Maternal and neonatal outcomes in pregnancies following colorectal cancer.

BACKGROUND: The risks of adverse obstetric outcomes among young women survivors of colorectal cancer (CRC) are uncertain. METHODS: This Western Australian, whole-jurisdictional linked-data, retrospective cohort study compared maternal and neonatal outcomes of first postcancer pregnancies among women CRC survivors against randomly selected pregnancies of women with no cancer history. Logistic regression models were used to investigate a range of adverse outcomes independently associated with CRC and its surgical and adjunctive treatments. RESULTS: Among 627,762 deliveries during the study period (1983-2007), 232 were first pregnancies following CRC. Whether following laparoscopic or open cancer surgery, these pregnancies were independently associated with a significantly increased risk of antepartum hemorrhage [odds ratios (ORs): 1.25; 2.13 for the respective procedures], postpartum hemorrhage (ORs: 1.61; 3.31), Cesarean delivery (ORs: 2.42; 4.24), infant low Apgar score (ORs: 1.32; 2.64), need for neonatal resuscitation (ORs: 1.49; 3.20), and special care admission (ORs: 1.42; 2.87). A history of open (but not laparoscopic) cancer surgery was associated with increased risk of gastrointestinal obstruction during pregnancy (OR 1.17) and prolonged postpartum hospitalization (OR 3.11). Neither was significantly associated with perinatal death. Among women with previous CRC, rectal (versus colonic) malignancy was independently associated with a significantly higher risk of overall maternal and neonatal adverse outcomes (ORs: 3.73 and 2.73, respectively), as was radiotherapy (ORs: 4.24 and 2.81, respectively). Chemotherapy was independently associated with a marginally but significantly higher risk of overall maternal but not neonatal outcomes (ORs: 1.11; 0.98). Open versus laparoscopic cancer surgery was associated with a significantly higher risk of antepartum and postpartum hemorrhage, low Apgar score, need for neonatal resuscitation, and neonatal special care admission. CONCLUSIONS: Previous CRCs, particularly rectal and radiation-treated tumors, appear to confer an increased likelihood of adverse outcomes in subsequent pregnancies. Laparoscopic technique for CRC surgery may reduce adverse gestational outcomes.

Neonatal outcomes after preterm birth by mothers' health insurance status at birth: a retrospective cohort study.

BACKGROUND: Publicly insured women usually have a different demographic background to privately insured women, which is related to poor neonatal outcomes after birth. Given the difference in nature and risk of preterm versus term births, it would be important to compare adverse neonatal outcomes after preterm birth between these groups of women after eliminating the demographic differences between the groups. METHODS: The study population included 3085 publicly insured and 3380 privately insured, singleton, preterm deliveries (32-36 weeks gestation) from Western Australia during 1998-2008. From the study population, 1016 publicly insured women were matched with 1016 privately insured women according to the propensity score of maternal demographic characteristics and pre-existing medical conditions. Neonatal outcomes were compared in the propensity score matched cohorts using conditional log-binomial regression, adjusted for antenatal risk factors. Outcomes included Apgar scores less than 7 at five minutes after birth, time until establishment of unassisted breathing (>1 minute), neonatal resuscitation (endotracheal intubation or external cardiac massage) and admission to a neonatal special care unit. RESULTS: Compared with infants of privately insured women, infants of publicly insured women were more likely to receive a low Apgar score (ARR = 2.63, 95% CI = 1.06-6.52) and take longer to establish unassisted breathing (ARR = 1.61, 95% CI = 1.25-2.07), yet, they were less likely to be admitted to a special care unit (ARR = 0.84, 95% CI = 0.80-0.87). No significant differences were evident in neonatal resuscitation between the groups (ARR = 1.20, 95% CI = 0.54-2.67). CONCLUSIONS: The underlying reasons for the lower rate of special care admissions in infants of publicly insured women compared with privately insured women despite the higher rate of low Apgar scores is yet to be determined. Future research is warranted in order to clarify the meaning of our findings for future obstetric care and whether more equitable use of paediatric services should be recommended.

Cancer incidence and mortality trends in Australian adolescents and young adults, 1982-2007.

BACKGROUND: Increasing incidence and lack of survival improvement in adolescents and young adults (AYAs) with cancer have led to increased awareness of the cancer burden in this population. The objective of this study was to describe overall and type-specific cancer incidence and mortality trends among AYAs in Western Australia from 1982-2007. METHODS: Age-adjusted incidence and mortality rates were calculated for all malignancies combined and for each of the most common diagnostic groups, using five-year age-specific rates. Joinpoint regression analysis was used to derive annual percentage changes (APC) for incidence and mortality rates. RESULTS: The annual incidence rate for all cancers combined increased in males from 1982 until 2000 (APC = 1.5%, 95%CI: 0.9%; 2.1%) and then plateaued, whilst rates for females remained stable across the study period (APC = -0.1%; 95%CI: -0.2%; 0.4%) across the study period. For males, significant incidence rate increases were observed for germ cell tumors, lymphoblastic leukemia and thyroid cancer. In females, the incidence of Hodgkin's lymphoma, colorectal and breast cancers increased. Significant incidence rate reductions were noted for cervical, central nervous system and lung cancers. Mortality rates for all cancers combined decreased from 1982 to 2005 for both males (APC = -2.6%, 95%CI:-3.3%;-2.0%) and females (APC = -4.6%, 95%CI:-5.1%;-4.1%). With the exception of bone sarcoma and lung cancer in females, mortality rates for specific cancer types decreased significantly for both sexes during the study period. CONCLUSIONS: Incidence of certain AYA cancers increased, whilst it decreased for others. Mortality rates decreased for most cancers, with the largest improvement observed for breast carcinomas. Further research is needed to identify the reasons for the increasing incidence of certain cancers.

Seasonal variation in fetal growth: accounting for sociodemographic, biological, and environmental exposures.

OBJECTIVE: We sought to investigate seasonal variation in fetal growth, accounting for important sociodemographic, biological, and environmental exposures. STUDY DESIGN: Records of births 1998 through 2006 in Perth, Western Australia were obtained (N = 147,357). We investigated small for gestational age and sex and the proportion of optimal birthweight (POBW) in relation to seasonal exposures (season, temperature, sunlight) by trimester of pregnancy. Adjustment was made for a wide range of risk factors. RESULTS: The POBW for neonates with third trimesters predominantly in summer was 0.18% (0.00-0.36%) lower than for those in winter. POBW decreased by 0.14% (0.01-0.27%) per interquartile range increase in third-trimester temperature (9.15°C). An interquartile range increase in temperature over pregnancy (0.73°C) was associated with an odds ratio of 1.02 (95% confidence interval, 1.00-1.05) for small for gestational age and sex. CONCLUSION: Reduced fetal growth was associated with elevated ambient temperatures throughout and late in pregnancy, independently of air pollution and other risk factors.

Locally derived traffic-related air pollution and fetal growth restriction: a retrospective cohort study.

BACKGROUND: Fetal growth restriction has been inconsistently associated with maternal exposure to elevated levels of traffic-related air pollution. OBJECTIVE: We investigated the relationship between an individualised measure of fetal growth and maternal exposure to a specific marker for traffic-related air pollution. METHODS: We estimated maternal residential exposure to a marker for traffic-related air pollution (nitrogen dioxide, NO2) during pregnancy for 23,452 births using temporally adjusted land-use regression. Logistic regression was used to investigate associations with small for gestational age and sex (SGA) and fetal growth restriction, defined as proportion of optimal birth weight (POBW) below the 10th percentile. Sub-populations investigated were: women who spent most time at home, women who did not move house, women with respiratory or circulatory morbidity, women living in low/middle/high socio-economic areas, women who delivered before 37 weeks gestation, and women who delivered from 37 weeks gestation. RESULTS: An IQR increase in traffic-related air pollution in the second trimester across all women was associated with an OR of 1.31 (95% CI 1.07 to 1.60) for fetal growth restriction. Effects on fetal growth restriction (low POBW) were highest among women who subsequently delivered before 37 weeks of gestation. Effects on SGA were highest among women who did not move house: OR 1.35 (95% CI 1.08 to 1.69). CONCLUSIONS: Larger effect sizes were observed for low POBW than for SGA. Exposure to traffic-related air pollution in mid to late pregnancy was associated with risk of SGA and low POBW in this study.

Hand assisted laparoscopic surgery versus conventional laparoscopy for colorectal surgery.

BACKGROUND: Laparoscopic surgery for colon disease has been shown to have advantages over the open approach in the perioperative period in terms of shorter hospital stay, decreased analgesic use and a more rapid return of bowel function but provides these benefits at the expense of increased technical difficulty and operative time. Hand assisted surgery which a is a hybrid of open surgery and laparoscopic surgery may offer patients the perioperative advantages of minimally invasive surgery without the technical difficulty and increased operative time associated with the conventional laparoscopic approach. This review compares the benefits and harms of laparoscopic and hand assisted laparoscopic surgery for colon disease. OBJECTIVES: To estimate the perioperative outcomes of hand assisted laparoscopic surgery compared to conventional laparoscopic surgery in adult patients requiring colorectal resections. SEARCH STRATEGY: We searched EMBASE (1980- Feb 2010), Medline (1966- Feb 2010) and the Cochrane Central Register of Controlled Trials (CENTRAL, 2010 issue 1), references of included studies, relevant review articles and conference abstracts. SELECTION CRITERIA: Randomised controlled trials (RCTs) in which adult patients were allocated to either receive hand-assisted laparoscopic surgery or conventional laparoscopic colorectal resection for benign or malignant colorectal disease. Studies were not restricted by language of publication. DATA COLLECTION AND ANALYSIS: Reports of potentially relevant articles were retrieved in full text, and two reviewers independently assessed the eligibility of these studies. Data abstraction was performed independently by two reviewers. Meta-analysis of perioperative outcome measures was carried out using a random effects model.  MAIN RESULTS: Three randomised controlled studies met the inclusion criteria (n=189). One study focused exclusively on malignant pathology, the second study focused mostly on benign pathology and the third trial had a mixed variety of pathology with approximately a third representing malignant pathology. Conversion rates were significantly decreased in patients undergoing hand assisted surgery but there was no statistically significant difference in operative time or complication rates when comparing hand assisted surgery to conventional laparoscopy.  All studies were associated with methodological limitations.    AUTHORS' CONCLUSIONS: Despite the limited number of trials performed, meta-analysis demonstrated a statistically significant decrease in conversion rates among the hand assisted group. There was no difference in operating time or perioperative complication rates.  Additional adequately powered and methodologically sound trials are needed to determine if there is a clinically important difference in perioperative outcomes.  Due to significant costs associated with the use of hand-assist devices, economic analyses are also warranted. 

The adoption of laparoscopic colorectal surgery: a national survey of general surgeons.

BACKGROUND: Laparoscopic surgery may become the standard of care for the treatment of colorectal disease. Little is known regarding North American patterns of practice or the limiting factors and strategies for adoption among surgeons. METHODS: We sent a 28-item questionnaire to all general surgeon members of the Royal College of Physicians and Surgeons of Canada. We derived descriptive and correlative information using chi(2), Wilcoxon rank sum and Student t tests and multivariate logistic regression. RESULTS: The return rate was 55% (694/1266). A total of 67% (462/694; 95% confidence interval 63%-70%) of respondents perform colorectal surgery. Of these, 54% perform laparoscopic colorectal surgery. Multivariate logistic regression identified 5 factors related to performing laparoscopic colorectal surgery: fewer years in practice (p < 0.001), male sex (p = 0.015), practising in the province of Quebec (p = 0.005), university-hospital affiliation (p = 0.034) and minimally invasive surgery fellowship training (p = 0.023). Lack of adequate operating time and formal training were the main reasons cited by surgeons not offering laparoscopic colon resections. Most surgeons (67%) felt that site visits from a minimally invasive surgeon would represent the most effective training method for acquiring advanced laparoscopic skills. CONCLUSION: About half of Canadian general surgeons offer laparoscopic colorectal resections. Recent graduation, male sex, practice location, university-hospital affiliation and minimally invasive surgery training are significant predictors for offering a laparoscopic approach. Lack of operative time and formal training are the main barriers to adoption of the technique. Site visits by trained laparoscopic surgeons is the preferred method of acquiring advanced skills.

Identifying stroke therapeutics from preclinical models: A protocol for a novel application of network meta-analysis.

Introduction: Globally, stroke is the second leading cause of death. Despite the burden of illness and death, few acute interventions are available to patients with ischemic stroke. Over 1,000 potential neuroprotective therapeutics have been evaluated in preclinical models. It is important to use robust evidence synthesis methods to appropriately assess which therapies should be translated to the clinical setting for evaluation in human studies. This protocol details planned methods to conduct a systematic review to identify and appraise eligible studies and to use a network meta-analysis to synthesize available evidence to answer the following questions: in preclinical in vivo models of focal ischemic stroke, what are the relative benefits of competing therapies tested in combination with the gold standard treatment alteplase in (i) reducing cerebral infarction size, and (ii) improving neurobehavioural outcomes? Methods: We will search Ovid Medline and Embase for articles on the effects of combination therapies with alteplase. Controlled comparison studies of preclinical in vivo models of experimentally induced focal ischemia testing the efficacy of therapies with alteplase versus alteplase alone will be identified. Outcomes to be extracted include infarct size (primary outcome) and neurobehavioural measures. Risk of bias and construct validity will be assessed using tools appropriate for preclinical studies. Here we describe steps undertaken to perform preclinical network meta-analysis to synthesise all evidence for each outcome and obtain a comprehensive ranking of all treatments. This will be a novel use of this evidence synthesis approach in stroke medicine to assess pre-clinical therapeutics. Combining all evidence to simultaneously compare mutliple therapuetics tested preclinically may provide a rationale for the clinical translation of therapeutics for patients with ischemic stroke.  Dissemination: Review findings will be submitted to a peer-reviewed journal and presented at relevant scientific meetings to promote knowledge transfer. Registration: PROSPERO number to be submitted following peer review.

Neoadjuvant therapy and anastomotic leak after tumor-specific mesorectal excision for rectal cancer.

PURPOSE: This study was designed to evaluate whether neoadjuvant therapy is a risk factor for anastomotic leakage after rectal cancer surgery. METHODS: A retrospective review of 220 patients who underwent tumor-specific mesorectal excision for rectal cancer from 2000 to 2005 was performed. Risk factors for leak were identified by using a multivariable regression model. RESULTS: A total of 54 patients received neoadjuvant chemoradiation therapy and surgery, whereas 166 received surgery alone. No difference in clinically significant leaks was observed between the two groups (5.6 vs. 6.6 percent, P = 1). A diverting ileostomy was performed in 26.4 percent of patients who received neoadjuvant therapy compared with 9.7 percent for surgery alone (P = 0.0021). Neoadjuvant patients were more likely to have ultralow anastomoses (17.6 vs. 2.5 percent, P < 0.0001). On multivariate analysis, smoking (odds ratio, 6.37 (1.8, 22.2), P = 0.004), difficult anastomosis (odds ratio, 7.66 (1.8, 31.5), P = 0.0048), and low level of anastomosis (

Laparoscopic repair of paraesophageal hernias: a Canadian experience.

BACKGROUND: The surgical approach to paraesophageal hernias (PEH) has changed with the advent of laparoscopic techniques. Variation in both perioperative outcomes and hernia recurrence rates are reported in the literature. We sought to evaluate the short- and intermediate-term outcomes with laparoscopic PEH repair. METHODS: We performed a retrospective review of patients having laparoscopic repair of PEH between June 1998 and September 2002. We included patients with more than 120 days of follow-up. RESULTS: A total of 58 patients with a mean age of 60.4 (standard deviation [SD] 15.0) years had a laparoscopic procedure to repair a primary PEH, as well as adequate follow-up, during the study period. The types of PEH included type II (n = 13), III (n = 44) and IV (n = 1). The most common symptoms were epigastric pain (57%), dysphagia (40%), heartburn (31%) and vomiting (28%). Associated procedures included 56 (96%) Nissen fundoplications and 2 (4%) gastropexies. We closed all crural defects either with or without pledgets, and 2 patients required the use of mesh. There was 1 conversion to open surgery owing to intraoperative bleeding secondary to a consumptive coagulopathy; we observed no other major intraoperative emergencies. Minor or major complications occurred in 15 patients (26%). Late postoperative complications included 1 umbilical hernia. The mean length of stay in hospital was 3.8 (SD 2.5) days. After surgery, 19 patients were completely asymptomatic, and the majority of the remaining patients (83%) described marked symptom improvement. Upper gastrointestinal series performed in symptomatic patients in the postoperative setting identified 5 recurrent paraesophageal hernias (8.6%) and 5 small sliding hernias (9%). CONCLUSION: Laparoscopic repair of PEH is associated with improved long-term symptom relief, low morbidity and acceptable recurrence rates when performed in an experienced centre.

Efficacy and safety of chimeric antigen receptor T-cell (CAR-T) therapy in patients with haematological and solid malignancies: protocol for a systematic review and meta-analysis.

INTRODUCTION: Patients with relapsed or refractory malignancies have a poor prognosis. Immunotherapy with chimeric antigen receptor T (CAR-T) cells redirects a patient's immune cells against the tumour antigen. CAR-T cell therapy has demonstrated promise in treating patients with several haematological malignancies, including acute B-cell lymphoblastic leukaemia and B-cell lymphomas. CAR-T cell therapy for patients with other solid tumours is also being tested. Safety is an important consideration in CAR-T cell therapy given the potential for serious adverse events, including death. Previous reviews on CAR-T cell therapy have been limited in scope and methodology. Herein, we present a protocol for a systematic review to identify CAR-T cell interventional studies and examine the safety and efficacy of this therapy in patients with haematology malignancies and solid tumours. METHODS AND ANALYSIS: We will search MEDLINE, including In-Process and Epub Ahead of Print, EMBASE and the Cochrane Central Register of Controlled Trials from 1946 to 22 February 2017. Studies will be screened by title, abstract and full text independently and in duplicate. Studies that report administering CAR-T cells of any chimeric antigen receptor construct targeting antigens in patients with haematological malignancies and solid tumours will be eligible for inclusion. Outcomes to be extracted will include complete response rate (primary outcome), overall response rate, overall survival, relapse and adverse events. A meta-analysis will be performed to synthesise the prevalence of outcomes reported as proportions with 95% CIs. The potential for bias within included studies will be assessed using a modified Institute of Health Economics tool. Heterogeneity of effect sizes will be determined using the Cochrane I 2 statistic. ETHICS AND DISSEMINATION: The review findings will be submitted for peer-reviewed journal publication and presented at relevant conferences and scientific meetings to promote knowledge transfer. PROSPERO REGISTRATION NUMBER: CRD42017075331.

Adverse obstetric and perinatal outcomes following treatment of adolescent and young adult cancer: a population-based cohort study.

OBJECTIVE: To investigate obstetric and perinatal outcomes among female survivors of adolescent and young adult (AYA) cancers and their offspring. METHODS: Using multivariate analysis of statewide linked data, outcomes of all first completed pregnancies (n = 1894) in female survivors of AYA cancer diagnosed in Western Australia during the period 1982-2007 were compared with those among females with no cancer history. Comparison pregnancies were matched by maternal age-group, parity and year of delivery. RESULTS: Compared with the non-cancer group, female survivors of AYA cancer had an increased risk of threatened abortion (adjusted relative risk 2.09, 95% confidence interval 1.51-2.74), gestational diabetes (2.65, 2.08-3.57), pre-eclampsia (1.32, 1.04-1.87), post-partum hemorrhage (2.83, 1.92-4.67), cesarean delivery (2.62, 2.22-3.04), and maternal postpartum hospitalization>5 days (3.01, 1.72-5.58), but no excess risk of threatened preterm delivery, antepartum hemorrhage, premature rupture of membranes, failure of labor to progress or retained placenta. Their offspring had an increased risk of premature birth (<37 weeks: 1.68, 1.21-2.08), low birth weight (<2500 g: 1.51, 1.23-2.12), fetal growth restriction (3.27, 2.45-4.56), and neonatal distress indicated by low Apgar score (<7) at 1 minute (2.83, 2.28-3.56), need for resuscitation (1.66, 1.27-2.19) or special care nursery admission (1.44, 1.13-1.78). Congenital abnormalities and perinatal deaths (intrauterine or ≤7 days of birth) were not increased among offspring of survivors. CONCLUSION: Female survivors of AYA cancer have moderate excess risks of adverse obstetric and perinatal outcomes arising from subsequent pregnancies that may require additional surveillance or intervention.

Assessing the feasibility of a randomised, double-blinded, placebo-controlled trial to investigate the role of intraperitoneal ropivacaine in gastric bypass surgery: a protocol.

INTRODUCTION: Postoperative pain control remains a major challenge for surgical procedures, including laparoscopic gastric bypass. Pain management is particularly relevant in obese patients who experience a higher number of cardiovascular and pulmonary events. Effective pain management may reduce their risk of serious postoperative complication, such as deep vein thrombosis and pulmonary emboli. The objective of this study is to evaluate the efficacy of intraperitoneal local anaesthetic, ropivacaine, to reduce postoperative pain in patients undergoing laparoscopic Roux-en-Y gastric bypass. METHODS AND ANALYSIS: A randomised controlled trial will be conducted to compare intraperitoneal ropivacaine (intervention) versus normal saline (placebo) in 120 adult patients undergoing bariatric bypass surgery. Ropivacaine will be infused over the oesophageal hiatus and throughout the abdomen. Patients in the control arm will undergo the same treatment with normal saline. The primary end point will be postoperative pain at 1, 2 and 4 h postoperatively. Pain measurements will then occur every 4 h for 24 h and every 8 h until discharge. Secondary end points will include opioid use, peak expiratory flow, 6 min walk distance and quality of life assessed in the immediate postoperative period. Intention-to-treat analysis will be used and repeated measures will be analysed using mixed modelling approach. Post-hoc pairwise comparison of the treatment groups at different time points will be carried out using multiple comparisons with adjustment to the type 1 error. Results of the study will inform the feasibility of recruitment and inform sample size of a larger definitive randomised trial to evaluate the effectiveness of intraperitoneal ropivacaine. ETHICS AND DISSEMINATION: This study has been approved by the Ottawa Health Science Network Research Ethics Board and Health Canada in April 2014. The findings of the study will be disseminated through national and international conferences and peer-reviewed journals. TRIAL REGISTRATION NUMBER: Clinicaltrial.gov NCT02154763.

Access to alcohol outlets, alcohol consumption and mental health.

The objective of this study was to investigate residential exposure to alcohol outlets in relation to alcohol consumption and mental health morbidity (anxiety, stress, and depression). This was a cross-sectional study of 6,837 adults obtained from a population representative sample for the period 2006-2009 in Perth, Western Australia. The number of alcohol outlets was ascertained for a 1600 m service area surrounding the residential address. Zero-inflated negative binomial and logistic regression were used to assess associations with total alcohol consumption, harmful alcohol consumption (7-10 drinks containing 10 g of alcohol for men, 5-6 drinks for women) and medically diagnosed and hospital contacts (for anxiety, stress, and depression), respectively. The rate ratio for the number of days of harmful consumption of alcohol per month and the number of standard drinks of alcohol consumed per drinking day was 1.06 (95% CI: 1.02, 1.11) and 1.01 (95% CI: 1.00, 1.03) for each additional liquor store within a 1600 m service area, respectively. The odds ratio of hospital contact for anxiety, stress, or depression was 1.56 (95% CI: 0.98, 2.49) for those with a liquor store within the service area compared to those without. We observed strong evidence for a small association between residential exposure to liquor stores and harmful consumption of alcohol, and some support for a moderate-sized effect on hospital contacts for anxiety, stress, and depression.

Association between pre-eclampsia and locally derived traffic-related air pollution: a retrospective cohort study.

BACKGROUND: Pre-eclampsia is a common complication of pregnancy and is a major cause of fetal-maternal mortality and morbidity. Despite a number of plausible mechanisms by which air pollutants might contribute to this process, few studies have investigated the association between pre-eclampsia and traffic emissions, a major contributor to air pollution in urban areas. OBJECTIVE: The authors investigated the association between traffic-related air pollution and risk of pre-eclampsia in a maternal population in the urban centre of Perth, Western Australia. METHOD: The authors estimated maternal residential exposure to a marker for traffic-related air pollution (nitrogen dioxide, NO(2)) during pregnancy for 23 452 births using temporally adjusted land-use regression. Logistic regression was used to investigate associations with pre-eclampsia. RESULTS: Each IQR increase in levels of traffic-related air pollution in whole pregnancy and third trimester was associated with a 12% (1%-25%) and 30% (7%-58%) increased risk of pre-eclampsia, respectively. The largest effect sizes were observed for women aged younger than 20 years or 40 years or older, aboriginal women and women with pre-existing and gestational diabetes, for whom an IQR increase in traffic-related air pollution in whole pregnancy was associated with a 34% (5%-72%), 35% (0%-82%) and 53% (7%-219%) increase in risk of pre-eclampsia, respectively. CONCLUSIONS: Elevated exposure to traffic-related air pollution in pregnancy was associated with increased risk of pre-eclampsia. Effect sizes were highest for elevated exposures in third trimester and among younger and older women, aboriginal women and women with diabetes.

Cancer survival and excess mortality estimates among adolescents and young adults in Western Australia, 1982-2004: a population-based study.

BACKGROUND: Data are limited on cancer outcomes in adolescents and young adults. METHODS: Based on data from the Western Australian Data Linkage System, this study modelled survival and excess mortality in all adolescents and young adults aged 15-39 years in Western Australia who had a diagnosis of cancer in the period 1982-2004. Relative survival and excess all-cause mortality for all cancers combined and for principal tumour subgroups were estimated, using the Ederer II method and generalised linear Poisson modelling, respectively. RESULTS: A cancer diagnosis in adolescents and young adults conferred substantial survival decrement. However, overall outcomes improved over calendar period (excess mortality hazard ratio [HR], latest versus earliest diagnostic period: 0.52, trend p<0.0001). Case fatality varied according to age group (HR, oldest versus youngest: 1.38, trend p<0.0001), sex (HR, female versus male: 0.66, 95% confidence interval [CI] 0.62-0.71), ethnicity (HR, Aboriginal versus others: 1.47, CI 1.23-1.76), geographical area (HR, rural/remote versus urban: 1.13, CI 1.04-1.23) and residential socioeconomic status (HR, lowest versus highest quartile: 1.14, trend p<0.05). Tumour subgroups differed substantially in frequency according to age group and sex, and were critical outcome determinants. CONCLUSIONS: Marked progressive calendar-time improvement in overall outcomes was evident. Further research is required to disentangle the contributions of tumour biology and health service factors to outcome disparities between ethno-demographic, geographic and socioeconomic subgroups of adolescents and young adults with cancer.

Assisted vaginal deliveries in mothers admitted as public or private patients in Western Australia.

BACKGROUND: Mothers delivering as private patients in Australia have a high rate of assisted deliveries, which could lead to adverse infant outcomes in this group of patients. We investigated whether the risk of adverse infant outcomes after assisted deliveries was different for mothers admitted as public or private patients for delivery, when compared with unassisted deliveries. METHODS AND FINDINGS: We included 158,241 vaginal, singleton, term birth admissions in our study where the infant was live born and without birth defects. The study population was identified from statutory birth and hospital data collections held by the Western Australian (WA) Department of Health. We estimated odds ratios and confidence intervals using logistic regression models adjusted for a range of maternal demographic, pregnancy and birth characteristics. Interaction was assessed by including interaction terms in the models. Outcomes included low Apgar scores at five minutes (< 7), neonatal resuscitation and special care admission. Mothers delivering as private patients had an increased risk of assisted vaginal delivery compared with public patients (adjusted OR 1.74, 95% CI  =  1.68-1.80). Compared with unassisted vaginal deliveries, assisted deliveries were associated with increased risk of Apgar scores at five minutes below 7 (OR 1.25, 1.08-1.45), neonatal resuscitation (OR  =  1.69, 1.42-2.00) and admission to special care nursery (OR  =  1.64, 1.53-1.76). The increased risk of neonatal resuscitation was higher for mothers admitted as private patients for delivery (OR  =  2.13) than public patients (OR  = 1 .55, p(interaction)  =  0.03). CONCLUSIONS: Our results suggested that the high risk of neonatal resuscitation following assisted vaginal deliveries compared to unassisted is higher in private patients than public patients. Whether this phenomenon is due to the twofold higher rate of assisted vaginal deliveries in this group of patients or a higher rate of fetal indications for assisted vaginal delivery remains to be answered.

Neonatal complications in public and private patients: a retrospective cohort study.

OBJECTIVE: To use propensity score methods to create similar groups of women delivering in public and private hospitals and determine any differences in mode of delivery and neonatal outcomes between the matched groups. DESIGN: Population-based, retrospective cohort study. SETTING: Public and private hospitals in Western Australia. PARTICIPANTS: Included were 93 802 public and 66 479 private singleton, term deliveries during 1998-2008, from which 32 757 public patients were matched with 32 757 private patients on the propensity score of maternal characteristics. MAIN OUTCOME MEASURES: Neonatal outcomes were compared in the propensity score-matched cohorts using conditional logistic regression, adjusted for antenatal risk factors and mode of delivery. Outcomes included Apgar score <7 at 5 min, neonatal resuscitation (endotracheal intubation or external cardiac massage) and admission to a neonatal special care unit. RESULTS: No significant differences in maternal characteristics were found between the propensity score-matched groups. Private patients were more likely than their matched public counterparts to undergo prelabour caesarean section (25.2% vs 18%, p<0.0001). Public patients had lower rates of neonatal unit admission (AOR 0.67, 95% CI 0.62 to 0.73) and neonatal resuscitation (AOR 0.73, 95% CI 0.56 to 0.95), but higher rates of low Apgar scores at 5 min (AOR 1.31, 95% CI 1.06 to 1.63) despite adjustment for antenatal factors. Additional adjustment for mode of delivery reduced the resuscitation risk (AOR 0.86, 95% CI 0.63 to 1.18) but did not significantly alter the other estimates. CONCLUSIONS: Propensity score methods can be used to generate comparable groups of public and private patients. Despite the rates of low Apgar scores being higher in public patients, the rates of special care admission were lower. Whether these findings stem from differences in paediatric services or clinical factors is yet to be determined.