Resolution of Melanoma to Programmed Death-1 Blockade but Simultaneous Rapid Progression of Concomitant Chronic Lymphocytic Leukemia.

Here, we present a novel case of a patient with chronic lymphocytic leukemia (CLL) who received CTLA-4 and then PD-1 immune-checkpoint blockade (ICB) as treatment for concomitant metastatic melanoma. Whereas the metastatic melanoma was responsive to ICB, the CLL rapidly progressed (but responded to ICB cessation and ibrutinib). There were no new genetic mutational drivers to explain the altered clinical course. PD-1/PD-L1/PD-L2 and CTLA-4/CD80/CD86 expression was not increased in CLL B cells, CD8+ or CD4+ T-cell subsets, or monocytes. The patient's CLL B cells demonstrated strikingly prolonged in vitro survival during PD-1 blockade, which was not observed in samples taken before or after ICB, or with other patients. To our knowledge, a discordant clinical course to ICB coupled with these biological features has not been reported in a patient with dual malignancies.

Agenda-setting by young adults with type 1 diabetes and associations with emotional well-being/social support: results from an observational study.

BACKGROUND: The Diabetes Psychosocial Assessment Tool (DPAT) was developed to assess the psychosocial well-being of young adults with type 1 diabetes in clinical practice. The DPAT includes three validated questionnaires (assessing diabetes distress, anxiety/depressive symptoms and emotional well-being) and an agenda-setting tool. It is currently used by the Queensland Statewide Diabetes Clinical Network (available at Clinical Excellence Queensland). AIMS: To describe agenda items set by young adults with type 1 diabetes and investigate their association with emotional well-being/social support. METHODS: The DPAT was completed by young adults attending routine diabetes outpatient appointments at the Mater Hospital (Brisbane) between November 2016 and January 2020. For the current analysis, data included responses on agenda-setting and outcomes from three validated questionnaires. RESULTS: Responses of 277 young adults (15-26 years) were analysed. Ninety-four (34%) reported one to three agenda item(s). Common agenda items were diabetes technology and medications, but other topics raised included pregnancy, body image and eating concerns. Participants with moderate diabetes distress or anxiety symptoms were more likely to list at least one agenda item (P = 0.006; P = 0.002), as were females and older participants. CONCLUSION: Several agenda items for young adults with type 1 diabetes were identified and were more likely to be raised by those with elevated diabetes distress and anxiety symptoms. The DPAT is a valuable and convenient tool that can be easily applied in routine clinical practice to enable clinicians to understand the concerns of the young adult population and deliver personalised medicine to optimise long-term outcomes.

Melanoma diagnosis at a specialist dermatology practice without the use of photographic surveillance.

BACKGROUND/OBJECTIVE: Photographic aides are increasingly used in melanoma surveillance. We report melanoma characteristics detected using traditional surveillance without photographic technologies. METHODS: Retrospective study of melanomas diagnosed by three dermatologists at a private dermatology practice over 7 years. Patients underwent full skin examinations with dermoscopy and suspect lesions were excised or biopsied. Total body photography (TBP) and serial digital dermoscopic imaging (SDDI) were not used. Patient demographics, melanoma subtype and thickness, location, biopsy technique and keratinocyte cancers diagnosed at the same visit were recorded. Ratio of in situ to invasive melanomas was calculated. Melanoma risk factors were recorded for 69 randomly-selected patients. RESULTS: 492 patients were diagnosed with 615 melanomas during 579 visits. 505 (82%) were in situ (in situ to invasive ratio of 4.6:1). Of the invasive melanomas, 85.5% had a Breslow thickness <0.8 mm, 10 (9.1%) 0.8-1 mm and 6 (5.5%) >1 mm. 43.3% of in situ melanomas were lentiginous or lentigo maligna and 41.6% were superficial spreading melanomas (SSM). Of invasive melanomas, 24.3% were lentigo maligna melanoma and 59.5% were SSM. 48.4% of melanomas were diagnosed by shave procedures. Where risk factors were known, 25% were very-high-risk and 43% had a history of melanoma. Keratinocyte carcinoma was diagnosed by biopsy at 26.1% of visits. Studies using TBP and/or SDDI report in situ to invasive ratios of 0.59:1 to 2.17:1. CONCLUSION: Tradiational melanoma surveillance with immediate biopsy of suspect lesions results in high in situ to invasive ratios. Studies using photographic surveillance show lower ratios of in situ to invasive disease.

GDM care re-imagined: Maternal and neonatal outcomes following a major model of care change for gestational diabetes mellitus at a large metropolitan hospital.

BACKGROUND: The rapidly rising prevalence of gestational diabetes mellitus (GDM) poses major challenges to the efficient, timely and sustainable provision of diabetes care. AIM: To assess whether the implementation of a novel, digital model of care would provide improved efficiency without compromising clinical outcomes in a cohort of women with GDM. METHODS: A digital model of care was developed, implemented and evaluated using a prospective pre-post study design in 2020-21 at a quaternary centre. We introduced six culturally and linguistically tailored educational videos, home delivery of equipment and prescriptions, and a smartphone app-to-clinician portal for glycaemic review and management. Outcomes were prospectively recorded by an electronic medical record. Associations between model of care and maternal and neonatal characteristics and birth outcomes were examined for all women and separately by treatment received (diet, metformin, insulin). RESULTS: Comparing pre-implementation (n = 598) and post-implementation (n = 337) groups, maternal (onset, mode of birth) and neonatal (birthweight, large for gestational age (LGA), nursery admission) clinical outcomes confirmed that the novel model of care was similar to standard, traditional care. Minor birthweight variation was noted when separated by treatment type (diet, metformin, insulin). CONCLUSION: This pragmatic service redesign demonstrates reassuring clinical outcomes in a culturally diverse GDM cohort. Despite the lack of randomisation, this intervention has potential generalisability for GDM care and important key learnings for service redesign in the digital era.

Continuous Glucose Monitoring in Young Adults With Type 1 Diabetes: Impact on Hypoglycemia Confidence and Fear.

Background: Fear of hypoglycemia in people with type 1 diabetes has a detrimental effect on glycemic control and quality of life. The association between continuous glucose monitoring (CGM) and hypoglycemia confidence and fear has not previously been assessed in the young adult population. Methods: This was a prospective cohort study using questionnaires to assess the impact of CGM on hypoglycemia confidence (using the Hypoglycemia Confidence Scale [HCS]) and hypoglycemia fear (using the Hypoglycemia Fear Survey II [HFS]) in 40 young adults with a preexisting diagnosis of type 1 diabetes. Results: Scores on the HCS were greater at baseline for those with a longer duration of diabetes. Participants with higher general anxiety scores on the Generalized Anxiety Disorder 7-item scale had higher hypoglycemia fear at baseline (total score and worry component, but not behavior component of the HFS). Between baseline and follow-up, HCS scores increased on average by 0.2 (95% CI 0.1-0.4, P = 0.01) on a scale of 1-4. HFS scores decreased by 1.8 (95% CI -3.0 to -0.5, P = 0.006) on a scale of 0-24 for the worry component and by 2.5 (95% CI -4.4 to -0.6, P = 0.01) on a scale of 0-44 for total (worry + behavior components). At follow up, 83% of participants planned to continue using CGM all or most of the time. There was a very high self-reported effect of CGM on life with diabetes (median 8.0 [interquartile range 6.5-10.0], where 10 indicated a very big difference). Conclusion: Hypoglycemia confidence and fear improve with CGM use in young adults.

Association between type of phototherapy management and hospital and patient-related outcomes in neonates with non-haemolytic jaundice at an Australian community hospital.

AIM: To evaluate the associations between type of light-emitting diode phototherapy intervention and hospital and patient related outcomes in term neonates with non-haemolytic jaundice. METHODS: A retrospective observational study in a community hospital within a disadvantaged area in Australia was conducted. Data was extracted from hospital systems and medical records regarding the use of three types of phototherapy surface-area exposure for term neonates ≤28 days with non-haemolytic neonatal jaundice. Associations between type of phototherapy management and length of stay (LOS), rate of serum bilirubin (SBR) decline and duration of phototherapy were estimated using the general linear mixed model or linear regression. RESULTS: Of 102 neonates diagnosed with non-haemolytic jaundice between 1 June 2016 and 31 August 2017, 82 were included in final analyses. Neonates treated for jaundice during their first (birth) admission had a median LOS of 118 h for single-sided and 125 h for maximal double-sided phototherapy. Differences by phototherapy type were not statistically significant (P = 0.06). SBR rate of decline increased as surface-area of phototherapy increased (P < 0.001) with the fastest decline seen in maximal double-sided phototherapy. Estimated duration of phototherapy did not vary by phototherapy type but did vary by age at initiation of phototherapy (P = 0.006), with 16 fewer hours of phototherapy if commenced at ≥72 to <96 h versus ≥24 to 48 h of age (difference -16.4 h, 95% confidence interval -29.1 to -3.7 h). CONCLUSIONS: LOS and phototherapy duration were not associated with phototherapy type. Older neonates with neonatal jaundice required shorter phototherapy duration. Double-sided phototherapy was associated with faster reduction in SBR.

Evaluation of an online education module designed to reduce stillbirth.

BACKGROUND: The Safer Baby Bundle (SBB) eLearning is an online education module that addresses practice gaps in stillbirth prevention in Australia. It provides healthcare professionals with evidence-based resources for: smoking cessation; fetal growth restriction; decreased fetal movements; maternal safe going-to-sleep position; and timing of birth for women with risk factors for stillbirth. AIMS: To determine whether participants' reported knowledge and confidence in providing care designed to reduce stillbirth changed following completion of the module. To assess the module's suitability and acceptability, and participants' reported likelihood to change practice. MATERIALS AND METHODS: In-built surveys undertaken pre- and post-eLearning module assessed participant knowledge and confidence, module suitability and acceptability, and likelihood of practice change using Likert items. Responses were dichotomised. Differences pre- and post-module were tested using McNemar's test and differences by profession were examined using descriptive statistics and Pearson's χ2 test. RESULTS: Between 15 October 2019 and 2 November 2020, 5223 participants across Australia were included. Most were midwives (82.0%), followed by student midwives (4.6%) and obstetricians (3.3%). Reported knowledge and confidence improved in all areas (P < 0.001). Post-module 96.7-98.9% 'agreed' they had a sound level of knowledge and confidence across all elements of the SBB. Over 95% of participants agreed that the module was helpful and relevant, well organised, and easy to access and use. Eighty-eight percent reported they were likely to change some aspect of their clinical practice. CONCLUSIONS: The SBB eLearning module is a valuable education program that is well-received and likely to result in improvements in practice.

Exploring the association between BMI and mortality in Australian women and men with and without diabetes: the AusDiab study.

AIMS/HYPOTHESIS: There is conflicting evidence about the obesity paradox-the counterintuitive survival advantage of obesity among certain subpopulations of individuals with chronic conditions. It is believed that results supporting the obesity paradox are due to methodological flaws, such as collider bias. The aim of this study was to examine the association between obesity and mortality in Australian men and women. In addition, we explored whether obesity would appear to be protective if the analysis was restricted to a subpopulation with disease, and to discuss the potential role of collider bias in producing such a result. METHODS: The examined cohort included 10,575 Australian adults (4844 men and 5731 women) aged 25-91 years who were recruited for the AusDiab baseline survey in 1999 and followed-up through 2014. The main predictor variable was BMI categorised as normal weight (18.5 to <25 kg/m2), overweight (25 to <30 kg/m2) and obese (≥30 kg/m2), and the outcome of interest was all-cause mortality. Hazard ratios were estimated from Cox proportional hazards regression models in the entire cohort and then in subpopulations with and without diabetes. RESULTS: A total of 1477 deaths occurred during 145,384 person-years (median 14.6 years) of follow-up. Mortality was higher in obese than in normal-weight individuals for the full population (HR 1.18; 95% CI 1.05, 1.32). When an interaction between diabetes status and BMI category was added to the model, there was no evidence of an interaction between BMI and diabetes status (p = 0.92). When participants with and without diabetes were analysed separately, there was no evidence of an association between obesity and mortality in those with diabetes (HR 0.91; 95% CI 0.62, 1.33). CONCLUSIONS/INTERPRETATION: In the entire AusDiab cohort, we found a significantly higher mortality among obese participants as compared with their normal-weight counterparts. We found no difference in the obesity-mortality association between individuals with and without diabetes.

Binge drinking, reflection impulsivity, and unplanned sexual behavior: impaired decision-making in young social drinkers.

BACKGROUND: The repeated pattern of heavy intoxication followed by withdrawal from alcohol (i.e., "binge drinking") has been found to have substantial adverse effects on prefrontal neural systems associated with decision-making and impulse control. Repeated binge drinking has been linked to risky and unplanned sexual behavior; however few studies have examined the role of impulsivity and related cognitive processes in understanding this association. The aim of this study was to examine the relationship between binge drinking, "reflection impulsivity" (deficits in gathering and evaluating information during decision-making), alcohol-related expectancies, and unplanned sexual behavior in a sample of young social drinkers. METHODS: Ninety-two university students completed the alcohol use questionnaire (AUQ) to measure alcohol intake and binge drinking. Two groups (low-binge and high-binge) were generated from the AUQ data. The Information Sampling Task (IST) was used to measure reflection impulsivity; the Alcohol Expectancy Questionnaire (AEQ) for alcohol outcome expectancies; and an unplanned sexual behavior questionnaire, which asked about the number of unplanned sexual events. RESULTS: When compared to the low-binge drinking group, the high-binge drinkers had significantly more unplanned sexual encounters and were impaired on the IST, reflection-impulsivity task. They scored higher on the alcohol expectancy factors of sociability, risk and aggression, negative self-perception, and in particular liquid courage. In a regression analysis, number of unplanned sexual encounters, binge drinking score, and liquid courage were all significantly related. CONCLUSIONS: These results support the role of binge drinking in reduced impulse control and decision-making deficits. The findings indicate that high-binge drinkers demonstrate impairments on an impulse control task similar to that observed in dependent samples and this may be a factor in understanding the negative behavioral consequences associated with excessive alcohol use.

Impact of the COVID-19 pandemic on the use of an inpatient and community palliative care service.

BACKGROUND: The COVID-19 pandemic disrupted the usual provision of healthcare, changing models of care, clinical loads, service provision and patient behaviour. AIMS: This study assesses the impact of COVID-19 on community and inpatient palliative care service provision. METHODS: A retrospective audit and comparison of service use conducted over two defined periods, before and during the COVID-19 pandemic, 2019-2020. FINDINGS: The community palliative care service had a 9% increase in referrals, with a lower proportion of referrals (2.4%) from subacute/palliative care hospitals during the COVID-19 pandemic. Provision of care during the pandemic included less face-to-face contact with patients (24.1% versus 30.2% before), and markedly more contact with patients via videoconference (2.1% versus 0.1% before the pandemic). CONCLUSION: The community specialist palliative care service was busier during the pandemic period, and experienced a shift in mode of care delivery, while the inpatient unit experienced no difference in service use.

Impact of dental state and surgical factors on postoperative neck infection in oral cancer patients.

Postoperative neck infection (PONI) is a known complication of neck dissection. In this study we explored the impact of dental status on the development of PONI, using orthopantomograms to assess edentulism, periodontal health, and caries status. Retrospective analysis was performed for all new oral cancer patients who had neck dissection between January 2008 and January 2020 in a tertiary head and neck centre. PONI risk factors assessed included patient characteristics, dental status, tumour, and surgical factors. Development of PONI was the primary outcome. Edentulous patients had lower risk of PONI (OR 0.06, p = 0.026) compared to those with 21 or more teeth. Periodontitis and dental caries were not statistically significant. Current smokers (OR 2.09, p = 0.044) and free flap reconstruction (OR 5.41, p < 0.001) were also significant predictors for development of PONI. This study highlights the presence of teeth as a potential source of infection post neck dissection and that orthopantomogram assessment may be inadequate to identify at risk patients. Future studies are required on direct clinical assessment of dentition to evaluate the impact of dental optimisation in prevention of PONI.

"Impact of the introduction of the national antimicrobial stewardship standard across Queensland Health hospitals: Ecological observational study exploring patterns of antimicrobial use."

BACKGROUND: Antimicrobial stewardship programs are a critical tool for addressing the rising threat of antimicrobial resistance. AIMS: To determine changes in patterns of antimicrobial use in Queensland public hospitals following introduction of the National Safety and Quality Health Service antimicrobial stewardship standard. METHODS: A retrospective pre/post intervention study was conducted across Queensland public hospitals at the ecological level using Queensland Health's MedTRx database. An interrupted time series analysis was performed using linear regression models to determine rates of antimicrobial use by quarterly aggregated defined daily dose per 1000 patient days, for groups of hospitals stratified by peer group classification. Pre-defined time periods for antimicrobial stewardship program implementation in response to the introduction of the standard were analysed. FINDINGS: In the post intervention period, there was a decrease in overall use of systemic antimicrobials, glycopeptides, carbapenems and fluoroquinolones in principal referral and public acute group A hospitals. A decrease in overall use was also observed for smaller regional and remote public acute group C and D hospitals, however, increases in glycopeptide and fluoroquinolone use were observed. Third generation cephalosporin use was unchanged for all hospital peer groups. The proportion of overall use that was accounted for by narrow spectrum penicillin was low for all facilities, with modest improvements in the post intervention period observed in principal referral facilities only. CONCLUSIONS: These findings add to current knowledge on the effectiveness of legislative quality standards on antimicrobial stewardship at the macro level and highlight gaps to target for future programs.

Does an allied health transdisciplinary stroke assessment save time, improve quality of care, and save costs? Results of a pre-/post- clinical study.

PURPOSE: Demand for stroke services is increasing. To save time and costs, stroke care could be reorganised using a transdisciplinary assessment model embracing overlapping allied health professional skills. The study compares transdisciplinary assessment to discipline-specific allied health assessment on an acute stroke unit, by evaluating assessment time, quality of care, and cost implications. METHOD: The pre-/post- clinical study used non-randomised groups and 3-month follow-up after hospital admission. Patients with confirmed/suspected stroke received usual discipline-specific allied health assessment (pre-implementation phase) or the novel transdisciplinary assessment (post-implementation phase). Staff/student assessment times (primary outcome) and medical record data (secondary outcomes) were collected. Time differences were estimated using multivariable linear regression controlling for confounding factors. Cost minimisation and sensitivity analyses estimated change in hospital resource use. FINDINGS: When the transdisciplinary assessment was used (N = 116), compared to usual assessment (N = 63), the average time saving was 37.6 min (95% CI -47.5, -27.7; p < 0.001) for staff and 62.2 min (95% CI -74.1, -50.3; p < 0.001) for students. The median number of allied health occasions of service reduced from 8 (interquartile range 4-23) to 5 (interquartile range 3-10; p = 0.011). There were no statistically significant or clinically important changes in patient safety, outcomes or stroke guideline adherence. Improved efficiency was associated with an estimated cost saving of $379.45 per patient (probabilistic 95% CI -487.15, -271.48). DISCUSSION AND CONCLUSION: Transdisciplinary stroke assessment has potential for reorganising allied health services to save assessment time and reduce healthcare costs. The transdisciplinary stroke assessment could be considered for implementation in other stroke services.

Emotional well-being and HbA1c following the implementation of the Diabetes Psychosocial Assessment Tool (DPAT) in young adults with type 1 diabetes (T1DM): An observational study.

AIMS: This observational study evaluated the implementation of the Diabetes Psychosocial Assessment Tool (DPAT), assessing emotional well-being of young adults with type 1 diabetes (T1DM) and the clinical congruency between DPAT-recommended and specialist-led referrals. METHODS: Young adults with T1DM attending the clinic completed the DPAT on two occasions. The DPAT includes the PAID (diabetes distress), PHQ-4 (depression/anxiety) and WHO-5 (general well-being), a diabetes health audit and a referral pathway to (allied) health professionals. Demographic and clinical information was retrieved from medical records. Data was analyzed using descriptive statistics and generalized estimating equations. RESULTS: 115 people with T1DM, aged 16-25 years, were included in the analysis. Symptoms of moderate-severe diabetes distress were present in 29 (25%) participants, symptoms of depression/anxiety and impaired well-being in 21 (19%) and 26 (23%) participants, respectively. The odds of depression/anxiety symptoms was lower at the second timepoint compared to the first timepoint (OR 0.55, 95% CI 0.32-0.96, p = 0.03). The odds of moderate-severe diabetes distress tended to be lower. No change was observed in general well-being or HbA1c. There was moderate concordance between DPAT and clinician referrals to psychologists (81%) and dieticians (70%). CONCLUSIONS: Using the DPAT facilitates the conversation about emotional well-being during routine consultation and follow-up.

Coleadership in Maternity Teams, a Randomized, Counterbalanced, Crossover Trial in Simulation.

OBJECTIVE: This study aimed to measure the effect of a coleadership model on team performance compared with singular leadership model in simulated maternity emergencies. METHODS: A randomized, counterbalanced, crossover trial was performed at 2 tertiary maternity hospitals. Teams of obstetric physicians and nurse/midwives responded to 2 simulated maternity emergencies in either a singular or coleadership model. The primary outcome measure was teamwork rated with the Auckland Team Behavior tool. Secondary outcome measures included clinical performance (completion of critical tasks, time to critical intervention, documentation), self-rated teamwork (TEAM tool) and workload. Participants also answered a survey assessing their views on the coleadership model. Paired t tests and mixed-effects linear regression considering team as a random effect were used to estimate the unadjusted and adjusted associations between leadership model and the outcomes of interest. RESULTS: There was no difference between leadership models for the primary outcome of teamwork (5.3 vs. 5.3, P = 0.91). Clinical outcome measures and self-rated teamwork scores were also similar. Team leaders reported higher workload than other team members, but these were not different between the leadership models. Participants viewed coleadership positively despite no measured objective evidence of benefit. CONCLUSIONS: A coleadership model did not lead to a difference in team performance within simulated maternity emergencies. Despite this, participants viewed coleadership positively.

Risk profiles of the preterm behavioral phenotype in children aged 3 to 18 years.

Objective: Characterize the Preterm Behavioral Phenotype in children born preterm by identifying distinct profiles based on patterns of symptomatology or severity of the risk for attention-deficit/hyperactivity disorder, autism spectrum disorder, and anxiety, and determine their associations with child sex, gestational age, and chronological age. Methods: Sample comprised 2,406 children born preterm aged 3-18 years with primary caregiver behavioral ratings on the standardized Strengths and Weaknesses of ADHD Symptoms and Normal Behavior Scale, Social Responsiveness Scale, and Preschool Anxiety Scale or Screen for Child Anxiety and Related Emotional Disorders. Results: Statistical fit indices of latent profile analysis supported a 3-profile model as optimal. Using this model, 75% of children born preterm were identified as having low expression, 20% moderate expression, and 5% high expression profiles of the Preterm Behavioral Phenotype described as co-occurring symptomatology of attention-deficit/hyperactivity disorder, autism spectrum disorder, and anxiety. Male children were more likely than females to be categorized in the moderate expression [Relative Risk Ratio (RRR) = 1.29, 95% CI = 1.05-1.59], and high expression profiles (RRR = 1.77, 95% CI = 1.17-2.66). Children born extremely preterm were more likely than those born moderate/late preterm to be categorized in the moderate expression (RRR = 1.68, 95% CI = 1.30-2.19) and high expression profiles (RRR = 2.06, 95% CI = 1.31-3.25). Finally, those in the school-age (RRR = 1.68, 95% CI = 1.32-2.14; RRR = 1.95, 95% CI = 1.21-3.13), early adolescence (RRR = 1.85, 95% CI = 1.38-2.48; RRR = 2.61, 95% CI = 1.53-4.44) and late adolescence (RRR = 2.09, 95% CI = 1.38-3.19; RRR = 2.28, 95% CI = 1.02-5.08) periods were more likely than those in the preschool period to be categorized in the moderate and high expression profiles, respectively. Conclusion: A quarter of children born preterm were at elevated risk for manifesting symptomatology across all three domains of the Preterm Behavioral Phenotype. Findings emphasize accounting for symptom co-occurrence of this phenotype in neurodevelopmental follow-up and psychosocial interventions to optimize child outcomes.

Chronic villitis of unknown aetiology: an Australian institution's 5-year experience.

Villitis of unknown aetiology (VUE) is a chronic inflammatory condition of the placenta that is associated with increased morbidity and mortality in perinatal medicine. The cause remains elusive and recent studies have explored immune-mediated, infectious and environmental triggers in the pathogenesis of VUE. The objective of this study was to identify the characteristics of VUE diagnoses at Mater Mothers' Hospital over a 5-year period, including any association with seasons, maternal age and histological patterns of the disorder. We retrospectively reviewed reports for placentas sent to Mater Pathology, Brisbane, over 5 years (December 2015 to November 2020). Case level data were retrieved including maternal age, the month of delivery, gestational age, parity, VUE status, recurrence, histopathological subtype and grade. Univariable and multivariable logistic regression was used to estimate the unadjusted and adjusted association between VUE and season, maternal age and trimester at delivery. While more placentas were examined during summer than winter (p=0.005), there was no evidence of seasonal variation in the incidence of VUE over the 5 years (p=0.17). Both univariable and multivariable logistic regression analyses showed that VUE increased with maternal age (p<0.001) and gestational age (9.8% of examined placentas in the third trimester compared to 2.1% in first and second trimesters, p<0.001). Seven of 714 women with VUE (0.98%) had one or more recurrences of the condition within the study period. Of these, VUE was of lower grade in two of the three women who were prescribed aspirin in the subsequent pregnancy. Furthermore, basal VUE without basal myometrial fibres (6.6%), was over-represented among clinically morbidly adherent placentas (MAP) reported in this cohort. Our study does not show evidence of a seasonal variation in VUE incidence. The immune-mediated pathogenesis of VUE is favoured, with our data showing increased rates of the condition as maternal age increases.

Impact of simulation training on decision to delivery interval in cord prolapse.

Background: Umbilical cord prolapse is a rare obstetric emergency requiring rapid coordination of a multidisciplinary team to effect urgent delivery. The decision to delivery interval (DDI) is a marker of quality of teamwork. Multidisciplinary team simulation-based training can be used to improve clinical and teamwork performance. Aim: To assess the DDI for cord prolapse before and after the introduction of simulation-based training at a quaternary maternity unit in Australia. Method: A retrospective, observational cohort study comparing the DDI before and after the introduction of simulation-based training activities. The general linear model was used to estimate the association between DDI and simulation training while adjusting for potential confounders including model of care (public or private) and time of birth (regular or after hours). Results: After the introduction of simulation training, mean DDI decreased by 4.1 min (difference -4.1, 95% CI -6.2 to -1.9), after adjustment for confounding factors. Despite this, there was no difference in selected neonatal outcomes including Apgar score at 5 min and arterial cord pH. Conclusions: The introduction of simulation-based training was associated with a decrease in the DDI in the setting of cord prolapse.

Weight gain in the first week of life and its association with morbidity and mortality in extremely low birthweight (ELBW) infants.

BACKGROUND: Weight gain in the first week of life is indicative of fluid excess in preterm neonates. AIMS: To determine if morbidity and/or mortality of extremely low birthweight (ELBW) infants was lower in those who did not have excess weight gain in the first week of life, compared with those who did. STUDY DESIGN: Retrospective cohort study. SUBJECTS: ELBW infants born from 1st May 2014 - 31st May 2019. EXCLUSIONS: major congenital abnormalities (including hydrops), died within the first 7 days, no recorded weight on day 6, 7 or 8. OUTCOME MEASURES: We compared infants whose weight was greater than birthweight by day 7 and infants whose weight remained at, or below, birthweight by day 7. RESULTS: There were 312 ELBW infants in the study population: 15 (5%) died before discharge from hospital. Holding birthweight and gestational age (GA) constant, the odds of death in neonates with day 7 weight >birthweight was about 3 times the odds of death in neonates with day 7 weight ≤birthweight (adjusted odds ratio 3.18, 95% confidence interval 0.66-15.26, p = 0.15). Neonates with day 7 weight >birthweight were more likely to have had a PDA that required treatment than those with day 7 weight ≤birthweight (65% versus 43% respectively; p <0.001). CONCLUSIONS: ELBW infants who gain weight in the first week of postnatal life, have a greater risk of PDA requiring treatment and may have a higher risk of mortality than infants who lose weight in the first week of life.