Initial group dietary education compared to individual education in gestational diabetes mellitus management: Do outcomes differ?

AIMS: To assess the effectiveness of Initial Group versus Initial Individual GDM dietary education in terms of insulin requirements and pregnancy outcomes. METHODS: A retrospective audit of clinical data was conducted where English speaking women who received initial education in a group setting (01-2-2012 to 01-2-2014) (Group), were compared to women who received initial individual education with a dietitian (1-2-2010 to 31-1-2012) (Individual), all followed by one individual dietitian appointment. The same dietary information was provided in both settings. Data collected included: attendance rates, insulin requirements, maternal weight gain, and rates of adverse birth outcomes. Data were compared by t-test or Chi-squared test. Multivariable logistic regression analysis was conducted to determine independent predictors of insulin therapy. RESULTS: Of 743 women; (362 Group and 381 Individual), Group women had a lower HbA1c at GDM diagnosis 5.3 ±â€¯0.6% versus 5.5 ±â€¯0.5% (34 ±â€¯6.6 mmol/mol versus 37 ±â€¯5.5 mmol/mol p < 0.0001). There were no other differences in baseline characteristics. More Group women required insulin (42.0% versus 34.6%, p = 0.048). Group education was found to be an independent predictor of insulin therapy (OR = 1.9 [1.29, 2.75] p < 0.001). CONCLUSIONS: Despite adjusting for all known potential confounders, unlike Individual education, Group education remained a significant predictor of insulin therapy (but resulted in similar therapeutic and pregnancy outcomes to Individual education).

A feasibility study using geographic access to general practices and routinely collected data in public health and health services research.

BACKGROUND: Advances in geographic information systems (GIS) and increased availability of routinely collected data have the potential to contribute to public health and health services research. The aim of this feasibility study was to explore the use of GIS to measure access to general practices and its relationship to selected antenatal behaviours. METHODS: We obtained the Perinatal Data Collection, 2004-2008, for South Western Sydney Local Health District from the New South Wales Ministry of Health. Using a GIS, we generated circular and polygon-based 1 km and 2 km road network buffers from a maternal residential address and then calculated the number of general practices within those buffers (density measures). Distances to general practices from maternal residences were also calculated in the GIS as another measure of geographic access to general practices (proximity measures). We used generalised estimating equations logistic regression to examine associations between access to general practices, and smoking during pregnancy and late first antenatal visit. RESULTS: The numbers of general practices within circular buffers were significantly greater than within polygon-based road network buffers. The average distance to the five closest general practices from a mother's residence was 2.3 km ± 3.0 km (median 1.4 km, range 0.05 km to 40.0 km). For two of the five measures of access, a higher number of general practices was associated with increased risk for late first antenatal visit. However, the associations were weak, with odds ratios very close to unity. Choice of metrics of geographic access to general practices did not alter the associations with smoking during pregnancy or late first antenatal visit. CONCLUSION: GIS can be used to quantify measures of geographic access to health services for public health and health services research. Geographic access to general practices was generally not associated with smoking during pregnancy or late first antenatal visit. GIS and routinely collected health data can be used to answer novel questions in public health and health services research.

Trends in knee arthroscopy and subsequent arthroplasty in an Australian population: a retrospective cohort study.

BACKGROUND: Knee arthroscopy is a common procedure in orthopaedic surgery. In recent times the efficacy of this procedure has been questioned with a number of randomized controlled trials demonstrating a lack of effect in the treatment of osteoarthritis. Consequently, a number of trend studies have been conducted, exploring rates of knee arthroscopy and subsequent conversion to Total Knee Arthroplasty (TKA) with varying results. Progression to TKA is seen as an indicator of lack of effect of primary knee arthroscopy. The aim of this paper is to measure overall rates of knee arthroscopy and the proportion of these patients that undergo subsequent total knee arthroplasty (TKA) within 24 months, and to measure trends over time in an Australian population. METHODS: We conducted a retrospective cohort study of all adults undergoing a knee arthroscopy and TKA in all hospitals in New South Wales (NSW), Australia between 2000 and 2008. Datasets obtained from the Centre for Health Record Linkage (CHeReL) were analysed using negative binomial regression. Admission rates for knee arthroscopy were determined by year, age, gender and hospital status (public versus private) and readmission for TKA within 24 months was calculated. RESULTS: There was no significant change in the overall rate of knee arthroscopy between 2000 and 2008 (-0.68%, 95% CI: -2.80 to 1.49). The rates declined in public hospitals (-1.25%, 95% CI: -2.39 to -0.10) and remained relatively steady in private hospitals (0.42%, 95% CI: -1.43 to 0.60). The proportion of patients 65 years or over undergoing TKA within 24 months of knee arthroscopy was 21.5%. After adjusting for age and gender, there was a significant decline in rates of TKA within 24 months of knee arthroscopy for all patients (-1.70%, 95% CI:-3.13 to -0.24), patients admitted to private hospitals (-2.65%, 95% CI: -4.06 to -1.23) and patients aged ≥65 years (-3.12%, 95% CI: -5.02 to -1.18). CONCLUSIONS: Rates of knee arthroscopy are not increasing, and the proportion of patients requiring a TKA within 24 months of a knee replacement is decreasing in the age group most likely to have degenerative changes in the knee.

Predictors of neck pain after motor vehicle collisions: a prospective survey.

PURPOSE: To identify possible predictors (psychosocial) of neck pain in patients with acute injuries following motor vehicle trauma. METHODS: 221 male and 85 female patients aged 18 to 85 (mean, 38) years who had acute fractures of the humerus, radius, ulna, pelvis, femur, patella, tibia, talus or calcaneus following motor vehicle trauma were prospectively recruited. No patient sustained a cervical spine injury. Patients sustaining minor trauma were excluded. As putative predictors of neck pain, data relating to demographics, injury, socio-economic status, and compensation were collected at the time of presentation and at month 6. Neck pain was measured by adapting the bodily pain questions from the SF-36 general health survey. Simple unadjusted and multiple regression analyses were conducted. RESULTS; 232 (76%) of the 306 patients completed the 6-month questionnaire. In multiple regression analysis, neck pain at 6 months was significantly associated with female gender, having a primary level of education only, and use of a lawyer. CONCLUSION: Adversarial legal and compensation involvement may attribute to the development and continuation of neck pain after motor vehicle trauma.

Feasibility, acceptability and impact of a telephone support service initiated in primary medical care to help Arabic smokers quit.

Evidence-based tobacco control in ethnic minorities is compromised by the near absence of rigorous testing of interventions in either prevention or cessation. This randomised controlled trial was designed to evaluate the feasibility, acceptability and impact of a culturally specific cessation intervention delivered in the context of primary medical care in the most culturally diverse region of New South Wales. Adult Arabic smokers were recruited from practices of 29 general practitioners (GPs) in south-west Sydney and randomly allocated to usual care (n=194) or referred to six sessions of smoking cessation telephone support delivered by bilingual psychologists (n=213). Although 62.2% of participants indicated that telephone support would benefit Arabic smokers, there were no significant differences at 6 or 12 months between intervention and control groups in point prevalence abstinence rates (11.7% vs 12.9%, P=0.83; 8.4% vs 11.3%, P=0.68, respectively) or the mean shift in stage-of-change towards intention to quit. As participants and GPs found telephone support acceptable, we also discuss redesign and the unfulfilled obligation to expand the evidence base in tobacco control from which the ethnic majority already benefits.

Smoking patterns and readiness to quit--a study of the Australian Arabic community.

BACKGROUND: Smoking cessation interventions have typically focused on majority populations who, in Australia, are English speaking. There has been an overall decline in the prevalence of smoking in the Australian community. However, there remains a relative paucity of useful information about tobacco use and the effectiveness of tobacco interventions among specific ethnic minorities. OBJECTIVE: To determine associations of tobacco use and tobacco control indicators for Arabic speakers seen in the Australian general practice setting. METHODS: A cross sectional study in a consecutive sample of Arabic patients (n=1371) attending the practices of 29 Arabic speaking general practitioners in Sydney, New South Wales. RESULTS: Twenty-nine (53.7%) of 54 eligible Arabic speaking GPs in southwest Sydney participated in this study. Of 1371 patients seen, 29.7% were smokers. Smokers were more likely to report poorer health (chi2=21.7, df=1, p<0.001); 35.7% reported high nicotine dependence. Dependence was more in men (chi2=11.7, df=1, p<001) and those who reported poorer health (chi2=4.9, df=1, p<0.03); 35.9% had attempted to quit in the previous year; 17% were in preparation stage of change; 42.7% recalled quit advice. Poorer self reported health status (AOR=2.13, 95% CI: 1.14-3.97, p=0.017) and unemployment (AOR=1.69, 95% CI: 1.51-4.90, p=0.033) were independent predictors of advice from a health professional, most often a GP (71%). CONCLUSION: Our study confirms previous reports that the proportion of self reported current smokers among the Arabic community is higher than for the Anglo-European majority. There is a need for ethno specific campaigns in tobacco control.

Predictors of patient and surgeon satisfaction after orthopaedic trauma.

INTRODUCTION: Patient satisfaction has only recently gained attention as an outcome measure in orthopaedics, where it has been reported for joint replacement surgery. Little has been published regarding predictors of patient satisfaction in orthopaedic trauma. This study aims to explore the predictors of patient satisfaction, and of surgeon satisfaction, after orthopaedic trauma. MATERIALS AND METHODS: Adult patients admitted to hospital with fractures after motor vehicle trauma were surveyed on admission, and at six months. Demographic, injury, socio-economic and compensation-related factors were measured. The two outcomes were satisfaction with progress of the injury, and satisfaction with recovery. The treating surgeons were also surveyed at six months to determine surgeon satisfaction with progress, and recovery (using the same questions), and the presence or absence of fracture union and any complications. Multivariate analysis was used to determine significant predictors of satisfaction for both groups, and satisfaction rates were compared between surgeons and patients. RESULTS: Of 306 patients recruited, 232 (75.8%) returned completed questionnaires, but only 141 (46.1%) surgeons responded. Patients rated their satisfaction with progress and recovery as 74.6% and 44.4%, respectively, whereas surgeon-rated satisfaction with progress and recovery was significantly higher, at 88.0% and 66.7%, respectively (p<0.0001). Significant predictors of patient dissatisfaction were: blaming others for the injury, being female, and using a lawyer. Patient-rated satisfaction was not significantly associated with objective injury or treatment factors. The only significant predictor of surgeon dissatisfaction was fracture non-union. CONCLUSIONS: Orthopaedic surgeons overestimated the progress of the injury and the level of recovery compared to patients' own ratings. Surgeons' ratings were influenced by objective, treatment-related factors, whereas patients' ratings were not. Measures of outcome commonly used by orthopaedic surgeons, such as fracture union, do not predict patient satisfaction.

Predictors of post-traumatic stress disorder following major trauma.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a common sequel to physical trauma, but there is disagreement regarding the predictors of this condition. This study aims to examine the role of physical, psychosocial and compensation-related factors in the development of PTSD following major trauma. METHODS: Participants were consecutive adult patients presenting to one major trauma centre with major trauma (Injury Severity Score 16 or higher). Baseline characteristics and clinical data were obtained from the hospital trauma database. The presence of PTSD (as measured by the PTSD Checklist, civilian version) and additional data were obtained from a questionnaire mailed to patients between 1 and 6 years after the injury. Multiple linear regression was used to identify significant independent associations with PTSD. RESULTS: Among 355 patients (61.0% response fraction), 129 (36.3%, 95% confidence interval 43.2-53.2%) were classed as having PTSD. Symptoms of PTSD were not significantly related to measures of injury severity, the time since the injury, education level, household income or employment status at the time of injury. PTSD was significantly associated with younger age (P < 0.0001), the presence of chronic illnesses (P < 0.0001), unemployment at the time of follow up (P < 0.0001), use of a lawyer (P < 0.0001), blaming others for the injury (P = 0.003) and having an unsettled compensation claim (P = 0.007). CONCLUSION: Post-traumatic stress disorder after major trauma was not related to measures of injury severity, but was related to other factors, such as blaming others for the accident and the processes involved in claiming compensation.

Direct tumor invasion in colon cancer: correlation with tumor spread and survival.

PURPOSE: This study examined the correlation between depth of local invasion in colon cancer and tumor spread and patient survival. METHODS: A cohort of 796 patients with a complete set of TNM staging information following an elective resection for colon cancer was selected. The rates of lymph node and distant metastasis, tumor differentiation, and extramural venous invasion for different tumor (T) categories were compared. The effects of initial tumor (T) category on overall patient survival were studied. RESULTS: The depth of local tumor invasion correlated strongly with nodal involvement (P = 0.0001), rates of extramural venous invasion (P = 0.0002), poor differentiation (P = 0.0001), and distant metastasis (P = 0.0001). Fifty-seven percent of the patients remained lymph node-negative and distant metastasis-negative irrespective of their depth of tumor invasion had no impact on overall survival (P = 0.49). For patients with lymph node or distant metastasis (43 percent), depth of tumor invasion had significant impact on overall survival (P = 0.001). Thirteen percent of T3N1, 33 percent of T3N2, 40 percent of T4N1, and 68.percent of T4N2 cases had distant metastasis at presentation. CONCLUSION: Two types of colon cancer were observed: locally active and tendency to metastasize. For the latter, overall mortality and the risk of metastasis increased with depth of tumor invasion.

Tumor pathology and long-term survival in emergency colorectal cancer.

PURPOSE: Patients who have an emergency operation for colorectal cancer have poorer long-term survival outcomes compared with elective patients. This study was designed to define the role of tumor pathology as a basis for the differences in survival outcomes. METHODS: There were 1,537 elective and 286 emergency patients who had an operation for bowel cancer from 1997 to 2003. Tumor pathology and survival data collected prospectively for these patients were compared by modes of presentation. RESULTS: Excluding 30-day mortality, emergency patients as a whole had a five-year all-cause survival rate of 39.2 percent compared with 64.7 percent for elective patients P<0.0001 they also had more advanced Dukes C and D tumors (P<0.0001). The rates of early T1 and T2 cancers were 4.7 percent for the emergency and 25 percent for the elective group. Emergency cases had more lymph node-positive patients and N2 patients (57.1 vs. 41.8 percent and 26.6 vs. 15.9 percent, respectively; P<0.0001). Curatively resected emergency colon patients again had more advanced Dukes staged tumors (P<0.0001) with a five-year survival rate of 51.6 percent compared with 75.6 percent for elective patients P<0.0001. On stage-for-stage analysis, the survival rates for curatively resected Dukes B and C colon cancers remained worse for emergency patients (P=0.003 and P=0.0002, respectively). Both emergency Dukes B and C groups had more T4 cases (21.5 vs. 10.6 percent; P=0.017 and 26.4 vs. 15 percent; P=0.016, respectively). CONCLUSION: Advanced tumor pathology is a basis for poor long-term survival in emergency colorectal cancers.

Physical and Psychosocial Factors Associated with Neck Pain after Major Accidental Trauma.

Neck pain after physical trauma is common; but previous research regarding the role of psychological and physical predictors for neck pain is inconsistent. A retrospective survey of consecutive patients presenting to a metropolitan trauma centre with major accidental trauma was performed between 1 and 6 years post injury. Possible predictor variables (demographic, injury severity, and psychosocial factors) were determined from the hospital trauma registry and the questionnaire. The main outcome was a combined score of neck pain severity and functional limitation. Multivariate logistic regression was performed to develop a predictive model for neck pain. A multivariate analysis of 355 patients showed that neck pain was not significantly associated with measures of injury severity. Neck pain was significantly more likely to be severe in patients with a cervical spine fracture, with pre-existing chronic illnesses, those with post-traumatic stress disorder (PTSD) at the time of follow up, those who had retained the services of a lawyer regarding the injury, and those with lower education levels. Psychosocial factors are important predictors of neck pain after major physical trauma. These findings do not support models for post-traumatic neck pain that are restricted to physical factors.

Socio-economic status and patterns of care in lung cancer.

OBJECTIVE: This retrospective study aims to explore the associations between socio-economic factors and lung cancer management and outcomes in the Australian setting. METHODS: The study population consisted of patients who were living in the Northern Sydney Area Health Service (NSAHS) or South Western Sydney Area Health Service (SWSAHS) at the time of their lung cancer diagnosis in 1996. Data on patient demographics, tumour characteristics, management details, recurrence and survival were collected and compared between the two areas. Socio-economic status indicators of the two Area Health Services were obtained from the Australian Bureau of Statistics. RESULTS: There were 270 and 256 new cases of lung cancer identified in NSAHS and SWSAHS respectively. Patients in NSAHS were slightly older and there were more women. Based on the 1996 Census data, the population of NSAHS is more affluent, better educated and more likely to be employed compared with SWSAHS. The stage distributions and performance status of the two areas were similar. The utilisation rates of different treatment modalities in the two areas were similar except for chemotherapy. The five-year overall survival rate was 10.5% in NSAHS and 7.2% in SWSAHS (p=0.08). Comparison based on the SEIFA Index of Relative Socio-economic Disadvantage did not reveal significant differences. CONCLUSION: Patients with lung cancer had similar patterns of care and survival despite differences in socio-economic profiles between the two Area Health Services. IMPLICATION: There seems to be equity of access to lung cancer services between the two Area Health Services.

Part-time consultants in radiation oncology.

The aim of this study was to evaluate the attitudes and experiences of staff towards radiation oncologists who work part-time. A questionnaire was sent to all radiation oncologists, radiation oncology registrars and radiation therapists, and a nursing and clerical representative working in all radiation oncology departments throughout Australia and New Zealand. Of 1242 questionnaires, 446 (35.9%) were returned. Of these, 323 out of 435 respondents (74.2%) supported the concept of a radiation oncologist working part-time. The main barriers to part-time work were inadequate provision of cover, the inability to be contacted when not rostered on, and perceived reduced quality of patient care. The majority of respondents supported part-time employment in radiation oncology. However, the conclusions made from this survey are limited by the poor response rate. For a successful part-time career in radiation oncology, the following points need to be ensured: (i) an equitable pro-rata workload that encompasses both clinical and non-clinical duties; (ii) a clear and well-publicized timetable that is strictly adhered to with special emphasis on completing work prior to non-rostered days; (iii) clear mechanisms in place to deal with patient or other queries on non-rostered days; (iv) a mechanism for being contacted for urgent problems; and (v) good communication between the part-time radiation oncologist, other staff and patients.

A basic treatment equivalent for high-dose-rate gynaecological brachytherapy--a pilot study.

BACKGROUND & PURPOSE: The aims of this pilot study were to assess the factors that were predictive of high-dose-rate (HDR) gynaecological brachytherapy duration and to model them using previously described Basic Treatment Equivalent (BTE) methodology. MATERIALS AND METHODS: This was a prospective single arm pilot study that aimed to enrol 20 patients from two centres. Patient, tumour and treatment factors were recorded. The duration of each component of brachytherapy was recorded. Univariate and bivariate analyses were conducted to identify factors that predicted overall brachytherapy duration. The generalized estimating equations method was used to derive an equation that predicted the duration of brachytherapy. RESULTS: Data were collected for 20 patients who underwent 53 episodes of brachytherapy, either as part of definitive radiotherapy (tandem and ovoids) or post-operatively (vaginal cylinder). Factors that were predictive of overall duration were technique (tandem and ovoids vs vaginal cylinder, P = 0.0007), treatment intention (definitive vs post-operative, P = 0.0001), type of plan (individual vs standard, P = 0.0001), hospital (1 vs 2, P = 0.0001) and body mass index (P = 0.0001). CONCLUSIONS: This study demonstrates the feasibility of examining factors that influence the duration of gynaecological brachytherapy using BTE methodology. To develop a reliable model, a larger multicentre study is needed. Such a model will allow comparisons of efficiency and more accurate assessment of treatment capacity between centres.