Quality of life and functional outcomes 12 months after out-of-hospital cardiac arrest.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a significant global health problem. There has been considerable investment in improving the emergency medical response to OHCA, with associated improvements in survival. However, concern remains that survivors have a poor quality of life. This study describes the quality of life of OHCA survivors at 1-year postarrest in Victoria, Australia. METHODS AND RESULTS: Adult OHCA patients who arrested between 2010 and 2012 were identified from the Victorian Ambulance Cardiac Arrest Registry. Paramedics attended 15 113 OHCA patients of which 46.3% received an attempted resuscitation. Nine hundred and twenty-seven (13.2%) survived to hospital discharge of which 76 (8.2%) died within 12 months. Interviews were conducted with 697 (80.7%) patients or proxies, who were followed-up via telephone interview, including the Glasgow Outcome Scale-Extended, the 12-item short form health survey, and the EuroQol. The majority (55.6%) of respondents had a good recovery via the Glasgow Outcome Scale-Extended≥7 (41.1% if patients who died postdischarge were included and nonrespondents were assumed to have poor recovery). The mean EuroQol index score for respondents was 0.82 (standard deviation, 0.19), which compared favorably with an adjusted population norm of 0.81 (standard deviation, 0.34). The mean 12-item short form Mental Component Summary score for patients was 53.0 (standard deviation, 10.2), whereas the mean Physical Component Summary score was 46.1 (standard deviation, 11.2). CONCLUSIONS: This is the largest published study assessing the quality of life of OHCA survivors. It provides good evidence that many survivors have an acceptable quality of life 12 months postarrest, particularly in comparison with population norms.

Changes in patterns of use of cigarettes and alcohol in women after a first diagnosis of invasive breast cancer: a cohort study of women from Victoria, Australia.

PURPOSE: Smoking and alcohol consumption after breast cancer diagnosis have received little attention. The aim of this study was to describe the change in smoking and alcohol consumption of women in the BUPA Health Foundation Health and Wellbeing After Breast Cancer Study in the first 2 years after diagnosis. METHODS: We documented cigarette and alcohol use at diagnosis in a prospective cohort study of 1,588 Australian women with invasive breast cancer in an enrolment questionnaire and again 2 years later (follow-up questionnaire, FQ1). RESULTS: Twelve percent of participants smoked at diagnosis. Nearly one third of these had quit by FQ1 and of those continuing, 1 in 4 were smoking fewer cigarettes per day. Smoking more at diagnosis was significantly associated with smoking at FQ1.Over 70% of women reported consuming alcohol in each questionnaire. The proportion of women consuming more than four alcoholic drinks per occasion at least weekly dropped between the time of diagnosis and FQ1, although by FQ1, 1 in 12 women still reported this drinking pattern. CONCLUSIONS: Smoking and alcohol consumption are important health issues for women with breast cancer. Health care providers should consider using evidence-based interventions to reduce smoking and drinking in this group.

Psychological well-being in a cohort of women with invasive breast cancer nearly 2 years after diagnosis.

PURPOSE: The aim of this study was to document the psychological well-being of a group of women with invasive breast cancer (BC) on an average of nearly 2 years after their diagnosis. METHODS: Participants were women in the Medical Benefits Fund Australia Limited Foundation Health and Wellbeing after Breast Cancer Study, a cohort study of 1,684 women recruited within 12 months of their diagnosis with invasive BC, who completed their first annual follow-up questionnaire. Psychological well-being was measured using the Psychological General Well Being Index questionnaire (PGWB) in women with BC. RESULTS: The PGWB questionnaire was completed by 1,589 women on an average of 92 weeks after their BC diagnosis, of whom 46 had evidence of active disease. PGWB total scores for all age groups of the BC cohort were lower than community-based norms (p < 0.001 for age groups > or =70, 60-<70, 50-60; p = 0.002 for age group 40-<50 and p = 0.05 for age group <40). PGWB total scores for the BC cohort were positively associated with age (p < 0.001) and living with others (p < 0.01) and inversely associated with active disease (p < 0.001) and education beyond secondary school (p = 0.03). For the domain of anxiety, there was no statistically significant association with living with others but an inverse association with education beyond school. CONCLUSION: A higher level of education may be associated with increased anxiety and lower well-being. Social support is particularly important for women with BC who are known to live alone.

Use of a cancer registry is preferable to a direct-to-community approach for recruitment to a cohort study of wellbeing in women newly diagnosed with invasive breast cancer.

BACKGROUND: Breast cancer (BC) mortality is declining such that the number of survivors of BC in the community is increasing. BC survivors report a range of sequelae from their cancer and its management beyond the period of their immediate treatment. Previous studies to document these have generally been small, clinic-based or commenced years after diagnosis. We have recruited a large cohort of women newly diagnosed with invasive BC from the community who will be followed for five years in order to systematically document the physical, psychological and socio-economic consequences of BC and its treatment. The aim of this manuscript is to describe the issues encountered in the recruitment of this community-based study population. METHODS: Women residing in the southern Australian state of Victoria newly diagnosed with invasive BC were recruited to this cohort study using two approaches: directly from the community using an advertising campaign and contemporaneously using an invitation to participate from the Victorian Cancer Registry (VCR). RESULTS: Over the two and half year recruitment period, 2135 women were recruited and agreed to receive the enrollment questionnaire (EQ). Of these, 1684 women were eligible and completed an EQ, with the majority of participants having been recruited through the VCR (n = 1321). Only 16% of women contacted by the VCR actively refused participation following a letter of invitation and phone follow-up. The age distribution and tumour characteristics of participants are consistent with state-wide data and their residential postcodes include 400 of a possible 699. Recruitment through a direct community awareness program aimed at women with newly diagnosed invasive BC was difficult, labour-intensive and expensive. Barriers to the recruitment process were identified. CONCLUSION: Most of the women in this study were recruited through a state-based cancer registry. Limitations to recruitment occurred because we required questionnaires to be completed within 12 months of diagnosis in a setting where there is several months delay in notification of new cases to the Registry. Characteristics of the cohort suggest that it is generally representative of women in the state of Victoria newly diagnosed with BC.

Are sociodemographic characteristics associated with spatial variation in the incidence of OHCA and bystander CPR rates? A population-based observational study in Victoria, Australia.

BACKGROUND: Rates of out-of-hospital cardiac arrest (OHCA) and bystander cardiopulmonary resuscitation (CPR) have been shown to vary considerably in Victoria. We examined the extent to which this variation could be explained by the sociodemographic and population health characteristics of the region. METHODS: Using the Victorian Ambulance Cardiac Arrest Registry, we extracted OHCA cases occurring between 2011 and 2013. We restricted the calculation of bystander CPR rates to those arrests that were witnessed by a bystander. To estimate the level of variation between Victorian local government areas (LGAs), we used a two-stage modelling approach using random-effects modelling. RESULTS: Between 2011 and 2013, there were 15 830 adult OHCA in Victoria. Incidence rates varied across the state between 41.9 to 104.0 cases/100 000 population. The proportion of the population over 65, socioeconomic status, smoking prevalence and education level were significant predictors of incidence in the multivariable model, explaining 93.9% of the variation in incidence among LGAs. Estimates of bystander CPR rates for bystander witnessed arrests varied from 62.7% to 73.2%. Only population density was a significant predictor of rates in a multivariable model, explaining 73% of the variation in the odds of receiving bystander CPR among LGAs. CONCLUSIONS: Our results show that the regional characteristics which underlie the variation seen in rates of bystander CPR may be region specific and may require study in smaller areas. However, characteristics associated with high incidence and low bystander CPR rates can be identified and will help to target regions and inform local interventions to increase bystander CPR rates.

Effect of diabetes and pre-hospital blood glucose level on survival and recovery after out-of-hospital cardiac arrest.

OBJECTIVE: Diabetes mellitus and blood glucose level (BGL) are emerging as important prognosticators of outcome in critically ill patients. We evaluated the effect of diabetes and pre-hospital BGL on survival to hospital discharge and on 12-month functional recovery after out-of-hospital cardiac arrest (OHCA). DESIGN, SETTING AND PARTICIPANTS: We performed a retrospective analysis of data from a statewide cardiac arrest registry in Victoria, Australia. We included 11 873 adult patients who had had an OHCA of presumed cardiac aetiology between 1 January 2007 and 30 June 2015. Of these, 2438 (20.5%) had documented diabetes. MAIN OUTCOME MEASURES: Survival to hospital discharge and 12-month functional recovery, measured using the Extended Glasgow Outcome Scale. RESULTS: Crude survival to hospital discharge differed among patients with and without diabetes (6.8% v 13.4%; P < 0.001). Diabetes significantly reduced the odds of survival to hospital discharge for patients presenting with a shockable rhythm (adjusted odds ratio [OR], 0.57; 95% CI, 0.38-0.86; P = 0.007) and reduced the odds of good 12-month functional recovery for patients discharged alive (OR, 0.57; 95% CI, 0.35-0.95; P = 0.03). In contrast, a mild-to-moderate elevation of pre-hospital BGL (8.0- 15.9 mmol/L) was present in 695 of 1319 patients with available data (52.7%) and was associated with improved survival and functional recovery outcomes, which were independent of diabetes status. CONCLUSIONS: Diabetes affects at least one in five patients who have had an OHCA and is associated with poorer survival and 12-month functional recovery after OHCA. In comparison, an elevated pre-hospital BGL is common in the peri-arrest period and may be associated with improved outcomes.

Using a cardiac arrest registry to measure the quality of emergency medical service care: decade of findings from the Victorian Ambulance Cardiac Arrest Registry.

BACKGROUND: Although the value of clinical registries has been well recognized in developed countries, their use for measuring the quality of emergency medical service care remains relatively unknown. We report the methodology and findings of a statewide emergency medical service surveillance initiative, which is used to measure the quality of systems of care for patients with out-of-hospital cardiac arrest. METHODS AND RESULTS: Between July 1, 2002, and June 30, 2012, data for adult out-of-hospital cardiac arrest cases of presumed cardiac cause occurring in the Australian Southeastern state of Victoria were extracted from the Victorian Ambulance Cardiac Arrest Registry. Regional and temporal trends in bystander cardiopulmonary resuscitation, event survival, and survival to hospital discharge were analyzed using logistic regression and multilevel modeling. A total of 32,097 out-of-hospital cardiac arrest cases were identified, of whom 14,083 (43.9%) received treatment by the emergency medical service. The risk-adjusted odds of receiving bystander cardiopulmonary resuscitation (odds ratio [OR], 2.96; 95% confidence interval, 2.62-3.33), event survival (OR, 1.55; 95% confidence interval, 1.30-1.85), and survival to hospital discharge (OR, 2.81; 95% confidence interval, 2.07-3.82) were significantly improved by 2011 to 2012 compared with baseline. Significant variation in rates of bystander cardiopulmonary resuscitation and survival were observed across regions, with arrests in rural regions less likely to survive to hospital discharge. The median OR for interhospital variability in survival to hospital discharge outcome was 70% (median OR, 1.70). CONCLUSIONS: Between 2002 and 2012, there have been significant improvements in bystander cardiopulmonary resuscitation and survival outcome for out-of-hospital cardiac arrest patients in Victoria, Australia. However, regional survival disparities and interhospital variability in outcomes pose significant challenges for future improvements in care.

Regions of High Out-Of-Hospital Cardiac Arrest Incidence and Low Bystander CPR Rates in Victoria, Australia.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains a major public health issue and research has shown that large regional variation in outcomes exists. Of the interventions associated with survival, the provision of bystander CPR is one of the most important modifiable factors. The aim of this study is to identify census areas with high incidence of OHCA and low rates of bystander CPR in Victoria, Australia. METHODS: We conducted an observational study using prospectively collected population-based OHCA data from the state of Victoria in Australia. Using ArcGIS (ArcMap 10.0), we linked the location of the arrest using the dispatch coordinates (longitude and latitude) to Victorian Local Government Areas (LGAs). We used Bayesian hierarchical models with random effects on each LGA to provide shrunken estimates of the rates of bystander CPR and the incidence rates. RESULTS: Over the study period there were 31,019 adult OHCA attended, of which 21,436 (69.1%) cases were of presumed cardiac etiology. Significant variation in the incidence of OHCA among LGAs was observed. There was a 3 fold difference in the incidence rate between the lowest and highest LGAs, ranging from 38.5 to 115.1 cases per 100,000 person-years. The overall rate of bystander CPR for bystander witnessed OHCAs was 62.4%, with the rate increasing from 56.4% in 2008-2010 to 68.6% in 2010-2013. There was a 25.1% absolute difference in bystander CPR rates between the highest and lowest LGAs. CONCLUSION: Significant regional variation in OHCA incidence and bystander CPR rates exists throughout Victoria. Regions with high incidence and low bystander CPR participation can be identified and would make suitable targets for interventions to improve CPR participation rates.

CD151 protein expression predicts the clinical outcome of low-grade primary prostate cancer better than histologic grading: a new prognostic indicator?

OBJECTIVE: CD151 is the first member of the tetraspanin family to be associated as a promoter of human tumor metastasis. However, its biological function and expression phenotype among different tumors has not been well investigated. METHOD: Tissue specimens from 76 primary prostate cancers and 30 benign prostate hyperplasia (BPH) controls were obtained from the Department of Anatomical Pathology at the Austin and Repatriation Medical Centre (now Austin Health) from 1984 to 1993. We used quantitative immunohistochemical analysis to measure CD151 protein expression. Analyses of differences among BPH and prostate cancer groups were done with one-way ANOVA and Newman-Keuls test. The Kaplan-Meier method and the log-rank test were used to estimate the overall survival. RESULTS: CD151 expression was found to be significantly higher in prostate cancer specimens compared with BPH specimens (P < 0.001). Poorly differentiated cancers expressed the strongest staining, whereas well-differentiated cancers expressed the weakest staining for CD151 (P < 0.001). The overall survival rate for cases in which CD151 expression was reduced was significantly higher than for cases in which CD151 expression was increased (P = 0.039) especially in well and moderately differentiated cancers (P = 0.014). This effect was independent of the patients' age or preoperative prostate-specific antigen values and superior in the predictive ability of the Gleason score. CONCLUSIONS: CD151 has an increasing expression pattern in prostate cancer progression, and higher levels of CD151 are associated with poorer prognosis. CD151 had better predicting value for the clinical outcome of prostate cancer patients than does the traditional histologic grading method (Gleason grading).

Toward an understanding of the molecular genetics of prostate cancer progression.

The study of the disease process of prostate cancer has revealed, over many years, numerous chromosomal and genetic alterations associated with the development and progression of this cancer. Although there is much information relating to prostate cancer at the molecular level, little is known as to how these alterations relate to each other. Also, a link between prostate cancer and its likely precursor lesions, such as prostatic intraepithelial neoplasia and atypical adenomatous hyperplasia, is not well established. This review aims to summarize current knowledge of the genetics of prostate cancer and its precursor lesions, with particular mention of the relatively new class of genes involved in the acquisition of the metastatic phenotype, the metastasis suppressor genes.

Exploring which patients without return of spontaneous circulation following ventricular fibrillation out-of-hospital cardiac arrest should be transported to hospital?

BACKGROUND: Currently many emergency medical services (EMS) that provide advanced cardiac life support (ACLS) at scene do not routinely transport out-of-hospital cardiac arrest (OHCA) patients without sustained return of spontaneous circulation (ROSC). This is due to logistical difficulties and historical poor outcomes. However, new technology for mechanical chest compression has made transport to hospital safer and extracorporeal membrane oxygenation during cardiopulmonary resuscitation (ECPR) enabling further intervention, may result in ROSC. We aimed to explore the characteristics and outcomes of patients with OHCA who were transported to hospital with ongoing CPR in the absence of ROSC, who might benefit from this new technology. METHODS AND RESULTS: The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for adult OHCA with an initial shockable rhythm between 2003 and 2012. There were 5593 OHCA meeting inclusion criteria. Analysis was performed on 3095 (55%) of patients who did not achieve sustained ROSC in the field. Of these only 589 (20%) had ongoing CPR to hospital. There was a significant decline in rates of transport over the study period. Predictors of transport with ongoing CPR included younger patients, decreased time to first shock and intermittent ROSC prior to transport. Survival to hospital discharge occurred in 52 (9%) of patients who had ongoing CPR to hospital. CONCLUSION: In an EMS that provides ACLS at scene, patients without ROSC in the field who receive CPR to hospital have poor outcomes. Developing a system which provides safe transport with ongoing CPR to a hospital that provides ECPR, should be considered.

The relationship between hormone therapy use at the time of diagnosis of breast cancer and tumor characteristics.

Exposure to postmenopausal hormone therapy (HT) may affect the stage, histological type, and hormone receptor (HR) status of invasive breast cancer at the time of diagnosis. One thousand six hundred eighty-four women with newly diagnosed first invasive breast cancer were recruited to the "MBF Foundation Health and Wellbeing after Breast Cancer Study." Women using systemic HT estrogen (E) or E combined with progesterone (P) at the time of diagnosis of breast cancer were compared with those not using HT. Breast cancer tumor data were obtained from the Victorian Cancer Registry. Regression analysis was used to determine the associations between HT use or not at the time of diagnosis and tumor histology (ductal vs lobular), stage (I vs II, III, IV), HR status (ER+ or PR+ or both vs ER- or PR-). Of 1,377 women included in the analysis, 226 (16%) were using HT at the time of diagnosis. Of HT users, 20.4% had lobular breast cancer, 50% were stage I, and 85.8% had HR-positive tumors. Of non-users, 13.6% had lobular breast cancer, 48.2% were stage I, and 82.4% had HR-positive tumors. Use of systemic HT was associated with increased odds of having lobular compared with ductal breast cancer (OR = 1.75, 95% CI = 1.14-2.69, p = 0.01). There were no associations between HT use and either breast cancer stage or HR status. Women using systemic HT at the time of diagnosis were more likely to have lobular rather than ductal breast cancer compared with women not on HT.

Use of complementary and alternative therapy by women in the first 2 years after diagnosis and treatment of invasive breast cancer.

OBJECTIVE: Our aim was to document patterns of consultation with alternative practitioners, use of complementary and alternative medicine (CAM) commonly used to alleviate menopausal symptoms, and lifestyle changes made by women in the first 2 years after their diagnosis with invasive breast cancer. METHODS: A total of 1,588 women in the MBF Foundation Health and Wellbeing After Breast Cancer Study completed both the enrollment questionnaire and the first follow-up questionnaire (FQ1), on average, 41 and 92 weeks after diagnosis, respectively. The Menopause Quality of Life Questionnaire and the Psychological General Wellbeing Index were included in the FQ1. Logistic regression analysis was used to examine characteristics associated with consulting a CAM practitioner or using CAMs. RESULTS: At the time of completion of the FQ1, 16.4% of women had consulted a CAM practitioner and 10.6% reported using at least one CAM commonly used to alleviate menopausal symptoms. Women who consulted a CAM practitioner and women who were using at least one CAM at the time of completion of the FQ1 were, on average, younger and more educated and had a higher Menopause Quality of Life Questionnaire score than did women who did not. Of the women, 33.6% reported having made a dietary change, and the most common lifestyle change was an increase in physical activity, which was reported by 29.0% of women. CONCLUSIONS: The frequency of use of CAMs in common usage for menopausal symptoms by women with breast cancer was lower than anticipated, increased with time from diagnosis, and is associated with more severe menopausal symptoms.

Lack of knowledge of hormone receptor status and use of endocrine therapy in invasive breast cancer.

OBJECTIVE: The aim of this study was to investigate the level of understanding in women with newly diagnosed invasive breast cancer of the key clinical features of their disease that are important determinants in treatment decision making. METHODS: The 1684 women aged between 26 and 88 years at diagnosis enrolled in a 5-year cohort study were asked by questionnaire about their estrogen receptor (ER) and progesterone receptor (PR) status and about their past or current treatment with adjuvant endocrine therapy. Information was linked with their ER and PR status determined from the histopathology report. Logistic regression analysis was used to explore the relationship between age and education status and the likelihood of being able to correctly report hormone receptor status, as well as the relationship between the likelihood of receiving adjuvant endocrine therapy and knowledge of hormone receptor status in women who were ER or PR positive. RESULTS: Not being able to correctly report hormone receptor status was associated with being older and having a lower level of education. Of women who were ER positive or PR positive or both and were at least 40 weeks from diagnosis, having received some form of endocrine therapy was significantly associated with self-identification as being ER or PR positive (OR=1.82, 95% CI 1.24-2.68, p=0.002), even when age was taken into account. CONCLUSIONS: That self-knowledge of hormone receptor status was independently associated with likelihood of receiving endocrine therapy suggests that the methods of helping women understand the nature of their breast cancer are worthy of review.

The relationship between knowledge of family history and cancer characteristics at diagnosis in women newly-diagnosed with invasive breast cancer.

AIM: To document the prevalence of family history of breast cancer (BC) amongst women newly-diagnosed with invasive BC and to explore the relationship between family history and cancer size and stage. METHODS: A cross-sectional analysis was conducted on baseline questionnaire data from a cohort study of 1,684 women diagnosed with invasive BC within the previous 12 months and recruited between 2004 and 2006 in Victoria, Australia. RESULTS: Women with affected first degree relative(s) were more likely to have a smaller BC (odds ratio for

A pragmatic approach to the classification of menopausal status for community-based research.

OBJECTIVE: The aim of this article was to describe a pragmatic approach to the menopausal status classification of clinical research study participants that allows for women who have gynecological circumstances that mask their natural menstrual pattern. DESIGN: We demonstrate the application of an algorithm for the Health and Wellbeing After Breast Cancer study based on self-reported menstrual cycle pattern, gynecological history, presence or absence of vasomotor symptoms, and systemic hormone use to classify women with newly diagnosed breast cancer as premenopausal, perimenopausal, or postmenopausal for research purposes. RESULTS: Within 12 months of their breast cancer diagnosis, 1,684 participants, mean +/- SD age 57.4 +/- 11.9 years, completed a comprehensive women's health questionnaire. Menopausal status in 71.8% of the women was classified by reported bilateral oophorectomy, age, greater than 12 months of amenorrhea, or regular menstrual cycles and absence of symptoms. Status in the remainder was classified by progression through the decision tree. CONCLUSIONS: The Health and Wellbeing After Breast Cancer study menopausal classification algorithm is a useful tool for research involving female participants that allows for the classification of women who have had a hysterectomy and/or use systemic hormonal contraception or hormone therapy.

KAI1/CD82 protein expression in primary prostate cancer and in BPH associated with cancer.

Current prognostic methods in primary prostate cancer cannot accurately identify patients with clinically significant disease at highest risk of developing metastases. This study examined KAI1/CD82 metastasis suppressor expression by quantitative immunohistochemical analysis of benign prostatic hyperplasia (BPH) and prostate cancer specimens. Altogether, prostate cancers exhibited significant KAI1 overexpression compared to BPH not associated with cancer (P = 0.022). Increased KAI1 expression in well and moderately differentiated cancers, above levels seen in BPH, with decreased expression in poorly differentiated cancers was observed. Interestingly, KAI1 expression in BPH associated with cancers was significantly higher than in BPH not associated with cancer (P = 0.009). Thus, KAI1 overexpression may restrain onset and early stage prostate cancer development, whilst its loss may predispose the patient to more aggressive cancer behaviour. Altered KAI1 expression in prostate cancers and BPH associated with cancer may have important diagnostic roles.