Prevalence of frailty and pain in hospitalised cancer patients: implications for older adult care.

A hospital-wide point prevalence study investigated frailty and pain in patients with a cancer-related admission. Modifiable factors associated with frailty in people with cancer were determined through logistic regression. Forty-eight patients (19%) with cancer-related admissions were 2.65 times more likely to be frail and 2.12 more likely to have moderate pain. Frailty and pain were highly prevalent among cancer-related admissions, reinforcing the need for frailty screening and importance of pain assessment for patients with cancer.

Automated CT Perfusion Detection of the Acute Infarct Core in Ischemic Stroke: A Systematic Review and Meta-Analysis.

INTRODUCTION: In patients with acute ischemic stroke, the location and volume of an irreversible infarct core determine prognosis and treatment. We aimed to determine if automated CT perfusion (CTP) is non-inferior to diffusion-weighted imaging (DWI) or fluid-attenuated inversion recovery (FLAIR) in predicting the acute infarct core. METHODS: In this systematic review and meta-analysis, we searched MEDLINE and EMBASE from 1960 to December 2020. Five outcome measures were examined: volumetric difference, volumetric correlation, sensitivity and specificity at the patient level, Dice coefficient, and sensitivity and specificity at the voxel level. A random-effects meta-analysis was performed for volumetric difference and correlation. RESULTS: From 3,986 studies retrieved, 48 studies met our inclusion criteria with 46 studies on anterior circulation, one study on posterior circulation, and one study on lacunar infarct strokes. In anterior circulation stroke, there were no significant mean volumetric differences between CTP and acute DWI (cerebral blood flow [CBF] 0.52 mL, 95% CI [-0.07, 1.11], I2 0.0%; relative CBF [rCBF] 3.01 mL, 95% CI [-0.46, 6.48], I2 82.6%; relative cerebral blood volume [rCBV] -12.84 mL, 95% CI [-38.56, 12.88], I2 96.2%) and between CTP and delayed DWI or FLAIR (rCBF -1.29 mL, 95% CI [-6.49, 3.92], I2 91.8%; rCBV -5.80 mL, 95% CI [-16.20, 4.60], I2 84.2%). Mean correlation between CTP and acute DWI was 0.90 (95% CI [0.80, 0.95], I2 60.0%) for rCBF and 0.84 (95% CI [0.58, 0.94], I2 93.5%) for rCBV. Mean correlation between CTP and delayed DWI or FLAIR was 0.74 (95% CI [0.57, 0.85], I2 94.6%) for rCBF and 0.90 (95% CI [0.69, 0.97], I2 93.1%) for rCBV. Sensitivity and specificity at the patient level were reported by three studies and Dice coefficient by four studies. Statistical analysis could not be performed for sensitivity and specificity at the voxel level. Limited evidence was available for posterior circulation or lacunar infarct strokes. CONCLUSION: Due to significant heterogeneity and insufficient high-quality studies reporting each outcome, there is insufficient evidence to reliably determine the accuracy of CTP prediction of the infarct core compared to DWI or FLAIR.

Long term risk of distant metastasis in women with non-metastatic breast cancer and survival after metastasis detection: a population-based linked health records study.

OBJECTIVES: To estimate the long term risk of distant metastases (DM) for women with initial diagnoses of non-metastatic breast cancer; to estimate breast cancer-specific and overall survival for women with DM. DESIGN: Population-based health record linkage study. SETTING, PARTICIPANTS: Women diagnosed with localised or regional primary breast cancer recorded in the NSW Cancer Registry, 2001-2002. MAJOR OUTCOME MEASURES: Time from breast cancer diagnosis to first DM, time from first DM to death from breast cancer. SECONDARY OUTCOME: time to death from any cause. RESULTS: 6338 women were diagnosed with non-metastatic breast cancer (localised, 3885; regional, 2453; median age, 59 years [IQR, 49-69 years]). DM were recorded (to 30 September 2016) for 1432 women (23%; median age, 62 years [IQR, 51-73 years]). The 14-year cumulative DM incidence was 22.2% (95% CI, 21.1-23.2%; localised disease: 14.3% [95% CI, 13.2-15.4%]; regional disease: 34.7% [95% CI, 32.8-36.6%]). Annual hazard of DM was highest during the second year after breast cancer diagnosis (localised disease: 2.8%; 95% CI, 2.3-3.3%; regional disease: 9.1%; 95% CI, 7.8-10.3%); from year five it was about 1% for those with localised disease, from year seven about 2% for women with regional disease at diagnosis. Five years after diagnosis, the 5-year conditional probability of DM was 4.4% (95% CI, 3.7-5.1%) for women with localised and 10.4% (95% CI, 9.1-12.0%) for those with regional disease at diagnosis. Median breast cancer-specific survival from first DM record date was 28 months (95% CI, 25-31 months); the annual hazard of breast cancer death after the first DM record declined from 36% (95% CI, 33-40%) during the first year to 14% (95% CI, 11-18%) during the fourth year since detection. CONCLUSIONS: DM risk declines with time from diagnosis of non-metastatic breast cancer, and the annual risk of dying from breast cancer declines with time from initial DM detection. These findings can be used to inform patients at follow-up about changes in risk over time since diagnosis and for planning health services.

The impact of bilateral salpingo-oophorectomy on sexuality and quality of life in women with breast cancer.

OBJECTIVE: To compare sexual function and quality of life (QoL) in breast cancer survivors with and without a history of bilateral salpingo-oophorectomy (BSO). METHODS: A cross-sectional study of breast cancer survivors treated at a tertiary referral hospital in Western Australia. The Female Sexual Function Index was used to determine rates of female sexual dysfunction (FSD) and hypoactive sexual desire disorder (HSDD). Participants also completed the Relationship Assessment Scale, Menopause-specific quality of life questionnaire and Short Form Health Survey-36. RESULTS: A total of 427 women were invited to participate: 119 had undergone BSO and 308 were controls with at least one ovary remaining. A total of 172 women participated (overall response rate 40.3%), consisting of 76 women in the BSO group (response rate 63.9%) and 96 women with at least one ovary remaining (response rate 31.2%). There was no difference in FSD between the two groups: 63/76 (82.9%) women who had undergone BSO had FSD compared to 75/96 (78.1%) controls (p = 0.458). No difference in HSDD was observed (p = 0.084) between the BSO group 70/76 (96.0%) and the controls 96/96 (100%). Women who had undergone BSO had lower general health scores compared to the control group (p = 0.034). Both groups had similar energy levels, emotional well-being, pain scores, physical functioning levels and social functioning levels. CONCLUSIONS: In this study, women with prior treatment for breast cancer had high levels of FSD and HSDD, irrespective of whether they had undergone BSO. Both groups reported similar sexual function scores and QoL.

Botulinum toxin type A for facial wrinkles.

BACKGROUND: Botulinum toxin type A (BontA) is the most frequent treatment for facial wrinkles, but its effectiveness and safety have not previously been assessed in a Cochrane Review. OBJECTIVES: To assess the effects of all commercially available botulinum toxin type A products for the treatment of any type of facial wrinkles. SEARCH METHODS: We searched the following databases up to May 2020: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA: We included RCTs with over 50 participants, comparing BontA versus placebo, other types of BontA, or fillers (hyaluronic acid), for treating facial wrinkles in adults. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Primary outcomes were participant assessment of success and major adverse events (AEs) (eyelid ptosis, eyelid sensory disorder, strabismus). Secondary outcomes included physician assessment of success; proportion of participants with at least one AE and duration of treatment effect. We used GRADE to assess the certainty of the evidence for each outcome. MAIN RESULTS: We included 65 RCTs, involving 14,919 randomised participants. Most participants were female, aged 18 to 65 years. All participants were outpatients (private office or day clinic). Study duration was between one week and one year. No studies were assessed as low risk of bias in all domains; the overall risk of bias was unclear for most studies. The most common comparator was placebo (36 studies). An active control was used in 19 studies. There were eight dose-ranging studies of onabotulinumtoxinA, and a small number of studies compared against fillers. Treatment was given in one cycle (54 studies), two cycles (three studies), or three or more cycles (eight studies). The treated regions were glabella (43 studies), crow's feet (seven studies), forehead (two studies), perioral (two studies), full face (one study), or more than two regions (nine studies). Most studies analysed moderate to severe wrinkles; mean duration of treatment was 20 weeks. The following results summarise the main comparisons, based on studies of one treatment cycle for the glabella. AEs were collected over the duration of these studies (over four to 24 weeks). Compared to placebo, onabotulinumtoxinA-20 U probably has a higher success rate when assessed by participants (risk ratio (RR) 19.45, 95% confidence interval (CI) 8.60 to 43.99; 575 participants; 4 studies; moderate-certainty evidence) or physicians (RR 17.10, 95% CI 10.07 to 29.05; 1339 participants; 7 studies; moderate-certainty evidence) at week four. Major AEs are probably higher with onabotulinumtoxinA-20 U (Peto OR 3.62, 95% CI 1.50 to 8.74; 1390 participants; 8 studies; moderate-certainty evidence), but there may be no difference in any AEs (RR 1.14, 95% CI 0.89 to 1.45; 1388 participants; 8 studies; low-certainty evidence). Compared to placebo, abobotulinumtoxinA-50 U has a higher participant-assessed success rate at week four (RR 21.22, 95% CI 7.40 to 60.56; 915 participants; 6 studies; high-certainty evidence); and probably has a higher physician-assessed success rate (RR 14.93, 95% CI 8.09 to 27.55; 1059 participants; 7 studies; moderate-certainty evidence). There are probably more major AEs with abobotulinumtoxinA-50 U (Peto OR 3.36, 95% CI 0.88 to 12.87; 1294 participants; 7 studies; moderate-certainty evidence). Any AE may be more common with abobotulinumtoxinA-50 U (RR 1.25, 95% CI 1.05 to 1.49; 1471 participants; 8 studies; low-certainty evidence). Compared to placebo, incobotulinumtoxinA-20 U probably has a higher participant-assessed success rate at week four (RR 66.57, 95% CI 13.50 to 328.28; 547 participants; 2 studies; moderate-certainty evidence), and physician-assessed success rate (RR 134.62, 95% CI 19.05 to 951.45; 547 participants; 2 studies; moderate-certainty evidence). Major AEs were not observed (547 participants; 2 studies; moderate-certainty evidence). There may be no difference between groups in any AEs (RR 1.17, 95% CI 0.90 to 1.53; 547 participants; 2 studies; low-certainty evidence). AbobotulinumtoxinA-50 U is no different to onabotulinumtoxinA-20 U in participant-assessed success rate (RR 1.00, 95% CI 0.92 to 1.08, 388 participants, 1 study, high-certainty evidence) and physician-assessed success rate (RR 1.01, 95% CI 0.95 to 1.06; 388 participants; 1 study; high-certainty evidence) at week four. Major AEs are probably more likely in the abobotulinumtoxinA-50 U group than the onabotulinumtoxinA-20 U group (Peto OR 2.65, 95% CI 0.77 to 9.09; 433 participants; 1 study; moderate-certainty evidence). There is probably no difference in any AE (RR 1.02, 95% CI 0.67 to 1.54; 492 participants; 2 studies; moderate-certainty evidence). IncobotulinumtoxinA-24 U may be no different to onabotulinumtoxinA-24 U in physician-assessed success rate at week four (RR 1.01, 95% CI 0.96 to 1.05; 381 participants; 1 study; low-certainty evidence) (participant assessment was not measured). One participant reported ptosis with onabotulinumtoxinA, but we are uncertain of the risk of AEs (Peto OR 0.02, 95% CI 0.00 to 1.77; 381 participants; 1 study; very low-certainty evidence). Compared to placebo, daxibotulinumtoxinA-40 U probably has a higher participant-assessed success rate (RR 21.10, 95% CI 11.31 to 39.34; 683 participants; 2 studies; moderate-certainty evidence) and physician-assessed success rate (RR 23.40, 95% CI 12.56 to 43.61; 683 participants; 2 studies; moderate-certainty evidence) at week four. Major AEs were not observed (716 participants; 2 studies; moderate-certainty evidence). There may be an increase in any AE with daxibotulinumtoxinA compared to placebo (RR 2.23, 95% CI 1.46 to 3.40; 716 participants; 2 studies; moderate-certainty evidence). Major AEs reported were mainly ptosis; BontA is also known to carry a risk of strabismus or eyelid sensory disorders. AUTHORS' CONCLUSIONS: BontA treatment reduces wrinkles within four weeks of treatment, but probably increases risk of ptosis. We found several heterogeneous studies (different types or doses of BontA, number of cycles, and different facial regions) hindering meta-analyses. The certainty of the evidence for effectiveness outcomes was high, low or moderate; for AEs, very low to moderate. Future RCTs should compare the most common BontA (onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, daxibotulinumtoxinA, prabotulinumtoxinA) and evaluate long-term outcomes. There is a lack of evidence about the effects of multiple cycles of BontA, frequency of major AEs, duration of effect, efficacy of recently-approved BontA and comparisons with other treatments.

Capecitabine for hormone receptor-positive versus hormone receptor-negative breast cancer.

BACKGROUND: Retrospective analyses suggest that capecitabine may carry superior activity in hormone receptor-positive relative to hormone receptor-negative metastatic breast cancer. This review examined the veracity of that finding and explored whether this differential activity extends to early breast cancer. OBJECTIVES: To assess effects of chemotherapy regimens containing capecitabine compared with regimens not containing capecitabine for women with hormone receptor-positive versus hormone receptor-negative breast cancer across the three major treatment scenarios: neoadjuvant, adjuvant, metastatic. SEARCH METHODS: On 4 June 2019, we searched the Cochrane Breast Cancer Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 5) in the Cochrane Library; MEDLINE; Embase; the World Health Organization International Clinical Trials Registry Platform; and ClinicalTrials.gov. SELECTION CRITERIA: Randomised controlled trials looking at chemotherapy regimens containing capecitabine alone or in combination with other agents versus a control or similar regimen without capecitabine for treatment of breast cancer at any stage. The primary outcome measure for metastatic and adjuvant trials was overall survival (OS), and for neoadjuvant studies pathological complete response (pCR). DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed risk of bias and certainty of evidence using the GRADE approach. Hazard ratios (HRs) were derived for time-to-event outcomes, and odds ratios (ORs) for dichotomous outcomes, and meta-analysis was performed using a fixed-effect model. MAIN RESULTS: We included 26 studies with outcome data by hormone receptor: 12 metastatic studies (n = 4325), 6 neoadjuvant trials (n = 3152), and 8 adjuvant studies (n = 13,457). Capecitabine treatment was added in several different ways across studies. These could be classified as capecitabine alone compared to another treatment, capecitabine substituted for part of the control chemotherapy, and capecitabine added to control chemotherapy. In the metastatic setting, the effect of capecitabine was heterogenous between hormone receptor-positive and -negative tumours. For OS, no difference between capecitabine-containing and non-capecitabine-containing regimens was observed for all participants taken together (HR 1.01, 95% confidence interval (CI) 0.98 to 1.05; 12 studies, 4325 participants; high-certainty evidence), for those with hormone receptor-positive disease (HR 0.93, 95% CI 0.84 to 1.04; 7 studies, 1834 participants; high-certainty evidence), and for those with hormone receptor-negative disease (HR 1.00, 95% CI 0.88 to 1.13; 8 studies, 1577 participants; high-certainty evidence). For progression-free survival (PFS), a small improvement was seen for all people (HR 0.89, 95% CI 0.82 to 0.96; 12 studies, 4325 participants; moderate-certainty evidence). This was largely accounted for by a moderate improvement in PFS for inclusion of capecitabine in hormone receptor-positive cancers (HR 0.82, 95% CI 0.73 to 0.91; 7 studies, 1594 participants; moderate-certainty evidence) compared to no difference in PFS for hormone receptor-negative cancers (HR 0.96, 95% CI 0.83 to 1.10; 7 studies, 1122 participants; moderate-certainty evidence). Quality of life was assessed in five studies; in general there did not seem to be differences in global health scores between the two treatment groups at around two years' follow-up. Neoadjuvant studies were highly variable in design, having been undertaken to test various experimental regimens using pathological complete response (pCR) as a surrogate for disease-free survival (DFS) and OS. Across all patients, capecitabine-containing regimens resulted in little difference in pCR in comparison to non-capecitabine-containing regimens (odds ratio (OR) 1.12, 95% CI 0.94 to 1.33; 6 studies, 3152 participants; high-certainty evidence). By subtype, no difference in pCR was observed for either hormone receptor-positive (OR 1.22, 95% CI 0.76 to 1.95; 4 studies, 964 participants; moderate-certainty evidence) or hormone receptor-negative tumours (OR 1.28, 95% CI 0.61 to 2.66; 4 studies, 646 participants; moderate-certainty evidence). Four studies with 2460 people reported longer-term outcomes: these investigators detected no difference in either DFS (HR 1.02, 95% CI 0.86 to 1.21; high-certainty evidence) or OS (HR 0.97, 95% CI 0.77 to 1.23; high-certainty evidence). In the adjuvant setting, a modest improvement in OS was observed across all participants (HR 0.89, 95% CI 0.81 to 0.98; 8 studies, 13,547 participants; moderate-certainty evidence), and no difference in OS was seen in hormone receptor-positive cancers (HR 0.86, 95% CI 0.68 to 1.09; 3 studies, 3683 participants), whereas OS improved in hormone receptor-negative cancers (HR 0.72, 95% CI 0.59 to 0.89; 5 studies, 3432 participants). No difference in DFS or relapse-free survival (RFS) was observed across all participants (HR 0.93, 95% CI 0.86 to 1.01; 8 studies, 13,457 participants; moderate-certainty evidence). As was observed for OS, no difference in DFS/RFS was seen in hormone receptor-positive cancers (HR 1.03, 95% CI 0.91 to 1.17; 5 studies, 5604 participants; moderate-certainty evidence), and improvements in DFS/RFS with inclusion of capecitabine were observed for hormone receptor-negative cancers (HR 0.74, 95% CI 0.64 to 0.86; 7 studies, 3307 participants; moderate-certainty evidence). Adverse effects were reported across all three scenarios. When grade 3 or 4 febrile neutropenia was considered, no difference was seen for capecitabine compared to non-capecitabine regimens in neoadjuvant studies (OR 1.31, 95% CI 0.97 to 1.77; 4 studies, 2890 participants; moderate-certainty evidence), and a marked reduction was seen for capecitabine in adjuvant studies (OR 0.55, 95% CI 0.47 to 0.64; 5 studies, 8086 participants; moderate-certainty evidence). There was an increase in diarrhoea and hand-foot syndrome in neoadjuvant (diarrhoea: OR 1.95, 95% CI 1.32 to 2.89; 3 studies, 2686 participants; hand-foot syndrome: OR 6.77, 95% CI 4.89 to 9.38; 5 studies, 3021 participants; both moderate-certainty evidence) and adjuvant trials (diarrhoea: OR 2.46, 95% CI 2.01 to 3.01; hand-foot syndrome: OR 13.60, 95% CI 10.65 to 17.37; 8 studies, 11,207 participants; moderate-certainty evidence for both outcomes). AUTHORS' CONCLUSIONS: In summary, a moderate PFS benefit by including capecitabine was seen only in hormone receptor-positive cancers in metastatic studies. No benefit of capecitabine for pCR was noted overall or in hormone receptor subgroups when included in neoadjuvant therapy. In contrast, the addition of capecitabine in the adjuvant setting led to improved outcomes for OS and DFS in hormone receptor-negative cancer. Future studies should stratify by hormone receptor and triple-negative breast cancer (TNBC) status to clarify the differential effects of capecitabine in these subgroups across all treatment scenarios, to optimally guide capecitabine inclusion.

Strength Training in Long-Distance Triathletes: Barriers and Characteristics.

ABSTRACT: Luckin, KM, Badenhorst, CE, Cripps, AJ, Landers, GJ, Merrells, RJ, Bulsara, MK, and Hoyne, GF. Strength training in long-distance triathletes: Barriers and characteristics. J Strength Cond Res 35(2): 495-502, 2021-The purpose of this investigation was to identify perceived and physical barriers toward the completion of concurrent strength training and endurance training in long-distance triathletes. Three hundred ninety long-distance triathletes (224 women, 166 men; age [y]: 39 ± 10) completed a 68-question self-administered, semiquantitative survey that assessed endurance and strength training characteristics, experience in triathlon, and perceived barriers regarding the completion of strength training. Mean training hours per week was 14.92 ± 5.25, with 54.6% reporting participation in strength training. Heavy strength training was the most commonly reported (39.4%), with significantly more men completing this form of strength training (p < 0.001). Results from subjects who did not complete strength training indicated that perceived time constraints (53.1%) in addition to lack of knowledge on exercise progression and form (52.5%) are prominent perceived barriers to strength training completion. Identification of the barriers perceived by long-distance triathletes that prevent them from completing concurrent strength training and endurance training may be useful for coaches, athletes, and sports scientists who seek to incorporate strength training for injury prevention and performance improvement.

Can a Modified Environment Assessment Tool Guide Priorities for Minor Refurbishments at a Residential Aged Care Facility?

This pilot study aimed to examine EVOLVE UK extra care housing tool in an Australian residential aged care minor refurbishment context. The tool's content validity was established with 34 subcategories (I-CVI ≥0.75) and 612 statements (n = 509 I-CVI ≥0.75) relevant. A subsequent audit indicated high concordance (Rho-C = 0.750 to 0.997) within four experts' ratings of the care facility and correlation (Kendall's τ-statistic) between raters ranged from strong (0.5 to 0.9) to very strong (0.9 to 1.0). Lighting was the highest refurbishment element represented (50.54%). Assessment can inform funding, demonstrate standards compliance, and the components of physical environment refurbishments which support resident function.

Excisional treatment comparison for in situ endocervical adenocarcinoma (EXCISE): A phase 2 pilot randomized controlled trial to compare histopathological margin status, specimen size and fragmentation after loop electrosurgical excision procedure and cold knife cone biopsy.

OBJECTIVE: Adenocarcinoma in situ (AIS) of the cervix is a precursor to cervical adenocarcinoma. When AIS is detected by cervical screening an excision biopsy is mandatory to exclude invasion. We aimed to compare margins status, specimen size and fragmentation after loop electrosurgical excision procedure (LEEP) and 'cold knife cone biopsy' (CKC). METHODS: The EXCISE Trial was an investigator-initiated, multicenter, open-label, parallel-group, phase 2, randomized study. Patients were enrolled at seven hospitals in Australia and New Zealand. We randomly assigned women aged ≥18 to ≤45 years with screen detected AIS to LEEP or CKC. Co-primary endpoints were margin status, specimen size and fragmentation. Analysis was by intention-to-treat. RESULTS: Between August 2, 2017 and September 6, 2019, 40 patients were randomly assigned 2:1 to LEEP or CKC. Margin status was evaluable in 36 cases. The proportion of patients with involved margins did not differ between groups. 25 of 26 LEEP and all 14 CKC biopsies were excised as single specimens (p = 1·00). There were no differences in specimen dimensions. Patients in the CKC group had more post-operative complications (64.3% compared to 15.4% for LEEP p = ·00). There were no differences in grade three complications (p = ·65). CONCLUSIONS: LEEP was not associated with a greater likelihood of positive margins, specimen fragmentation or smaller excision compared to CKC when performed according to a standardized protocol. However, the study was not powered to establish non-inferiority of LEEP and a definitive phase 3 trial to compare margin status and rates of treatment failure after LEEP and CKC is warranted.

Incidence of type 1 diabetes in 0 to 14 year olds in Australia from 2002 to 2017.

OBJECTIVE: To determine the incidence of childhood onset type 1 diabetes in Australia from 2002 to 2017, and analyze incidence rate trends by calendar year, sex, and age at diagnosis. RESEARCH DESIGN AND METHODS: Children newly diagnosed with type 1 diabetes aged <15 years between 2002 and 2017 were identified from the National Diabetes Register, estimated to be ~99% complete. Data were obtained for diagnosis year, sex, age, and residential State/Territory at time of diagnosis. Population estimates by year, sex, single year of age, and State/Territory were obtained from the Australian Bureau of Statistics and Poisson regression used to examine incidence and trends by calendar year, sex, and age group at diagnosis. RESULTS: Between 2002 and 2017, there were 16 783 newly diagnosed cases of type 1 diabetes in children aged < 15 years (8684 boys: 8099 girls), giving a mean incidence of 25.0/1 00 000 person years (95%CI: 24.6, 25.4). A sinusoidal pattern in the incidence rate trend was observed with 5-yearly cycles providing the best model fit. No significant difference was observed in boys compared to girls (IRR 0.98 [95%CI: 0.95, 1.01]). Compared to 0 to 4 year olds, the mean incidence was 75% higher in 5 to 9 year olds, and 224% higher in 10 to 14 year olds. A decreasing incidence rate trend was observed in 0 to 4 year old boys and girls. CONCLUSIONS: This study reports updated incidence and incidence rate trends in children and adolescents diagnosed with type 1 diabetes in Australia. A cyclical pattern in incidence trend persists, with an overall decreasing trend observed only in the youngest age group.

A randomized controlled trial of WATAAP to promote physical activity in colorectal and endometrial cancer survivors.

OBJECTIVE: The objective of this study was to ascertain whether wearable technology coupled with action planning was effective in increasing physical activity (PA) in colorectal and endometrial cancer survivors at cardiovascular risk. METHODS: Sixty-eight survivors who had cardiovascular risk factors and were insufficiently active were randomized to intervention and control arms. Intervention participants were given a wearable tracker for 12 weeks, two group sessions, and a support phone call. Participants in the control arm received print materials describing PA guidelines. Assessments at baseline and 12 weeks measured triaxial and uniaxial estimates of moderate-vigorous physical activity (MVPA), sedentary behaviour, blood pressure, and body mass index (BMI). RESULTS: The intervention group significantly increased MVPA by 45 min/wk compared with a reduction of 21 min/wk in the control group. Group by time interactions were significant for minutes of MVPA (F1,126  = 5.14, P = 0.025). For those with diastolic hypertension, there was a significant group by time interaction (F1,66  = 4.89, P = 0.031) with a net reduction of 9.89 mm Hg in the intervention group. CONCLUSIONS: Significant improvements in MVPA were observed following the intervention. The results display promise for the use of pragmatic, low-intensity interventions using wearable technology.

Patient preferences for adjuvant radiotherapy in early breast cancer are strongly influenced by treatment received through random assignment.

OBJECTIVE: TARGIT-A randomised women with early breast cancer to receive external beam radiotherapy (EBRT) or intraoperative radiotherapy (TARGIT-IORT). This study aimed to identify what extra risk of recurrence patients would accept for perceived benefits and risks of different radiotherapy treatments. METHODS: Patient preferences were determined by self-rated trade-off questionnaires in two studies: Stage (1) 209 TARGIT-A participants (TARGIT-IORTn = 108, EBRTn = 101); Stage (2) 123 non-trial patients yet to receive radiotherapy (pre-treatment group), with 85 also surveyed post-radiotherapy. Patients traded-off risks of local recurrence in preference selection between TARGIT-IORT and EBRT. RESULTS: TARGIT-IORT patients were more accepting of IORT than EBRT patients with 60% accepting the highest increased risk presented (4%-6%) compared to 12% of EBRT patients, and 2% not accepting IORT at all compared to 43% of EBRT patients. Pre-treatment patients were more accepting of IORT than post-treatment patients with 23% accepting the highest increased risk presented compared to 15% of post-treatment patients, and 15% not accepting IORT at all compared to 41% of pre-treatment patients. CONCLUSIONS: Breast cancer patients yet to receive radiotherapy accept a higher recurrence risk than the actual risk found in TARGIT-A. Measured patient preferences are highly influenced by experience of treatment received. This finding challenges the validity of post-treatment preference studies.

Incidence of childhood onset type 1 diabetes in Western Australia from 1985 to 2016: Evidence for a plateau.

OBJECTIVE: To determine the incidence of childhood type 1 diabetes mellitus (T1D) in Western Australia from 2011 to 2016, and to examine the temporal trends between 1985 and 2016. METHODS: An observational cohort study was undertaken of all children newly diagnosed with T1D aged 0 to 14 years in Western Australia from 1985 to 2016. Cases were identified from the Western Australian Children's Diabetes Database, a population-based diabetes register previously estimated to be >99% complete. Annual age-standardized and age- and sex-specific incidence rates were calculated and the Joinpoint Regression Program used to identify any significant changes in trends over the study period. RESULTS: A total of 2499 cases were included (1272 boys, 1227 girls). The overall mean annual incidence was 19.1/100 000 person years (95% confidence interval, CI: 18.3-19.8), with no significant difference found between boys and girls. The mean annual incidence of 12.1/100 000 person years (95% CI: 11.1-13.1) in 0 to 4-years was significantly lower than that observed in 5 to 9 (21.6/100 000 [95% CI: 20.2-23.0]) and 10 to 14 (23.5/100 000 [95% CI: 22.1-25.0]) years. Joinpoint regression analysis identified a significant change in the temporal trend occurring in 2003. From 1985 to 2003, the incidence increased on an average of 3.3% per year (95% CI: 1.9-4.7). However, from 2003 to 2016, no significant change in the temporal trend occurred (-0.6% per year [95% CI: -2.4-1.2]). CONCLUSIONS: This study provides evidence for a possible plateauing in the incidence of childhood T1D in Western Australia, following a peak in 2003. Ongoing monitoring of the incidence will be essential to determine how temporal trends continue to evolve.

Cuffed endotracheal tubes in infants less than 3 kg: A retrospective cohort study.

BACKGROUND: Cuffed endotracheal tubes are being increasingly used in infants; however, current evidence in the literature mostly includes infants ≥ 3-kg weight. AIMS: The aim of this observational study was to compare the short-term outcomes with the use of Microcuff® cuffed vs uncuffed endotracheal tubes in neonates < 3 kg. METHODS: We performed a retrospective cohort study in a single-centre, tertiary children's hospital neonatal intensive care unit. The study included all infants < 3 kg receiving Microcuff® cuffed endotracheal tubes over the period January 2015 to January 2016. Controls were all infants 2000-2999 g receiving an uncuffed endotracheal tube over the period September 2015 to January 2016. RESULTS: Twenty-three patients < 3 kg were intubated with cuffed endotracheal tubes. All were inserted in the operating room. Of 23 patients, 14 (60.9%) patients had the cuff inflated in the operating room and none subsequently in the neonatal intensive care unit. The group receiving cuffed endotracheal tubes was compared with 23 patients with uncuffed endotracheal tubes. There was no difference in weight (median 2620 g vs 2590 g, diff in median = 10, 95% CI -120, 130) or duration of intubation (median 27 vs 44 hours, diff in median = 17, 95% CI -5, 46). However, there was a significant difference in gestational age (median 37 vs 35 weeks, diff in median = -1, 95% CI -2, 0) and age at intubation (median 6 vs 0 days, diff in median = -4, 95% CI -10, -1). There were no significant differences in the rates of: change of endotracheal tube to find correct size (0/23 vs 4/23, P = .109, OR = 0.13, 95% CI 0.01, 1.41); median ventilator leak reading (0% [IQR 0%-12%] vs 0% [IQR 0%-5.5%], P = .201, diff in median = 0, 95% CI -5.5, 0); unplanned extubations (0/23 vs 2/23; atelectasis (4/23 vs 0/23; endotracheal tube blockage (0/23 vs 0/23; pneumonia (0/23 vs 0/23; or postextubation stridor (1/23 vs 2/23). CONCLUSION: This retrospective study with a small sample size found that Microcuff® cuffed endotracheal tubes may be safe in neonates < 3 kg. Well-designed randomized controlled trials are needed to address this issue definitively.

Reliability and criterion-related validity testing (construct) of the Endotracheal Suction Assessment Tool (ESAT©).

AIMS AND OBJECTIVES: To establish criterion-related construct validity and test-retest reliability for the Endotracheal Suction Assessment Tool© (ESAT©). BACKGROUND: Endotracheal tube suction performed in children can significantly affect clinical stability. Previously identified clinical indicators for endotracheal tube suction were used as criteria when designing the ESAT©. Content validity was reported previously. The final stages of psychometric testing are presented. DESIGN: Observational testing was used to measure construct validity and determine whether the ESAT© could guide "inexperienced" paediatric intensive care nurses' decision-making regarding endotracheal tube suction. Test-retest reliability of the ESAT© was performed at two time points. METHODS: The researchers and paediatric intensive care nurse "experts" developed 10 hypothetical clinical scenarios with predetermined endotracheal tube suction outcomes. "Experienced" (n = 12) and "inexperienced" (n = 14) paediatric intensive care nurses were presented with the scenarios and the ESAT© guiding decision-making about whether to perform endotracheal tube suction for each scenario. Outcomes were compared with those predetermined by the "experts" (n = 9). Test-retest reliability of the ESAT© was measured at two consecutive time points (4 weeks apart) with "experienced" and "inexperienced" paediatric intensive care nurses using the same scenarios and tool to guide decision-making. RESULTS: No differences were observed between endotracheal tube suction decisions made by "experts" (n = 9), "inexperienced" (n = 14) and "experienced" (n = 12) nurses confirming the tool's construct validity. No differences were observed between groups for endotracheal tube suction decisions at T1 and T2. CONCLUSION: Criterion-related construct validity and test-retest reliability of the ESAT© were demonstrated. Further testing is recommended to confirm reliability in the clinical setting with the "inexperienced" nurse to guide decision-making related to endotracheal tube suction. RELEVANCE TO CLINICAL PRACTICE: The ESAT© is the first validated tool to systematically guide endotracheal nursing practice for the "inexperienced" nurse.

Content validity testing of the ESAT©: A decision aid tool for performing endotracheal suction in children.

BACKGROUND AND PURPOSE: Endotracheal tube suction performed in children can affect clinical stability. Previous research has identified clinical indicators used to perform endotracheal suction. These were used to develop the Endotracheal Suction Assessment Tool© (ESAT©). This study sought to evaluate the degree to which the ESAT© items as a whole constitute an operational definition of the construct used to determine whether a paediatric intensive care nurse should perform the endotracheal tube suction procedure. METHODS: Lynn's process for calculation of content validity and scale content validity index using a team of expert reviewers was adopted. Experts were drawn from paediatric intensive care units in Australia (n=6), United Kingdom (n=1), Switzerland (n=1) and Canada (n=1). These experts established the content validity index of the Endotracheal Suction Assessment Tool© using a minimum preset a-priori criterion agreement of 0.78 and a scale content validity index of 0.8. Scale content validity index was used to enhance the interpretability of the content validity data. RESULTS: All 15 items achieved the preset a-priori agreement for apparent internal consistency. Minor adjustments were required to improve the clarity of four items. The content validity index ranged from 0.8 to 1.0 and scale content validity index ranged from 0.9 to 1.0 for all items. CONCLUSION: Item and scale content validity indexes of the tool were established. Further psychometric testing for construct validity and stability over time is required to establish clinical utility of the tool and practice of novice paediatric intensive care nurses and other PIC health professionals.

The ability of Hepascore to predict liver fibrosis in chronic liver disease: a meta-analysis.

BACKGROUND & AIMS: Hepascore is a serum model that was developed to assess the severity of liver fibrosis. It has been well validated in common causes of chronic liver disease. This study performed a meta-analysis to evaluate the pooled diagnostic performance of Hepascore and to compare it for different aetiologies of chronic liver disease. METHODS: Two reviewers searched electronic databases from October 2005 to September 2015 for studies that evaluated the diagnostic performance of Hepascore for liver fibrosis in chronic liver disease. RESULTS: 21 studies were included. The AUROC was adjusted according to the distribution of fibrosis stages. The mean adjusted AUROC was 0.83 (95% CI, 0.81-0.85) for significant fibrosis, 0.89 (95% CI, 0.85-0.92) for advance fibrosis and 0.93 (95% CI, 0.91-0.95) for cirrhosis. A cut point of 0.50-0.55 achieved a summary sensitivity of 70% and a summary specificity of 79% to predict significant fibrosis. A cut point of 0.50-0.61 had a summary sensitivity of 81% and a summary specificity of 74% to predict advanced fibrosis. A cut point of 0.80-0.84 had a summary sensitivity of 72% and a summary specificity of 0.88% to predict cirrhosis. The accuracy of Hepascore was similar among all disease aetiologies for the prediction of cirrhosis. However, Hepascore had better diagnostic ability for significant and advanced fibrosis in chronic hepatitis C, chronic hepatitis B and alcoholic liver disease than for non-alcoholic fatty liver disease and HIV co-infected viral hepatitis. CONCLUSIONS: Hepascore is a clinically useful measure of liver fibrosis in patients with common causes of chronic liver disease.

Working hours of obstetrics and gynaecology trainees in Australia and New Zealand.

BACKGROUND: The importance of doctors' working hours has gained significant attention with evidence suggesting long hours and fatigue may compromise the safety and wellbeing of both patients and doctors. This study aims to quantify the working hours of The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) specialist trainees in order to better inform discussions of working hours and safety within our region. METHODS: An anonymous, online survey of RANZCOG trainees was conducted. Demographic data were collected. The primary outcomes were: hours per week at work and hours per week on-call. Secondary outcomes included the frequency of long days (>12 h) and 24-h shifts, time spent studying, staff shortages and opinions regarding current rostering. RESULTS: Response rate was 49.5% (n = 259). Full-time trainees worked an average of 53.1 ± 10.0 h/week, with 11.6% working on-call. Long-day shifts were reported by 85.8% of respondents, with an average length of 14.2 h. Fifteen percent reported working 24-h shifts, with a median duration of uninterrupted sleep during this shift being 1-2 h. Trainees in New Zealand worked 7.0 h/week more than Australian trainees (P ≤0.001), but reported less on-call (P = 0.021). Trainees in Western Australia were more likely to work on-call (P ≤0.001) and 24-h shifts (P ≤0.001). CONCLUSION: While 53.1 h/week at work is similar to the average Australian hospital doctor, high rates of long days and 24-h shifts with minimal sleep were reported by RANZCOG trainees in this survey.

Fatigue and training of obstetrics and gynaecology trainees in Australia and New Zealand.

BACKGROUND: Several studies have linked doctor fatigue with adverse patient events and an increase in risk to doctors' personal safety and wellbeing. The present study assesses the rostering structure of Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) trainees and its association with trainees' reported fatigue levels, training opportunities and wellbeing, which were secondary outcomes of a larger study of trainee working hours which has been separately reported. METHODS: An anonymous, online survey of RANZCOG trainees was conducted. Demographic data collected included: age, gender, level of training and current rotation. Data were also collected on hours worked per week, long shifts (>12 h), self-reported fatigue levels, and opinions regarding current rostering and training. RESULTS: A majority (72.9%) of respondents regularly felt fatigued, with higher fatigue levels being associated with more hours worked per week (P = <0.001) and working long shifts (>12 h) (P = 0.007). Fatigue was associated with an increased risk of dozing while driving (P = 0.028), with 56.1% of respondents reporting that this occurs. Trainees appeared to be less confident in achieving their technical skill requirements, with increasing hours not increasing confidence in achieving these skills (P = 0.594). Trainees who worked under 50 h per week were less likely to report fatigue (P = <0.001) and more likely to report greater work enjoyment (P = 0.043), and working hours being conducive to learning (P = 0.015). CONCLUSION: Fatigue was frequently reported by RANZCOG trainees with increased working hours and long shifts being significant factors in fatigue levels. Strategies should be developed and trialled to enable trainees to obtain adequate case exposure and teaching without compromising patient and doctor safety.

Preferred practice location at medical school commencement strongly determines graduates' rural preferences and work locations.

OBJECTIVE: To identify factors influencing whether Australian medical graduates prefer to, or actually, work rurally. DESIGN: Secondary analysis of longitudinal data from Medical Schools Outcomes Database (MSOD) using univariate and multivariate logistic regression. SETTING: Twenty Australian medical schools. PARTICIPANTS: Australian or New Zealand citizens and Australian permanent residents who completed MSOD questionnaires between 2006 and 2013. MAIN OUTCOME MEASURES: Preferred and actual work locations 1 (PGY1) and 3 (PGY3) years postgraduation. RESULTS: Of 20 784 participants, 4028 completed a PGY1 or PGY3 questionnaire. Self-reported preference for rural practice location at medical school commencement was the most consistent independent predictor of whether a graduate would have a rural location preference at PGY1 (odds ratio (OR) 6.07, 95% confidence interval (CI) 4.91-7.51) and PGY3 (OR 7.95, 95% CI 4.93-12.84), and work rurally during PGY1 (OR 1.38, 95% CI 1.01-1.88) and PGY3 (OR 1.86, 95% CI 1.30-2.64). The effect of preferred practice location at medical school commencement is independent of, and enhances the effect of, rural background. Graduates of graduate-entry programs or with dependent children were less likely to have worked rurally during PGY1 and PGY3 respectively. CONCLUSION: The most consistent factor associated with rural preferences and work location was students' preferred location of practice at medical school commencement; this association is independent of, and enhances the effect of, rural background. Better understanding of what determines rural preference at medical school commencement and its influence on rural workplace outcomes beyond PGY3 is required to inform Australian medical school selection policies and rural health curricula.