Preparing linked population data for research: cohort study of prisoner perinatal health outcomes.

BACKGROUND: A study of pregnancy outcomes related to pregnancy in prison in New South Wales, Australia, designed a two stage linkage to add maternal history of incarceration and serious mental health morbidity, neonatal hospital admission and infant congenital anomaly diagnosis to birth data. Linkage was performed by a dedicated state-wide data linkage authority. This paper describes use of the linked data to determine pregnancy prison exposure pregnancy for a representative population of mothers. METHODS: Researchers assessed the quality of linked records; resolved multiple-matched identities; transformed event-based incarceration records into person-based prisoner records and birth records into maternity records. Inconsistent or incomplete records were censored. Interrogation of the temporal relationships of all incarceration periods from the prisoner record with pregnancies from birth records identified prisoner maternities. Interrogation of maternities for each mother distinguished prisoner mothers who were incarcerated during pregnancy, from prisoner control mothers with pregnancies wholly in the community and a subset of prisoner mothers with maternities both types of maternity. Standard descriptive statistics are used to provide population prevalence of exposures and compare data quality across study populations stratified by mental health morbidity. RESULTS: Women incarcerated between 1998 and 2006 accounted for less than 1 % of the 404,000 women who gave birth in NSW between 2000 and 2006, while women with serious mental health morbidity accounted for 7 % overall and 68 % of prisoners. Rates of false positive linkage were within the predicted limits set by the linkage authority for non-prisoners, but were tenfold higher among prisoners (RR 9.9; 95%CI 8.2, 11.9) and twice as high for women with serious mental health morbidity (RR 2.2; 95%CI 1.9, 2.6). This case series of 597 maternities for 558 prisoners pregnant while in prison (of whom 128 gave birth in prison); and 2,031 contemporaneous prisoner control mothers is one of the largest available. CONCLUSIONS: Record linkage, properly applied, offers the opportunity to extend knowledge about vulnerable populations not amenable to standard ascertainment. Dedicated linkage authorities now provide linked data for research. The data are not research ready. Perinatal exposures are time-critical and require expert processing to prepare the data for research.

Palliative care, Version 1.2014. Featured updates to the NCCN Guidelines.

The NCCN Guidelines for Palliative Care provide interdisciplinary recommendations on palliative care for patients with cancer. These NCCN Guidelines Insights summarize the NCCN panel's discussions and guideline updates from 2013 and 2014. These include modifications/additions to palliative care screening and assessment protocols, new considerations for discussing the benefits and risks of anticancer therapy, and approaches to advance care planning. Recent updates focus on enhanced patient-centered care and seek to promote earlier integration of palliative care and advance care planning in oncology.

Pregnancy, prison and perinatal outcomes in New South Wales, Australia: a retrospective cohort study using linked health data.

BACKGROUND: Studies from the United States and the United Kingdom have found that imprisoned women are less likely to experience poorer maternal and perinatal outcomes than other disadvantaged women. This population-based study used both community controls and women with a history of incarceration as a control group, to investigate whether imprisoned pregnant women in New South Wales, Australia, have improved maternal and perinatal outcomes. METHODS: Retrospective cohort study using probabilistic record linkage of routinely collected data from health and corrective services in New South Wales, Australia. Comparison of the maternal and perinatal outcomes of imprisoned pregnant women aged 18-44 years who gave birth between 2000-2006 with women who were (i) imprisoned at a time other than pregnancy, and (ii) community controls. OUTCOMES OF INTEREST: onset of labour, method of birth, pre-term birth, low birthweight, Apgar score, resuscitation, neonatal hospital admission, perinatal death. RESULTS: Babies born to women who were imprisoned during pregnancy were significantly more likely to be born pre-term, have low birthweight, and be admitted to hospital, compared with community controls. Pregnant prisoners did not have significantly better outcomes than other similarly disadvantaged women (those with a history of imprisonment who were not imprisoned during pregnancy). CONCLUSIONS: In contrast to the published literature, we found no evidence that contact with prison health services during pregnancy was a "therapunitive" intervention. We found no association between imprisonment during pregnancy and improved perinatal outcomes for imprisoned women or their neonates. A history of imprisonment remained the strongest predictor of poor perinatal outcomes, reflecting the relative health disadvantage experienced by this population of women.

Trends in HIV, hepatitis B and hepatitis C prevalence among Australian prisoners - 2004, 2007, 2010.

OBJECTIVE: To report the prevalence of markers for HIV infection, hepatitis B and hepatitis C among Australian prison entrants. DESIGN: Cross-sectional survey conducted over 2-week periods in 2004, 2007 and 2010. SETTING: Reception prisons in New South Wales, Queensland, Tasmania and Western Australia. PARTICIPANTS: Individuals entering prison from the community during the survey periods. MAIN OUTCOME MEASURE: Prevalence of anti-HIV antibody (anti-HIV), hepatitis B surface antigen (HBsAg), anti-hepatitis B core antibody (anti-HBc) and anti-hepatitis C virus antibody (anti-HCV). RESULTS: The study included 1742 prison entrants: 588 (33.8%) in 2004, 536 (30.8%) in 2007 and 618 (35.5%) in 2010. The age-standardised prevalence estimates for anti-HIV, HBsAg and anti-HBc were 0.4%, 2.3% and 21.7% respectively, and remained stable over the three survey periods. The age-standardised prevalence estimate for anti-HCV was 29.0%; it decreased over time (33.3% in 2004 v 23.2% in 2010; P = 0.001), and this coincided with a decrease in prison entrants reporting injecting drug use (58.3% [343/588] in 2004 v 45.3% [280/618] in 2010; P < 0.001). Among injecting drug users, the prevalence of anti-HCV was 57.2% and did not change significantly over time. Of those who were anti-HCV positive, 33.7% (140/415) were unaware of their infection status, and 74.3% (185/249) of those who tested positive for anti-HBc reported that they had never had hepatitis B. CONCLUSIONS: HIV prevalence is low in the Australian prisoner population but transmission remains a risk. Despite a decrease in the proportion of prison entrants reporting injecting drug use, prevalence of hepatitis B and hepatitis C has remained high. Treatment and prevention initiatives should be prioritised for this population.

Adult cancer pain.

Pain is a common symptom associated with cancer and its treatment. Pain management is an important aspect of oncologic care, and unrelieved pain significantly comprises overall quality of life. These NCCN Guidelines list the principles of management and acknowledge the range of complex decisions faced in the management oncologic pain. In addition to pain assessment techniques, these guidelines provide principles of use, dosing, management of adverse effects, and safe handling procedures of pharmacologic therapies and discuss a multidisciplinary approach for the management of cancer pain.

Distress management.

The integration of psychosocial care into the routine care of all patients with cancer is increasingly being recognized as the new standard of care. These NCCN Clinical Practice Guidelines in Oncology for Distress Management discuss the identification and treatment of psychosocial problems in patients with cancer. They are intended to assist oncology teams identify patients who require referral to psychosocial resources and to give oncology teams guidance on interventions for patients with mild distress to ensure that all patients with distress are recognized and treated.

Palliative care.

These guidelines were developed and updated by an interdisciplinary group of experts based on clinical experience and available scientific evidence. The goal of these guidelines is to help patients with cancer experience the best quality of life possible throughout the illness trajectory by providing guidance for the primary oncology team for symptom screening, assessment, palliative care interventions, reassessment, and afterdeath care. Palliative care should be initiated by the primary oncology team and augmented by collaboration with an interdisciplinary team of palliative care experts.

Establishment of a successful assessment and treatment service for Australian prison inmates with chronic hepatitis C.

OBJECTIVE: To evaluate the assessment and treatment outcomes of a prison hepatitis service. DESIGN AND SETTING: A retrospective, observational cohort study of prison inmates who attended hepatitis clinics from 1996 to 2005 at correctional centres in New South Wales. PATIENTS: Inmates who attended the clinics, including a nested case-control series of patients who received antiviral treatment and age- and sex-matched patients who did not receive treatment. MAIN OUTCOME MEASURES: Demographic and clinical characteristics of patients who attended the service; correlates of selection for antiviral treatment; and clinical and virological outcomes of treatment. RESULTS: Of the 1043 inmates who attended the clinics, 851 were men (82%) and 994 (95%) were referred for HCV infection; the mean age for this group was 33 years (range, 18-74 years). In the case-control series (185 treated and 186 untreated patients), selection for treatment was not biased by culturally and linguistically diverse background, current methadone treatment or psychiatric status. In the treated group, 76 of 138 genotyped patients had a genotype that is predictive of favourable treatment response, and a small minority of those with available liver biopsy results had established cirrhosis (7/119 patients). Of treated patients for whom complete follow-up data were available, 55% achieved sustained virological response and 100% adhered to therapy. In addition, treatment episodes were not especially complicated. CONCLUSION: Although the prison population has high rates of injecting drug use and poor mental health, imprisonment offers an opportunity for assessment and treatment of chronic HCV infection.

Health-state utilities in a prisoner population: a cross-sectional survey.

BACKGROUND: Health-state utilities for prisoners have not been described. METHODS: We used data from a 1996 cross-sectional survey of Australian prisoners (n = 734). Respondent-level SF-36 data was transformed into utility scores by both the SF-6D and Nichol's method. Socio-demographic and clinical predictors of SF-6D utility were assessed in univariate analyses and a multivariate general linear model. RESULTS: The overall mean SF-6D utility was 0.725 (SD 0.119). When subdivided by various medical conditions, prisoner SF-6D utilities ranged from 0.620 for angina to 0.764 for those with none/mild depressive symptoms. Utilities derived by the Nichol's method were higher than SF-6D scores, often by more than 0.1. In multivariate analysis, significant independent predictors of worse utility included female gender, increasing age, increasing number of comorbidities and more severe depressive symptoms. CONCLUSION: The utilities presented may prove useful for future economic and decision models evaluating prison-based health programs.

Management of chronic pain in cancer survivors.

Chronic pain is a frequent complication of cancer and its treatments and is often underreported, underdiagnosed, and undertreated. Pain in cancer survivors is caused by residual tissue damage from the cancer and/or the cancer therapy. This pain can be divided into 3 pathophysiologic categories: somatic, visceral, and neuropathic. The most common treatment-induced chronic pain syndromes are neuropathies secondary to surgery, radiation therapy, and chemotherapy. Comfort and function are optimized in cancer survivors by a multidisciplinary approach using an individually tailored combination of opioids, coanalgesics, physical therapy, interventional procedures, psychosocial interventions, and complementary and alternative modalities. Management of chronic pain must be integrated into comprehensive cancer care so that cancer patients can fully enjoy their survival.

Managing pain from advanced cancer in the palliative care setting.

Managing complex pain at the end of life is an essential aspect of palliative care. Such care is best guided by a comprehensive evaluation of the physiologic sources of pain to determine appropriate analgesia. Using the case of Mrs. J, a woman with advanced ovarian cancer, key principles of complex pain management at the end of life are reviewed, including optimum use of opioids and co-analgesics. In addition to physical assessment, total care of the patient and family facing imminent death should be based on an assessment of psychological, social, and spiritual factors. The assessment and management of pain and suffering are guided by an interdisciplinary team focused on goals of comfort and facilitating a death that respects the life of the patient who is dying.