Ambulance management of patients with penetrating truncal trauma and hypotension in Melbourne, Australia.

OBJECTIVE: Penetrating truncal trauma with hypotension is uncommon in Australia. Current pre-hospital clinical practice guidelines based on overseas studies recommend expedited transport to definitive trauma care and that i.v. fluid should only be administered to maintain palpable blood pressure. METHODS: A retrospective review included all adult patients with penetrating truncal trauma and hypotension (systolic blood pressure <90 mmHg) attended by emergency medical services in Victoria between January 2006 and December 2018. Patient pre-hospital characteristics and hospital outcomes are described using descriptive statistics. Predictors of fluid resuscitation and mortality were examined using logistic regression analyses. RESULTS: Between 2006 and 2018 there were 101 hypotensive, penetrating truncal injury major trauma patients in Melbourne, Victoria transported by road ambulance to a major trauma service. The median age of these patients was 38 years (interquartile range [IQR] 27-50) and 85% were male. Median scene time was 16.6 min (IQR 12-26) and median pre-hospital time was 53.0 min (IQR 38-66). Intravenous fluid resuscitation was given in 54.5% of cases. The mechanism of injury was stabbing in 91.1% and gunshot wound in 8.9%. Urgent surgery was required in 72.3% of cases, 32.7% of patients were admitted to the intensive care unit and there were eight deaths (8.3%). CONCLUSION: Penetrating truncal trauma with hypotension is rare in Melbourne, Australia with most patients having the injury caused by stabbing rather than shooting. Compared with outcomes reported in the USA and Europe, the mortality rate is low.

Affordability of out-of-pocket health care expenses among older Australians.

Australia has universal health insurance, and provides price concessions on health care and prescription pharmaceuticals through government subsidies. However Australia ranks among the highest OECD nations for out-of-pocket health care spending. With high prevalence of multimorbidity (27% aged 65 and over have 2 or more long-term health conditions) older Australians may face a severe financial burden from out-of-pocket health expenses. We surveyed 4574 members of National Seniors Australia aged 50 years or more on their inability to pay out-of-pocket health-related expenses across categories of medical consultations and tests, medications, dental appointments, allied health appointments (e.g. physiotherapy, podiatry) and transport to medical appointments or tests. Almost 4% of those surveyed were unable to afford out-of-pocket costs in at least one category of health care expenses in the previous 3 months. The odds of being unable to afford out-of-pocket medical costs increased with the number of chronic medical conditions (3 conditions: OR 3.05, 95% CI 1.17-6.30; 4 or more conditions: OR 3.45, 95% CI 1.34-7.28, compared with no chronic medical conditions). Despite Australia's universal health insurance, and safety nets for medical and pharmaceutical contributions, older Australians with multiple chronic conditions are at risk of being unable to afford out-of-pocket health care expenses.

Thyrotropin and thyroid cancer diagnosis: a systematic review and dose-response meta-analysis.

CONTEXT: TSH is the major growth factor for thyrocytes and may have a causative role in thyroid cancer. OBJECTIVE: The objective of the study was to systematically assess the association between serum TSH and thyroid cancer. DATA SOURCES: The MEDLINE and EMBASE databases were searched using synonyms for TSH and thyroid cancer, supplemented with reference list searches and author contact. STUDY SELECTION: Prospective cohort, case-control, and cross-sectional studies were identified with TSH the exposure and thyroid cancer the outcome. DATA EXTRACTION: Three reviewers independently extracted data. Studies reporting odds ratio (OR) for TSH levels and thyroid cancer were analyzed via meta-analysis and generalized least-squares trend estimation for dose-response relationships. DATA SYNTHESIS: Data extracted from 28 studies included a total of 42,032 subjects and 5,786 thyroid cancer cases. Dose-response spline analysis revealed a nonlinear relationship (P < 0.001). For TSH levels less than 1 mU/liter, the OR for thyroid cancer was 1.72 (1.42, 2.07) per milliunits per liter. However, the relationship changed for TSH levels 1 mU/liter and greater, with the OR thereafter being 1.16 (1.12, 1.21) per milliunits per liter. Studies controlling for autoimmunity reported the lowest OR [TSH below 2.5 mU/liter, OR 1.23 (1.02-1.47) per milliunits per liter; TSH 2.5 mU/liter or greater, OR 0.98 (0.89-1.09) per milliunits per liter]. Six groups assessed serum TSH in relation to markers of poor thyroid cancer prognosis, with three showing significant positive relationships. CONCLUSIONS: Higher serum TSH concentration is associated with an increased risk of thyroid cancer. Thyroid autoimmunity may partially explain the association, but further epidemiological assessment is required. Future clinical research should investigate the validity of including serum TSH in diagnostic nomograms, its prognostic importance, and the potential for therapeutic TSH suppression in thyroid cancer prevention.