Air pollution mortality benefits of sustained COVID-19 mobility restrictions in Australian cities.

OBJECTIVES: Emissions from road traffic, power generation and industry were substantially reduced during pandemic lockdown periods globally. Thus, we analysed reductions in traffic-related air pollution in Australian capital cities during March-April 2020 and then modelled the mortality benefits that could be realised if similar reductions were sustained by structural policy interventions. STUDY DESIGN: Satellite, air pollution monitor and land use observations were used to estimate ground-level nitrogen dioxide (NO2) concentrations in all Australian capital cities during: (a) a typical year with no prolonged air pollution events; (b) a hypothetical sustained reduction in NO2 equivalent to the COVID-19 lockdowns. METHODS: We use the WHO recommended NO2 exposure-response coefficient for mortality (1.023, 95 % CI: 1.008-1.037, per 10 µg/m3 annual average) to assess gains in life expectancy and population-wide years of life from reduced exposure to traffic-related air pollution. RESULTS: We attribute 1.1 % of deaths to anthropogenic NO2 exposures in Australian cities, corresponding to a total of 13,340 years of life lost annually. Although COVID-19-related reductions in NO2 varied widely between Australian cities during April 2020, equivalent and sustained reductions in NO2 emissions could reduce NO2-attributable deaths by 27 %, resulting in 3348 years of life gained annually. CONCLUSIONS: COVID-19 mobility restrictions reduced NO2 emissions and population-wide exposures in Australian cities. When sustained to the same extent by policy interventions that reduce fossil fuel consumption by favouring the uptake of electric vehicles, active travel and public transport, the health, mortality and economic benefits will be measurable in Australian cities.

Cognitive impairment in Parkinson's disease: impact on quality of life of carers.

BACKGROUND: The quality of life (QoL) of informal caregivers of people with Parkinson's disease (PD) (PwP) can be affected by the caring role. Because of cognitive symptoms and diminished activities of daily living, in addition to the management of motor symptoms, carers of PwP and cognitive impairment may experience increased levels of burden and poorer QoL compared with carers of PwP without cognitive impairment. This study aimed to investigate the impact of cognitive impairment in PD upon QoL of carers. METHODS: Approximately 36 months after diagnosis, 66 dyadic couples of PwP and carers completed assessments. PwP completed a schedule of neuropsychological assessments and QoL measures; carers of PwP completed demographic questionnaires and assessments of QoL. Factor scores of attention, memory/executive function and global cognition, as derived by principal component analysis, were used to evaluate cognitive domains. RESULTS: Hierarchical regression analysis found lower Montreal Cognitive Assessment was a significant independent predictor of poorer carer QoL, in addition to number of hours spent caregiving, carer depression and PD motor severity. Attentional deficits accounted for the largest proportion of variance of carer QoL. Carers of PwP and dementia (n = 9) had significantly poorer QoL scores compared with PwP and mild cognitive impairment (n = 18) or normal cognition (n = 39) carers (p < 0.01). CONCLUSIONS: Attentional deficits were the strongest predictor of carer QoL compared with other cognitive predictors. Carers for those with PD dementia reported the poorest QoL. Interventions such as respite or cognitive behavioural therapy to improve mood and self-efficacy in carers may improve carer QoL. © 2016 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons, Ltd.

A cross-sectional survey of environmental health in remote Aboriginal communities in Western Australia.

INTRODUCTION: The Australian Aboriginal population experiences significantly poorer health than the non-Aboriginal population. The contribution of environmental risk factors in remote communities to this health disparity is poorly understood. OBJECTIVE: To describe and quantify major environmental risk factors and associated health outcomes in remote Aboriginal communities in Western Australia. METHODS: The association between environmental health indicators, community infrastructure and reported health outcomes was analysed using linear and logistic regression of survey data. RESULTS: Housing/overcrowding was significantly associated with increased reports of hearing/eyesight (OR 3.01 95 % CI 1.58-5.73), skin (OR 2.71 95 % CI 1.31-5.60), gastrointestinal (OR 3.51 95 % CI 1.49-8.26) and flu/colds (OR 2.47 95 % CI 1.27-4.78) as health concerns. Dust was significantly associated with hearing/eyesight (OR 3.16 95 % CI 1.82-5.48), asthma/respiratory (OR 2.48 95 % CI 1.43-4.29) and flu/colds (OR 3.31 95 % CI 1.88-5.86) as health concerns. CONCLUSION: Poor environmental health is prevalent in remote Aboriginal communities and requires further delineation to inform environmental health policy.

Impact of chemotherapy on survival in surgically resected retroperitoneal sarcoma.

BACKGROUND: The role of systemic chemotherapy (CT) in the multimodality treatment strategy for retroperitoneal sarcomas (RPS) remains controversial. We hypothesized that chemotherapy does not improve overall survival for patients with surgically resected RPS. METHODS: The National Cancer Database was used to identify all patients with RPS that underwent surgical resection from 1998 to 2011. Univariate and multivariable Cox proportional hazards modeling were used to assess overall survival (OS) and logistic regression was used for associations. Propensity score (PS) modeling was performed to create balanced cohorts for analysis. RESULTS: A total of 8653 patients with surgically resected RPS were identified; 1525 (17.6%) received CT; 10.6% of patients (n = 163) in the neoadjuvant setting. Factors associated with receipt of CT included moderate (OR 2.3) to poorly differentiated (OR 4.3) tumors, leiomyosarcoma (OR 1.8) or undifferentiated pleomorphic sarcoma (OR 2.3) histology, and R2 resection status (OR 2.2) (all p < 0.05). Unadjusted median OS for patients receiving CT compared to surgery alone was 40 vs 68.2 months respectively (p < 0.01). Following propensity score matching, worse median OS persisted among the CT cohort (40 vs 52 months, p = 0.002). Receipt of chemotherapy was not associated with improved long term survival in adjusted models for the raw and propensity matched cohorts (HR 1.17, 95% CI: 1.04-1.31; p = 0.009). CONCLUSION: Current available chemotherapy regimens for RPS do not confer a survival benefit. Routine use of chemotherapy for RPS should be discouraged until new effective systemic agents become available.

Patency rates of portal vein/superior mesenteric vein reconstruction after pancreatectomy for pancreatic cancer.

BACKGROUND: Pancreatectomy with venous reconstruction (VR) for pancreatic cancer (PC) is occurring more commonly. Few studies have examined the long-term patency of the superior mesenteric-portal vein confluence following reconstruction. METHODS: From 2007 to 2013, patients who underwent pancreatic resection with VR for PC were classified by type of reconstruction. Patency of VR was assessed using surveillance computed tomographic imaging obtained from date of surgery to last follow-up. RESULTS: VR was performed in 43 patients and included the following: tangential resection with primary repair (7, 16%) or saphenous vein patch (9, 21%); segmental resection with splenic vein division and either primary anastomosis (10, 23%) or internal jugular vein interposition (8, 19%); or segmental resection with splenic vein preservation and either primary anastomosis (3, 7%) or interposition grafting (6, 14%). All patients were instructed to take aspirin after surgery; low molecular weight heparin was not routinely used. An occluded VR was found in four (9%) of the 43 patients at a median follow-up of 13 months; median time to detection of thrombosis in the four patients was 72 days (range 16-238). CONCLUSIONS: Pancreatectomy with VR can be performed with high patency rates. The optimal postoperative pharmacologic therapy to prevent thrombosis requires further investigation.

Prognostic value of CpG island methylator phenotype among colorectal cancer patients: a systematic review and meta-analysis.

BACKGROUND: Divergent findings regarding the prognostic value of CpG island methylator phenotype (CIMP) in colorectal cancer (CRC) patients exist in current literature. We aim to review data from published studies in order to examine the association between CIMP and CRC prognosis. MATERIALS AND METHODS: A comprehensive search for studies reporting disease-free survival (DFS), overall survival (OS), or cancer-specific mortality of CRC patients stratified by CIMP is carried out. Study findings are summarized descriptively and quantitatively, using adjusted hazard ratios (HRs) as summary statistics. RESULTS: Thirty-three studies reporting survival in 10 635 patients are included for review. Nineteen studies provide data suitable for meta-analysis. The definition of CIMP regarding gene panel, marker threshold, and laboratory method varies across studies. Pooled analysis shows that CIMP is significantly associated with shorter DFS (pooled HR estimate 1.45; 95% confidence interval (CI) 1.07-1.97, Q = 3.95, I(2) = 0%) and OS (pooled HR estimate 1.43; 95% CI 1.18-1.73, Q = 4.03, I(2) = 0%) among CRC patients irrespective of microsatellite instability (MSI) status. Subgroup analysis of microsatellite stable (MSS) CRC patients also shows significant association between shorter OS (pooled HR estimate 1.37; 95% CI 1.12-1.68, Q = 4.45, I(2) = 33%) and CIMP. Seven studies have explored CIMP's value as a predictive factor on stage II and III CRC patient's DFS after receiving adjuvant 5-fluorouracil (5-FU) therapy: of these, four studies showed that adjuvant chemotherapy conferred a DFS benefit among CIMP(+) patients, one concluded to the contrary, and two found no significant correlation. Insufficient data was present for statistical synthesis of CIMP's predictive value among CRC patients receiving adjuvant 5-FU therapy. CONCLUSION: CIMP is independently associated with significantly worse prognosis in CRC patients. However, CIMP's value as a predictive factor in assessing whether adjuvant 5-FU therapy will confer additional survival benefit to CRC patients remained to be determined through future prospective randomized studies.

Tuberculosis and alcohol misuse in Scotland: a population-based study using enhanced surveillance data.

OBJECTIVE: To identify for the first time in Scotland the epidemiological characteristics of tuberculosis (TB) patients who misuse alcohol. DESIGN: A retrospective cohort study using Enhanced Surveillance of Mycobacterial Infections (ESMI) scheme data for adult (aged ≥ 18 years) TB cases notified in Scotland, 2001-2007. Characteristics and treatment outcomes of TB cases with and without recorded alcohol misuse were compared. RESULTS: Of 2419 adult TB cases, alcohol misuse was recorded in 426 (18%). Alcohol misuse was associated with male sex, White ethnicity, birth in the United Kingdom, unemployment, urban residence and socio-economic deprivation. Alcohol misusers were more likely than other TB cases to have pulmonary TB (92% vs. 61%, P < 0.001), be sputum smear-positive (74% vs. 58%, P < 0.001) and be enrolled on directly observed treatment (30% vs. 3%, P < 0.001). Treatment completion rates were respectively 77% and 79% (P = 0.34) in alcohol misusers and other TB cases. CONCLUSION: We have identified epidemiological characteristics associated with alcohol misuse among TB patients in Scotland, notably socio-economic deprivation. We suggest improvements in data collection to allow more robust findings to inform policy decisions to assist the prevention and management of alcohol misuse and reduce the TB incidence in Scotland.

Unrestricted access to sugammadex: impact on neuromuscular blocking agent choice, reversal practice and associated healthcare costs.

Sugammadex is known to rapidly and completely reverse the effects of amino-steroidal neuromuscular blocking agents. However, the high costs of sugammadex have so far prevented its introduction as the standard reversal agent in most healthcare systems. At the Royal Perth Hospital, sugammadex was recently introduced as an unrestricted alternative to neostigmine for the reversal of amino-steroidal neuromuscular blocking agents. The aim of this retrospective observational audit was to investigate the impact of this change on clinical practice and associated healthcare costs. Data from all patients intubated during a one-month period in April to May 2010 and for a similar period in 2011 were retrospectively collected and the use of neuromuscular blocking agents and reversal agents were identified and the associated costs were calculated. More steroidal neuromuscular blocking agents and sugammadex (+743%), but less glycopyrrolate and neostigmine (-48%) were used in 2011. Using the manufacturer's list price, muscle relaxation and reversal costs increased from about A$42 per case to about A$127 per case. Between the investigated time periods no differences were found for anaesthesia time, operating time or time spent in the post anaesthesia care unit. However, there was a statistically significant decrease in the time between surgery and discharge (median 2.0 vs 2.2 days). While the design of the audit was such that no inferences can be made about the cause of this change, this is an interesting observation worthy of further investigation.

Trends in multidrug-resistant tuberculosis in Scotland, 2000-7.

Overall numbers of multidrug-resistant (MDR) tuberculosis (TB) rose sharply in the United Kingdom and Scotland in 2007. Risk factors associated with MDR TB in the United Kingdom have been identified but there has been no previous report on risk factors associated with MDR TB in Scotland. Enhanced Surveillance of Mycobacterial Infections (ESMI) data were used to examine demographic and clinical characteristics and treatment outcome of MDR TB cases notified in Scotland between 2000-7. There was a total of 11 culture-positive cases of MDR TB, five of which were notified in 2007. The majority of patients were female, 15-44 years old and unemployed. All were born outside the United Kingdom and most had arrived within the past year from or frequently travelled to their home countries in China, the Indian subcontinent or Africa. Except for one individual, our patients did not self report a history of previous diagnosis of TB which was previously identified as a risk factor for MDR TB in the United Kingdom. Only three patients received directly observed treatment (DOT). Only two patients had completed treatment at 12 months, partially due to the inadequate length of follow-up under the current ESMI system. Our results suggest that most patients had primary resistance due to transmission of MDR TB in high incidence countries and thus point to the importance of international efforts to control MDR TB in these countries. In Scotland, national efforts should be made to increase the number of MDR TB patients receiving DOT and to extend follow-up to improve monitoring of treatment outcome. It is important to identify high risk groups for MDR TB infection in order to deliver effective community-based disease control measures.

Severe complications of chickenpox in hospitalised children in the UK and Ireland.

AIMS: To estimate the annual incidence of hospitalisations due to severe complications of varicella, describe the complications and estimate annual mortality. METHODS: Active surveillance throughout the UK and Ireland for 13 months by paediatricians notifying cases to the British Paediatric Surveillance Unit and completing a questionnaire. The case definition was any child aged <16 years hospitalised with complicated varicella, as defined by a list of conditions, or admitted to ICU/HDU with varicella. RESULTS: 188 cases were notified for the surveillance period, of which 112 (0.82/100 000 children/year) met the case definition and were not duplicates. Confirmed cases had a median age of 3 years (range 0-14). The complications were: bacteraemia/septic shock (n = 30), pneumonia (n = 30), encephalitis (n = 26), ataxia (n = 25), toxic shock syndrome/toxin-mediated disease (n = 14), necrotising fasciitis (n = 7), purpura fulminans/disseminated coagulopathy (n = 5), fulminant varicella (n = 5) and neonatal varicella (n = 3). 52 children (46%) had additional bacterial infections. Six deaths were due, or possibly due, to varicella, including one intrauterine death. Four of the other five children who died (ages 2-14 years) had a pre-existing medical condition. Sequelae on discharge were reported for 41 cases (40%), most frequently ataxia or skin scarring. The median length of hospital stay was 7 days (range 1-68). CONCLUSIONS: This study provides a minimum estimate of severe complications and death resulting from varicella in children in the UK and Ireland. Most complications, excluding deaths, occur in otherwise healthy children and thus would be preventable only through a universal childhood immunisation programme.

Respiratory hospital admissions were associated with ambient airborne pollen in Darwin, Australia, 2004-2005.

BACKGROUND: Although the role of pollen and fungus in specific allergic disorders has been well established, the public health impacts of ambient concentrations of airborne pollen and fungal spores; the shapes of concentration-response relationships; and the relative effects of different taxa are gaps in current knowledge. OBJECTIVE: To investigate associations between daily average ambient pollen and fungal spore concentrations with hospital admissions for total respiratory diseases; asthma; chronic obstructive pulmonary disease (COPD); and respiratory infections in Darwin, Australia, during the period from April 2004 to November 2005. METHODS: We assessed these relationships in a two-stage modelling approach designed to quantify potential non-linear relationships. First, generalized additive models determined the shapes of concentration-response relationships. Second, linear associations were examined using generalized linear models. Non-linear relationships were analysed by categorizing pollen and fungal spore concentrations based on their distributions. RESULTS: Positive linear associations were found between total pollen concentrations and hospital admissions for total respiratory diseases and COPD. While our exploratory first-stage analysis suggested non-linear relationships for total pollen with asthma and respiratory infections, no convincing evidence for these relationships was found in the second-stage analysis. When individual taxa were investigated, associations were the strongest in relation to Myrtaceae pollen (the dominant tree taxa in the region), while positive associations not attaining statistical significance were observed for Poaceae, Cyperaceae and Arecaceae. No associations were evident for any conditions with fungal spores. CONCLUSIONS: Our finding of an association between pollen count and respiratory hospital admissions that could not be explained by asthma admissions suggests that ambient airborne pollens might have a wider public health impact than previously recognized.

Multi-center evaluation of analytical performance of the microparticle enzyme immunoassay for sirolimus.

OBJECTIVES: This study evaluated the analytical characteristics of the new Abbott microparticle enzyme immunoassay (MEIA) for sirolimus. DESIGN AND METHODS: The protocol consisted of nine sections: evaluation of antibody specificity, linearity, detection limit, quantification limit, endogenous interferents, exogenous interferents, precision, proficiency testing panel, and method comparison. RESULTS: The mean analytical detection limit was 0.68 microg/L. The sirolimus concentration corresponding to a total CV of 20% was 1.5 microg/L. Linearity of response was demonstrated across the dynamic range of the assay. Total precision (CVs) at QC control levels from 5 to 22 microg/L ranged from 5.7 to 12.6%. Assay standardization was found to be in good agreement with LC/MS/MS as compared with target values for spiked sirolimus proficiency samples from an international sirolimus proficiency testing program. Good correlations (R values) of the immunoassay were observed in comparisons to LC/MS/MS. R values tended to be lower in comparisons with LC/UV methods. Across both LC-based methods and all study sites, there was approximately 25% overall positive slope bias due to cross reactivity of the MEIA antibody to metabolites of sirolimus. The assay cross-reactivity to metabolites of sirolimus parent drug ranged from 6 to 63%. Assay interferences were minimal with the exception of hematocrit, which presented a negative relationship to measured sirolimus concentration. CONCLUSIONS: The MEIA demonstrated acceptable analytical characteristics for use for routine monitoring of sirolimus immunosuppressive therapy, and is a viable alternative to HPLC-based methods for sirolimus monitoring.

WITHDRAWN: Multi-center evaluation of analytical performance of the microparticle enzyme immunoassay for sirolimus.

The Publisher regrets that this article is an accidental duplication of an article that has already been published in Clin. Biochem. 39 (2006) 378-386, doi:10.1016/j.clinbiochem.2006.01.017. The duplicate article has therefore been withdrawn. This article has been withdrawn consistent with Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). The Publisher apologizes for any inconvenience this may cause.

Validation of surgical site infection surveillance data in Scotland.

Validation of surveillance data is necessary to ensure its scientific credibility, to identify methodological problems within the surveillance programme, to help increase compliance and participation in the surveillance programme, and to identify data quality issues at local level. Surgical site infection surveillance (SSIS) in Scotland has been implemented in collaboration between Health Protection Scotland (HPS) and staff in acute divisions in Scotland. A team at HPS carried out a study to validate the SSIS data reported to them. The aims of the validation study were: (i) to measure the completeness of the denominator data; (ii) to measure the accuracy of all SSIS data items reported to HPS; and (iii) to determine the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the SSIs reported to HPS against the SSIs validated as part of this study. The methodology utilized for validation of SSIS data was based on an evaluation research approach. The evaluation research approach involves a range of investigative activities, aimed at judging the worth of a programme or practice, and measures SSIS in terms of structure, process and outcome. The completeness of the denominator and the means of identifying eligible patients was identified. Descriptive information about how SSIS data were collected and managed at hospital level was collated, and the accuracy and completeness of the reported SSIS data were measured by case note review of selected cases. SSIS data from 27 hospitals in 15 acute divisions and one special health board were validated. The results indicated that a total of 91% of the procedures carried out (denominator) during a specified three-month period were reported to HPS. The case notes validated over 90% of records reported to HPS; however, there was variation in data quality between hospitals. The sensitivity, specificity, PPV and NPV of the SSIs reported to HPS were 96.7, 99.0, 94.6 and 99.4%, respectively. Where problems with data were identified at local level, hospitals have been offered guidance to improve their data. As a result of this study, HPS are confident that the Scottish SSIS data are reliable and robust.

Healthy country: healthy people? Exploring the health benefits of indigenous natural resource management.

OBJECTIVE: Decades of health-related research have produced a large body of knowledge describing alarming rates of morbidity, mortality and social/cultural disruption among Indigenous Australians, but have failed to deliver sustainable interventions to arrest the deepening spiral of ill-health. This paper explores the potential of Indigenous natural resource management (NRM) activities to promote and preserve Indigenous health in remote areas of northern Australia. METHOD: A literature review of the health, social science and ecology peer-reviewed journals and secondary literature. CONCLUSIONS AND IMPLICATIONS: Effective interventions in Indigenous health will require trans-disciplinary, holistic approaches that explicitly incorporate Indigenous health beliefs and engage with the social and cultural drivers of health. Aboriginal peoples maintain a strong belief that continued association with and caring for ancestral lands is a key determinant of health. Individual engagement with 'country' provides opportunities for physical activity and improved diet as well as boosting individual autonomy and self-esteem. Internationally, such culturally congruent health promotion activities have been successful in programs targeting substance abuse and chronic diseases. NRM is fundamental to the maintenance of biodiversity of northern Australia. Increased support for Indigenous involvement in land and sea NRM programs would also deliver concrete social benefits for communities including opportunities for sustainable and culturally apt regional employment, applied education and economic development. NRM may also reinvigorate societal/cultural constructs, increasing collective esteem and social cohesion.

Keratoconus: an analysis of corneal asymmetry.

BACKGROUND: Keratoconus, a non-inflammatory corneal ectasia, is reported to have bilateral involvement in over 90% of patients. The purpose of this study was to quantify the extent of asymmetry of disease at presentation to a regional corneal clinic. METHODS: Eighty three patients diagnosed at presentation, using a combination of videokeratography, slit lamp examination, and refractive findings were retrospectively selected. On this basis, 73 patients were designated as having evidence of keratoconus in both eyes. In order to quantify the degree of asymmetry between fellow eyes in these bilateral patients, intraclass correlation was calculated for best spectacle corrected visual acuity (BSCVA) and for 13 different topographical indices generated using videokeratography. In order to examine the link between each index and visual function, the intrapatient differences in each index were compared to the intrapatient differences in BSCVA using Pearson's correlation. RESULTS: BSCVA showed a high degree of asymmetry between fellow eyes with a correlation coefficient of r = 0.006. With the exception of area analysed, all of the topographical indices also showed disparity between paired eyes (r = 0.01 to r = 0.25). Pearson's analysis found that the intrapatient differences in the standard deviation of the power (SDP), average corneal power (ACP), central corneal power (K), as well as the composite keratoconus prediction index (KPI) inversely correlated with the intrapatient differences in best spectacle corrected acuity (r = -0.76,-0.75,-0.69, and -0.73 respectively). CONCLUSIONS: This study demonstrates, quantitatively, the asymmetry of disease found in patients at the point of initial diagnosis of keratoconus. It also suggests that increases in indices which reflect various aspects of corneal power as well as the composite index KPI correlate with a decrease in BSCVA.

Unusual cervical nerve root arrangement exposed during surgery: case report and review of the literature.

Anatomical variations of neural structures in the cervical spine are rare and are not necessarily visible on pre-operative imaging. The authors report an unusual arrangement of neural structures identified during cervical foraminotomy. Anatomical variations of the cervical nerve roots are reviewed and their importance in neurosurgical practice is discussed.

High and low pressure states associated with posterior sacral meningocele.

We describe the rare cases of a 44-year-old woman and a 28-year-old woman each presenting with a large posterior sacrococcygeal mass and alternating symptoms of high and low intracranial pressure. The first patient underwent excision of her large sacral meningocele and simple ligation of the neck, resulting in resolution of all her associated symptoms. The second patient suffered traumatic rupture of the meningocele; she underwent excision of the redundant sac and repair of the dural defect using a musculofascial flap, also resulting in resolution of her symptoms.

Fatal instability following "odontoid sparing" transoral decompression of a periodontoid pseudotumour.

Pseudotumour of the craniovertebral junction is an uncommon cause of high cervical myelopathy in the elderly. The anterior transoral approach is the preferred means of accessing these lesions. An "odontoid sparing" transoral approach, in which there is only minimal bone removal, is thought to preserve stability of the craniovertebral junction, obviating the need for posterior stabilisation. This report is of an 82 year old man who developed fatal atlanto-axial instability following an odontoid sparing transoral resection of a pseudotumour. This complication has not previously been described and its occurrence has important implications for the surgical management of this condition.