Anxiety, Disability, and Pain Predict Outcomes of Complex Regional Pain Syndrome: An 8-year Follow-up of a Prospective Cohort.

Factors contributing to the varied outcomes of complex regional pain syndrome (CRPS) are not well known. This study aimed to determine whether baseline psychological factors, pain, and disability influence long-term CRPS outcomes. We conducted an 8-year follow-up from a previous prospective study of CRPS outcomes. Sixty-six people diagnosed with acute CRPS were previously assessed at baseline, 6 months, and 12 months and in the current study, 45 were followed up after 8 years. At each timepoint, we measured signs and symptoms of CRPS, pain, disability, and psychological factors. Mixed-model repeated measures were used to identify baseline predictors of CRPS severity, pain, and disability at 8 years. Predictors of greater CRPS severity at 8 years were female sex, greater baseline disability, and greater baseline pain. Predictors of greater pain at 8 years were greater baseline anxiety and disability. The only predictor of greater disability at 8 years was greater baseline pain. Findings suggest CRPS is best understood from a biopsychosocial perspective, and baseline anxiety, pain, and disability may influence the trajectory of CRPS outcomes as far as 8 years later. These variables could be used to identify those at risk of poor outcomes or form targets for early interventions. PERSPECTIVE: This paper presents the findings of the first study to prospectively investigate predictors of CRPS outcomes over 8 years. Baseline anxiety, pain, and disability predicted greater CRPS severity, pain, and disability over 8 years. These factors could identify those at risk of poor outcomes or form targets for early interventions.

Use of public sector diabetes eye services in New Zealand 2006-2019: Analysis of national routinely collected datasets.

OBJECTIVE: To assess diabetes eye service use in New Zealand among people aged ≥15 years by estimating service attendance, biennial screening rate, and disparities in the use of screening and treatment services. METHODS: We obtained Ministry of Health data from the National Non-Admitted Patient Collection on diabetes eye service events between 1 July 2006 and 31 December 2019 and sociodemographic and mortality data from the Virtual Diabetes Register and linked these using a unique patient identifier (encrypted National Health Index). We 1) summarized attendance at retinal screening and ophthalmology services, 2) calculated biennial and triennial screening rate, 3) summarized treatment with laser and anti-VEGF and used log-binomial regression to examine associations of all of these with age group, ethnicity, and area-level deprivation. RESULTS: In total, 245,844 people aged ≥15 years had at least one diabetes eye service appointment attended or scheduled; half of these (n = 125,821, 51.2%) attended only retinal screening, one-sixth attended only ophthalmology (n = 35,883, 14.6%) and one-third attended both (n = 78,300, 31.8%). The biennial retinal screening rate was 62.1%, with large regional variation (73.9% in Southern District to 29.2% in West Coast). Compared with NZ Europeans, Maori were approximately twice as likely to never receive diabetes eye care or to access ophthalmology when referred from retinal screening, 9% relatively less likely to receive biennial screening and received the fewest anti-VEGF injections when treatment was commenced. Disparities in service access were also present for Pacific Peoples compared to NZ Europeans, younger and older age groups compared to those aged 50-59 years and those living in areas with higher deprivation. CONCLUSIONS: Access to diabetes eye care is suboptimal, with substantial disparity between age groups, ethnicity groups, area level deprivation quintile and across districts. Efforts to improve access to and quality of diabetes eye care services must include strengthening data collection and monitoring.

Parental satisfaction with an advanced audiology-led triage service in paediatric ENT outpatient clinics.

OBJECTIVE: The advanced audiology-led service is designed to triage and manage children who are referred to Ear Nose and Throat (ENT) outpatient services with middle ear or hearing concerns. This service has resulted in shorter waiting times for children to receive ENT treatment, and improved ENT capacity. The aim of this study was to explore parental satisfaction with the advanced audiology-led ENT service and to determine if there were cultural or process factors affecting satisfaction. DESIGN: Prospective cross-sectional study using a modified Visit-Specific Satisfaction Questionnaire (VSQ-9) survey. STUDY SAMPLE: One hundred and thirteen parents of children consecutively attending a first appointment in the advanced audiology-led service recruited between October 2016 and October 2017. RESULTS: There were a total of 100 valid responses (rate of 88.5%). The survey showed high levels of satisfaction. Satisfaction scores were significantly higher for items related to interactions with the audiologist compared to items related to waiting times. There were no differences in satisfaction across cultural groups. Parents were equally satisfied with the service whether their child was managed independently by the audiologist or required another appointment for medical input. CONCLUSIONS: The advanced audiology-led service had high levels of satisfaction from parents attending with their children.

Pre-sleep cognitive arousal exacerbates sleep disturbance in chronic pain: an exploratory daily diary and actigraphy study.

OBJECTIVES: Insomnia is commonly comorbid with chronic pain, and typically leads to worse outcomes. Two factors that could contribute to a cycle of pain and sleeplessness are pre-sleep cognitive arousal (repetitive thought processes) and low mood. This study aimed to examine how pain, sleep disturbance, mood, and pre-sleep cognitive arousal inter-relate, to determine whether low mood or pre-sleep cognitive arousal contribute to a vicious cycle of pain and insomnia. METHODS: Forty seven chronic pain patients completed twice daily diary measures and actigraphy for one week. Analyses investigated the temporal and directional relationships between pain intensity, sleep quality, time awake after sleep onset, anhedonic and dysphoric mood, and pre-sleep cognitive arousal. Fluctuations in predictor variables were used to predict outcome variables the following morning using mixed-effects modelling. RESULTS: For people with chronic pain, an evening with greater pre-sleep cognitive arousal (relative to normal) led to a night of poorer sleep (measured objectively and subjectively), lower mood in the morning, and a greater misperception of sleep (underestimating sleep). A night of poorer sleep quality led to greater pain the following morning. Fluctuations in pain intensity and depression did not have a significant influence on subsequent sleep. CONCLUSIONS: For people with chronic pain, cognitive arousal may be a key variable exacerbating insomnia, which in turn heightens pain. Future studies could target cognitive arousal to assess effects on sleep and pain outcomes.

Professional footballers have a limited understanding of the precompetition medical assessment and the possible outcomes including disqualification: a cross-sectional survey.

OBJECTIVES: To determine professional footballers' level of understanding of the purpose of the precompetition medical assessment (PCMA) and to evaluate their knowledge of potential outcomes following a PCMA, including disqualification. METHODS: Professional footballers from the Australasian A-League and Westfield W-League were asked to complete a 25-question survey. The relationship between dichotomised outcomes and explanatory variables was analysed with multivariate logistic regression; p<0.05 was considered statistically significant. RESULTS: A total of 212 players participated (response rate=48.8%). Most respondents selected 'To detect medical conditions that may affect performance' and 'To detect current injuries' (n=137, 64.6%; n=130, 61.3%) as the purpose of a PCMA. Approximately one-third (n=74, 38.1%) were neutral or believed that a normal PCMA prevented cardiac arrest. Receiving more PCMAs (p<0.0003) and receiving an explanation during their PCMA (p=0.0175) led to greater awareness of the assessment's limitations. Most participants did not know the definitions of syncope (n=181, 93.3%) or Marfan syndrome (n=183, 94.3%). Fifty players (28.1%) did not know that disqualification was a possible outcome of a PCMA, and younger players were less aware of this possible outcome (p=0.0216). CONCLUSION: Professional footballers appear to have a limited understanding of the purpose of a PCMA, emphasising the musculoskeletal system and performance. They also appear unfamiliar with the components of the PCMA and medical terms. Finally, many are unaware that disqualification can result from an abnormal PCMA. Player health knowledge must be improved; the informed consent process appears an ideal time to provide this education.

Can an advanced audiology-led service reduce waiting times for paediatric ear nose and throat outpatient services?

AIM: Children with middle ear disease often experience lengthy delays waiting for outpatient paediatric ear nose and throat (ENT) services. This study aimed to investigate whether an alternative service delivery model using audiologists working in an expanded scope of practice reduced waiting times for children to access such services. METHODS: A total of 131 children consecutively referred to a large ENT outpatient service in Queensland, Australia, for middle ear and hearing concerns were prospectively allocated to either a standard ENT service or an advanced audiology (AA)-led service. Waiting times and attendance rates were collected and compared between the two patient groups. RESULTS: The median waiting time from referral to first offered appointment was 96 days for children in the AA-led service versus 417.5 days for children in the standard ENT service. Seventy-nine percent of children in the AA-led service attended their first offered appointment versus 61% in the standard ENT service. For children receiving grommets, the median waiting time from initial referral to grommet insertion was 226 days for children in the AA-led service versus 627 days for children in the standard ENT service. CONCLUSION: The AA-led service was an effective alternative pathway to reduce waiting times for children referred to ENT services with middle ear and hearing concerns.

Vaccine-Preventable Disease-Associated Hospitalisations Among Migrant and Non-migrant Children in New Zealand.

Migrants may experience a higher burden of vaccine-preventable disease (VPD)-associated hospitalisations compared to the host population. A retrospective cohort study from 2006 to 2015 was conducted that linked de-identified data from government sources using Statistic NZ's Integrated Data Infrastructure. VPD-related hospitalisations were compared between three cohorts of children from birth to 5 years old: foreign-born children who migrated to NZ, children born in NZ of recent migrant mothers, and a comparator group of children born in NZ without a recent migration background. VPD-related hospitalisation rates were higher among NZ-born non-migrant children compared to NZ-born migrant and foreign-born children for all of the diseases of interest. For instance, 5.21% of NZ-born non-migrant children were hospitalised at least once due to all-cause gastroenteritis compared to 4.47% of NZ-born migrant children and only 1.13% of foreign-born migrant children. The overall hospitalisation rate for NZ-born non-migrant children was 3495 hospitalisations per 100,000 person years. Among children with migrant backgrounds, higher hospitalisation rates were noted among those of Pacific ethnicity and those with refugee backgrounds. Those arriving on Pacific visa schemes were hospitalised at rates ranging from 2644/100,000 person years among foreign-born migrant children and 4839/100,000 person years among NZ-born migrant children. Foreign-born quota refugee children and NZ-born children of quota refugee mothers were hospitalised at a rate of 4000-5000/100,000 person years. It is important to disaggregate migrant data to improve our understanding of migrant health. Children need to be age-appropriately vaccinated, and other individual and environmental factors addressed, to reduce the risk of infectious diseases.

Survey of Barriers and Facilitators to Engagement in a Multidisciplinary Healthy Lifestyles Program for Children.

OBJECTIVE: To understand facilitators and barriers to engagement in a multidisciplinary assessment and intervention program for children and adolescents with obesity, particularly for Maori, the Indigenous people of New Zealand. METHODS: Whanau Pakari participants and caregivers (n = 71, 21% response rate) referred to the family-based healthy lifestyles program in Taranaki, New Zealand, were asked to participate in a confidential survey, which collected self-reported attendance levels and agreement with statements around service accessibility and appropriateness and open-text comments identifying barriers and facilitators to attendance. RESULTS: Self-reported attendance levels were higher when respondents reported sessions to be conveniently located (P = .03) and lower when respondents considered other priorities as more important for their family (P = .02). Maori more frequently reported that past experiences of health care influenced their decision to attend (P = .03). Facilitators included perceived convenience of the program, parental motivation to improve child health, and ongoing support from the program. CONCLUSIONS AND IMPLICATIONS: Program convenience and parental and/or self-motivation to improve health were facilitators of attendance. Further research is required to understand the relationship between past experiences with health care and subsequent engagement with services.

Global trends in ultraprocessed food and drink product sales and their association with adult body mass index trajectories.

This study evaluated global trends in ultraprocessed food and drink (UPFD) volume sales/capita and associations with adult body mass index (BMI) trajectories. Total food/drink volume sales/capita from Euromonitor for 80 countries (2002-2016) were matched to mean adult BMI from the NCD Risk Factor Collaboration (2002-2014). Products were classified as UPFD/non-UPFD according to the NOVA classification system. Mixed models for repeated measures were used to analyse associations between UPFD volume sales/capita and adult BMI trajectories, controlling for confounding factors. The increase in UPF volume sales was highest for South and Southeast Asia (67.3%) and North Africa and the Middle East (57.6%), while for UPD, the increase was highest for South and Southeast Asia (120.0%) and Africa (70.7%). In 2016, baked goods were the biggest contributor to UPF volume sales (13.1%-44.5%), while carbonated drinks were the biggest contributor to UPD volume sales (40.2%-86.0%). For every standard deviation increase (51 kg/capita, 2002) in UPD volume sales, mean BMI increased by 0.195 kg/m2 for men (P < .001) and 0.072 kg/m2 for women (P = .003). For every standard deviation (40 kg/capita, 2002) increase in UPF volume sales, mean BMI increased by 0.316 kg/m2 for men (P < .001), while the association was not significant for women. Increases in UPFD volume sales/capita were positively associated with population-level BMI trajectories.

Effect of a text message intervention on alcohol-related harms and behaviours: secondary outcomes of a randomised controlled trial.

OBJECTIVE: Mobile Health approaches show promise as a delivery mode for alcohol screening and brief intervention. The 'YourCall' trial evaluated the effect of a low-intensity mobile phone text message brief intervention compared with usual care on hazardous drinking and alcohol-related harms among injured adults. This paper extends our previously published primary outcome analysis which revealed a significant reduction in hazardous drinking associated with the intervention at 3 months, with the effect maintained across 12 months follow-up. The objective of the current study was to evaluate the effect of the intervention on alcohol-related harms and troubles and help-seeking behaviours (secondary outcomes) at 12-months follow-up. RESULTS: A parallel two-group, single-blind, randomised controlled trial was conducted in 598 injured inpatients aged 16-69 years identified as having medium-risk hazardous drinking. Logistic regression models applied to 12-month follow-up data showed no significant differences between intervention and control groups in self-reported alcohol-related harms and troubles and help-seeking behaviours. Although this text message intervention led to a significant reduction in hazardous alcohol consumption (previously published primary outcome), changes in self-reported alcohol-related harms and troubles and help seeking behaviours at 12-months follow up (secondary outcomes) were small and non-significant. TRIAL REGISTRATION: ACTRN12612001220853. Retrospectively registered 19 November 2012.

Body Mass Index is Negatively Associated with Endometrial Cancer Stage, Regardless of Subtype and Menopausal Status.

Objective: Obesity is one of the common risk factors for developing of endometrial cancer and is negatively associated with its survival, although this result is controversial. Endometrial cancer stages range from stage I, which has better clinical outcomes to stage IV, which has poorer clinical outcomes. Endometrial cancer traditionally divides into type 1 and type 2 dependent on histology which has different clinical outcomes. In this study we investigated whether obesity is associated with the stages of endometrial cancer taking into account subtypes of cancer and menopausal status. Methods: Data on 1,104 women with endometrial cancer were retrospectively collected from the largest women's hospital in China and analysed. Data included age at diagnosis, body mass index (BMI), histology of cancer and menopausal status. Results: The BMI in patients with stage I endometrial cancer was significantly higher than that in patients with stage II or III or IV (p=0.0001). However, there was no statistical difference in BMI between patients with stage II, and stage III endometrial cancer. This negative association was persisted with type 1 and type 2 endometrial cancer (p=0.1989) and premenopausal and post-menopausal status (p=0.4342). In addition, the proportion of over-weight or obese women in type1 endometrial cancer with stage I was not different to type 2 endometrial cancer with stage I. Conclusion: Our data demonstrate that BMI is negatively associated with endometrial cancer in early stage regardless of subtypes of cancer, menopausal status and obesity may be also a potential risk factor for developing type 2 endometrial cancer.

Continuous support during labour in childbirth: a Cross-Sectional study in a university teaching hospital in Shanghai, China.

BACKGROUND: Fear or anxiety could result in adverse consequences on the course of labour. To date, family members are still not permitted in the delivery rooms in the majority of hospitals in China, and continuous support from hospital professional staff is also limited. This study aimed to evaluate the benefits of continuous support by family members and hospital professional staff during labour in China. METHODS: In this Cross-Sectional study, 362 primiparous pregnancies who self-requested to receive continuous or one to one support with vaginal delivery and 362 primiparous pregnant women with routine hospital maternal care were included from a university teaching hospital. Data on the length of labour, postpartum haemorrhage (PPH), use of pain relief, use of oxytocin, fetal distress, emergency caesarean section and apgar score at 1 and 5 min were retrospectively collected from hospital medical data-base and compared between the two groups. RESULTS: Multiple linear regressions adjusting for maternal age, BMI and birth weight, revealed the estimated length of labour for women with routine hospital maternal care was 2.03 times (95%CI 1.86 to 2.21) the duration of women with supportive care (median time, 3.05 h vs 1.5 h). In addition, Fisher's exact test showed the emergency caesarean section rate was significantly lower in women with supportive care compared to women with routine hospital maternal care (3.3% vs 24%). CONCLUSION: Our results suggest that continuous support from family members together with hospital professional staff should be considered as part of intrapartum care in hospitals in China.

Exploring immunisation inequities among migrant and refugee children in New Zealand.

Migrants may experience immunisation inequities compared with the host population related to barriers with accessing immunisations in their home countries, while migrating and/or post-arrival. This retrospective cohort study explored vaccination rates among migrant and non-migrant children in New Zealand (NZ). Linked de-identified data from various government sources from 1 January 2006 to 31 December 2015 were analysed using Statistic NZ's Integrated Data Infrastructure. Vaccination rates were compared between three cohorts of children aged up to 5 years: foreign-born children who migrated to NZ; children born in NZ of migrant mothers; and a comparator group of children born in NZ to non-migrant mothers. Less than half of foreign-born children (46%) had a record in the NZ National Immunisation Register compared with 95% and 96% among migrant and non-migrant NZ-born children, respectively. Foreign-born migrant children had lower age-appropriate reported vaccination rates by vaccine of interest, ethnicity and visa category compared with NZ-born children. Migrant children from Pacific ethnicities had lower reported coverage than other ethnicities. High rates of not age-appropriately vaccinated were noted among foreign-born children on refugee, Pacific and humanitarian visa schemes. This study highlights possible shortfalls around immunisation data, particularly about recording vaccinations given overseas for foreign-born children, and potential challenges around engagement with immunisation services for migrant children. However, results highlight the successful engagement of quota refugee children as part of NZ's refugee orientation programme. It is important to monitor vaccination coverage by migrant and refugee background to inform improvements to policy and practice for wider population health benefits.

Preoperative biliary drainage in resectable pancreatic cancer: a systematic review and network meta-analysis.

BACKGROUND: Controversy remains about the best pre-operative management of jaundice in patients with resectable pancreatic head cancer (RPC) undergoing planned pancreaticoduodenectomy (PD). OBJECTIVE: The aim of this study was to compare rates of post-operative complications in patients undergoing four pre-operative approaches (POA): preoperative biliary drainage with plastic stent (PBD-PS), metal stent (PBD-MS), and percutaneous transhepatic drain (PBD-PT), or no pre-operative biliary drainage (NPBD). METHOD: A study was included in the systematic review if it assessed the effects of PBD on post-operative outcomes in jaundiced patients with RPC. Endpoints were the rate of any post-operative complication, wound infection, intra-abdominal infection and post-operative bleeding. A network meta-analysis (NMA) was performed to rank the POAs from the best to worst, for each outcome. RESULTS: Thirty-two studies were included in the systematic review. Ten out of 32 studies included in the systematic review reported at least one of the 4 outcomes of interest and thus were used for NMA. The calculated odds ratios and P-scores ranked NPBD as the best approach. There was insufficient evidence to determine the best modality of PBD among PBD-PS, PBD-MS and PBD-PT. CONCLUSIONS: No preoperative biliary drainage may be the best management of preoperative jaundice in patients with RPC before PD. Further studies are needed to determine the best modality in patients that need PBD.

Differences in the risk of cardiovascular disease for movers and stayers in New Zealand: a survival analysis.

OBJECTIVES: To explore if risk of cardiovascular disease (CVD) for participants who moved before their first CVD event is higher than for stayers, and examine whether the relationship is moderated by ethnicity. METHODS: The sample comprised 2,068,360 New Zealand residents enrolled in any Primary Health Organisation, aged between 30 and 84 years, had complete demographic information, and no prior history of CVD. Cox proportional regression was used to compare CVD risk between movers and stayers. The analysis was conducted for the whole sample and stratified by ethnicity. RESULTS: The combined analysis suggested that movers have a lower risk of CVD than stayers. This is consistent for all ethnic groups with some variation according to experience of deprivation change following residential mobility. CONCLUSIONS: Although mobile groups may have a higher risk of CVD than immobile groups overall, risk of CVD in the period following a residential mobility event is lower than for stayers. Results are indicative of a short-term healthy migrant effect comparable to that observed for international migrants.

Effect of a text message intervention to reduce hazardous drinking among injured patients discharged from a trauma ward: a randomized controlled trial.

Screening and brief intervention for hazardous alcohol use in trauma care settings is known to reduce alcohol intake and injury recidivism, but is often not implemented due to resource constraints. Brief interventions delivered by mobile phone could overcome this challenge. This study aimed to evaluate the effect of a mobile phone text message intervention (YourCallTM) on hazardous drinkers admitted for an injury. The parallel two-group, single-blind, randomised controlled trial enrolled 598 injured patients aged 16-69 years identified as medium-risk drinkers at recruitment. The intervention group (n = 299) received 16 text messages incorporating brief intervention principles in the 4 weeks following discharge from hospital. Controls (n = 299) received usual care and one text message acknowledging participation in the trial. The primary outcome was the difference in hazardous alcohol use (assessed using AUDIT-C) between study groups at 3 months, with the maintenance of effect examined at 6 and 12 months' follow-up. Data were analysed using a mixed-effects model for repeated measures. Both groups had similar baseline features. Compared to controls, hazardous drinking was significantly lower in the intervention group at 3 months and maintained over the 12-month follow-up period (least squares mean difference in AUDIT-C scores: -0.322; 95% CI: -0.636, -0.008; p = 0.04). The intervention effect was similar among Maori (New Zealand's indigenous population) and non-Maori (interaction p = 0.59), and among younger (16-29 years) and older (30-69 years) patients (p = 0.77). The effectiveness of this intervention reflects the potential of low cost, scalable mobile health technologies to overcome common barriers in implementing alcohol harm reduction strategies following injury.

Changes in clinical disease activity are weakly linked to changes in MRI inflammation on treat-to-target escalation of therapy in rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis (RA) treat-to-target (T2T) regimens often use the disease activity score (28 joints) incorporating C-reactive protein (DAS28CRP) as an outcome measure. We compared changes in the DAS28CRP with changes in magnetic resonance imaging (MRI) inflammation on treatment escalation. METHODS: Eighty seropositive RA patients with active disease were enrolled. Group A (N = 57) escalated to another conventional disease-modifying therapy (cDMARD) combination, and Group B (N = 23) to anti-TNF therapy/cDMARDs. Contrast-enhanced 3T-MRI wrist scans were obtained before and 4 months after regimen change. Scan pairs were scored for inflammation (MRI(i)) and damage. Disease activity was assessed using the DAS28CRP. RESULTS: Eighty patients were enrolled and 66 MRI scan pairs were available for analysis. Intra-reader reliability was high: intraclass correlation coefficient (average) 0.89 (0.56-0.97). ΔDAS28CRP did not differ between groups: Group A, -0.94 (-3.30, 1.61); Group B, -1.53 (-3.59, 0.56) (p = 0.45). ΔMRI(i) also did not differ: Group A, 0 (-25, 10); Group B, -1 (-15, 28) (p = 0.12). Combining groups, ΔMRI(i) correlated weakly with ΔDAS28CRP (Spearman's 0.36, p = 0.003). Using multiple linear regression analysis adjusting for confounders, ΔDAS28CRP was associated with ΔMRI(i) (p = 0.056). Of the individual MRI measures, only Δtenosynovitis correlated with ΔDAS28CRP (Spearman's 0.33, p = 0.007). ΔMRI(i) was negatively associated with the MRI erosion score at entry (p = 0.0052). CONCLUSIONS: We report the first study investigating the link between changes in clinical and imaging inflammation in a real-world RA cohort escalating to conventional and biologic DMARDs. The association was significant but relatively weak, suggesting that MRI targets cannot yet be advocated as outcomes for T2T escalation. TRIAL REGISTRATION: ANZCTR 12614000895684 . Registered 22 August 2014.

SHARPSports mental Health Awareness Research Project: Prevalence and risk factors of depressive symptoms and life stress in elite athletes.

OBJECTIVES: Our study aims to estimate the prevalence of symptoms of depression and daily life hassles in elite athletes. DESIGN: A cross-sectional prospective epidemiological study design. METHODS: An online anonymous survey was administered during a 2-month period from May to July 2015. Athletes 18 years of age (or older) who were members of the High Performance Sport New Zealand programme were invited to participate. Of 370 potential participants, 187 completed responses were received (51%). Symptoms of depression were measured by the Centre for Epidemiological Studies Depression Scale-Revised (CESD-R). Life stress was measured by the Daily Hassles Questionnaire. RESULTS: Overall 21% (n=39) of participants reported symptoms consistent with depression. Only 2 of the 39 athletes were currently taking an anti-depressant medication. Those contemplating retirement, partaking in individual sport, and who were less than 25 years old had significantly increased odds of experiencing depression. Reported life stressors were higher in females, in those who play an individual sport and those in a centralised programme. There was a significant correlation between higher levels of life stress and experiencing depressive symptoms. CONCLUSIONS: This study highlights that depressive symptoms are prevalent in elite athletes with multiple potential risk factors identified including high life stress. These variables warrant further exploration to enable the early identification of athletes with depressive symptoms, screening and support for elite athletes.

Effective cataract surgical coverage: An indicator for measuring quality-of-care in the context of Universal Health Coverage.

OBJECTIVE: To define and demonstrate effective cataract surgical coverage (eCSC), a candidate UHC indicator that combines a coverage measure (cataract surgical coverage, CSC) with quality (post-operative visual outcome). METHODS: All Rapid Assessment of Avoidable Blindness (RAAB) surveys with datasets on the online RAAB Repository on April 1 2016 were downloaded. The most recent study from each country was included. By country, cataract surgical outcome (CSOGood, 6/18 or better; CSOPoor, worse than 6/60), CSC (operated cataract as a proportion of operable plus operated cataract) and eCSC (operated cataract and a good outcome as a proportion of operable plus operated cataract) were calculated. The association between CSC and CSO was assessed by linear regression. Gender inequality in CSC and eCSC was calculated. FINDINGS: Datasets from 20 countries were included (2005-2013; 67,337 participants; 5,474 cataract surgeries). Median CSC was 53.7% (inter-quartile range[IQR] 46.1-66.6%), CSOGood was 58.9% (IQR 53.7-67.6%) and CSOPoor was 17.7% (IQR 11.3-21.1%). Coverage and quality of cataract surgery were moderately associated-every 1% CSC increase was associated with a 0.46% CSOGood increase and 0.28% CSOPoor decrease. Median eCSC was 36.7% (IQR 30.2-50.6%), approximately one-third lower than the median CSC. Women tended to fare worse than men, and gender inequality was slightly higher for eCSC (4.6% IQR 0.5-7.1%) than for CSC (median 2.3% IQR -1.5-11.6%). CONCLUSION: eCSC allows monitoring of quality in conjunction with coverage of cataract surgery. In the surveys analysed, on average 36.7% of people who could benefit from cataract surgery had undergone surgery and obtained a good visual outcome.

Enoxaparin for the prevention of preeclampsia and intrauterine growth restriction in women with a history: a randomized trial.

BACKGROUND: Preeclampsia and small-for-gestational-age pregnancy are major causes of maternal and perinatal morbidity and mortality. Women with a previous pregnancy affected by these conditions are at an increased risk of recurrence in a future pregnancy. Past trials evaluating the effect of low-molecular-weight heparin for the prevention of recurrence of preeclampsia and small-for-gestational-age pregnancy have shown conflicting results with high levels of heterogeneity displayed when trials were compared. OBJECTIVE: We sought to assess the effectiveness of enoxaparin in addition to high-risk care for the prevention of preeclampsia and small-for-gestational-age pregnancy in women with a history of these conditions. STUDY DESIGN: This was an open-label randomized controlled trial in 5 tertiary care centers in 3 countries. Women with a viable singleton pregnancy were invited to participate between >6+0 and <16+0 weeks if deemed to be at high risk of preeclampsia and/or small for gestational age based on their obstetric history. Eligible participants were randomly assigned in a 1-to-1 ratio to standard high-risk care or standard high-risk care plus enoxaparin 40 mg (4000 IU) by subcutaneous injection daily from recruitment until 36+0 weeks or delivery, whichever occurred sooner. Standard high-risk care was defined as care coordinated by a high-risk antenatal clinic service, aspirin 100 mg daily until 36+0 weeks, and-for women with prior preeclampsia-calcium 1000-1500 mg daily until 36+0 weeks. In a subgroup of participants serum samples were taken at recruitment and at 20 and 30 weeks' gestation and later analyzed for soluble fms-like tyrosine kinase-1, soluble endoglin, endothelin-1, placental growth factor, and soluble vascular cell adhesion molecule 1. The primary outcome was a composite of preeclampsia and/or small-for-gestational-age <5th customized birthweight percentile. All data were analyzed on an intention-to-treat basis. The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12609000699268). RESULTS: Between July 26, 2010, and Oct. 28, 2015, a total of 156 participants were enrolled and included in the analysis. In all, 149 participants were included in the outcome analysis (72 receiving standard high-risk care plus enoxaparin and 77 receiving standard high-risk care only). Seven women who miscarried <16 weeks' gestation were excluded. The majority of participants (151/156, 97%) received aspirin. The addition of enoxaparin had no effect on the rate of preeclampsia and/or small-for-gestational-age <5th customized birthweight percentile: enoxaparin 18/72 (25%) vs no enoxaparin 17/77 (22.1%) (odds ratio, 1.19; 95% confidence interval, 0.53-2.64). There was also no difference in any of the secondary outcome measures. Levels of soluble fms-like tyrosine kinase-1 and soluble endoglin increased among those who developed preeclampsia, but there was no difference in levels of these antiangiogenic factors (nor any of the other serum analytes measured) among those treated with enoxaparin compared to those receiving standard high-risk care only. CONCLUSION: The use of enoxaparin in addition to standard high-risk care does not reduce the risk of recurrence of preeclampsia and small-for-gestational-age infants in a subsequent pregnancy.