Prevalence of, and factors associated with, diabetes mellitus in people with severe mental illness attending a multidisciplinary, outpatient cardiometabolic health assessment service.

INTRODUCTION: Evaluate the prevalence of, and factors associated with, diabetes in people with severe mental illness (SMI) attending the Collaborative Centre for Cardiometabolic Health in Psychosis (ccCHiP) tertiary referral clinics. RESEARCH DESIGN AND METHODS: Adult patients attending an initial ccCHiP clinic consultation (2014-2019) were studied. Diabetes was defined by an hemoglobin A1c of ≥6.5%, fasting blood glucose of ≥7.0 mmol/L, or a self-reported diagnosis of diabetes and prescription of antihyperglycemic medication. RESULTS: Over 5 years, 1402 individuals attended a baseline consultation. Mean age of 43.9±12.8 years, 63.1% male and 63.5% had a diagnosis of schizophrenia. Prevalence of diabetes was 23.0% (n=322); an additional 19.5% fulfilled criteria for pre-diabetes. Of those with diabetes, 15.8% were newly diagnosed. Of those with pre-existing diabetes, 84.5% were receiving treatment with antihyperglycemic medication. Over 94% of individuals with diabetes had dyslipidemia; half were current smokers; and 46.4% reported sedentary behavior. On multivariate analysis, diabetes was associated with older age, Aboriginal, Indian or Middle Eastern maternal ethnicity, elevated waist-to-height ratio, family history of diabetes and use of antipsychotic medication. CONCLUSION: Prevalence of diabetes mellitus in this multiethnic cohort with SMI is significantly higher than the Australian population. Targeted interventions via an assertive integrated approach are required to optimize cardiometabolic health in this population.

Feasibility of the Archercise biofeedback device to strengthen foot musculature.

BACKGROUND: Foot muscle weakness can produce foot deformity, pain and disability. Toe flexor and foot arch exercises focused on intrinsic foot muscle strength and functional control may mitigate the progression of foot deformity and disability. Ensuring correct exercise technique is challenging due to the specificity of muscle activation required to complete some foot exercises. Biofeedback has been used to improve adherence, muscle activity and movement patterns. We investigated the feasibility of using a novel medical device, known as "Archercise", to provide real-time biofeedback of correct arch movement via pressure change in an inflatable bladder, and foot location adherence via sensors embedded in a footplate during four-foot exercises. METHODS: Thirty adults (63% female, aged 23-68 years) performed four-foot exercises twice on the Archercise sensor footplate alone and then with biofeedback. One-way repeated measures ANOVA with pairwise comparisons were computed to assess the consistency of the exercise protocol between trial 1 and trial 2 (prior to biofeedback), and the effectiveness of the Archercise biofeedback device between trial 2 and trial 3 (with biofeedback). Outcome measures were: Arch movement exercises of arch elevation and lowering speed, controlled arch elevation, controlled arch lowering, endurance of arch elevation; Foot location adherence was determined by percentage of time the great toe, fifth toe and heel contacted footplate sensors during testing and were analysed with paired sample t-tests. Participant survey comments on the use of Archercise with biofeedback were reported thematically. RESULTS: Seventeen (89%) arch movement and foot location variables were collected consistently with Archercise during the foot exercises. Archercise with biofeedback improved foot location adherence for all exercises (p = 0.003-0.008), coefficient of determination for controlled arch elevation (p < 0.0001) and endurance area ratio (p = 0.001). Twenty-nine (97%) participants reported Archercise with biofeedback, helped correct exercise performance. CONCLUSIONS: Archercise is a feasible biofeedback device to assist healthy participants without foot pathologies perform foot doming exercises. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): 12616001559404. Registered 11 November 2016, http://www.ANZCTR.org.au/ACTRN12616001559404p.aspx.

Alarm interventions for nocturnal enuresis in children.

BACKGROUND: Enuresis (bedwetting) affects up to 20% of five-year-olds and can have considerable social, emotional and psychological effects. Treatments include alarms (activated by urination), behavioural interventions and drugs. OBJECTIVES: To assess the effects of enuresis alarms for treating enuresis in children. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 25 June 2018), and reference lists of relevant articles. SELECTION CRITERIA: We included randomised or quasi-randomised trials of enuresis alarms or alarms combined with another intervention for treating nocturnal enuresis in children between 5 and 16 years old. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed risk of bias and extracted data. MAIN RESULTS: We included 74 trials (5983 children). At treatment completion, alarms may reduce the number of wet nights a week compared to control or no treatment (mean difference (MD) -2.68, 95% confidence interval (CI) -4.59 to -0.78; 4 trials, 127 children; low-quality evidence). Low-quality evidence suggests more children may achieve complete response (14 consecutive dry nights) with alarms compared to control or no treatment (RR 7.23, 95% CI 1.40 to 37.33; 18 trials, 827 children) and that more children may remain dry post-treatment (RR 9.67, 95% CI 4.74 to 19.76; 10 trials, 366 children; low-quality evidence). At treatment completion, we are uncertain whether there is any difference between alarms and placebo drugs in the number of wet nights a week (MD -0.96, 95% CI -2.32 to 0.41; 1 trial, 47 children; very low-quality evidence). Alarms may result in more children achieving complete response than with placebo drugs (RR 1.59, 95% CI 1.16 to 2.17; 2 trials, 181 children; low-quality evidence). No trials comparing alarms to placebo reported the number of children remaining dry post-treatment. Compared with control alarms, code-word alarms probably slightly increase the number of children achieving complete response at treatment completion (RR 1.11, 95% CI 0.97 to 1.27; 1 trial, 353 children; moderate-quality evidence) but there is probably little to no difference in the number of children remaining dry post-treatment (RR 0.91, 95% CI 0.79 to 1.05; moderate-quality evidence). Very low-quality evidence means we are uncertain if there are any differences in effectiveness between the other different types of alarm. At treatment completion, alarms may reduce the number of wet nights a week compared with behavioural interventions (waking, bladder training, dry-bed training, and star chart plus rewards) (MD -0.81, 95% CI -2.01 to 0.38; low-quality evidence) and may increase the number of children achieving complete response (RR 1.77, 95% CI 0.98 to 3.19; low-quality evidence) and may slightly increase the number of children remaining dry post-treatment (RR 1.39, 95% CI 0.81 to 2.41; low-quality evidence). The evidence relating to alarms compared with desmopressin in the number of wet nights a week (MD -0.64, 95% CI -1.77 to 0.49; 4 trials, 285 children) and the number of children achieving complete response at treatment completion (RR 1.12, 95% CI 0.93 to 1.36; 12 trials, 1168 children) is low-quality, spanning possible harms and possible benefits. Alarms probably slightly increase the number of children remaining dry post-treatment compared with desmopressin (RR 1.30, 95% CI 0.92 to 1.84; 5 trials, 565 children; moderate-quality evidence). At treatment completion, we are uncertain if there is any difference between alarms and tricyclics in the number of wet nights a week, the number of children achieving complete response or the number of children remaining dry post-treatment, because the quality of evidence is very low. Due to very low-quality evidence we are uncertain about any differences in effectiveness between alarms and cognitive behavioural therapy, psychotherapy, hypnotherapy and restricted diet. Alarm plus desmopressin may reduce the number of wet nights a week compared with desmopressin monotherapy (MD -0.88, 95% CI -0.38 to -1.38; 2 trials, 156 children; low-quality evidence). Alarm plus desmopressin may increase the number of children achieving complete response (RR 1.32, 95% CI 1.08 to 1.62; 5 trials, 359 children; low-quality evidence) and the number of children remaining dry post-treatment (RR 2.33, 95% CI 1.26 to 4.29; 2 trials, 161 children; low-quality evidence) compared with desmopressin alone. Alarm plus dry-bed training may increase the number of children achieving a complete response compared to dry-bed training alone (RR 3.79, 95% CI 1.85 to 7.77; 1 trial, 80 children; low-quality evidence). It is unclear if there is any difference in the number of children remaining dry post-treatment because of the wide confidence interval (RR 0.56, 95% CI 0.15 to 2.12; low-quality evidence). Due to very low-quality evidence, we are uncertain about any differences in effectiveness between alarm plus bladder training versus bladder training alone. Of the 74 included trials, 17 reported one or more adverse events, nine reported no adverse events and 48 did not mention adverse events. Adverse events attributed to alarms included failure to wake the child, ringing without urination, waking others, causing discomfort, frightening the child and being too difficult to use. Adverse events of comparator interventions included nose bleeds, headaches and abdominal pain. There is probably a slight increase in adverse events between code-word alarm and standard alarm (RR 1.34, 95% CI 0.75 to 2.38; moderate-quality evidence), although we are uncertain because of the wide confidence interval. Alarms probably reduce the number of children experiencing adverse events compared with desmopressin (RR 0.38, 95% CI 0.20 to 0.71; 5 trials, 565 children; moderate-quality evidence). Very low-quality evidence means we cannot be certain whether the adverse event rate for alarms is lower than for other treatments. AUTHORS' CONCLUSIONS: Alarm therapy may be more effective than no treatment in reducing enuresis in children. We are uncertain if alarm therapy is more effective than desmopressin but there is probably a lower risk of adverse events with alarms than with desmopressin. Despite the large number of trials included in this review, further adequately-powered trials with robust randomisation are still needed to determine the full effect of alarm therapy.

Predictors of confidence in anatomy knowledge for work as a junior doctor: a national survey of Australian medical students.

BACKGROUND: Major changes to the teaching of anatomy associated with the integration of basic and clinical sciences in modern medical curricula have coincided with students reporting concern over achievement of learning outcomes in anatomy. Little guidance exists for medical educators designing anatomy courses that account for factors that positively influence medical student confidence in their own anatomy knowledge. We sought to determine what factors are associated with medical students' self-reported confidence in their anatomy knowledge in preparation for clinical practice. METHODS: Cross-sectional national survey of Australian medical students distributed using social media. We performed univariate and multivariable ordinal regression to determine the factors in anatomy learning and teaching that influence medical student self-reported confidence to have sufficient anatomy knowledge by the time of graduation, for practice as a junior doctor. RESULTS: Of 1309 surveyed, 1101 (84%) responded, representing 6.5% of the Australian medical student population. Mean age was 23.9 years (SD 4.8 years), a majority were female (644, 58.5%), and students in all years of both undergraduate (52%, 575) and graduate entry courses (48%, 529) were represented. Items associated with increased self-reported confidence in anatomy knowledge included adequate assessment of anatomy (Odds Ratio 2.17 [95% CI 1.69-2.81]), integration of anatomy with other basic sciences (OR 1.97 [1.52-2.56]) and clinical teaching (OR 1.90 [1.46-2.48]), male gender (OR 1.89 [1.48-2.42]), anatomy education prior to medical school (OR 1.46 [1.14-1.87]) and exposure to dissection (OR 1.39 [1.08-1.78]). Medical students in their clinical years reported lower confidence in their anatomy knowledge (OR 0.6 [0.47-0.77], p < 0.0001). Age and career intention were not significant predictors of confidence. CONCLUSIONS: Medical educators can enhance student confidence in their own anatomy knowledge by developing curricula that vertically integrating anatomy learning and teaching, integrate anatomy teaching with other basic sciences, and providing consistent assessment through both the pre-clinical and clinical stages of medical training. Anatomy education should also incorporate dissection as a teaching method, and students could benefit from completion of anatomy education prior to medical school. Consideration should also be given to further investigate the confidence of female students in their anatomy knowledge.

Multiple mini interview (MMI) for general practice training selection in Australia: interviewers' motivation.

BACKGROUND: Multiple Mini Interviews (MMIs) are being used by a growing number of postgraduate training programs and medical schools as their interview process for selection entry. The Australian General Practice and Training (AGPT) used a National Assessment Centre (NAC) approach to selection into General Practice (GP) Training, which include MMIs. Interviewing is a resource intensive process, and implementation of the MMI requires a large number of interviewers, with a number of candidates being interviewed simultaneously. In 2015, 308 interviewers participated in the MMI process - a decrease from 340 interviewers in 2014, and 310 in 2013. At the same time, the number of applicants has steadily increased, with 1930 applications received in 2013; 2254 in 2014; and 2360 in 2015. This has raised concerns regarding the increasing recruitment needs, and the need to retain interviewers for subsequent years of MMIs. In order to investigate interviewers' reasons for participating in MMIs, we utilised self-determination theory (SDT) to consider interviewers' motivation to take part in MMIs at national selection centres. METHODS: In 2015, 308 interviewers were recruited from 17 Regional Training Providers (RTPs) to participate in the MMI process at one of 15 NACs. For this study, a convenience sample of NAC sites was used. Forty interviewers were interviewed (n = 40; 40/308 = 13%) from five NACs. Framework analysis was used to code and categorise data into themes. RESULTS: Interviewers' motivation to take part as interviewers were largely related to their sense of duty, their desire to contribute their expertise to the process, and their desire to have input into selection of GP Registrars; a sense of duty to their profession; and an opportunity to meet with colleagues and future trainees. Interviewers also highlighted factors hindering motivation, which sometimes included the large number of candidates seen in one day. CONCLUSION: Interviewers' motivation for contributing to the MMIs was largely related to their desire to contribute to their profession, and ultimately improve future patient care. Interviewers recognised the importance of interviewing, and felt their individual roles made a crucial contribution to the profession of general practice. Good administration and leadership at each NAC is needed. By gaining an understanding of interviewers' motivation, and enhancing this, engagement and retention of interviewers may be increased.

Female genital mutilation in children presenting to Australian paediatricians.

OBJECTIVE: The WHO reports that female genital mutilation/cutting (FGM/C) is an ancient cultural practice prevalent in many countries. FGM/C has been reported among women resident in Australia. Our paper provides the first description of FGM/C in Australian children. DESIGN: Cross-sectional survey conducted in April-June 2014. SETTING: Paediatricians and other child health specialists recruited through the Australian Paediatric Surveillance Unit were asked to report children aged <18 years with FGM/C seen in the last 5 years, and to provide data for demographics, FGM/C type, complications and referral for each case. PARTICIPANTS: Of 1311 eligible paediatricians/child health specialists, 1003 (76.5%) responded. RESULTS: Twenty-three (2.3%) respondents had seen 59 children with FGM/C and provided detailed data for 31. Most (89.7%) were identified during refugee screening and were born in Africa. Three (10.3%) were born in Australia: two had FGM/C in Australia and one in Indonesia. All parents were born overseas, mainly Africa (98.1%). Ten children had WHO FGM/C type I, five type II, five type III and six type IV. Complications in eight children included recurrent genitourinary infections, menstrual, sexual, fertility and psychological problems. Nineteen children (82.6%) were referred to obstetrics/gynaecology: 16 (69.9%) to social work and 13 (56.5%) to child protection. CONCLUSIONS: This study confirms that FGM/C is seen in paediatric clinical practice within Australia. Paediatricians need cultural awareness, education and resources to help them identify children with FGM/C and/or at risk of FGM/C, to enable appropriate referral and counselling of children, families and communities to assist in the prevention of this practice.

Factors related to doctors' choice of rural pathway in general practice specialty training.

OBJECTIVE: To investigate the factors eligible applicants consider in electing for a rural pathway into specialty training. DESIGN: Cohort study. SETTING: Australia. PARTICIPANTS: Applicants to the Australian General Practice Training program. MAIN OUTCOME MEASURES: Applicants' initial preference of either a general or rural pathway to undertake specialty training. RESULTS: Of the 2,221 applicants, 45% were Australian Medical Graduates (AMGs), 27% Foreign Graduates of Accredited Medical Schools (FGAMS) and 29% International Medical Graduates (IMGs). Through government regulation, two thirds (70%) were eligible to train on both general and rural pathways and a third (30%) were required to train rurally. For applicants eligible for general pathway (n = 1552), those with rural background [Odds Ratio (OR) = 3.7, 95% CI 2.7-5.2] and rural clinical school experience (OR = 2.0, 95% CI 1.5-2.8) were more likely to choose the rural pathway. In addition, FGAMS who were eligible for the general pathway were less likely to choose a rural pathway when compared with IMGs (OR = 0.33, 95%CI 0.1 = 0.7). In applicants who changed their training pathway from their initial to revised preference, lower Multiple-Mini-Interview (OR = 0.54, 95% CI 0.43-0.66) and Situational Judgement Test z-scores (OR = 0.68, 95% CI 0.56-0.83) were associated with a higher probability of changing from a general to rural pathway preference. CONCLUSION: For those eligible for a general or rural pathway, rural background and rural clinical school experience are associated with the decision to elect for rural training. Targeted support for international and foreign graduates of Australia/New Zealand schools may influence them to train rurally.

Female genital mutilation: Survey of paediatricians' knowledge, attitudes and practice.

The study objective was to determine paediatricians' experience with female genital mutilation (FGM) in Australian children and adolescents. A cross-sectional, pilot-tested national survey of paediatricians practising in Australia and contributing to the Australian Paediatric Surveillance Unit was conducted. Clinicians' knowledge, attitudes and clinical experience with FGM, awareness of clinical guidelines and education/training needs were recorded. Of 1311 paediatricians surveyed, 497 (38%) responded. Fifty-seven percent were aged 50 years or more, and 51.3% were males. Over half believed that FGM was performed in children in Australia and most were aware of its complications, but few asked about or examined for FGM. Fifty (10.3%) had seen at least one case of FGM in girls aged <18 years during their clinical career, including 16 (3.3%) in the past 5 years. Most were aware that FGM is illegal in Australia (93.9%), agreed all types of FGM were harmful (97.4%) and agreed that FGM violated human rights (98.2%). Most (87.6%) perceived FGM as a traditional cultural practice, although 11.6% thought it was required by religion. The majority (81.8%) knew notification of FGM to child protection authorities was mandatory. Over half (62.0%) were aware of the WHO Statement on FGM, but only 22.0% knew the WHO classification of FGM. These novel data indicate a minority of paediatricians in Australia have clinical experience with or education about FGM. Educational programs, best-practice clinical guidelines and policies are required to address knowledge gaps and help paediatricians identify, manage and prevent FGM in children.

Tricyclic and related drugs for nocturnal enuresis in children.

BACKGROUND: Enuresis (bedwetting) affects up to 20% of five year-olds and 2% of adults. Although spontaneous remission often occurs, the social, emotional and psychological costs can be great. Tricyclics have been used to treat enuresis since the 1960s. OBJECTIVES: To assess the effects of tricyclic and related drugs compared with other interventions for treating children with enuresis. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Trials Register (containing trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings), on 30 November 2015, and reference lists of relevant articles. SELECTION CRITERIA: We included all randomised and quasi-randomised trials comparing a tricyclic or related drug with another intervention for treating enuresis. We also included combination therapies that included tricyclics. We excluded trials for treating daytime wetting. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the quality of the eligible trials, and extracted data. We settled differences by discussion with a third review author. MAIN RESULTS: Sixty-four trials met the inclusion criteria, involving 4071 children. The quality of many trials was poor, with comparisons addressed by single studies. Minor adverse effects were common, and reported in 30 trials. These included dizziness, headache, mood changes, gastrointestinal discomforts and neutropenia. More serious side-effects can occur but were not reported. Seven trials reported no adverse effects.Tricyclics are more effective than placebo, particularly for short-term outcomes. Compared to placebo, imipramine resulted in one fewer wet nights per week (mean difference (MD) -0.95, 95% confidence interval (CI) -1.40 to -0.50; 4 trials, 347 children), with fewer failing to achieve 14 consecutive dry nights (78% versus 95% for placebo, RR 0.74, 95% CI 0.61 to 0.90; 12 trials, 831 children). Amitriptyline and desipramine were more effective than placebo, but nortriptyline and mianserin showed no difference. Most tricyclics did not have a sustained effect after ceasing treatment, with 96% wetting at follow-up for imipramine versus 97% for placebo.Imipramine combined with oxybutynin is also more effective than placebo, with 33% failing to achieve 14 consecutive dry nights at the end of treatment versus 78% for placebo (RR 0.43, 95% CI 0.23 to 0.78; 1 trial, 47 children) and 45% wetting at follow-up versus 79% for placebo (RR 0.58, 95% CI 0.34 to 0.99; 1 trial, 36 children).There was insufficient evidence to judge the effect between different doses of tricyclics, and between different tricyclics. Treatment outcomes between tricyclic and desmopressin were similar, but were mixed when tricyclic was compared with an anticholinergic. However, when imipramine was compared with desmopressin plus oxybutynin (1 trial, 45 children), the combination therapy was more effective, with one fewer wet nights per week (MD 1.07, 95% CI 0.06 to 2.08) and 36% failing to achieve 14 consecutive dry nights versus 87% for imipramine (RR 2.39, 95% CI 1.35 to 4.25). Tricyclics were also more effective or showed no difference in response when compared to other drugs which are no longer used for enuresis.Tricyclics were less effective than alarms. Although there was no difference in the number of wet nights, 67% failed to achieve 14 consecutive dry nights for imipramine versus only 17% for alarms (RR 4.00, 95% CI 1.06 to 15.08; 1 trial, 24 children). Alarm therapy also had a more sustained effect after ceasing treatment with 100% on imipramine versus 58% on alarms wetting at follow-up (RR 1.67, 95% CI 1.03 to 2.69; 1 trial, 24 children).Imipramine was more effective than simple behavioural therapies during treatment, with one fewer wet nights per week compared with star chart plus placebo (MD -0.80, 95% CI -1.33 to -0.27; 1 trial, 250 children). At follow-up 40% were wet with imipramine versus 80% with fluids and avoiding punishment (RR 0.50, 95% CI 0.28 to 0.89; 1 trial, 40 children). However, imipramine was less effective than complex behavioural therapies, with 61% failing to achieve 14 consecutive dry nights for imipramine versus 33% for the three-step programme (RR 1.83, 95% CI 1.08 to 3.12; 1 trial, 72 children) and 16% for the three-step programme combined with motivational therapy and computer-led education (RR 3.91, 95% CI 2.30 to 6.66; 1 trial, 132 children) at the end of treatment, with similar results at follow-up.Tricyclics were more effective than restricted diet, with 99% failing to achieve 14 consecutive dry nights versus 84% for imipramine (RR 0.84, 95% CI 0.75 to 0.93; 1 trial, 147 children).There was insufficient evidence to judge the effect of tricyclics compared to the other miscellaneous interventions studied.At the end of treatment there were about two fewer wet nights for imipramine plus oxybutynin compared with imipramine monotherapy (MD -2.10, 95% CI -2.99 to -1.21; 1 trial, 63 children) and 48% on imipramine plus oxybutynin failed to achieve 14 consecutive dry nights compared with 74% on imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.92; 2 trials, 101 children). At follow-up, 45% on imipramine plus oxybutynin were wetting versus 83% on imipramine monotherapy (RR 0.55, 95% CI 0.32 to 0.92; 1 trial, 36 children).When imipramine combined with desmopressin was compared with imipramine monotherapy, there was no difference in outcomes. However, when imipramine plus desmopressin was compared with desmopressin monotherapy, the combination was more effective, with 15% not achieving 14 consecutive dry nights at the end of treatment for imipramine plus desmopressin versus 40% for desmopressin monotherapy (RR 0.38, 95% CI 0.17 to 0.83; 1 trial, 86 children). Tricyclics combined with alarm therapy were not more effective than alarm monotherapy, alarm combined with desmopressin or alarm combined with nortriptyline. The addition of a tricyclic to other behavioural therapies did not alter treatment response. AUTHORS' CONCLUSIONS: There was evidence that tricyclics are effective at reducing the number of wet nights during treatment, but do not have a sustained effect after treatment stops, with most children relapsing. In contrast, there was evidence that alarm therapy has better short- and long-term outcomes. There was some evidence that tricyclics combined with anticholinergics may be more effective that tricyclic monotherapy.

A randomised controlled trial of a code-word enuresis alarm.

OBJECTIVE: To compare a novel code-word alarm with a commercially available wireless alarm for treating enuresis. SETTING: A tertiary paediatric centre. PATIENTS: Children aged 6-18 with at least 3 wet nights per week in the previous 6 months referred by doctors. OUTCOMES: Primary outcome: the proportion who achieved a full response (14 consecutive dry nights) by 16 weeks. Secondary outcomes: change in frequency of wetting, duration of alarm training, percentage of wet nights that the child woke to the alarm, adherence to treatment, adverse events and satisfaction with treatment. RESULTS: Of the 353 participants, 176 were assigned to the code-word alarm and 177 to control. At 16 weeks, 54% (95% CI 47% to 61%) in the experimental group and 47% (95% CI 40% to 55%) in the control group had achieved a full response (p=0.22), with 74% and 66%, respectively, attaining a 50% or more reduction in wetting frequency (p=0.14). The experimental group woke more often than the control group (median percentage of waking 88% vs 77%, p=0.003) and had a greater reduction in wet nights (median reduction of 10 vs 9 nights per fortnight). Fewer in the experimental group discontinued therapy before achieving a full response (27% vs 37% discontinued, p=0.04). There were no significant differences in relapse rates at 6 months, adverse events or satisfaction between the two alarms. CONCLUSIONS: Although the code-word alarm increased waking, no difference in full response rates was demonstrated between the two alarms. TRIAL REGISTRATION NUMBER: ACTRN12609000070235.

Female genital mutilation and cutting: a systematic literature review of health professionals' knowledge, attitudes and clinical practice.

BACKGROUND: The World Health Organisation (WHO) estimates that 100-140 million girls and women have undergone female genital mutilation or cutting (FGM/C). FGM/C is an ancient cultural practice prevalent in 26 countries in Africa, the Middle East and Asia. With increased immigration, health professionals in high income countries including UK, Europe, North America and Australia care for women and girls with FGM/C. FGM/C is relevant to paediatric practice as it is usually performed in children, however, health professionals' knowledge, clinical practice, and attitudes to FGM/C have not been systematically described. We aimed to conduct a systematic review of the literature to address this gap. METHODS: The review was conducted according to guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42015015540, http://www.crd.york.ac.uk/PROSPERO/). Articles published in English 2000-2014 which used quantitative methods were reviewed. RESULTS: Of 159 unique articles, 18 met inclusion criteria. The methodological quality was poor - six studies met seven of the eight quality criteria. Study participants included mainly obstetricians, gynaecologists and midwives (15 studies). We found no papers that studied paediatricians specifically, but two papers reported on subgroups of paediatricians within a mixed sample of health professionals. The 18 articles covered 13 different countries: eight from Africa and 10 from high income countries. Most health professionals were aware of the practice of FGM/C, but few correctly identified the four FGM/C categories defined by WHO. Knowledge about FGM/C legislation varied: 25% of professionals in a Sudanese study, 46 % of Belgian labour ward staff and 94 % of health professionals from the UK knew that FGM/C was illegal in their country. Health professionals from high income countries had cared for women or girls with FGM/C. The need to report children with FGM/C, or at risk of FGM/C, to child protection authorities was mentioned by only two studies. CONCLUSION: Further research is needed to determine health professionals' attitudes, knowledge and practice to support the development of educational materials and policy to raise awareness and to prevent this harmful practice.

Risk of bias in randomized trials of pharmacological interventions in children and adults.

OBJECTIVE: To determine whether randomized controlled trials of pharmacologic interventions in children are more likely to be biased than similar trials in adults. STUDY DESIGN: Trials involving only children and published in MEDLINE between January 2008 and October 2009 (n=100) were randomly selected and matched, by drug class and therapeutic area, with a similar trial completed in adults. The Cochrane risk of bias tool was used to compare the pediatric and adult trials. RESULTS: The characteristics of adult and pediatric trials included were similar, except that adult studies were more likely to be conducted in Europe and published in specialty journals. Two-thirds of all trials were single center, and 62% had 100 or fewer participants. Many trials had an unclear risk of bias for allocation concealment (65% adult, 52% pediatric). More pediatric trials had a low risk of bias for random sequence generation (59% pediatric, 41% adult, P=.002) and blinding of outcome assessment (63% pediatric, 48% adult, P=.04) than adult trials; however, a sensitivity analysis of trials published since 2008 (and so matched by year of publication) did not confirm this finding, suggesting year of publication was an important confounder. CONCLUSIONS: When randomized controlled trials are matched for drug class and therapeutic area, trials involving children display a similar risk of bias. Differences in the risk of bias between pediatric and adult trials are not caused by differences in the capacity of researchers to conduct and report trials of high quality.

Predictors of remission and relapse in idiopathic nephrotic syndrome: a prospective cohort study.

BACKGROUND: Although most children with idiopathic nephrotic syndrome will respond to corticosteroid therapy, 80-90 % suffer one or more relapses. METHODS: Using Cox proportional hazard models, we analyzed predictors of remission and relapse in 1-year follow-up data on children aged below 15 years with new-onset nephrotic syndrome. RESULTS: Of 129 children, 107 achieved remission with corticosteroid therapy and 86 subsequently relapsed. Boys achieved remission more often than girls (adjusted hazard ratio [AHR] 1.52, 95 % confidence interval (CI) 1.02-2.3). Boys relapsed significantly more frequently than girls (AHR 1.77, 95 % CI 1.11-2.83) and were more likely to have frequently relapsing disease (AHR 3.3, 95 % CI 1.18-9.23). The risk of first relapse increased with the number of days to first remission (AHR 1.02, 95 % CI 1.01-1.04). The risk for a frequently relapsing course increased with a shorter time from remission to first relapse (AHR 0.92, 95 % CI 0.87-0.97). CONCLUSIONS: In idiopathic nephrotic syndrome, boys are more likely to respond initially, more likely to relapse, and to be classified as having frequently relapsing nephrotic syndrome. A decrease in time from remission to first relapse predicts for a frequently relapsing course.

Simple behavioural interventions for nocturnal enuresis in children.

BACKGROUND: Nocturnal enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15% to 20% of five year olds and up to 2% of adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs can be great. Behavioural interventions for treating bedwetting are defined as interventions that require a behaviour or action by the child which promotes night dryness and includes strategies which reward that behaviour. Behavioural interventions are further divided into:(a) simple behavioural interventions - behaviours or actions that can be achieved by the child without great effort; and(b) complex behavioural interventions - multiple behavioural interventions which require greater effort by the child and parents to achieve, including enuresis alarm therapy.This review focuses on simple behavioural interventions.Simple behavioural interventions are often used as a first attempt to improve nocturnal enuresis and include reward systems such as star charts given for dry nights, lifting or waking the children at night to urinate, retention control training to enlarge bladder capacity (bladder training) and fluid restriction. Other treatments such as medications, complementary and miscellaneous interventions such as acupuncture, complex behavioural interventions and enuresis alarm therapy are considered elsewhere. OBJECTIVES: To determine the effects of simple behavioural interventions in children with nocturnal enuresis.The following comparisons were made:1. simple behavioural interventions versus no active treatment;2. any single type of simple behavioural intervention versus another behavioural method (another simple behavioural intervention, enuresis alarm therapy or complex behavioural interventions);3. simple behavioural interventions versus drug treatment alone (including placebo drugs) or drug treatment in combination with other interventions. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, and handsearching of journals and conference proceedings (searched 15 December 2011). The reference lists of relevant articles were also searched. SELECTION CRITERIA: All randomised or quasi-randomised trials of simple behavioural interventions for treating nocturnal enuresis in children up to the age of 16. Studies which included children with daytime urinary incontinence or children with organic conditions were also included in this review if the focus of the study was on nocturnal enuresis. Trials focused solely on daytime wetting and trials of adults with nocturnal enuresis were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the quality of the eligible trials and extracted data. Differences between reviewers were settled by discussion with a third reviewer. MAIN RESULTS: Sixteen trials met the inclusion criteria, involving 1643 children of whom 865 received a simple behavioural intervention. Within each comparison, outcomes were mostly addressed by single trials, precluding meta-analysis. The only exception was bladder training versus enuresis alarm therapy which included two studies and demonstrated that alarm therapy was superior to bladder training.In single small trials, rewards, lifting and waking and bladder training were each associated with significantly fewer wet nights, higher full response rates and lower relapse rates compared to controls. Simple behavioural interventions appeared to be less effective when compared with other known effective interventions (such as enuresis alarm therapy and drug therapies with imipramine and amitriptyline). However, the effect was not sustained at follow-up after completion of treatment for the drug therapies. Based on one small trial, cognitive therapy also appeared to be more effective than rewards. When one simple behavioural therapy was compared with another, there did not appear to be one therapy that was more effective than another. AUTHORS' CONCLUSIONS: Simple behavioural methods may be superior to no active treatment but appear to be inferior to enuresis alarm therapy and some drug therapy (such as imipramine and amitriptyline). Simple behavioural therapies could be tried as first line treatment before considering enuresis alarm therapy or drug therapy, which may be more demanding and have adverse effects, although evidence supporting their efficacy is lacking.

Prevention, detection and management of early chronic kidney disease: a systematic review of clinical practice guidelines.

AIM: In response to the increase in Chronic Kidney Disease (CKD) worldwide, several professional organizations have developed clinical practice guidelines to manage and prevent its progression. This study aims to compare the scope, content and consistency of published guidelines on CKD stages I-III. METHODS: Electronic databases of the medical literature, guideline organizations, and the websites of nephrology societies were searched to November 2011. The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument and textual synthesis was used to appraise and compare recommendations. RESULTS: One consensus statement and 15 guidelines were identified and included. Methodological rigour across guidelines was variable, with average domain scores ranging from 24% to 95%. For detection of CKD, all guidelines recommended estimated glomerular filtration rate measurement, some also recommended serum creatinine and dipstick urinalysis. The recommended protein and albumin creatinine ratios and proteinuria definition thresholds varied (>150-300 mg/day to >500 mg/day). Blood pressure targets ranged (<125/75 to <140/90 mmHg). Angiotensin converting enzyme inhibitor and angiotensin receptor blockers were recommended for hypertension, as combined or as monotherapy. Protein intake recommendations varied (no restriction or 0.75 g/kg per day-1.0 g/kg per day). Salt intake of 6 g/day was recommended by most. Psychosocial support and education were recommended by few but specific strategies were absent. CONCLUSION: CKD guidelines were consistent in scope but were variable with respect to their recommendations, coverage and methodological quality. To promote effective primary and secondary prevention of CKD, regularly updated guidelines that are based on the best available evidence and augmented with healthcare context-specific strategies for implementation are warranted.

Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics).

BACKGROUND: Enuresis (bedwetting) is a socially stigmatising and stressful condition which affects around 15% to 20% of five-year olds and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great. Drugs (including desmopressin, tricyclics and other drugs) have often been tried to treat nocturnal enuresis. OBJECTIVES: To assess the effects of drugs other than desmopressin and tricyclics on nocturnal enuresis in children and to compare them with other interventions. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register of trials (searched 15 December 2011), which includes searches of MEDLINE and CENTRAL, to identify published and unpublished randomised and quasi-randomised trials. The reference lists of relevant articles were also searched. SELECTION CRITERIA: All randomised trials of drugs (excluding desmopressin or tricyclics) for treating nocturnal enuresis in children up to the age of 16 years were included in the review. Trials were eligible for inclusion if children were randomised to receive drugs compared with placebo, other drugs or behavioral interventions for nocturnal enuresis. Studies which included children with daytime urinary incontinence or children with organic conditions were also included in this review if the focus of the study was on nocturnal enuresis. Trials focused solely on daytime wetting and trials of adults with nocturnal enuresis were excluded. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the quality of the eligible trials and extracted data. Differences between review authors were settled by discussion with a third review author. MAIN RESULTS: A total of 40 randomised or quasi-randomised controlled trials (10 new in this update) met the inclusion criteria, with a total of 1780 out of 2440 children who enrolled receiving an active drug other than desmopressin or a tricyclic. In all, 31 different drugs or classes of drugs were tested. The trials were generally small or of poor methodological quality. There was an overall paucity of data regarding outcomes after treatment was withdrawn.For drugs versus placebo, when compared to placebo indomethacin (risk ratio [RR] 0.36, 95% CI 0.16 to 0.79), diazepam (RR 0.22, 95% CI 0.11 to 0.46), mestorelone (RR 0.32, 95% CI 0.17 to 0.62) and atomoxetine (RR 0.81, 95% CI 0.70 to 0.94) appeared to reduce the number of children failing to have 14 consecutive dry nights. Although indomethacin and diclofenac were better than placebo during treatment, they were not as effective as desmopressin and there was a higher chance of adverse effects. None of the medications were effective in reducing relapse rates, although this was only reported in five placebo controlled trials.For drugs versus drugs, combination therapy with imipramine and oxybutynin was more effective than imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.94) and also had significantly lower relapse rates than imipramine monotherapy (RR 0.35, 95% CI 0.16 to 0.77). There was an overall paucity of data regarding outcomes after treatment was withdrawn.For drugs versus behavioural therapy, bedwetting alarms were found to be better than amphetamine (RR 2.2, 95% CI 1.12 to 4.29), oxybutynin (RR 3.25, 95% CI 1.77 to 5.98), and oxybutynin plus holding exercises (RR 3.3, 95% CI 1.84 to 6.18) in reducing the number of children failing to achieve 14 consecutive dry nights.Adverse effects of drugs were seen in 19 trials while 17 trials did not adequately report the occurrence of side effects. AUTHORS' CONCLUSIONS: There was not enough evidence to judge whether or not the included drugs cured bedwetting when used alone. There was limited evidence to suggest that desmopressin, imipramine and enuresis alarms therapy were better than the included drugs to which they were compared. In other reviews, desmopressin, tricyclics and alarm interventions have been shown to be effective during treatment. There was also evidence to suggest that combination therapy with anticholinergic therapy increased the efficacy of other established therapies such as imipramine, desmopressin and enuresis alarms by reducing the relapse rates, by about 20%, although it was not possible to identify the characteristics of children who would benefit from combination therapy. Future studies should evaluate the role of combination therapy against established treatments in rigorous and adequately powered trials.

Parental consent to participation in a randomised trial in children: associated child, family, and physician factors.

BACKGROUND: Low participation rates in randomised controlled trials involving children are almost a universal problem, leading to high cost and low statistical power. Trial, parent/family, child, and physician factors have been reported to influence parental willingness to consent for paediatric trials. PURPOSE: To identify modifiable and unmodifiable factors associated with parental consent. METHODS: Demographic and clinical characteristics of children and their families and physician characteristics associated with parental consent were evaluated in a recent randomised placebo-controlled trial of prophylactic antibiotics to prevent recurrent urinary tract infection. RESULTS: Of 1109 eligible children identified (mean age, 2.0 years), 412 parents (37.2%) consented. On a multivariate analysis, the only modifiable factor associated with consent was request for consent by a member of the research study team rather than by a member of the clinical team (risk ratio (RR) = 1.9, 95% confidence interval (CI): 1.2-2.9). The unmodifiable factors significantly associated with consent were age of the child (≥4 years) (RR = 1.2, 95% CI: 1.1-1.4), presence of vesicoureteric reflux (RR = 1.5, 95% CI: 1.3-1.8), inpatient management of the index infection (RR = 0.8, 95% CI: 0.7-0.9), and multiple (≥4) symptoms at presentation (RR = 1.3, 95% CI: 1.1-1.5). LIMITATIONS: We have reported data from only one of the four participating centres in this trial. Data on non-consenters in other participating centres were not completely collected. Data on characteristics of the recruiting physician were limited. These findings are applicable for those considering a single randomised controlled trial. CONCLUSIONS: Parent, child, and physician factors are associated with consent for trial participation, with most not being modifiable. Having a member of the research study team approach the parent for consent appears to be the only feasible strategy for increasing recruitment to randomised trials in this setting.

Diagnosing daytime bladder symptoms in children with nocturnal enuresis: a comparison of brief parental questionnaire with in-depth, physician-elicited, assessment.

AIMS: To assess the accuracy of brief parental questionnaire reporting of daytime bladder symptoms in children with nocturnal enuresis and compare with in-depth reporting elicited by physician assessment, for diagnosing monosymptomatic and non-monosymptomatic nocturnal enuresis. METHODS: A cross-sectional study of consecutive children attending an outpatient nocturnal enuresis clinic at a tertiary paediatric hospital participated in the study. Parents were asked to complete a questionnaire as part of routine assessment at their first visit which was compared with a detailed clinical assessment by the physician involving eliciting a thorough history from the parent and child. RESULTS: Parents of 585 children participated in the study (mean age 9.2 years, range 5.0-17.5 years). Sixty percent of children were males. There was poor agreement between initial parental reporting and physician diagnosis of monosymptomatic and non-monosymptomatic nocturnal enuresis (Kappa = 0.3, 95% confidence interval 0.21-0.37), mainly because parents underreport daytime incontinence and urgency compared with physician-elicited information (43% vs. 69% and 66% vs. 87%, respectively). CONCLUSIONS: Parents underreport daytime symptoms by 20-25%. Reliance on a brief parental history without prompting by physicians for daytime symptoms for diagnosing type of nocturnal enuresis may be misleading and result in suboptimal management.

Paediatrician's responses to an evidence summary about renal tract imaging tests in children after urinary tract infection.

INTRODUCTION: Renal tract imaging after urinary tract infection (UTI) has been widely recommended but clinical practice varies substantially among paediatricians. AIM: To describe changes in knowledge and reported ordering practices of paediatricians in response to an evidence based summary about prevalence of abnormalities and test performance of renal tract imaging, in the setting of UTI in children. METHODS: 354 paediatricians were randomly selected from a register of Australasian physicians and surveyed 14 months before, and concurrent with, a summary of a relevant systematic review. Respondents' estimates were dichotomised and labelled as correct when within 5% of the evidence-based value. Frequency of correct responses was compared using McNemar's test for paired proportions. RESULTS: Response rate for the return of both surveys was 61% (215/354). Provision of the evidence summary significantly improved knowledge of the frequencies of associated renal tract abnormalities (vesicoureteric reflux and kidney damage), with an increase in correct responses of about 30% post summary (p<0.001 for reflux and damage). Prior to the summary, clinicians underestimated the sensitivity of all imaging tests for the diagnosis of renal damage and reflux by about 30%, with an increase in correct responses of 30-50% for all tests after the summary (p<0.001 for all). In contrast, reported imaging practices for all tests showed no significant change in practice after receipt of the evidence summary. CONCLUSIONS: Provision of evidence based information on rates of abnormality and test sensitivity improved knowledge but did not result in any significant change in reported practice. Properties of diagnostic tests conventionally thought to modify use, sensitivity and likelihood of detecting abnormalities, did not influence test ordering practices.