Evaluation of implementation of risk management guidelines for carriers of pathogenic variants in mismatch repair genes: a nationwide audit of familial cancer clinics.

INTRODUCTION: This nationwide study assessed the impact of Lynch syndrome-related risk management guidelines on clinicians' recommendations of risk management strategies to carriers of pathogenic variants in mismatch repair genes and the extent to which carriers took up strategies in concordance with guidelines. MATERIALS AND METHODS: Clinic files of 464 carriers (with and without colorectal cancer) were audited for carriers who received their genetic testing results in July 2008-July 2009 (i.e. before guideline release), July 2010-July 2011 and July 2012-July 2013 (both after guideline release) at 12 familial cancer clinics (FCCs) to ascertain the extent to which carriers were informed about risk management in accordance with guidelines. All carriers captured by the audit were invited to participate in interviews; 215 were interviewed to assess adherence to recommended risk management guidelines. RESULTS: The rates of documentation in clinic files increased significantly from pre- to post-guideline for only two out of eight risk management strategies. The strategies with the highest compliance of carriers post-guidelines were: uptake of one or two-yearly colonoscopy (87%), followed by hysterectomy to prevent endometrial cancer (68%), aspirin as risk-reducing medication (67%) and risk-reducing salpingo-oophorectomy (63%). Interrater reliability check for all guidelines showed excellent agreement (k statistics = 0.89). CONCLUSION: These results indicate that there is scope to further increase provision of advice at FCCs to ensure that all carriers receive recommendations about evidence-based risk management. A multi-pronged behaviour change and implementation science approach tailored to specific barriers is likely to be needed to achieve optimal clinician behaviours and outcomes for carriers.

The effects of ambient temperature and heatwaves on daily Campylobacter cases in Adelaide, Australia, 1990-2012.

Campylobacter spp. is a commonly reported food-borne disease with major consequences for morbidity. In conjunction with predicted increases in temperature, proliferation in the survival of microorganisms in hotter environments is expected. This is likely to lead, in turn, to an increase in contamination of food and water and a rise in numbers of cases of infectious gastroenteritis. This study assessed the relationship of Campylobacter spp. with temperature and heatwaves, in Adelaide, South Australia. We estimated the effect of (i) maximum temperature and (ii) heatwaves on daily Campylobacter cases during the warm seasons (1 October to 31 March) from 1990 to 2012 using Poisson regression models. There was no evidence of a substantive effect of maximum temperature per 1 °C rise (incidence rate ratio (IRR) 0·995, 95% confidence interval (95% CI) 0·993-0·997) nor heatwaves (IRR 0·906, 95% CI 0·800-1·026) on Campylobacter cases. In relation to heatwave intensity, which is the daily maximum temperature during a heatwave, notifications decreased by 19% within a temperature range of 39-40·9 °C (IRR 0·811, 95% CI 0·692-0·952). We found little evidence of an increase in risk and lack of association between Campylobacter cases and temperature or heatwaves in the warm seasons. Heatwave intensity may play a role in that notifications decreased with higher temperatures. Further examination of the role of behavioural and environmental factors in an effort to reduce the risk of increased Campylobacter cases is warranted.

Undiagnosed hypertension in a rural district in Bangladesh: The Bangladesh Population-based Diabetes and Eye Study (BPDES).

Hypertension is mainly asymptomatic and remains undiagnosed until the disease progresses. The objective of the study was to determine the prevalence of and risk factors for hypertension in rural Bangladesh. Using a population-based cluster random sampling strategy, 3096 adults aged ⩾30 years were recruited from a rural district in Bangladesh. Data collected included two blood pressure (BP) measurements, fasting blood glucose, socio-demographic and anthropometric measurements. Hypertension was defined as systolic BP (SBP) ⩾140 mm Hg or diastolic BP (DBP) ⩾90 mm Hg or self-reported diagnosed hypertension. Logistic regression techniques were used for data analyses. The crude prevalence of hypertension was 40% (95% confidence interval (CI) 38-42%) of which 82% were previously undiagnosed. People from lower socio-economic status (SES) had a significantly higher percentage of undiagnosed hypertension compared with people with higher SES (P<0.001). There was no significant gender difference in severity of hypertension. Males with higher education level compared with no education had a higher prevalence of hypertension (odds ratio 2.34, 95% CI 1.49-3.69). Older age and waist circumference in both genders, and diabetes, lack of physical activity in females were found to be associated with higher prevalence of hypertension. Our research suggests the prevalence of undiagnosed hypertension was higher in the rural area in Bangladesh than that reported from the rural area in neighbouring India and China. Lower SES was associated with a higher risk of undiagnosed hypertension. Public health programs at the grass-roots level must emphasise the provision of primary care and preventive services in managing this non-communicable disease.

The effect of temperature on different Salmonella serotypes during warm seasons in a Mediterranean climate city, Adelaide, Australia.

Changing trends in foodborne disease are influenced by many factors, including temperature. Globally and in Australia, warmer ambient temperatures are projected to rise if climate change continues. Salmonella spp. are a temperature-sensitive pathogen and rising temperature can have a substantial effect on disease burden affecting human health. We examined the relationship between temperature and Salmonella spp. and serotype notifications in Adelaide, Australia. Time-series Poisson regression models were fit to estimate the effect of temperature during warmer months on Salmonella spp. and serotype cases notified from 1990 to 2012. Long-term trends, seasonality, autocorrelation and lagged effects were included in the statistical models. Daily Salmonella spp. counts increased by 1·3% [incidence rate ratio (IRR) 1·013, 95% confidence interval (CI) 1·008-1·019] per 1 °C rise in temperature in the warm season with greater increases observed in specific serotype and phage-type cases ranging from 3·4% (IRR 1·034, 95% CI 1·008-1·061) to 4·4% (IRR 1·044, 95% CI 1·024-1·064). We observed increased cases of S. Typhimurium PT9 and S. Typhimurium PT108 notifications above a threshold of 39 °C. This study has identified the impact of warm season temperature on different Salmonella spp. strains and confirms higher temperature has a greater effect on phage-type notifications. The findings will contribute targeted information for public health policy interventions, including food safety programmes during warmer weather.

Does Co-morbidity provide significant improvement on age adjustment when predicting medical outcomes?

OBJECTIVE: Using three risk-adjustment methods we evaluated whether co-morbidity derived from electronic hospital patient data provided significant improvement on age adjustment when predicting major outcomes following an elective total joint replacement (TJR) due to osteoarthritis. METHODS: Longitudinal data from 819 elderly men who had had a TJR were integrated with hospital morbidity data (HMD) and mortality records. For each participant, any morbidity or health-related outcome was retrieved from the linked data in the period 1970 through to 2007 and this enabled us to better account for patient co-morbidities. Co-morbidities recorded in the HMD in all admissions preceding the index TJR admission were used to construct three risk-adjustment methods, namely Charlson co-morbidity index (CCI), Elixhauser's adjustment method, and number of co-morbidities. Postoperative outcomes evaluated included length of hospital stay, 90-day readmission, and 1-year and 2-year mortality. These were modelled using Cox proportional hazards regression as a function of age for the baseline models, and as a function of age and each of the risk-adjustment methods. The difference in the statistical performance between the models that included age alone and those that also included the co-morbidity adjustment method was assessed by measuring the difference in the Harrell's C estimates between pairs of models applied to the same patient data using Bootstrap analysis with 1000 replications. RESULTS: Number of co-morbidities did not provide any significant improvement in model discrimination when added to baseline models observed in all outcomes. CCI significantly improved model discrimination when predicting post-operative mortality but not when length of stay or readmission was modelled. For every one point increase in CCI, postoperative 1- and 2-year mortality increased by 37% and 30%, respectively. Elixhauser's method outperformed the other two providing significant improvement on age adjustment in all outcomes. CONCLUSION: The predictive performance of co-morbidity derived from electronic hospital data is outcome and risk-adjustment method specific.

A systematic review of surgical biopsy for LCIS found at core needle biopsy - do we have the answer yet?

BACKGROUND: The natural history of lobular carcinoma in-situ (LCIS) suggests that women are at increased risk of subsequent invasive breast cancer. Questions of effective management for women with this lesion have led to the need for evidence-based guidance and, in particular, guidance regarding management after LCIS is found at core needle biopsy (CNB). METHODS: A systematic review was conducted to determine the most appropriate management for women with LCIS found at CNB. A comprehensive search of the scientific literature was conducted to identify the literature pertaining to this population. Critical appraisal of the literature, data extraction and a narrative synthesis of the results were conducted. The outcome of interest was upgrade of diagnosis to invasive breast cancer or ductal carcinoma in-situ (DCIS). RESULTS: Sparse data, with limited generalisability and considerable uncertainty, are available for women with LCIS at CNB. Nine studies were identified that met pre-specified inclusion criteria. The reported estimates of upgrade of diagnosis from LCIS to invasive breast cancer or DCIS ranged from 2% to 25%. The body of evidence was limited by its retrospective nature, risk of selection bias and poor generalisability to all women with LCIS at CNB. Further, higher quality research is required to determine the best approach for women with LCIS at CNB with any certainty.

Pre-market approval and post-market direct-to-consumer advertising of medical devices in Australia: a case study of breast cancer screening and diagnostic devices.

While research investigating direct-to-consumer advertising of therapeutic goods in Australia has historically focused on prescription medicines, recent action taken by regulators against companies promoting medical devices has placed the industry into the spotlight. Despite the need to effectively regulate direct-to-consumer advertising of medical devices due to its potential harms, inadequacies in the current regulatory system have been noted. Under the present system, devices with a questionable evidence base may enter the Australian marketplace without an evaluation of their effectiveness, and regulators are reliant on industry self-regulation and consumer complaints to draw attention to cases of advertising misconduct. Although some successes in the present system have been observed, we argue that the outlined inadequacies continue to enable the promotion of medical devices to consumers without thorough or sufficient examination of evidence.

Exploring policy makers' perspectives on a clinical controversy: airway surgery for adult obstructive sleep apnoea.

BACKGROUND AND OBJECTIVES: Worldwide, there is increasing focus on measures to reduce ineffective healthcare practices. Upper airway surgeries for the treatment of adult obstructive sleep apnoea (OSA) represent a case-study in this area, given recent publications that draw into question their efficacy. Policy stakeholders were canvassed to assess their perspectives on this. DESIGN AND SETTING: Senior health policy stakeholders from Australia were criterion and snowball sampled (to identify opinion leaders). Participants were presented with preparatory material and took part in individual semistructured interviews. These focused on eliciting responses to recently published evidence and a relevant Cochrane review. Questions were posed relating to clinical effectiveness and associated policy implications. Interviews were taped and transcribed for thematic analysis. Participant comments were de-identified. FINDINGS: Ten stakeholders were interviewed before saturation was reached. Thematic analysis highlighted participant concern with the diversity of procedures on offer, coupled with limited effectiveness (suggesting potential clinical uncertainty) and considerations therefore of resource allocation (potential opportunity cost). Stakeholders seem aware of the methodological complexities, the ethical issues raised and the role of patients in considerations regarding appropriateness. Finally, policy stakeholders acknowledge that these procedures appear appropriate only for a minority, with consensus that policy level restrictions to government funding for these procedures may be warranted. CONCLUSION: This report highlights that this clinical controversy is of interest and relevance from a policy perspective with lessons and potential implications for clinical practice. It further highlights the need for clinical consensus on definitions of surgical "success" in treating this condition, as this forms an important pretext to policy considerations.

Climate variability and Ross River virus infections in Riverland, South Australia, 1992-2004.

Ross River virus (RRV) infection is the most common notifiable vector-borne disease in Australia, with around 6000 cases annually. This study aimed to examine the relationship between climate variability and notified RRV infections in the Riverland region of South Australia in order to set up an early warning system for the disease in temperate-climate regions. Notified data of RRV infections were collected by the South Australian Department of Health. Climatic variables and monthly river flow were provided by the Australian Bureau of Meteorology and South Australian Department of Water, Land and Biodiversity Conservation over the period 1992-2004. Spearman correlation and time-series-adjusted Poisson regression analysis were performed. The results indicate that increases in monthly mean minimum and maximum temperatures, monthly total rainfall, monthly mean Southern Oscillation Index and monthly flow in the Murray River increase the likelihood, but an increase in monthly mean relative humidity decreases the likelihood, of disease transmission in the region, with different time-lag effects. This study demonstrates that a useful early warning system can be developed for local regions based on the statistical analysis of readily available climate data. These early warning systems can be utilized by local public health authorities to develop disease prevention and control activities.

Impact on the Australian Quitline of new graphic cigarette pack warnings including the Quitline number.

BACKGROUND: In March 2006, Australia introduced graphic pictorial warnings on cigarette packets. For the first time, packs include the Quitline number. OBJECTIVE: To measure the combined effect of graphic cigarette pack warnings and printing the Quitline number on packs on calls to the Australian Quitline service. METHODS: Calls to the Australian Quitline were monitored over 4 years, 2 years before and after the new packets were introduced. RESULTS: There were twice as many calls to the Quitline in 2006 (the year of introduction), as there were in each of the preceding 2 years. The observed increase in calls exceeds that explained by the accompanying television advertising alone. While call volume tapered back in 2007, it remained at a level higher than before the introduction of new packets. No change was observed in the proportion of first time callers. CONCLUSION: Introducing graphic cigarette packet warnings and the Quitline number on cigarette packets boosts demand for Quitline services, with likely flow on effects to cessation.

Mortality and cancer incidence of Australian participants in the British nuclear tests in Australia.

OBJECTIVES: To investigate the mortality and cancer incidence of Australian nuclear test participants, and to identify any association with exposure to ionising radiation. METHODS: A retrospective cohort study was carried out in which the mortality and cancer incidence rates of participants (n = 10,983) were compared with rates in the general male Australian population. Dose reconstructions were carried out by a panel of health physicists. Mortality and cancer rates were compared with the general population and between groups of subjects categorised by assessed radiation exposure. RESULTS: All-cause mortality was not raised. Mortality and incidence were significantly raised for cancers of the head and neck, lung, colon and rectum, and prostate, and for all cancers combined. For oesophageal cancer, melanoma, all leukaemias and non-chronic lymphatic leukaemia (non-CLL leukaemia), incidence was significantly raised, but mortality was non-significantly raised. No association was found between radiation exposure and overall cancer incidence or mortality, or with any cancer or cancer deaths occurring in excess. CONCLUSIONS: There is no evidence that the excess cancers and cancer deaths were caused by radiation exposure at the test sites. Possible contributing factors are high smoking prevalence and demographic differences from the Australian population with whom rates were compared. Asbestos is a likely contributor to some cancers in naval personnel.

Missing data on retrospective recall of early-life socio-economic position in surveillance systems: an additional disadvantage?

OBJECTIVES: Inclusion of information on early-life socio-economic position (SEP) in population chronic disease and risk factor surveillance systems enables better monitoring of effects of policies and interventions on health inequities and intergenerational disadvantage. Examining data quality, in terms of item non-response, informs choices about which indicators of early-life SEP to include in surveillance questionnaires. This study examined differences in recall of indicators of early-life SEP between different socio-economic groups. STUDY DESIGN: Cross-sectional population survey. METHODS: A representative population of people aged 18 years and over living in South Australia (n=2999) was selected at random from the electronic white pages, and a computer-assisted telephone interview was administered. RESULTS: Respondents with missing data on early-life SEP indicators were disadvantaged in terms of current SEP compared with those who provided this information. Among all respondents, the highest proportions of missing data were observed for maternal grandfather's main occupation (27.2%), and mother's (20.1%) and father's (19.6%) highest level of education. Family structure, housing tenure and family financial situation when the respondent was 10 years old, and mother's and father's main occupation were the indicators of early-life SEP that performed best in terms of recall. CONCLUSIONS: The differential response to early-life SEP questions according to current circumstances has implications for chronic disease surveillance examining the life-course impact of socio-economic disadvantage.

Internet use and risk behaviours: an online survey of visitors to three gay websites in China.

OBJECTIVES: To describe the risk behaviours of visitors to gay websites and to explore the role of the internet in the HIV transmission among the Chinese men who have sex with men (MSM). METHODS: Between May and August 2006, visitors of three Chinese gay websites were invited to complete an online questionnaire about the use of the internet and risk sexual behaviours. RESULTS: The median age of the online sample was 25 years old (range 18 to 64). Over three-quarters (77.6%) had an education of college or higher. Less than 44% of the online sample reported little or no risk for HIV transmission. These men had either had no anal intercourse (28.0%) or had always used a condom for anal intercourse (15.8%). Although only about half of the participants reported that their main purpose of visiting the gay websites was to look for sexual partners, most participants (86.1%) had used the internet to seek partners. Compared with men seeking sexual partners only on the internet, men seeking partners both in traditional gay venues and on the internet were older, less likely to be students and more likely to have unprotected anal intercourse, more than six sexual partners in the past 6 months and commercial sex behaviours. CONCLUSION: The users of the gay websites are relatively young and well educated, and highly vulnerable to HIV/AIDS, given their low prevalence of consistent condom use and multiple-risk sexual behaviours. Effective intervention programmes should be implemented and strengthened in China, especially for those who seek sexual partners both on the internet and in traditional gay venues.

Weather: driving force behind the transmission of severe acute respiratory syndrome in China?

BACKGROUND: The association between weather and severe acute respiratory syndrome (SARS) transmission in Beijing and Hong Kong in the 2003 epidemic was studied to examine the effect of weather on SARS transmission. METHODS: Pearson's correlation analyses and negative binomial regression analyses were used to quantify the correlations between the daily newly reported number of SARS cases and weather variables, using daily disease notification data and meteorological data from the two locations. RESULTS: The results indicate that there were inverse association between the number of daily cases and maximum and/or minimum temperatures whereas air pressure was found to be positively associated with SARS transmission. CONCLUSION: The study suggests that weather might be a contributory factor in the 2003 SARS epidemic, in particular in the transmission among the community members.

A life-course approach to measuring socioeconomic position in population health surveillance systems.

Measuring socioeconomic position (SEP) in population chronic disease and risk factor surveillance systems is essential for monitoring socioeconomic inequalities in health over time. Life-course measures are an innovative way to supplement other SEP indicators in surveillance systems. A literature review examined the indicators of early-life SEP that could potentially be used in population health surveillance systems. The criteria of validity, relevance, reliability and deconstruction were used to determine the value of potential indicators. Early-life SEP indicators used in cross-sectional and longitudinal studies included education level, income, occupation, living conditions, family structure and residential mobility. Indicators of early-life SEP should be used in routine population health surveillance to monitor trends in the health and SEP of populations over time, and to analyse long-term effects of policies on the changing health of populations. However, these indicators need to be feasible to measure retrospectively, and relevant to the historical, geographical and sociocultural context in which the surveillance system is operating.

Occupational blood and body fluid exposure in an Australian teaching hospital.

To examine work-related blood and body fluid exposure (BBFE) among health-care workers (HCWs), to explore potential risk factors and to provide policy suggestions, a 6-year retrospective study of all reported BBFE among HCWs (1998-2003) was conducted in a 430-bed teaching hospital in Australia. Results showed that BBFE reporting was consistent throughout the study period, with medical staff experiencing the highest rate of sharps injury (10.4%). Hollow-bore needles were implicated in 51.7% of all percutaneous injuries. Most incidents occurred during sharps use (40.4%) or after use but before disposal (27.1%). Nursing staff experienced 68.5% of reported mucocutaneous exposure. Many such exposures occurred in the absence of any protective attire (61.1%). This study indicated that emphasis on work practice, attire, disposal systems and education strategies, as well as the use of safety sharps should be employed to reduce work-related injuries among HCWs in Australia.

The index of relative socio-economic disadvantage: general population views on indicators used to determine area-based disadvantage.

OBJECTIVE: To ascertain general population perceptions of the importance of indicators comprising the Index of Relative Socio-economic Disadvantage (IRSD). METHODS: Data for this study came from a face-to-face Health Omnibus survey of 3,001 residents in metropolitan and country South Australia, conducted in 2003. RESULTS: Overall, respondents viewed the IRSD indicators as important. Of the 14 indicators, seven were seen as important by more than two-thirds of respondents (ranging from 90% perceiving the number of families with children and a low income important to 68% perceiving the number of one-parent families with dependent children as important). Younger respondents and those of lower educational attainment were more likely to perceive the indicators as unimportant, compared with older people. For example, 14% of people aged 15-24 vs. 5% of people aged 55-64 (p < or = 0.001) viewed the indicator 'number of one-parent families and dependent children' as unimportant. CONCLUSIONS: While the general population generally recognises the IRSD indicators as important measures of area-based disadvantage, there were systematic age differences in the degree to which individual indicators were deemed important. There was a general lack of support for several indicators (such as proportion of people separated/divorced, houses with no cars). IMPLICATIONS: This research raises the question of which factors are important in representing area-based disadvantage for young people and equally the use of this index when examining variations in the health of young Australians.

Systematic review of endovenous laser treatment for varicose veins.

BACKGROUND: The safety and effectiveness of endovenous laser treatment (EVLT) for varicose veins are not yet fully evaluated. METHODS: Medical bibliographic databases, the internet and reference lists were searched from January 1966 to September 2004. Only case series were available for inclusion in the review. RESULTS: : Thirteen studies met the inclusion criteria. Self-limiting features, such as pain, ecchymosis, induration and phlebitis, were commonly encountered after treatment. Deep vein thrombosis and incorrect placement of the laser in vessels were uncommon adverse events. No study has yet assessed the effectiveness of laser therapy in comparison to saphenofemoral junction ligation with saphenous vein stripping. Occlusion of the saphenous vein and abolition of venous reflux occurred in 87.9-100 per cent of limbs, with low rates of re-treatment and recanalization. CONCLUSION: From the low-level evidence available it seems that EVLT benefits most patients in the short term, but rates of recanalization, re-treatment, occlusion and reflux may alter with longer follow-up. The lack of such data, in addition to the small numbers of patients in the available studies, demonstrates the need for a randomized clinical trial of EVLT versus conventional surgery.

Systematic review of safety and effectiveness of an artificial bowel sphincter for faecal incontinence.

BACKGROUND: The aim was to determine the safety and effectiveness of the implantation of an artificial bowel sphincter for the treatment of severe faecal incontinence. METHOD: Medical bibliographic databases, the internet and reference lists were searched from January 1966 to January 2003. Only the lowest level of evidence was available for inclusion in this systematic review. Case series and case reports were selected to assess safety, whereas only case series were selected to assess effectiveness. RESULTS: Fourteen studies met the inclusion criteria. A number of safety issues were reported, including high explantation rates, and rates of adverse events owing to infection, device malfunction, ulceration and pain. Results in published reports were not analysed on an intention-to-treat basis. Continence, quality of life and manometry scores were reported for patients with a functioning device at the end of follow-up. These patients experienced a significant improvement in their level of continence. As no outcome data were presented for those with a non-functioning or explanted device, it is possible that such patients may have a worsened degree of incontinence or decreased quality of life. CONCLUSION: Implantation of an artificial bowel sphincter is of uncertain benefit and may possibly harm many patients. Patient selection is therefore critical and should be enhanced by higher-quality research.

Systematic review of the safety and effectiveness of methods used to establish pneumoperitoneum in laparoscopic surgery.

BACKGROUND: A systematic review was conducted to determine which of the methods of obtaining peritoneal access and establishing pneumoperitoneum is the safest and most effective. METHODS: Studies that met the inclusion criteria were identified from six bibliographic databases up to May 2002, the internet, hand-searches and reference lists. They were critically appraised using a validated checklist and data were extracted using standardized protocols. RESULTS: Meta-analysis of prospective, non-randomized studies of open versus closed (needle/trocar) access indicated a trend during open access towards a reduced risk of major complications (pooled relative risk (RR(p)) 0.30, 95 per cent confidence interval (c.i.) 0.09 to 1.03). Open access was also associated with a trend towards a reduced risk of access-site herniation (RR(p) 0.21, 95 per cent c.i. 0.04 to 1.03) and, in non-obese patients, a 57 per cent reduced risk of minor complications (RR(p) 0.43, 95 per cent c.i. 0.20 to 0.92) and a trend for fewer conversions to laparotomy (RR(p) 0.21, 95 per cent c.i. 0.04 to 1.17). Data on major complications in studies of direct trocar versus needle/trocar access were inconclusive. Minor complications in randomized controlled trials were fewer with direct trocar access (RR(p) 0.19, 95 per cent c.i. 0.09 to 0.40), predominantly owing to a reduction in extraperitoneal insufflation. CONCLUSION: The evidence on the comparative safety and effectiveness of the different access methods was not definitive, but there were trends in the data that merit further exploration.