Antenatal health and perinatal outcomes of Pacific Islander women in Australia with and without gestational diabetes: A ten-year retrospective cohort study.

BACKGROUND: Pacific Islander (PI) women in Australia have an increased risk of gestational diabetes (GDM); however, their perinatal outcomes are poorly understood. AIM: The aim was to determine the maternal characteristics and perinatal outcomes of PI women with and without GDM compared to Australian/European (AE)-born women. METHODS: A retrospective analysis of perinatal outcomes of singleton deliveries >20 weeks' gestation between 1 January 2011 and 31 December 2020 was conducted at a tertiary provider (Melbourne, Australia). Antenatal details and birth outcomes were extracted from the Birth Outcome Systems database. t-Tests and χ2, univariate and multivariable logistic regression analyses assessed the relationship between ethnicity and outcomes. RESULTS: Of 52,795 consecutive births, 24,860 AE women (13.3% with GDM) and 1207 PI-born women (20.1% with GDM) were compared. PI women had significantly greater pre-pregnancy body mass index (BMI) and significantly lower rates of smoking and nulliparity. PI women with GDM had higher rates of pre-eclampsia (P < 0.001), large-for-gestational age (LGA) neonates (P = 0.037) and neonatal hypoglycaemia (P = 0.017) but lower rates of small-for-gestational age neonates (P = 0.034). Neonatal intensive care unit (NICU)/special care nursery requirements did not increase. After having adjusted for covariates, PI women's risk of LGA neonates (adjusted odds ratio (aOR): 1.06, 95% confidence interval (CI): 0.86-1.31) was attenuated; however, risk of pre-eclampsia (aOR: 1.49, 95% CI: 1.01-2.21) and neonatal hypoglycaemia (aOR: 1.40, 95% CI: 1.01-1.96) still increased. They were less likely to require a primary caesarean section (aOR: 0.86, 95% CI: 0.73-0.99). CONCLUSION: PI women have higher BMI and GDM rates, contributing to an increased likelihood of adverse perinatal outcomes. BMI is a modifiable risk factor that could be addressed prenatally.

Prolactin ordering patterns in psychiatric inpatients and the impact this has on patient management.

OBJECTIVE: Guidelines stipulate that baseline prolactin be ordered prior to commencing antipsychotic treatment to facilitate investigation of any subsequent hyperprolactinaemic symptoms. The aim was to observe when and why prolactin levels are ordered for psychiatry inpatients commencing or continuing antipsychotics and how this alters clinical management. METHODS: Psychiatry inpatients admitted to the Alfred Hospital, Melbourne, Australia, in 2018 with the diagnoses of psychosis, schizophrenia, schizo-affective disorder or bipolar affective disorder were retrospectively analysed. Results and clinical history data were collected in patients in whom prolactin was ordered during or within 12 months of the relevant admission. RESULTS: Of 592 patients admitted during this period, 90 had prolactin ordered. Eight (8.9%) of the 90 tests were for hyperprolactinaemic symptoms, while the remainder were routine blood work. The results altered clinical management in 10 of the 90 (11.1%) patients. Of these 10, 8 were symptomatic. In the six patients with first episode psychosis, only one had prolactin ordered prior to antipsychotic commencement. CONCLUSIONS: Adherence to guideline recommendations of baseline prolactin testing was poor. When established on antipsychotics, measuring prolactin rarely changed management in asymptomatic patients; however, it did in those with hyperprolactinaemic symptoms. Measuring prolactin in asymptomatic patients on antipsychotics appears unhelpful.

"It Makes You Rethink Your Choice of the Pill": Theory-Based Formative Research to Design a Contraceptive Choice Campaign.

Half of all pregnancies in the United States remain unplanned despite improved access to highly effective long-acting reversible contraception, including the intrauterine device and the implant. This study conducted theory-based formative research to develop a contraceptive choice campaign aimed at increasing long-acting reversible contraception uptake by women ages 18-44 years in Charleston, South Carolina, an urban area in the southeastern United States. Researchers developed and tested message concepts and designs. Six focus groups and 18 interviews were conducted among reproductive-age women (n = 79). Qualitative data analysis revealed messages and designs that resonated with these women. Emphasizing long-acting reversible contraception as the healthy option, highlighting long-acting reversible contraception effectiveness, including relatable and trustworthy characters, and using language of control emerged as themes. Women reported a preference for statistics illustrating effectiveness combined with empowering messages of control over contraceptive decision making. Findings from this study offer practical recommendations for developing contraceptive choice campaigns targeting long-acting reversible contraception use and further the goal of reducing unintended pregnancy among women.

Follow up after surgery for colorectal liver metastases: A systematic review.

INTRODUCTION: Recurrence post hepatectomy for colorectal liver metastases (CRLM) occurs in 70 % of patients within two years. No established guidance on the method or intensity of follow-up currently exists. The aim of this systematic review was to summarise literature and determine whether it is possible to identify an optimal follow up regime. To this date there are no randomised prospective studies investigating this. METHODS: A systematic review was performed according to PRISMA guidelines. Outcomes included general demographics, method, frequency and duration of follow up, survival and recurrence data. Quality assessment of the papers was performed. RESULTS: Twenty-five articles published between 1994 and 2022 were included, including 9945 patients. CT was the most common imaging modality (n = 14) and CEA most common blood test (n = 11). Intensity of follow up was higher in the first two years post resection and only two papers continued follow up post 5 years resection. There was wide variation in outcome measures - Overall survival (OS) was most commonly reported. Nine papers reported OS ranging between 39 and 78.1 %. CONCLUSIONS: There is wide variation in follow up methods and outcome reporting. There is no strong evidence to support intensive follow up, and the benefits of long term follow up are also unknown due to the lack of patient centred data. High quality, prospective studies should be the focus of future research as further retrospective data is unlikely to resolve uncertainties around optimal follow up.

Monitoring and Managing Lifestyle Behaviors Using Wearable Activity Trackers: Mixed Methods Study of Views From the Huntington Disease Community.

BACKGROUND: There are early indications that lifestyle behaviors, specifically physical activity and sleep, may be associated with the onset and progression of Huntington disease (HD). Wearable activity trackers offer an exciting opportunity to collect long-term activity data to further investigate the role of lifestyle, physical activity, and sleep in disease modification. Given how wearable devices rely on user acceptance and long-term adoption, it is important to understand users' perspectives on how acceptable any device might be and how users might engage over the longer term. OBJECTIVE: This study aimed to explore the perceptions, motivators, and potential barriers relating to the adoption of wearable activity trackers by people with HD for monitoring and managing their lifestyle and sleep. This information intended to guide the selection of wearable activity trackers for use in a longitudinal observational clinical study. METHODS: We conducted a mixed methods study; this allowed us to draw on the potential strengths of both quantitative and qualitative methods. Opportunistic participant recruitment occurred at 4 Huntington's Disease Association meetings, including 1 international meeting and 3 United Kingdom-based regional meetings. Individuals with HD, their family members, and carers were invited to complete a user acceptance questionnaire and participate in a focus group discussion. The questionnaire consisted of 35 items across 8 domains using a 0 to 4 Likert scale, along with some additional demographic questions. Average questionnaire responses were recorded as positive (score>2.5), negative (score<1.5), or neutral (score between 1.5 and 2.5) opinions for each domain. Differences owing to demographics were explored using the Kruskal-Wallis and Wilcoxon rank sum tests. Focus group discussions (conducted in English) were driven by a topic guide, a vignette scenario, and an item ranking exercise. The discussions were audio recorded and then analyzed using thematic analysis. RESULTS: A total of 105 completed questionnaires were analyzed (47 people with HD and 58 family members or carers). All sections of the questionnaire produced median scores >2.5, indicating a tendency toward positive opinions on wearable activity trackers, such as the devices being advantageous, easy and enjoyable to use, and compatible with lifestyle and users being able to understand the information from trackers and willing to wear them. People with HD reported a more positive attitude toward wearable activity trackers than their family members or caregivers (P=.02). A total of 15 participants participated in 3 focus groups. Device compatibility and accuracy, data security, impact on relationships, and the ability to monitor and self-manage lifestyle behaviors have emerged as important considerations in device use and user preferences. CONCLUSIONS: Although wearable activity trackers were broadly recognized as acceptable for both monitoring and management, various aspects of device design and functionality must be considered to promote acceptance in this clinical cohort.

Conducting focus groups in neurodegenerative disease populations: ethical and methodological considerations.

BACKGROUND: Involvement of vulnerable populations in research is critical to inform the generalisability of evidence-based medicine to all groups of the population. OBJECTIVE: In this communication, we reflect on our previous research, and that of other authors, to identify and explore key ethical and methodological considerations. DISCUSSION: Focus groups are a widely implemented qualitative methodology, but their use, particularly in vulnerable neurodegenerative disease populations, is not straightforward. Although the risk of harm is generally low in focus group research, neurodegenerative disease populations are particularly vulnerable to issues relating to comprehension and their capacity to consent. Physical and cognitive impairments may also affect social interactions among participants and therefore impact data collection and analyses. CONCLUSION: We offer a number of ethical and methodological recommendations to facilitate the processes of recruitment and data collection when conducting focus groups with neurodegenerative disease populations.

Demographics and outcomes of inpatients with diabetic foot ulcers treated conservatively and surgically in a metropolitan hospital network.

AIMS: To describe the demographics of patients with diabetic foot ulcers (DFU) and their impact on inpatient management. Secondary outcomes identified relationships of treatment modality with mortality, length of hospital admission, readmissions and post-admission care. METHODS: Retrospective cohort study including patients with DFU admitted to a hospital network in Melbourne, Australia from 2016 to 2018. Medical records were manually reviewed for acute admission with DFU as a major presenting diagnosis; incidental ulcers and traumatic amputations were excluded. Amputations distal and proximal to the ankle were labelled 'minor' and 'major' respectively. Patients were followed until October 31, 2019. RESULTS: Of 338 patients, 21 and 148 had major and minor amputations, and 169 were managed conservatively. 94% had ≥1 microvascular and/or macrovascular complication. Conservative management (7 days) was associated with a shorter length of stay (major 18, minor 10 days, p < 0.001). Readmission rates were not significantly different. Mortality was greatest (38%) and survival time shortest (999 days) after major amputation than after either other treatment. Other factors associated with mortality were age and a history of coronary artery disease. CONCLUSIONS: Early identification and multi-disciplinary management of DFU is essential to reduce the significant morbidity and mortality associated with amputation in these complex patients.

The challenges of post-bariatric surgery hypocalcaemia in pre-existing hypoparathyroidism.

SUMMARY: Conventional treatment of hypoparathyroidism relies on oral calcium and calcitriol. Challenges in managing post-parathyroid- and post-thyroidectomy hypocalcaemia in patients with a history of bariatric surgery and malabsorption have been described, but postoperative management of bariatric surgery in patients with established hypoparathyroidism has not. We report the case of a 46-year-old woman who underwent elective sleeve gastrectomy on a background of post-surgical hypoparathyroidism and hypothyroidism. Multiple gastric perforations necessitated an emergency Roux-en-Y gastric bypass. She was transferred to a tertiary ICU and remained nil orally for 4 days, whereupon her ionised calcium level was 0.78 mmol/L (1.11-1.28 mmol/L). Continuous intravenous calcium infusion was required. She remained nil orally for 6 months due to abdominal sepsis and the need for multiple debridements. Intravenous calcium gluconate 4.4 mmol 8 hourly was continued and intravenous calcitriol twice weekly was added. Euthyroidism was achieved with intravenous levothyroxine. Maintaining normocalcaemia was fraught with difficulties in a patient with pre-existing surgical hypoparathyroidism, where oral replacement was impossible. The challenges in managing hypoparathyroidism in the setting of impaired enteral absorption are discussed with analysis of the cost and availability of parenteral treatments. LEARNING POINTS: Management of hypoparathyroidism is complicated when gastrointestinal absorption is impaired. Careful consideration should be given before bariatric surgery in patients with pre-existing hypoparathyroidism, due to potential difficulty in managing hypocalcaemia, which is exacerbated when complications occur. While oral treatment of hypoparathyroidism is cheap and relatively simple, available parenteral options can carry significant cost and necessitate a more complicated dosing schedule. International guidelines for the management of hypoparathyroidism recommend the use of PTH analogues where large doses of calcium and calcitriol are required, including in gastrointestinal disorders with malabsorption. Approval of subcutaneous recombinant PTH for hypoparathyroidism in Australia will alter future management.