Improving preoperative breast reconstruction consultations: a qualitative study on the impact of personalised audio-recordings.

BACKGROUND: To investigate the value of audio-recordings in aiding patient understanding and recall of preoperative breast reconstruction information. METHODS: This was a prospective cohort study. Participants were randomly allocated into either a recording group who were offered the opportunity to record their breast reconstruction explanation of surgery, or a standard information package group who received standard care. The value of having an audio-recording was assessed by semi-structured interviews and analysis of recurring themes. RESULTS: Between 21/2/19 and 19/3/20, 32 women attending consultations for breast reconstruction consented to participate in the study, 17 were randomly assigned to the recording group and 15 the standard information package group. Twenty-eight of the 32 participants completed qualitative interviews. All participants agreed that audio-recordings were a beneficial resource which allowed them to have a better understanding of the concepts discussed. Commonly reported themes included the ability to listen to the recording multiple times to refresh memory, as well as usefulness in helping to inform other family members. Participants also reported increased levels of trust in their clinician for allowing the audio-recordings. Very few participants raised any medico-legal implications of the recordings, their focus was more on the potential of the audio-recordings to alleviate the overwhelming nature of a pre-operative breast reconstruction consultation. CONCLUSIONS: There was a positive response from participants to the use of audio-recordings in the setting of breast reconstruction consultations. These types of recordings could potentially be used in other complex appointments where detailed information is discussed, with similar success.

Reproductive technologies and the risk of birth defects.

BACKGROUND: The extent to which birth defects after infertility treatment may be explained by underlying parental factors is uncertain. METHODS: We linked a census of treatment with assisted reproductive technology in South Australia to a registry of births and terminations with a gestation period of at least 20 weeks or a birth weight of at least 400 g and registries of birth defects (including cerebral palsy and terminations for defects at any gestational period). We compared risks of birth defects (diagnosed before a child's fifth birthday) among pregnancies in women who received treatment with assisted reproductive technology, spontaneous pregnancies (i.e., without assisted conception) in women who had a previous birth with assisted conception, pregnancies in women with a record of infertility but no treatment with assisted reproductive technology, and pregnancies in women with no record of infertility. RESULTS: Of the 308,974 births, 6163 resulted from assisted conception. The unadjusted odds ratio for any birth defect in pregnancies involving assisted conception (513 defects, 8.3%) as compared with pregnancies not involving assisted conception (17,546 defects, 5.8%) was 1.47 (95% confidence interval [CI], 1.33 to 1.62); the multivariate-adjusted odds ratio was 1.28 (95% CI, 1.16 to 1.41). The corresponding odds ratios with in vitro fertilization (IVF) (165 birth defects, 7.2%) were 1.26 (95% CI, 1.07 to 1.48) and 1.07 (95% CI, 0.90 to 1.26), and the odds ratios with intracytoplasmic sperm injection (ICSI) (139 defects, 9.9%) were 1.77 (95% CI, 1.47 to 2.12) and 1.57 (95% CI, 1.30 to 1.90). A history of infertility, either with or without assisted conception, was also significantly associated with birth defects. CONCLUSIONS: The increased risk of birth defects associated with IVF was no longer significant after adjustment for parental factors. The risk of birth defects associated with ICSI remained increased after multivariate adjustment, although the possibility of residual confounding cannot be excluded. (Funded by the National Health and Medical Research Council and the Australian Research Council.).

Is tropical pus in the hand special? A retrospective study comparing hand infection cases in Darwin and Adelaide.

BACKGROUND: Hand infections are a common reason for presenting to hospital and can be associated with significant morbidity and prolonged antibiotic use. Factors recognized to influence patient outcomes include resistant organisms and delayed presentation. Surgeons working around Australia may assume that hand infections and appropriate treatment algorithms will be similar between sites. This is the first study to examine differences between hand infections presenting in Darwin (with its tropical climate) vs. those in a more temperate city (Adelaide). METHODS: This is a two-site retrospective study, where diagnostic discharge codes were used to identify cases for a 12-month period and patient age, sex and rurality, duration of hospital stay, microbiology results and subsequent trips to theatre were reviewed. RESULTS: Despite significant differences in rurality between FMC and RDH patients, there was no significant difference in length of hospital stay, duration of intravenous antibiotics or return trips to theatre across the two sites. RDH reported a 25% rate of MRSA, compared to 18% at FMC, as well as a statistically significant increase in uncommon microbes, with 30% compared to 12% of patients growing microbes that may not be covered by antibiotics routinely administered in metropolitan areas. A limitation of this study was that compliance with antibiotics and hospital stay were not accounted for. CONCLUSION: It is often our training years that determine our norms of everyday practice, but fewer Australian surgical training posts are located in tropical centres. The results of this study highlight the importance of not assuming that the spectrum of organisms causing hand infections are the same as that in the surgeons' state of origin.

A qualitative study on the experiences of women undergoing surgery for developmental breast asymmetry.

BACKGROUND: Developmental breast asymmetry (DBA) is a largely underreported condition where the natural growth of one breast is smaller than the other. While some degree of asymmetry or difference in size and shape is present in most women, DBA can result in more profound differences that can impact a woman's psychosocial well-being. OBJECTIVES: This study aims to better understand the experiences of women living with DBA, their experiences seeking treatment, and their reconstructive surgical journey and outcomes. DESIGN: This was a qualitative study involving in-depth, one-on-one semi-structured interviews with women diagnosed with DBA. METHODS: Participants were women seeking treatment for DBA through the Plastic and Reconstructive Surgery Unit at Flinders Medical Centre, a tertiary healthcare centre in Adelaide, South Australia. Interviews were recorded digitally, transcribed verbatim and analysed thematically. RESULTS: Fourteen interviews were conducted with 14 women; 13 women had completed their reconstruction and 1 was undergoing reconstruction at the time of their interview. Interviews highlighted the significant psychosocial impact of DBA, the different experiences in seeking help for DBA, the information received or lack thereof, the need for medical and social support throughout the surgical process, and the varied satisfaction with surgical outcomes. CONCLUSION: This study highlighted the subjective experiences of women who have grown up with DBA, improving our understanding of the significant psychosocial impact of DBA. Not all participants experienced post-operative improvements in psychosocial well-being due to surgical complications or unmet expectations. This study also demonstrated the need to raise awareness about DBA and the importance of additional medical and social support for women throughout their surgical journey.

The anatomical distribution of non-melanoma skin cancer: a retrospective cohort study of 22 303 Australian cases.

BACKGROUND: Non-melanoma skin cancers (NMSC) are the most common skin cancers worldwide with research establishing that ultraviolet (UV) radiation influences occurrence. However, recent studies about NMSC tumour frequencies suggested high NMSC predilections in low UV-exposed skin regions. METHODS: The 'Human Surface Anatomy Labeling System' was used to define 100 skin regions to map NMSC locations excised at Flinders Medical Centre (FMC) between 1 January 2012 and 31 December 2017. Data were retrieved from the FMC histopathology database. A customised phrase algorithm was used to run a systematic word search on the dataset to quantify NMSC locations. RESULTS: A total of 22 303 NMSC excisions were identified; 80% were head and neck excisions. Scalp, periocular and nasal regions showed a significantly greater predilection for basal cell carcinomas (BCC). Squamous cell carcinomas (SCC) had significantly more excisions in lip, neck and scalp regions. Regarding gender-related variations, more males had BCC excisions in ear regions and more females had nasal, lip, and ankle excisions. In SCC excisions, more males had scalp excisions and more females had leg and lip excisions. Considering age-related variation, significantly higher proportions of BCC were found with forehead excisions compared to scalp, neck and lower limb regions for SCC, all being highest for 60-79-year age groups. CONCLUSION: The relationship between NMSC type and anatomical distribution may be partially explained by gender and age affecting NMSC predilections particularly in the head and neck. However, other skin regions could not be explained solely by these factors.

Predicted versus actual complications in Australian women undergoing post-mastectomy breast reconstruction: a retrospective cohort study using the BRA Score tool.

INTRODUCTION: The Breast Reconstruction Risk Assessment (BRA) Score tool is a risk calculator developed to predict the risk of complications in individual patients undergoing breast reconstruction. It was developed in a North American population exclusively undergoing immediate breast reconstruction. This study sought to assess the predictions of the BRA Score tool against the measured outcomes of surgery for an Australian public hospital population, including both immediate and delayed reconstructions. METHOD: This was a retrospective cohort study of data from women at a single Australian public teaching hospital unit. Data from the Flinders Breast Reconstruction Database was retrieved and compared to BRA Scores calculated for each patient. Receiver operating curve area under the curve analysis was performed as well as Brier scores to compare predicted versus observed complications. RESULTS: BRA Score predictions were reasonable or good (C-statistic >0.7, Brier score <0.09) for the complications of overall surgical complications, surgical site infection (SSI) and seroma at 30 days, and similarly accurate for prediction of the same complications for implant reconstructions at 12 months. There were similar findings between delayed and immediate reconstructions. CONCLUSION: The BRA Score risk calculator is valid to detect some risks in both patients undergoing immediate and delayed breast reconstruction in an Australian public hospital setting. SSI is the best predicted complication and is well-predicted across both autologous and prosthetic reconstruction types.

Motor function in 5-year-old children with cerebral palsy in the South Australian population.

The aim of this study was to describe the motor function of a population of children at age 5 years enrolled on the South Australian Cerebral Palsy Register. Among children born between 1993 and 1998, there were 333 with confirmed cerebral palsy (prevalence rate 2.2 per 1000 live births), in whom 247 assessments (56.7% males, 43.3% females) were completed. The distribution by Gross Motor Function Classification System (GMFCS) level was: level I, 50.6%; level II, 18.2%; level III, 9.3%; level IV, 9.7%; level V, 12.1%. The most common topographical classification was spastic diplegia (38.5%), followed by spastic hemiplegia (34.8%) and spastic quadriplegia (14.6%). Abnormal movements occurred at rest or with intention in 19.4% of children. A high proportion of the population with relatively mild gross motor impairments have difficulty with everyday bimanual tasks, reinforcing the need to assess upper limb function independently of gross motor function. The use of ankle-foot orthoses was common, particularly across GMFCS levels II to IV. Further refinement is indicated for this population's motor dataset, to include more recently described classification measures as well as future novel measures to better describe the presence of both spasticity and dystonia.

Genetic susceptibility to viral exposure may increase the risk of cerebral palsy.

AIM: Cytokine polymorphisms may alter the fetal inflammatory response, increasing susceptibility to cerebral palsy (CP). This study investigates associations between selected inflammatory mediator and cytokine gene polymorphisms (Toll-like receptor-4 (TLR-4) Asp299Gly, interleukin-6 G-174C and interleukin-4 C-589T) and CP from 443 CP infants and 883 control infants. Results were correlated with viral nucleic acids in the same samples. RESULTS: At all gestational ages (GA), TLR-4 was associated with a decreased risk of developing CP (homozygous/heterozygous odds ratio (OR) 0.70, 95% confidence interval (CI) 0.50-0.98) and interleukin (IL)-6 was associated with an increased risk of developing hemiplegia (OR 1.38, 95% CI 1.05-1.83). For infants born 32-36 weeks GA, there was a tenfold increase in the risk of quadriplegic CP with homozygous/heterozygous IL-6 (OR 10.42, 95% CI 1.34-80.82). Viral exposure in combination with IL-4 in preterm infants was associated with a fourfold increased risk of quadriplegia (homozygous/heterozygous OR 4.25, 95% CI 1.21-14.95). In very preterm infants, the absence of detectable viral exposure in combination with IL-4 decreased the risk of developing CP (homozygous/heterozygous OR 0.31, 95% CI 0.13-0.76). CONCLUSION: Polymorphisms in TLR-4 may be associated with a decreased risk of CP. Polymorphisms in IL-6 or IL-4 may act as susceptibility genes, in the presence of viral exposure, for the development of hemiplegic and quadriplegic CP. These associations require confirmation but they suggest a hypothesis for CP causation due to double jeopardy from neurotropic viral exposure and genetic susceptibility to infection.

Effectiveness of prenatal diagnosis of congenital heart defects in South Australia: a population analysis 1999-2003.

AIMS: To report on the efficiency of fetal echocardiography, outcome after prenatal diagnosis of congenital heart disease (CHD) and the effectiveness of South Australia's obstetric screening program in detecting CHD. METHODS: A retrospective audit of our institutional cardiac database, the South Australia Birth Defects Register and the South Australia Pregnancy Outcome Unit from 1999 to 2003. RESULTS: CHD was present in 10.7 per 1000 births and was potentially detectable in 5.2 per 1000 births. Of these, only 22.5% were referred for fetal echocardiography. Prenatal detection of transposition of the great arteries occurred in four of 27 (14.8%), atrioventricular septal defect in five of 21 (23.8%), tetralogy of Fallot in seven of 28 (25.0%) and hypoplastic left heart syndrome in 20 of 33 (60.6%). Fetal echocardiography had 95.2% sensitivity, 99.5% specificity, 99.0% positive predictive value and 97.6% negative predictive value for CHD. A prenatal diagnosis of CHD resulted in termination in 30.1%, stillbirth in 7.8% and neonatal death in 3.9% of cases. CONCLUSION: Routine obstetric ultrasound detects CHD infrequently. Outflow tract lesions are most commonly missed. Fetal echocardiography is an accurate tool for prenatal diagnosis of CHD. Pregnancy outcomes after prenatal diagnosis are comparable to other Australasian and western countries, suggesting uniformity in parental counselling and population behaviour. Strategies that improve routine obstetric ultrasound detection of CHD are likely to yield the greatest impact.

Cerebral palsy and the application of the international criteria for acute intrapartum hypoxia.

OBJECTIVE: To apply objective criteria for the identification of acute intrapartum hypoxia in a cohort of cerebral palsy cases and to identify other cerebral palsy-related pathologies. METHODS: A cohort of all 235 neonates with cerebral palsy from a single Australian tertiary care center born between 1986 and 2003. Cases were identified from the South Australian Cerebral Palsy Register. Maternal and pediatric case notes were audited with application of the 2003 American College of Obstetricians and Gynecologists/American Academy of Pediatrics criteria to identify acute intrapartum hypoxia. RESULTS: Data were available for analysis in 213 cases (91%). Major antenatal or pediatric cerebral palsy-related pathologies were identified in 98.1% of all these cases. An isolated acute intrapartum hypoxic event was defined as likely in only 2 of the 46 neonates born at term and none born preterm. Neonatal nucleated red blood cell counts were often high in neonates born preterm and following antenatal pathologies. CONCLUSION: Cerebral palsy was seldom preceded by acute intrapartum hypoxia but antenatal cerebral palsy-related pathologies are often detectable. The objective American College of Obstetricians and Gynecologists/American Academy of Pediatrics criteria are useful to audit cerebral palsy causation and exclude primary intrapartum hypoxia. LEVEL OF EVIDENCE: II-3.

Late diagnosis of developmental dysplasia of the hip: an analysis of risk factors.

A neonatal clinical screening program for developmental dysplasia of the hip (DDH) operates in South Australia to diagnose DDH as early as possible. However, some cases of DDH are diagnosed late (>3 months of age). The aims of this study were to identify the specific risk factors for late diagnosis by comparing early diagnosed DDH, late diagnosed DDH, and normal controls in the South Australian population. There were 1945 children with DDH born between 1988 and 2003, of which 67 cases were late diagnosis (3.4%). Maternal characteristics, pregnancy, and delivery details were analyzed, and compared with controls (early diagnosed DDH and the general population). There was a trimodal pattern of age at presentation with a gradual increase in the incidence of late diagnosed DDH over the time period in this study. Birthweight (<2500 g), birth in a rural setting, and early hospital discharge following delivery (<4 days) were significant risk factors for late diagnosed DDH. Breech presentation and delivery by caesarean section were protective for late diagnosed DDH. Risk factors for late diagnosed DDH relate to factors that influence the screening program. A rigorous population-based hip surveillance program is important for early diagnosis of DDH.

CP or not CP? A review of diagnoses in a cerebral palsy register.

The purpose of this study was to document the inaccuracy rate of diagnosis of cerebral palsy recorded on the South Australian Cerebral Palsy Register. A total of 402 children born in South Australia from 1993 to 2002 and notified to the Register as having cerebral palsy were identified through the Register database, and 21 children (5.2%) were later identified to have a noncerebral palsy diagnosis. Of these, 5 had either a metabolic or a neurodegenerative disorder and 2 had a syndromic disorder (1 Joubert syndrome and 1 Sotos syndrome); the remaining 14 children had one of the following final diagnoses: developmental delay, gross motor delay, perinatal myositis, spinal subdural and subarachnoid arteriovenous malformation, and Erb's palsy. In 16 of 21 children (76%), the diagnosis was changed at 5 years of age or older. Studies based on population registers may need to take into account the possibility of misclassification, estimated to be at least 5.2% in this study. A complete clinical assessment at the time of diagnosis followed by regular reassessment would enable the clinician to exclude children with alternative diagnoses, which has important implications for clinical management and research based on cerebral palsy registers.

Folate awareness and the prevalence of neural tube defects in South Australia, 1966-2007.

OBJECTIVES: To ascertain changes in: women's knowledge of the role of folic acid in the prevention of neural tube defects (NTDs); intake of folic acid among pregnant women; and prevalence of NTDs in South Australia. DESIGN, SETTING AND PARTICIPANTS: Computer-assisted telephone interviews of South Australian households from 1994 to 2007 over a period encompassing a statewide folate promotion campaign (1994-1995), continuing folate promotion, as well as the introduction of voluntary folate fortification of foods (1996); ascertainment of the total prevalence of NTDs from births and terminations of pregnancy from 1966 to 2007. MAIN OUTCOME MEASURES: Changes in women's knowledge of the role of folic acid in the prevention of NTDs; changes in the prevalence of NTDs. RESULTS: From 1994 to 2006 and 2007, knowledge about the role of folic acid increased from 25% to 77% (P < 0.001) and knowledge that folic acid needs to be taken in the periconceptional period increased from 12% to 39% (P < 0.001). The proportion of pregnant women who increased their periconceptional intake of folate rose from 61% in 1998 to 81% in 2006 and 2007 (P < 0.001), with significant increases in the consumption of fortified cereals (from 15% to 29%) and folic acid tablets (from 37% to 64%). The total prevalence of NTDs fell from 2.06 per 1000 births in 1986-1990 to 1.23 per 1000 births in 2002-2007 (relative risk, 0.60; 95% CI, 0.48-0.74; P < 0.001). CONCLUSIONS: Folate promotion and voluntary fortification of certain foods with folic acid were associated with increased awareness of the role of periconceptional folic acid, increased folate consumption and a reduction in the prevalence of NTDs in South Australia by 40% (95% CI, 26%-52%).