Incidence of unilateral arm lymphoedema after breast cancer : a systematic review and meta-analysis

Background The body of evidence related to breast-cancer-related lymphoedema incidence and risk factors has substantially grown and improved in quality over the past decade. We assessed the incidence of unilateral arm lymphoedema after breast cancer and explored the evidence available for lymphoedema risk factors. Methods We searched Academic Search Elite, Cumulative Index to Nursing and Allied Health, Cochrane Central Register of Controlled Trials (clinical trials), and Medline for research articles that assessed the incidence or prevalence of, or risk factors for, arm lymphoedema after breast cancer, published between January 1, 2000, and June 30, 2012. We extracted incidence data and calculated corresponding exact binomial 95% CIs. We used random effects models to calculate a pooled overall estimate of lymphoedema incidence, with subgroup analyses to assess the effect of different study designs, countries of study origin, diagnostic methods, time since diagnosis, and extent of axillary surgery. We assessed risk factors and collated them into four levels of evidence, depending on consistency of findings and quality and quantity of studies contributing to findings. Findings 72 studies met the inclusion criteria for the assessment of lymphoedema incidence, giving a pooled estimate of 16·6% (95% CI 13·6–20·2). Our estimate was 21·4% (14·9–29·8) when restricted to data from prospective cohort studies (30 studies). The incidence of arm lymphoedema seemed to increase up to 2 years after diagnosis or surgery of breast cancer (24 studies with time since diagnosis or surgery of 12 to <24 months; 18·9%, 14·2–24·7), was highest when assessed by more than one diagnostic method (nine studies; 28·2%, 11·8–53·5), and was about four times higher in women who had an axillary-lymph-node dissection (18 studies; 19·9%, 13·5–28·2) than it was in those who had sentinel-node biopsy (18 studies; 5·6%, 6·1–7·9). 29 studies met the inclusion criteria for the assessment of risk factors. Risk factors that had a strong level of evidence were extensive surgery (ie, axillary-lymph-node dissection, greater number of lymph nodes dissected, mastectomy) and being overweight or obese. Interpretation Our findings suggest that more than one in five women who survive breast cancer will develop arm lymphoedema. A clear need exists for improved understanding of contributing risk factors, as well as of prevention and management strategies to reduce the individual and public health burden of this disabling and distressing disorder.

Malnutrition in hospitalised patients and clinical outcomes : a missed opportunity?

This research programme has resulted in 5 published papers in international peer-reviewed journals and contributed to better outcomes for patients. It has provided clear evidence that the adverse outcomes of malnutrition are not just a consequence of the disease process, and lead to substantial increases in length of hospital stay, readmission rate, mortality and hospitalisation cost when compared with well-nourished patients of similar diagnoses and complexities. The research programme led to the development and validation of a new nutrition screening tool called 3-Minute Nutrition Screening (3-MinNS). It has also implemented quality improvement initiatives which proved successful in improving the compliance to 3-MinNS and ensuring referral of malnourished or 'at risk' patients to dietitians. Finally, this research programme has provided an effective method for following up malnourished patients post-discharge, which resulted in improved nutritional status and quality of life.

CPD : Using evidence based clinical practice guidelines in the management of anaemia in patients with chronic renal failure

Anaemia is a chronic problem in patients with renal insufficiency, especially chronic renal failure (CRF). In patients with CRF, anaemia is primarily due to a deficiency in erythropoietin (EPO), a glycoprotein growth factor that stimulates RBC production. The long-term effects and burden of anaemia for patients with CRF can be physical, emotional and financial. With efficient, systematic management of anaemia, clinicians have the potential to realise not only better clinical outcomes for CRF patients but also significant cost savings for them and the health system. During the last decade, significant advances have been made in clinicians’ understanding of how best to manage anaemia in this vulnerable population. One of the most important efforts to improve clinical practice has been the development of best practice guidelines.

Assessing the construct validity and reliability of the parental perception on antibiotics (PAPA) scales

Background: The overuse of antibiotics is becoming an increasing concern. Antibiotic resistance, which increases both the burden of disease, and the cost of health services, is perhaps the most profound impact of antibiotics overuse. Attempts have been made to develop instruments to measure the psychosocial constructs underlying antibiotics use, however, none of these instruments have undergone thorough psychometric validation. This study evaluates the psychometric properties of the Parental Perceptions on Antibiotics (PAPA) scales. The PAPA scales attempt to measure the factors influencing parental use of antibiotics in children. Methods: 1111 parents of children younger than 12 years old were recruited from primary schools’ parental meetings in the Eastern Province of Saudi Arabia from September 2012 to January 2013. The structure of the PAPA instrument was validated using Confirmatory Factor Analysis (CFA) with measurement model fit evaluated using the raw and scaled χ2, Goodness of Fit Index, and Root Mean Square Error of Approximation. Results: A five-factor model was confirmed with the model showing good fit. Constructs in the model include: Knowledge and Beliefs, Behaviors, Sources of information, Adherence, and Awareness about antibiotics resistance. The instrument was shown to have good internal consistency, and good discriminant and convergent validity. Conclusion: The availability of an instrument able to measure the psychosocial factors underlying antibiotics usage allows the risk factors underlying antibiotic use and overuse to now be investigated.

The baby boomers and beyond report : physical activity levels of older Western Australians 2006

Participation in sufficient levels of physical activity provides significant health benefits, particularly in older adults. The monitoring of physical activity levels in the Western Australian population is therefore necessary for developing and implementing strategies and programs for increasing participation. The Premier’s Physical Activity Taskforce (PATF) conducted a survey in 2006 to measure physical activity levels among Western Australian adults to follow-up the 1999 and 2002 state physical activity surveys. There is now widespread agreement that many health problems of older life – including the onset of frailty and disability – can be postponed or delayed by adopting health-enhancing habits such as physical activity. Adults over 65 years are the most rapidly growing age group and will continue to rise as more persons turn 65. If older adults could be encouraged to be more active as they age, frailty and disability associated with falls would be reduced, and function and physical and mental health in older people would be improved thereby reducing the burden of disease and injury. Given that physical inactivity is one of the most important and modifiable risk factors contributing to ill health, particularly for people as they age, the overall aim of this study was to examine patterns of physical activity in those aged 45 years and over – referred to hereafter as baby boomers+ – in more detail.

Nutrition screening and assessment in Parkinson's disease : a comparison of methods

Background & Aims Nutrition screening and assessment enable early identification of malnourished people and those at risk of malnutrition. Appropriate assessment tools assist with informing and monitoring nutrition interventions. Tool choice needs to be appropriate to the population and setting. Methods Community-dwelling people with Parkinson’s disease (>18 years) were recruited. Body mass index (BMI) was calculated from weight and height. Participants were classified as underweight according to World Health Organisation (WHO) (≤18.5kg/m2) and age specific (<65 years,≤18.5kg/m2; ≥65 years,≤23.5kg/m2) cut-offs. The Mini-Nutritional Assessment (MNA) screening (MNA-SF) and total assessment scores were calculated. The Patient-Generated Subjective Global Assessment (PG-SGA), including the Subjective Global Assessment (SGA), was performed. Sensitivity, specificity, positive predictive value, negative predictive value and weighted kappa statistic of each of the above compared to SGA were determined. Results Median age of the 125 participants was 70.0(35-92) years. Age-specific BMI (Sn 68.4%, Sp 84.0%) performed better than WHO (Sn 15.8%, Sp 99.1%) categories. MNA-SF performed better (Sn 94.7%, Sp 78.3%) than both BMI categorisations for screening purposes. MNA had higher specificity but lower sensitivity than PG-SGA (MNA Sn 84.2%, Sp 87.7%; PG-SGA Sn 100.0%, Sp 69.8%). Conclusions BMI lacks sensitivity to identify malnourished people with Parkinson’s disease and should be used with caution. The MNA-SF may be a better screening tool in people with Parkinson’s disease. The PG-SGA performed well and may assist with informing and monitoring nutrition interventions. Further research should be conducted to validate screening and assessment tools in Parkinson’s disease.  

The epidemiology of basal cell carcinoma

Basal cell carcinoma (BCC) is a skin cancer of particular importance to the Australian community. Its rate of occurrence is highest in Queensland, where 1% to 2% of people are newly affected annually. This is an order of magnitude higher than corresponding incidence estimates in European and North American populations. Individuals with a sun-sensitive complexion are particularly susceptible because sun exposure is the single most important causative agent, as shown by the anatomic distribution of BCC which is in general consistent with the levels of sun exposure across body sites. A distinguishing feature of BCC is the occurrence of multiple primary tumours within individuals, synchronously or over time, and their diagnosis and treatment costs contribute substantially to the major public health burden caused by BCC. A primary knowledge gap about BCC pathogenesis however was an understanding of the true frequency of multiple BCC occurrences and their body distribution, and why a proportion of people do develop more than one BCC in their life. This research project sought to address this gap under an overarching research aim to better understand the detailed epidemiology of BCC with the ultimate goal of reducing the burden of this skin cancer through prevention. The particular aim was to document prospectively the rate of BCC occurrence and its associations with constitutional and environmental (solar) factors, all the while paying special attention to persons affected by more than one BCC. The study built on previous findings and recent developments in the field but set out to confirm and extend these and propose more adequate theories about the complex epidemiology of this cancer. Addressing these goals required a new approach to researching basal cell carcinoma, due to the need to account for the phenomenon of multiple incident BCCs per person. This was enabled by a 20 year community-based study of skin cancer in Australians that provided the methodological foundation for this thesis. Study participants were originally randomly selected in 1986 from the electoral register of all adult residents of the subtropical township of Nambour in Queensland, Australia. On various occasions during the study, participants were fully examined by dermatologists who documented cumulative photodamage as well as skin cancers. Participants completed standard questionnaires about skin cancer-related factors, and consented to have any diagnosed skin cancers notified to the investigators by regional pathology laboratories in Queensland. These methods allowed 100% ascertainment of histologically confirmed BCCs in this study population. 1339 participants had complete follow-up to the end of 2007. Statistical analyses in this thesis were carried out using SAS and SUDAAN statistical software packages. Modelling methods, including multivariate logistic regressions, allowed for repeated measures in terms of multiple BCCs per person. This innovative approach gave new findings on two levels, presented in five chapters as scientific papers: 1. Incidence of basal cell carcinoma multiplicity and detailed anatomic distribution: longitudinal study of an Australian population The incidence of people affected multiple times by BCC was 705 per 100,000 person years compared to an incidence rate of people singly affected of 935 per 100,000 person years. Among multiply and singly affected persons alike, site-specific BCC incidence rates were far highest on facial subsites, followed by upper limbs, trunk, and then lower limbs 2. Melanocytic nevi and basal cell carcinoma: is there an association? BCC risk was significantly increased in those with forearm nevi (Odds Ratios (OR) 1.43, 95% Confidence Intervals (CI) 1.09-1.89) compared to people without forearm nevi, especially among those who spent their time mainly outdoors (OR 1.6, 95%CI 1.1-2.3) compared to those who spent their time mainly indoors. Nevi on the back were not associated with BCC. 3. Clinical signs of photodamage are associated with basal cell carcinoma multiplicity and site: a 16-year longitudinal study Over a 16-year follow-up period, 58% of people affected by BCC developed more than one BCC. Among these people 60% developed BCCs across different anatomic sites. Participants with high numbers of solar keratoses, compared to people without solar keratoses, were most likely to experience the highest BCC counts overall (OR 3.3, 95%CI 1.4-13.5). Occurrences of BCC on the trunk (OR 3.3, 95%CI 1.4-7.6) and on the limbs (OR 3.7, 95%CI 2.0-7.0) were strongly associated with high numbers of solar keratoses on these sites. 4. Occurrence and determinants of basal cell carcinoma by histological subtype in an Australian community Among 1202 BCCs, 77% had a single growth pattern and 23% were of mixed histological composition. Among all BCCs the nodular followed by the superficial growth patterns were commonest. Risk of nodular and superficial BCCs on the head was raised if 5 or more solar keratoses were present on the face (OR 1.8, 95%CI 1.2-2.7 and OR 4.5, 95%CI 2.1-9.7 respectively) and similarly on the trunk in the presence of multiple solar keratoses on the trunk (OR 4.2, 95%CI 1.5-11.9 and OR 2.2, 95%CI 1.1-4.4 respectively). 5. Basal cell carcinoma and measures of cumulative sun exposure: an Australian longitudinal community-based study Dermal elastosis was more likely to be seen adjacent to head and neck BCCs than trunk BCCs (p=0.01). Severity of dermal elastosis increased on each site with increasing clinical signs of cutaneous sun damage on that site. BCCs that occurred without perilesional elastosis per se, were always found in an anatomic region with signs of photodamage. This thesis thus has identified the magnitude of the burden of multiple BCCs. It does not support the view that people affected by more than one BCC represent a distinct group of people who are prone to BCCs on certain body sites. The results also demonstrate that BCCs regardless of site, histology or order of occurrence are strongly associated with cumulative sun exposure causing photodamage to the skin, and hence challenge the view that BCCs occurring on body sites with typically low opportunities for sun exposure or of the superficial growth pattern are different in their association with the sun from those on typically sun-exposed sites, or nodular BCCs, respectively. Through dissemination in the scientific and medical literature, and to the community at large, these findings can ultimately assist in the primary and secondary prevention of BCC, perhaps especially in high-risk populations.

Exploring differences in driving behaviour across age and years of education of taxi drivers in Addis Ababa, Ethiopia

Despite statistics indicating that the African region has the highest road traffic fatality rate globally, there is limited scientific literature identifying the determinants of driving behaviour. In this study, we explore differences in self-reported driving behaviour across age groups and years of education in a population of 213 drivers from Addis Ababa, Ethiopia. We hypothesize that younger, less educated drivers will report engaging in more unsafe driving behaviours compared to older, more educated drivers. Contrary to expectations, we found the opposite effect, whereby older, more educated drivers reported engaging in more unsafe driving behaviours than younger, less educated drivers. We explain these findings by describing key characteristics of the sample and cultural ideologies of the region. The findings of this study offer some practical guidance for intervention to address the burden of road traffic injury and death in the African region.

Malnutrition coding shortfalls in Australian and New Zealand hospitals

Aim The International Classification of Diseases, version 10, Australian modification (ICD-10-AM) is used to classify diseases in hospital patients in Australia and New Zealand. ICD-10-AM defines malnutrition as ‘[body mass index] BMI <18.5 kg/m2 or unintentional weight loss of ≥5% with evidence of suboptimal intake resulting in subcutaneous fat loss and/or muscle wasting’. The Australasian Nutrition Care Day Survey (ANCDS) is the most comprehensive survey to evaluate malnutrition prevalence in acute care patients from Australian and New Zealand hospitals. This study determined if malnourished participants were assigned malnutrition-related codes according to ICD-10-AM. Methods The ANCDS recruited acute care patients from 56 hospitals. Hospital-based dietitians evaluated participants' nutritional status using BMI and Subjective Global Assessment (SGA). In keeping with the ICD-10-AM definition, malnutrition was defined as BMI <18.5 kg/m2, SGA-B (moderately malnourished) or SGA-C (severely malnourished). After 3 months, in this prospective cohort study, staff members from each hospital's health information/medical records department provided coding results for malnourished participants. Results Malnutrition was prevalent in 30% (n = 869) of the cohort (n = 2976) and a significantly small number of malnourished patients were coded for malnutrition (n = 162, 19%, P < 0.001). In 21 hospitals, none of the malnourished participants were coded. Conclusions This is the largest study to provide a snapshot of malnutrition coding in Australian and New Zealand hospitals. Findings highlight gaps in malnutrition documentation and/or subsequent coding, which could potentially result in significant loss of casemix-related revenue for hospitals. Dietitians must lead the way in developing structured processes for malnutrition identification, documentation and coding.

Improving the performance of nutrition screening through a series of quality improvement initiatives

Background Nutrition screening identifies patients at risk of malnutrition to facilitate early nutritional intervention. Studies have reported incompletion and error rates of 30-90% for a range of commonly used screening tools. This study aims to investigate the incompletion and error rates of 3-Minute Nutrition Screening (3-MinNS) and the effect of quality improvement initiatives in improving the overall performance of the screening tool and the referral process for at risk patients. Methods Annual audits were carried out from 2008-2013 on 4467 patients. Value Stream Mapping, Plan-Do-Check-Act cycle and Root Cause Analysis were used in this study to identify gaps and determine the best intervention. The intervention included 1) implementing a nutrition screening protocol, 2) nutrition screening training, 3) nurse empowerment for online dietetics referral of at-risk cases, 4) closed-loop feedback system and 5) removing a component of 3-MinNS that caused the most error without compromising its sensitivity and specificity. Results Nutrition screening error rates were 33% and 31%, with 5% and 8% blank or missing forms, in 2008 and 2009 respectively. For patients at risk of malnutrition, referral to dietetics took up to 7.5 days, with 10% not referred at all. After intervention, the latter decreased to 7% (2010), 4% (2011) and 3% (2012 and 2013), and the mean turnaround time from screening to referral was reduced significantly from 4.3 ± 1.8 days to 0.3 ± 0.4 days (p < 0.001). Error rates were reduced to 25% (2010), 15% (2011), 7% (2012) and 5% (2013) and percentage of blank or missing forms reduced to and remained at 1%. Conclusion Quality improvement initiatives are effective in reducing the incompletion and error rates of nutrition screening, and led to sustainable improvements in the referral process of patients at nutritional risk.

Patient perspectives of the impact and long-term management of lymphoedema

Lymphoedema following cancer treatment is characterized by swelling, and adversely influences mobility, function and quality of life. There is no cure, but without treatment lymphedema may progress. Since lymphedema treatment options are costly and time consuming, understanding the influence of these, and other potential barriers, on treatment adherence is vital in reducing the public health burden of lymphedema. Complex physical therapy and compression are supported by scientific evidence and patients also perceive these treatments as effective for improving symptoms and function. Multiple treatments may be required to treat all aspects of the condition. Patients and health professionals should consider effect and costs when identifying optimal treatment strategies.

Cisplatin treatment of primary and metastatic epithelial ovarian carcinomas generates residual cells with mesenchymal stem cell-like profile

Epithelial mesenchymal transition (EMT) and cancer stem cells (CSC) have been associated with resistance to chemotherapy. Eighty percent of ovarian cancer patients initially respond to platinum-based combination therapy but most return with recurrence and ultimate demise. To better understand such chemoresistance we have assessed the potential role of EMT in tumor cells collected from advanced-stage ovarian cancer patients and the ovarian cancer cell line OVCA 433 in response to cisplatin in vitro. We demonstrate that cisplatin-induced transition from epithelial to mesenchymal morphology in residual cancer cells correlated with reduced E-cadherin, and increased N-cadherin and vimentin expression. The mRNA expression of Snail, Slug, Twist, and MMP-2 were significantly enhanced in response to cisplatin and correlated with increased migration. This coincided with increased cell surface expression of CSC-like markers such as CD44, α2 integrin subunit, CD117, CD133, EpCAM, and the expression of stem cell factors Nanog and Oct-4. EMT and CSC-like changes in response to cisplatin correlated with enhanced activation of extracellular signal-regulated kinase (ERK)1/2. The selective MEK inhibitor U0126 inhibited ERK2 activation and partially suppressed cisplatin-induced EMT and CSC markers. In vivo xenotransplantation of cisplatin-treated OVCA 433 cells in zebrafish embryos demonstrated significantly enhanced migration of cells compared to control untreated cells. U0126 inhibited cisplatin-induced migration of cells in vivo, suggesting that ERK2 signaling is critical to cisplatin-induced EMT and CSC phenotypes, and that targeting ERK2 in the presence of cisplatin may reduce the burden of residual tumor, the ultimate cause of recurrence in ovarian cancer patients.

The effect of preferential sampling on sampling variance

We examine some variations of standard probability designs that preferentially sample sites based on how easy they are to access. Preferential sampling designs deliver unbiased estimates of mean and sampling variance and will ease the burden of data collection but at what cost to our design efficiency? Preferential sampling has the potential to either increase or decrease sampling variance depending on the application. We carry out a simulation study to gauge what effect it will have when sampling Soil Organic Carbon (SOC) values in a large agricultural region in south-eastern Australia. Preferential sampling in this region can reduce the distance to travel by up to 16%. Our study is based on a dataset of predicted SOC values produced from a datamining exercise. We consider three designs and two ways to determine ease of access. The overall conclusion is that sampling performance deteriorates as the strength of preferential sampling increases, due to the fact the regions of high SOC are harder to access. So our designs are inadvertently targeting regions of low SOC value. The good news, however, is that Generalised Random Tessellation Stratification (GRTS) sampling designs are not as badly affected as others and GRTS remains an efficient design compared to competitors.

BIM for sustainable whole-of-life transport infrastructure asset management

The US National Institute of Standards and Technology (NIST) showed that, in 2004, owners and operations managers bore two thirds of the total industry cost burden from inadequate interoperability in construction projects from inception to operation, amounting to USD10.6 billion. Building Information Modelling (BIM) and similar tools were identified by Engineers Australia in 2005 as potential instruments to significantly reduce this sum, which in Australia could amount to total industry-wide cost burden of AUD12 billion. Public sector road authorities in Australia have a key responsibility in driving initiatives to reduce greenhouse gas emissions from the construction and operations of transport infrastructure. However, as previous research has shown the Environmental Impact Assessment process, typically used for project approvals and permitting based on project designs available at the consent stage, lacks Key Performance Indicators (KPIs) that include long-term impact factors and transfer of information throughout the project life cycle. In the building construction industry, BIM is widely used to model sustainability KPIs such as energy consumption, and integrated with facility management systems. This paper proposes that a similar use of BIM in early design phases of transport infrastructure could provide: (i) productivity gains through improved interoperability and documentation; (ii) the opportunity to carry out detailed cost-benefit analyses leading to significant operational cost savings; (iii) coordinated planning of street and highway lighting with other energy and environmental considerations; iv) measurable KPIs that include long-term impact factors which are transferable throughout the project life cycle; and (v) the opportunity for integrating design documentation with sustainability whole-of-life targets.

The validity and reliability of the Parent Fever Management Scale: A study from Palestine

Background Parental fever phobia and overuse of antipyretics to control fever is increasing. Little is known about childhood fever management among Arab parents. No scales to measure parents’ fever management practices in Palestine are available. Aims The aims of this study were to translate and examine the psychometric properties of the Arabic version of the Parent Fever Management Scale (PFMS). Methods A standard “forward–backward” procedure was used to translate PFMS into Arabic language. It was then validated on a convenience sample of 402 parents between July and October 2012. Descriptive statistics were used, and instrument reliability was assessed for internal consistency using Cronbach's alpha coefficient. Validity was confirmed using convergent and known group validation. Results Applying the recommended scoring method, the median (interquartile range) score of the PFMS was 26 (23-30). Acceptable internal consistency was found (Cronbach’s alpha = 0.733) and the test–retest reliability value was 0.92 (P < 0.001). The chi-squared (χ2) test showed a significant relationship between PFMS groups and frequent daily administration of antipyretic groups (χ2 = 52.86; P < 0.001). The PFMS sensitivity and specificity were 77.67% and 57.75%, respectively. The positive and negative predictive values were 67.89% and 32.11%, respectively. Conclusions The findings of this validation study indicate that the Arabic version of the PFMS is a reliable and valid measure which can be used as a useful tool for health professionals to identify parents’ fever management practices and thus provide targeted education to reduce the unnecessary burden of care they place on themselves when concerned for a febrile child.