Long-term survival after intensive care unit discharge in Thailand : a retrospective study

Introduction Economic evaluations of interventions in the hospital setting often rely on the estimated long-term impact on patient survival. Estimates of mortality rates and long-term outcomes among patients discharged alive from the intensive care unit (ICU) are lacking from lower- and middle-income countries. This study aimed to assess the long-term survival and life expectancy (LE) amongst post-ICU patients in Thailand, a middle-income country. Methods In this retrospective cohort study, data from a regional tertiary hospital in northeast Thailand and the regional death registry were linked and used to assess patient survival time after ICU discharge. Adult ICU patients aged at least 15 years who had been discharged alive from an ICU between 1 January 2004 and 31 December 2005 were included in the study, and the death registry was used to determine deaths occurring in this cohort up to 31st December 2010. These data were used in conjunction with standard mortality life tables to estimate annual mortality and life expectancy. Results This analysis included 10,321 ICU patients. During ICU admission, 3,251 patients (31.5%) died. Of 7,070 patients discharged alive, 2,527 (35.7%) were known to have died within the five-year follow-up period, a mortality rate 2.5 times higher than that in the Thai general population (age and sex matched). The mean LE was estimated as 18.3 years compared with 25.2 years in the general population. Conclusions Post-ICU patients experienced much higher rates of mortality than members of the general population over the five-year follow-up period, particularly in the first year after discharge. Further work assessing Health Related Quality of Life (HRQOL) in both post-ICU patients and in the general population in developing countries is needed.

The impact of community health professional contact postpartum on breastfeeding at 3 months : a cross-sectional retrospective study

This study investigated the effect of any health professional contact and the types of contact new mothers received in the first 10 days post-discharge on breastfeeding rates at 3 months. This cross-sectional retrospective self-report survey was distributed to women who birthed in Queensland, Australia between 1st February and 31st May 2010 at 4–5 months postpartum. Data were collected on pregnancy, birth, postpartum care and infant feeding. Logistic regression was used to assess the relationship between health professional contact and breastfeeding at 3 months. Data were analysed by birthing facility sector because of significant differences between sectors in health professional contact. The study cohort consisted of 6,852 women. Women in the public sector were more likely to be visited at home than women birthing in the private sector. Any health professional contact (AOR 1.65 99 % CI 0.98–2.76 public sector, AOR 0.78 99 % CI 0.59–1.03 private sector) and home visits (AOR 1.50 99 % CI 0.89–2.54 public sector, AOR 0.80 99 % CI 0.46–1.39 private sector) were not associated with breastfeeding at 3 months in either sector. A telephone call (AOR 2.07 99 % CI 1.06–4.03) or visit to a general practitioner (GP) (AOR 1.83 99 % CI 1.04–3.21) increased the odds of breastfeeding in public sector women. Health professional contact or home visiting in the first 10 days post-discharge did not have a significant impact on breastfeeding rates at 3 months. Post-discharge telephone contact for all women and opportunities for self-initiated clinic visits for women assessed to be at higher risk of ceasing breastfeeding may be the most effective care.

Flapless dental implant surgery : a retrospective study of 1,241 consecutive implants

Purpose: The purpose of this study was to identify retrospectively the predictors of implant survival when the flapless protocol was used in two private dental practices. Materials and Methods: The collected data were initially computer searched to identify the patients; later, a hand search of patient records was carried out to identify all flapless implants consecutively inserted over the last 10 years. The demographic information gathered on statistical predictors included age, sex, periodontal and peri-implantitis status, smoking, details of implants inserted, implant locations, placement time after extraction, use of simultaneous guided hard and soft tissue regeneration procedures, loading protocols, type of prosthesis, and treatment outcomes (implant survival and complications). Excluded were any implants that required flaps or simultaneous guided hard and soft tissue regeneration procedures, and implants narrower than 3.25 mm. Results: A total of 1,241 implants had been placed in 472 patients. Life table analysis indicated cumulative 5-year and 10-year implant survival rates of 97.9% and 96.5%, respectively. Most of the failed implants occurred in the posterior maxilla (54%) in type 4 bone (74.0%), and 55.0% of failed implants had been placed in smokers. Conclusion: Flapless dental implant surgery can yield an implant survival rate comparable to that reported in other studies using traditional flap techniques.

Fasting increases serum bilirubin levels in clinically normal, healthy males but not females : a retrospective study from phase I clinical trial participants

Aim: To examine if fasting affects serum bilirubin levels in clinical healthy males and females. Methods: We utilised retrospective data from phase 1 clinical trials where blood was collected in either a fed or fasting state at screening and pre-dosing time points and analysed for total bilirubin levels as per standard clinical procedures. Participants were clinically healthy males (n = 105) or females (n = 30) aged 18 to 48 inclusive who participated in a phase 1 clinical trial in 2012 or 2013. Results: We found a statistically significant increase in total serum bilirubin levels in fasting males as compared to non-fasting males. The fasting time correlated positively with increased bilirubin levels. The age of the healthy males did not correlate with their fasting bilirubin level. We found no correlation between fasting and bilirubin levels in clinically normal females. Conclusions: The recruitment and screening of volunteers for a clinical trial is a time-consuming and expensive process. This study clearly demonstrates that testing for serum bilirubin should be conducted on non-fasting male subjects. If fasting is required, then participants should not be excluded from a trial based on an elevated serum bilirubin that is deemed non-clinically significant.

What are pregnant women told about models of maternity care in Australia? A retrospective study of women's reports

Objective To describe women’s reports of the model of care options General Practitioners (GPs) discussed with them at the first pregnancy consultation and women’s self-reported role in decisionmaking about model of care. Methods Women who had recently given birth responded to survey items about the models of care GPs discussed, their role in final decision-making, and socio-demographic, obstetric history, and early pregnancy characteristics. Results The proportion of women with whom each model of care was discussed varied between 8.2% (for private midwifery care with home birth) and 64.4% (GP shared care). Only 7.7% of women reported that all seven models were discussed. Exclusive discussion about private obstetric care and about all public models was common, and women’s health insurance status was the strongest predictor of the presence of discussions about each model. Most women (82.6%) reported active involvement in final decision-making about model of care. Conclusion Although most women report involvement in maternity model of care decisions, they remain largely uninformed about the breadth of available model of care options. Practical implications Strategies that facilitate women’s access to information on the differentiating features and outcomes for all models of care should be prioritized to better ensure equitable and quality decisions.

Which mothers receive a postpartum home visit in Queensland, Australia? A cross-sectional retrospective study

Objective While home visiting in the early postpartum period appears to have increased, there are limited data defining which women receive a visit and none that include Queensland. We aimed to investigate patterns of postpartum home visiting in the public and private sectors in Queensland. Methods Data were collected via a retrospective cross-sectional survey of women birthing in Queensland between 1st February and 31st May 2010 at 4 months postpartum (N = 6948). Logistic regression was used to assess associations between receiving a home visit and sociodemographic, clinical and hospital variables. Analyses were stratified by public and private birthing sector because of significant differences between sectors. Results Public sector women were more likely to receive a visit from a nurse or midwife (from the hospital or child health sector) within 10 days of hospital discharge (67.2%) than private sector women (7.2%). Length of hospital stay was associated with home visiting in both sectors. Some vulnerable sub-populations in both sectors were more likely to be visited, while others were not. Conclusions Home visiting in Queensland varies markedly between the public and private sector and is less common in some vulnerable populations. Further consideration to improving the equity of community postpartum care in Queensland is needed.

Sleep and self-regulation from birth to 7 years: A retrospective study of children with and without ADHD at 8-9 years

Objective To examine mean level differences, and longitudinal and reciprocal relations among behavioral sleep problems, emotional dysregulation, and attentional regulation across early childhood for children with and without ADHD at 8-9 years. Method This study used data from Growing Up in Australia: The Longitudinal Study of Australian Children (LSAC) – Infant Cohort (n = 4109 analyzed). Children with and without ADHD were identified at age 8-9 years via parent-report of ADHD diagnosis and the 5-item Inattention-Hyperactivity subscale from the Strengths and Difficulties Questionnaire. Maternal report of child sleep problems and self-regulation was collected at 0-1, 2-3, 4-5 and 6-7 years of age. ANOVA was used to compare mean level differences in sleep problems, emotional and attentional regulation by ADHD group. Longitudinal structural equation modeling examined the relations among sleep and self-regulation across time in children with and without ADHD. Results Children with ADHD had persistently elevated levels of sleep problems (from infancy) and emotional and attentional dysregulation compared to controls (from 2-3 years of age). Sleep problems, emotional dysregulation, and attentional regulation were stable over time for both groups. Sleep problems were associated with greater emotional dysregulation two years later from 2-3 years of age for both groups, which in turn was associated with poorer attentional regulation. There was no direct relationship between sleep problems and later attentional regulation. Conclusion Sleep problems in children with and without ADHD are associated with emotional dysregulation, which in turn contributes to poorer attentional functioning. This study highlights the importance of assessing and managing sleep problems in young children.

Molecular biomarkers in non-small-cell lung cancer : a retrospective analysis of data from the phase 3 FLEX study

Background: Findings from the phase 3 FLEX study showed that the addition of cetuximab to cisplatin and vinorelbine significantly improved overall survival, compared with cisplatin and vinorelbine alone, in the first-line treatment of EGFR-expressing, advanced non-small-cell lung cancer (NSCLC). We investigated whether candidate biomarkers were predictive for the efficacy of chemotherapy plus cetuximab in this setting. Methods: Genomic DNA extracted from formalin-fixed paraffin-embedded (FFPE) tumour tissue of patients enrolled in the FLEX study was screened for KRAS codon 12 and 13 and EGFR kinase domain mutations with PCR-based assays. In FFPE tissue sections, EGFR copy number was assessed by dual-colour fluorescence in-situ hybridisation and PTEN expression by immunohistochemistry. Treatment outcome was investigated according to biomarker status in all available samples from patients in the intention-to-treat population. The primary endpoint in the FLEX study was overall survival. The FLEX study, which is ongoing but not recruiting participants, is registered with ClinicalTrials.gov, number NCT00148798. Findings: KRAS mutations were detected in 75 of 395 (19%) tumours and activating EGFR mutations in 64 of 436 (15%). EGFR copy number was scored as increased in 102 of 279 (37%) tumours and PTEN expression as negative in 107 of 303 (35%). Comparisons of treatment outcome between the two groups (chemotherapy plus cetuximab vs chemotherapy alone) according to biomarker status provided no indication that these biomarkers were of predictive value. Activating EGFR mutations were identified as indicators of good prognosis, with patients in both treatment groups whose tumours carried such mutations having improved survival compared with those whose tumours did not (chemotherapy plus cetuximab: median 17·5 months [95% CI 11·7-23·4] vs 8·5 months [7·1-10·8], hazard ratio [HR] 0·52 [0·32-0·84], p=0·0063; chemotherapy alone: 23·8 months [15·2-not reached] vs 10·0 months [8·7-11·0], HR 0·35 [0·21-0·59], p<0·0001). Expression of PTEN seemed to be a potential indicator of good prognosis, with patients whose tumours expressed PTEN having improved survival compared with those whose tumours did not, although this finding was not significant (chemotherapy plus cetuximab: median 11·4 months [8·6-13·6] vs 6·8 months [5·9-12·7], HR 0·80 [0·55-1·16], p=0·24; chemotherapy alone: 11·0 months [9·2-12·6] vs 9·3 months [7·6-11·9], HR 0·77 [0·54-1·10], p=0·16). Interpretation: The efficacy of chemotherapy plus cetuximab in the first-line treatment of advanced NSCLC seems to be independent of each of the biomarkers assessed. Funding: Merck KGaA. © 2011 Elsevier Ltd.

Evaluating patient presentations for care delivered by emergency nurse practitioners : a retrospective analysis of 12 months

Background The delivery of quality patient care in the emergency department (ED) is emerging as one of the most important service indicators to be measured in health services today. The emergency nurse practitioner role was implemented as a service innovation in a Emergency & Trauma Centre (ETC), Melbourne, Australia, in July 2004 .The primary aim of the role was intended to enhance healthcare services, improve the efficiency and timely delivery of high quality care to patients. Aim To conduct a retrospective study of patient presentations at the ETC to obtain a profile of the characteristics of patients managed by emergency nurse practitioners. Specifically the objectives of the study were to: 1) examine the demographics of the patient population 2) evaluate data on emergency department service indicators for this patient cohort Method All patients presenting to the ETC from January 01 2011 to December 31 2011 and managed by emergency nurse practitioners were included in the review. Data collection included baseline demographics, waiting times to be seen, length of stay, emergency department discharge diagnoses and referral patterns. Data were extracted and imported directly from the emergency department Patient Information System (Cerner log), for the specified time frame. Results A total of 5212 patients were reviewed in the study period. The median age of patients was 35 years and 61% of patients were male. The most common discharge diagnosis was open wounds to hand/wrist. Waiting times to be seen by the emergency nurse practitioner were 14 minutes and length of stay for patients with a discharge disposition of home were 122 minutes. Conclusions This study has provided information on patient baseline characteristics and performance on important service indicators for this patient sample that will inform further research to evaluate specific outcomes of the emergency nurse practitioner service.

Depression, anxiety and body image after treatment for invasive stage one epithelial ovarian cancer

Background: Diagnosis of epithelial ovarian cancer (EOC) in young women has major implications including those to their reproductive potential. We evaluated depression, anxiety and body image in patients with stage I EOC treated with fertility sparing surgery (FSS) or radical surgery (RS). We also investigated fertility outcomes after FSS.----- Methods: A retrospective study was undertaken in which 62 patients completed questionnaires related to anxiety, depression, body image and fertility outcomes. Additional information on adjuvant therapy after FSS and RS and demographic details were abstracted from medical records. Both bi and multivariate regression models were used to assess the relationship between demographic, clinical and pathological results and scores for anxiety, depression and body image.----- Results: Thirty-nine patients underwent RS and the rest, FSS. The percentage of patients reporting elevated anxiety and depression (subscores ≥ 11) were 27 % and 5% respectively. The median (inter quartile range) score for body image scale (BIS) was 6 (3-15). None of the demographic or clinical factors examined showed significant association with anxiety and BIS with the exception of ‘time since diagnosis’. For depression, post-menopausal status was the only independent predictor. Among those 23 patients treated by FSS, 14 patients tried to conceive (7 successful), resulting in 7 live births, one termination of pregnancy and one miscarriage.----- Conclusion: This study shows that psychological issues are common in women treated for stage I EOC. Reproduction after FSS is feasible and lead to the birth of healthy babies in about half of patients who wished to have another child. Further prospective studies with standardised instruments are required.

Identification of factors contributing to recurrence of venous leg ulcers

Background and Significance Venous leg ulcers are a significant cause of chronic ill-health for 1–3% of those aged over 60 years, increasing in incidence with age. The condition is difficult and costly to heal, consuming 1–2.5% of total health budgets in developed countries and up to 50% of community nursing time. Unfortunately after healing, there is a recurrence rate of 60 to 70%, frequently within the first 12 months after heaing. Although some risk factors associated with higher recurrence rates have been identified (e.g. prolonged ulcer duration, deep vein thrombosis), in general there is limited evidence on treatments to effectively prevent recurrence. Patients are generally advised to undertake activities which aim to improve the impaired venous return (e.g. compression therapy, leg elevation, exercise). However, only compression therapy has some evidence to support its effectiveness in prevention and problems with adherence to this strategy are well documented. Aim The aim of this research was to identify factors associated with recurrence by determining relationships between recurrence and demographic factors, health, physical activity, psychosocial factors and self-care activities to prevent recurrence. Methods Two studies were undertaken: a retrospective study of participants diagnosed with a venous leg ulcer which healed 12 to 36 months prior to the study (n=122); and a prospective longitudinal study of participants recruited as their ulcer healed and data collected for 12 months following healing (n=80). Data were collected from medical records on demographics, medical history and ulcer history and treatments; and from self-report questionnaires on physical activity, nutrition, psychosocial measures, ulcer history, compression and other self-care activities. Follow-up data for the prospective study were collected every three months for 12 months after healing. For the retrospective study, a logistic regression model determined the independent influences of variables on recurrence. For the prospective study, median time to recurrence was calculated using the Kaplan-Meier method and a Cox proportional-hazards regression model was used to adjust for potential confounders and determine effects of preventive strategies and psychosocial factors on recurrence. Results In total, 68% of participants in the retrospective study and 44% of participants in the prospective study suffered a recurrence. After mutual adjustment for all variables in multivariable regression models, leg elevation, compression therapy, self efficacy and physical activity were found to be consistently related to recurrence in both studies. In the retrospective study, leg elevation, wearing Class 2 or 3 compression hosiery, the level of physical activity, cardiac disease and self efficacy scores remained significantly associated (p<0.05) with recurrence. The model was significant (p <0.001); with a R2 equivalent of 0.62. Examination of relationships between psychosocial factors and adherence to wearing compression hosiery found wearing compression hosiery was significantly positively associated with participants’ knowledge of the cause of their condition (p=0.002), higher self-efficacy scores (p=0.026) and lower depression scores (p=0.009). Analysis of data from the prospective study found there were 35 recurrences (44%) in the 12 months following healing and median time to recurrence was 27 weeks. After adjustment for potential confounders, a Cox proportional hazards regression model found that at least an hour/day of leg elevation, six or more days/week in Class 2 (20–25mmHg) or 3 (30–40mmHg) compression hosiery, higher social support scale scores and higher General Self-Efficacy scores remained significantly associated (p<0.05) with a lower risk of recurrence, while male gender and a history of DVT remained significant risk factors for recurrence. Overall the model was significant (p <0.001); with an R2 equivalent 0.72. Conclusions The high rates of recurrence found in the studies highlight the urgent need for further information in this area to support development of effective strategies for prevention. Overall, results indicate leg elevation, physical activity, compression hosiery and strategies to improve self-efficacy are likely to prevent recurrence. In addition, optimal management of depression and strategies to improve patient knowledge and self-efficacy may positively influence adherence to compression therapy. This research provides important information for development of strategies to prevent recurrence of venous leg ulcers, with the potential to improve health and decrease health care costs in this population.

Is there a difference between narrowing of the spinal canal and neurological deficits comparing Denis and Magerl classifications?

We have read with great interest the retrospective study by Caffaro and Avanzi1 evaluating the relation between narrowing of the spinal canal and neurological deficits in patients with burst-type fractures of the spine. The authors are to be commended for obtaining detailed neurological and radiological data in a large cohort of 227 patients. The authors conclude: “The percentage of narrowing of the spinal canal proved to be a pre-disposing factor for the severity of the neurological status in thoracolumbar and lumbar burst-type fractures according to the classifications of Denis and Magerl.” Although this conclusion is mainly in accordance with previous findings, we would like to comment on the methodological approach applied in the current study.

What are the key conditions associated with lower limb amputations in a major Australian teaching hospital?

Background Lower extremity amputation results in significant global morbidity and mortality. Australia appears to have a paucity of studies investigating lower extremity amputation. The primary aim of this retrospective study was to investigate key conditions associated with lower extremity amputations in an Australian population. Secondary objectives were to determine the influence of age and sex on lower extremity amputations, and the reliability of hospital coded amputations. Methods: Lower extremity amputation cases performed at the Princess Alexandra Hospital (Brisbane, Australia) between July 2006 and June 2007 were identified through the relevant hospital discharge dataset (n = 197). All eligible clinical records were interrogated for age, sex, key condition associated with amputation, amputation site, first ever amputation status and the accuracy of the original hospital coding. Exclusion criteria included records unavailable for audit and cases where the key condition was unable to be determined. Chi-squared, t-tests, ANOVA and post hoc tests were used to determine differences between groups. Kappa statistics were used to measure reliability between coded and audited amputations. A minimum significance level of p < 0.05 was used throughout. Results: One hundred and eighty-six cases were eligible and audited. Overall 69% were male, 56% were first amputations, 54% were major amputations, and mean age was 62 ± 16 years. Key conditions associated included type 2 diabetes (53%), peripheral arterial disease (non-diabetes) (18%), trauma (8%), type 1 diabetes (7%) and malignant tumours (5%). Differences in ages at amputation were associated with trauma 36 ± 10 years, type 1 diabetes 52 ± 12 years and type 2 diabetes 67 ± 10 years (p < 0.01). Reliability of original hospital coding was high with Kappa values over 0.8 for all variables. Conclusions: This study, the first in over 20 years to report on all levels of lower extremity amputations in Australia, found that people undergoing amputation are more likely to be older, male and have diabetes. It is recommended that large prospective studies are implemented and national lower extremity amputation rates are established to address the large preventable burden of lower extremity amputation in Australia.

Postoperative pain relief using intermittent intrapleural analgesia following thoracoscopic anterior correction for progressive adolescent idiopathic scoliosis

Background Thoracoscopic anterior scoliosis instrumentation is a safe and viable surgical option for corrective fusion of progressive adolescent idiopathic scoliosis (AIS) and has been performed at our centre on 205 patients since 2000. However, there is a paucity of literature reporting on or examining optimum methods of analgesia following this type of surgery. A retrospective study was designed to present the authors’ technique for delivering intermittent local anaesthetic boluses via an intrapleural catheter following thoracoscopic scoliosis surgery; report the pain levels that may be expected and any adverse effects associated with the use of intrapleural analgesia, as part of a combined postoperative analgesia regime. Methods Records for 32 patients who underwent thoracoscopic anterior correction for AIS were reviewed. All patients received an intrapleural catheter inserted during surgery, in addition to patient-controlled opiate analgesia and oral analgesia. After surgery, patients received a bolus of 0.25% bupivacaine every four hours via the intrapleural catheter. Patient’s perceptions of their pain control was measured using the visual analogue pain scale scores which were recorded before and after local anaesthetic administration and the quantity and time of day that any other analgesia was taken, were also recorded. Results 28 female and four male patients (mean age 14.5 ± 1.5 years) had a total of 230 boluses of local anaesthetic administered in the 96 hour period following surgery. Pain scores significantly decreased following the administration of a bolus (p < 0.0001), with the mean pain score decreasing from 3.66 to 1.83. The quantity of opiates via patient-controlled analgesia after surgery decreased steadily between successive 24 hours intervals after an initial increase in the second 24 hour period when patients were mobilised. One intrapleural catheter required early removal due to leakage; there were no other associated complications with the intermittent intrapleural analgesia method. Conclusions Local anaesthetic administration via an intrapleural catheter is a safe and effective method of analgesia following thoracoscopic anterior scoliosis correction. Post-operative pain following anterior thoracic scoliosis surgery can be reduced to ‘mild’ levels by combined analgesia regimes. Keywords: Adolescent idiopathic scoliosis; Thoracoscopic anterior spinal fusion; Anterior fusion; Intrapleural analgesia; Endoscopic anterior surgery; Pain relief; Scoliosis surgery