Heart failure following cancer therapy in patients with hematological malignancies aged 18 years and under : a linked health data analysis (1996-2009)

Introduction: The causal link between chemotherapy treatments and subsequent cardiotoxicity is well established, particularly for children with hematological malignancies. Little information exists on the characteristics and outcomes for patients with heart failure (HF) after chemotherapy. This study aimed to describe the characteristics, survival and mortality of patients who received chemotherapy for hematological cancer (leukemias, lymphomas and related disorders) before 18 years old and subsequently developed HF compared to those who did not.

Methods: Linked health data (1996-2009) from the Queensland Cancer Registry, Death Registry and Hospital Administration records for HF and chemotherapy admissions were reviewed. From all breast and hematological cancers patients (n=73,158), 15,987 received chemotherapy, including 819 patients aged ≤18 years at time of cancer diagnosis. Patients were categorized as those with an index HF admission (occurred after cancer diagnosis) and those without an index HF admission (non HF).

Results: Of the 819 patients, 3.7% (n=30) had an index HF admission. Median age of HF patients at time of cancer diagnosis was 5 years (IQR 3-12) compared to 7 years (IQR 3-14) in the non HF group (p=0.503). Median follow up from cancer diagnosis was 2.5 years in the HF group compared to 5.42 years in the non HF group (p<0.01). Of those who developed HF, 70% (n=21) had the index admission within 12 months of their cancer diagnosis. Of those with HF, 53.3% (n=16) died (all cause) compared to 14.6% (n=115) with no HF. On adjustment for age, sex and chemotherapy admissions, HF patients had an almost 5 fold increased mortality risk compared to non HF patients (HR 4.91 [95% CI, 2.88-8.36]) (Figure 1).

Conclusions: This study demonstrated that in children with hematological cancers the onset of HF occurred soon after chemotherapy and mortality risk is almost 5 times that of children who do not develop HF. Innovative strategies are still needed for the prevention and management of cardiotoxicity in this population.

Twelve-month mortality and functional outcomes in hip fracture patients under 65 years of age

There has been a recent call for improved functional outcome reporting in younger hip fracture patients. Younger hip fracture patients represent a different population with different functional goals to their older counterparts. Therefore, previous research on mortality and functional outcomes in hip fracture patients may not be generalisable to the younger population. The aims of this study were to report 12-month survival and functional outcomes in hip fracture patients aged <65 years and predictors of functional outcome.

Children's conception of police authority when responding to requests for assistance

Children (five to six and seven to eight years old) were presented with scenarios in which various adults (a police officer, a teacher, and an unspecified adult) requested assistance from a child. Six scenarios were presented (two per adult) with half involving a reasonable request (requiring little effort from the child) and the others unreasonable. For each scenario, the participants stated: (i) whether the child in the story should comply with the adult's request, (ii) the reason for the compliance decision, (iii) the consequences of non-compliance, and (iv) the legitimacy of the adult's request. Compliance and perceived legitimacy of the request was highest for the police officer compared to the teacher, with both figures commanding greater compliance than the unspecified adult. Children's justifications suggested that the positive relationship between obedience and social status was due (albeit in part) to fear of punishment for non-compliance, particularly in the younger age group.

Rates of common communicable illnesses in non-anaemic 12-24 month old South Island, New Zealand children

Aims : To describe the incidence of parentally reported illness in otherwise healthy South Island toddlers; characterise the predictors of illness; and determine whether there was a relationship between teething and illness in this population.

Methods : A 20-week randomised controlled trial was conducted on 1-year-old children (n=225) from Otago and Southland between February 2004 and December 2005. Information on symptoms of morbidity, occurrence of teething, and childcare attendance were recorded daily throughout the intervention period. Morbidity symptoms were categorised into respiratory illness (RI), gastrointestinal illness (GII), ear infection, and total illness, and the number and duration of events were determined.

Results : The mean (SD) number of total illnesses was 3.4 (2.3) per 20 weeks, with an average duration of 4.5 days. Episodes of RI were most common (50% of total illness events), and tended to be the longest in duration (mean of 3.7 days). Having siblings aged less than 5 years (23% increase, 95%CI 6%–42%, p=0.007) and attending childcare (72% increase, 95%CI 38%–113%, p<0.001)), were positively associated with the number of total illness events but not duration. In addition, teething was positively associated with total events (OR 1.94, 95%CI 1.45–2.60, p<0.001), RI events (OR 2.03, 95%CI 1.41–2.93, p<0.001) and GII events (OR 1.90, 95%CI 1.36–2.67, p<0.001).

Conclusion : This study has shown that illness (particularly RI) is common in the second year of life. It has also confirmed that attending childcare and having siblings aged under 5 years increases the number of illness events. An association between teething and the occurrence of illness was also seen but the exact nature of this relationship requires verification.

The relationship between the incidence of medullated fibres in mohair and live weight over the lifetime of Angora goats

The presence of even a small amount of medullated fibre, in otherwise high quality mohair, may have a pronounced adverse effect on its value and end-use potential. However, there is considerable confusion about the effects, if any, of environmental variables and management upon the incidence of medullated fibres in mohair. This study examined how the incidence of medullated fibres (Med, % by number) is related to the fleece-free live weight (FFLwt) of Angora goats of different genetic origins over their lifetime, and how the relationship varies with other lifetime factors. Measurements were made over 11 shearing periods of 6 months, on a population of Angora goats representing the current range and diversity of genetic origins in Australia, including South African, Texan and interbred admixtures of these and Australian sources. Records of breed, sire, dam, date of birth, dam age, birth weight, birth parity, weaning weight, live weight, fleece growth and fleece quality were taken for castrated males (wethers) (n = 94 animals). A restricted maximum likelihood (REML) model was developed for log10(Med + 1), which allowed the observations of the same animal at different ages to be correlated in an unstructured manner. Med varied between 0.1% and 4.3%. The median average FFLwt during a shearing interval increased from 15 kg at 1 year old to 59 kg at 6 years old. Generally, within each shearing interval, Med increased with increasing average FFLwt. However, the size and shape of the relationship differed greatly between shearing ages. For example, at 3.5 years of age Med increased from about 1.1% at an average FFLwt of 26 kg to 2.6% at 50 kg, whilst at 5.0 years of age Med only changed from 1.4% at 32 kg to 1.6% at 56 kg. Goats with mixed genetic parentage showed an increase in Med at some shearings, particularly at younger ages. Variation in animal nutrition, as measured by live weight change during shearing periods, did not affect Med. The results supplement our earlier findings that mohair mean fibre diameter and clean mohair fleece weight, but not staple length, are greater in larger Angora goats. Live weight needs to be taken into account in genetic evaluation of the incidence of medullated fibres. We conclude that any advantage in handling fewer but larger Angora goats rather than more but smaller goats will come at the detriment of producing lower quality mohair, both in terms of increased Med and mean fibre diameter.

Factors influencing participation in a vascular disease prevention lifestyle program among participants in a cluster randomized trial

Background
Previous research suggests that lifestyle intervention for the prevention of diabetes and cardiovascular disease (CVD) are effective, however little is known about factors affecting participation in such programs. This study aims to explore factors influencing levels of participation in a lifestyle modification program conducted as part of a cluster randomized controlled trial of CVD prevention in primary care.

Methods
This concurrent mixed methods study used data from the intervention arm of a cluster RCT which recruited 30 practices through two rural and three urban primary care organizations. Practices were randomly allocated to intervention (n = 16) and control (n = 14) groups. In each practice up to 160 eligible patients aged between 40 and 64 years old, were invited to participate. Intervention practice staff were trained in lifestyle assessment and counseling and referred high risk patients to a lifestyle modification program (LMP) consisting of two individual and six group sessions over a nine month period. Data included a patient survey, clinical audit, practice survey on capacity for preventive care, referral and attendance records at the LMP and qualitative interviews with Intervention Officers facilitating the LMP. Multi-level logistic regression modelling was used to examine independent predictors of attendance at the LMP, supplemented with qualitative data from interviews with Intervention Officers facilitating the program.

Results
A total of 197 individuals were referred to the LMP (63% of those eligible). Over a third of patients (36.5%) referred to the LMP did not attend any sessions, with 59.4% attending at least half of the planned sessions. The only independent predictors of attendance at the program were employment status - not working (OR: 2.39 95% CI 1.15-4.94) and having high psychological distress (OR: 2.17 95% CI: 1.10-4.30). Qualitative data revealed that physical access to the program was a barrier, while GP/practice endorsement of the program and flexibility in program delivery facilitated attendance.

Conclusion
Barriers to attendance at a LMP for CVD prevention related mainly to external factors including work commitments and poor physical access to the programs rather than an individuals’ health risk profile or readiness to change. Improving physical access and offering flexibility in program delivery may enhance future attendance. Finally, associations between psychological distress and attendance rates warrant further investigation.

Hyponatraemia: an audit of aged psychiatry patients taking SSRIs and SNRIs

Objective: 

Coupling online control and inhibitory systems in children with developmental coordination disorder: goal-directed reaching

For children with Developmental Coordination Disorder (DCD), the real-time coupling between frontal executive function and online motor control has not been explored despite reported deficits in each domain. The aim of the present study was to investigate how children with DCD enlist online control under task constraints that compel the need for inhibitory control. A total of 129 school children were sampled from mainstream primary schools. Forty-two children who met research criteria for DCD were compared with 87 typically developing controls on a modified double-jump reaching task. Children within each skill group were divided into three age bands: younger (6-7 years), mid-aged (8-9), and older (10-12). Online control was compared between groups as a function of trial type (non-jump, jump, anti-jump). Overall, results showed that while movement times were similar between skill groups under simple task constraints (non-jump), on perturbation (or jump) trials the DCD group were significantly slower than controls and corrected trajectories later. Critically, the DCD group was further disadvantaged by anti-jump trials where inhibitory control was required; however, this effect reduced with age. While coupling online control and executive systems is not well developed in younger and mid-aged children, there is evidence of age-appropriate coupling in older children. Longitudinal data are needed to clarify this intriguing finding. The theoretical and applied implications of these results are discussed.

Toward a standard approach to measurement and reporting of perioperative mortality rate as a global indicator for surgery

INTRODUCTION: The proportion of patients who die during or after surgery, otherwise known as the perioperative mortality rate (POMR), is a credible indicator of the safety and quality of operative care. Its accuracy and usefulness as a metric, however, particularly one that enables valid comparisons over time or between jurisdictions, has been limited by lack of a standardized approach to measurement and calculation, poor understanding of when in relation to surgery it is best measured, and whether risk-adjustment is needed. Our aim was to evaluate the value of POMR as a global surgery metric by addressing these issues using 4, large, mixed, surgical datasets that represent high-, middle-, and low-income countries. METHODS: We obtained data from the New Zealand National Minimum Dataset, the Geelong Hospital patient management system in Australia, and purpose-built surgical databases in Pietermaritzburg, South Africa, and Port Moresby, Papua New Guinea. For each site, we calculated the POMR overall as well as for nonemergency and emergency admissions. We assessed the effect of admission episodes and procedures as the denominator and the difference between in-hospital POMR and POMR, including postdischarge deaths up to 30 days. To determine the need for risk-adjustment for age and admission urgency, we used univariate and multivariate logistic regression to assess the effect on relative POMR for each site. RESULTS: A total of 1,362,635 patient admissions involving 1,514,242 procedures were included. More than 60% of admissions in Pietermaritzburg and Port Moresby were emergencies, compared with less than 30% in New Zealand and Geelong. Also, Pietermaritzburg and Port Moresby had much younger patient populations (P < .001). A total of 8,655 deaths were recorded within 30 days, and 8-20% of in-hospital deaths occurred on the same day as the first operation. In-hospital POMR ranged approximately 9-fold, from 0.38 per 100 admissions in New Zealand to 3.44 per 100 admissions in Pietermaritzburg. In New Zealand, in-hospital 30-day POMR underestimated total 30-day POMR by approximately one third. The difference in POMR if procedures were used instead of admission episodes ranged from 7 to 70%, although this difference was less when central line and pacemaker insertions were excluded. Age older than 65 years and emergency admission had large, independent effects on POMR but relatively little effect in multivariate analysis on the relative odds of in-hospital death at each site. CONCLUSION: It is possible to collect POMR in countries at all level of development. Although age and admission urgency are strong, independent associations with POMR, a substantial amount of its variance is site-specific and may reflect the safety of operative and anesthetic facilities and processes. Risk-adjustment is desirable but not essential for monitoring system performance. POMR varies depending on the choice of denominator, and in-hospital deaths appear to underestimate 30-day mortality by up to one third. Standardized approaches to reporting and analysis will strengthen the validity of POMR as the principal indicator of the safety of surgery and anesthesia care.

The 45 year old health check - feasibility and impact on practices and patient behaviour

Background: The 45 year old health check (MBS item 717) for patients aged 45-49 years was introduced in 2006. This study evaluated its impact on preventive care and patient reported risk factors. Methods: A quantitative and qualitative study was conducted in eight general practices in Sydney, New South Wales. It involved follow up surveys of 118 patients taken both before the check and 3 months after. Practice staff were trained and supported to conduct the health checks and appropriate interventions. Results: There was ambivalence among some of the general practitioners toward the health check, but most found it feasible. The reported frequency of GP advice relating to each of the SNAP (smoking, nutrition, alcohol, and physical activity) risk factors increased; patient referrals, however, were infrequent. Patients' readiness to change their diet and exercise habits improved as a result of the check, with respondents showing an increase in both the consumption of vegetables and the frequency of physical activity. There was no change in body mass index, smoking or alcohol consumption. Discussion: The health check was associated with a short term improvement in diet and physical activity behaviours. Mechanisms to enhance referral need to be developed.