Glycaemic monitoring and control among high-risk patients with type 2 diabetes in Australian general practice during COVID-19

BACKGROUND

The COVID-19 pandemic disrupted general practice worldwide, primarily due to public health measures that restricted access to care for chronic diseases, such as type 2 diabetes. These measures disproportionately affected higher risk groups with type 2 diabetes, such as older people and those with obesity. This study aims to identify factors that may have influenced the rates of compliance with testing guidelines and target glycaemic control in Australian general practice settings during the COVID-19 pandemic.

METHODS

We used a serial cross-sectional study design of patient record data from general practices representative of the Nepean Blue Mountains Local Health District between 2020 and 2022. Aggregated patient records were analysed to determine percentages of subgroups with a blood glycaemic testing interval consistent with guidelines (≥1 within 15 months) and achieving target glycaemic control (by glycated haemoglobin of ≤7%). Linear regression models were used to test the association between independent and dependent variables, and to generate regression coefficients and 95% CI, corrected for time trends.

RESULTS

Of the average 14 356 patient records per month, 55% were male, 53% had a body mass index (BMI) <30 and 55% were aged 55-74 years. Compliance to testing guidelines slightly decreased (75-73%) but was positively associated with male sex (2.5%, 95% CI 1.7%, 3.4%), BMI≥30 (9.6%, 95% CI 8.8%, 10.4%) and 55-74 years (7.5%, 95% CI 6.6%, 8.5%) and 75 years and over age groups (7.1%, 95% CI 6.2%, 7.9%). Mean percentage of patient records achieving target glycaemic control slightly increased and was negatively associated with male sex (-3.7%, 95% CI -5.2%, -2.2%), but positively associated with 55-74 years (4.5%, 95% CI 3.8%, 5.1%) and 75 years and over age groups (12.2%, 95% CI 4.5%, 20.0%). Compliance to testing guidelines increased with each additional general practice per 10 000 persons (8.4%, 95% CI 4.9%, 11.8%).

CONCLUSIONS

During the COVID-19 pandemic, people with type 2 diabetes in Australia continued to follow glycaemic testing guidelines at the same rate. In fact, there was a slight improvement in glycaemic control among all subgroups of patients, including those at higher risk. These findings are encouraging, but the longer term impact of COVID-19 on type 2 diabetes care is still unclear.

PROTOCOL: The effectiveness of sensory interventions targeted at improving occupational outcomes, quality of life, well-being and behavioural and psychological symptoms for older adults living with dementia: A systematic review and meta-analysis

This is the protocol for a Campbell systematic review. The objectives are as follows: The primary objective is to systematically review the available evidence of the effects of sensory interventions on quality of life, well-being, occupational participation, and behavioural and psychological symptoms of older adults living with dementia.

Valproic acid as a radio-sensitizer in glioma: A systematic review and meta-analysis

Background

Histone deacetylase inhibitors (HDACi) including valproic acid (VPA) have the potential to improve radiotherapy (RT) efficacy and reduce treatment adverse events (AE) via epigenetic modification and radio-sensitization of neoplastic cells. This systematic review and meta-analysis aimed to assess the efficacy and AE associated with HDACi used as radio-sensitizers in adult solid organ malignancy patients.

Methods

A systematic review utilized electronic searches of MEDLINE(Ovid), Embase(Ovid), The Cochrane Library, and the International Clinical Trials Registry Platform to identify studies examining the efficacy and AEs associated with HDACi treatment in solid organ malignancy patients undergoing RT. Meta-analysis was performed with overall survival (OS) reported as hazard ratios (HR) as the primary outcome measure. OS reported as median survival difference, and AEs were secondary outcome measures.

Results

Ten studies reporting on the efficacy and/or AEs of HDACi in RT-treated solid organ malignancy patients met inclusion criteria. All included studies focused on HDACi valproic acid (VPA) in high-grade glioma patients, of which 9 studies (n = 6138) evaluated OS and 5 studies (n = 1055) examined AEs. The addition of VPA to RT treatment protocols resulted in improved OS (HR = 0.80, 95% CI 0.67-0.96). No studies focusing on non-glioma solid organ malignancy patients, or non-VPA HDACi met the inclusion criteria for this review.

Conclusions

This review suggests that glioma patients undergoing RT may experience prolonged survival due to HDACi VPA administration. Further randomized controlled trials are required to validate these findings. Additionally, more research into the use of HDACi radio-adjuvant treatment in non-glioma solid organ malignancies is warranted.

Study protocol for a phase III randomised controlled trial of Sailuotong (SLT) for vascular dementia and Alzheimer's disease with cerebrovascular disease

Vascular dementia (VaD) accounts for 15-20% of all dementia cases. It is a syndrome of acquired cognitive impairment with a complex pathophysiological basis. A novel herbal formulation (Sailuotong; SLT) consisting of Panax ginseng C.A Mey, Ginkgo biloba L and Crocus sativus L extracts was developed to treat VaD. Preclinical animal studies found significant improvements in memory and in pathogenic biochemical parameters. Appropriate safety of SLT was shown in acute and chronic toxicity studies, and early clinical trials of SLT demonstrated enhancements in cognition in VaD patients. A fully powered study with a long intervention period is needed to confirm the efficacy and safety of this novel intervention. A rigorous phase III clinical trial was developed with the aim of recruiting 238 patients diagnosed with mild to moderate probable VaD, or VaD mixed with Alzheimer's disease (where cerebrovascular disease is the clinical dominant contributor to dementia, abbreviated as CVD+AD). Using a permuted block strategy, participants will be randomly allocated to receive SLT (120 mg bd) or placebo capsules for an intervention period of 52 weeks and will be followed-up for an additional 13 weeks. The primary outcome measures are the Vascular Dementia Assessment Scale-cognitive subscale and Alzheimer's Disease Cooperative Study-Activities of Daily Living scale. Secondary outcome measures include the Clinician's Interview Based Impression of Change-Plus, CLOX, EXIT-25, Neuropsychiatric Inventory-Clinician rating scale, and Dementia Quality of Life questionnaire. Safety is assessed through adverse event reports and liver, renal, and coagulation studies. Primary and secondary outcome measures will be compared between treatment and placebo groups, using intention to treat and per protocol analyses. We hypothesise that a 52-week treatment of SLT will be clinically effective and well tolerated in participants with VaD or AD+CVD. This project will provide vital efficacy and safety data for this novel treatment approach to VaD.

Zao Ren An Shen capsule for insomnia: A double-blind, randomized, placebo-controlled trial

STUDY OBJECTIVES

The aim of this study was to test the efficacy and safety of Zao Ren An Shen (ZRAS) capsule, a Chinese herbal medicine product, for the treatment of insomnia.

METHODS

We conducted a double-blind randomized placebo-controlled trial. After a one-week placebo run-in, a total of 85 people with insomnia were randomly allocated to receive ZRAS or placebo for four weeks. The primary outcomes were insomnia severity assessed with the Insomnia Severity Index (ISI) and the number of participants with adverse events. Secondary outcomes included objective and subjective sleep parameters, psychological status, fatigue level, quality of life, acceptability, and tolerability.

RESULTS

A non-significant (p > 0.05) difference of 0.7 points in ISI in favor of ZRAS capsule was found at the end of the treatment. The number of participants with adverse events was not significantly different (p > 0.05) between the two groups. Except for subjective sleep onset latency, which had a non-significant (p > 0.05) medium effect (Cohen's d = 0.5), the effects in secondary efficacy outcomes were all small (Cohen's d < 0.4) and non-significant (p > 0.05). The acceptability and tolerability were high in the active group.

CONCLUSIONS

ZRAS capsule is safe, acceptable, and tolerable, yet not more effective than placebo in the treatment of insomnia. As previous evidence showed that Chinese herbal medicine was effective for insomnia, these results may be explained by the dose of the product, which was lower than the dose generally used in the clinic.

Using a simplified ATP algorithm to improve data reliability and improve cleanliness standards for surface and medical device hygiene

BACKGROUND

An algorithm has been improved to mitigate variability in cleanliness measurements of various surfaces using rapid Adenosine Triphosphate (ATP) testing. A cleaning intervention step (CIS) verifies the cleanability of those surfaces.

METHODS

ATP testing was performed on surfaces which were pre-approved as "clean" and ready for re-use. Adjacent (duplicate) ATP sampling was undertaken on 421 environmental surfaces, medical devices and other implements. The CIS was conducted on 270 surfaces using an aseptic technique and disposable cleaning wipes.

RESULTS

The two initial ATP results were plotted against each other with a 100 RLU threshold grading the results as clean (2x < 100RLU), dirty (2x > 100RLU) or equivocal (1x < 100RLU and 1x > 100RLU). Of the surfaces sampled, 68.5 % were clean (288/421), 13.5 % were dirty (57/421) and 18 % were equivocal (76/421). The duplicate testing demonstrated a false negative rate of 10 % (44/421) where the first swab was <100 RLU and the second swab >100 RLU. For the equivocal group, the gap between the two swabs was >100 RLU for 7.5 % of surfaces (33/421). The CIS was conducted on 270 of the surfaces tested and showed that cleaning could be improved (P=<0.001) on 88.5 % of surfaces (239/270).

CONCLUSION

The simplified ATP testing algorithm provides real-time discrimination between surface cleanliness levels and improved certainty over surface hygiene. The duplicate swab sampling approach mitigates uncontrolled variability in the results and the CIS provides a nuanced understanding of the measurable cleanliness of any surface.

Augmenting cancer registry data with health survey data with no cases in common: the relationship between pre-diagnosis health behaviour and post-diagnosis survival in oesophageal cancer

Background

For epidemiological research, cancer registry datasets often need to be augmented with additional data. Data linkage is not feasible when there are no cases in common between data sets. We present a novel approach to augmenting cancer registry data by imputing pre-diagnosis health behaviour and estimating its relationship with post-diagnosis survival time.

Methods

Six measures of pre-diagnosis health behaviours (focussing on tobacco smoking, ‘at risk’ alcohol consumption, overweight and exercise) were imputed for 28,000 cancer registry data records of US oesophageal cancers using cold deck imputation from an unrelated health behaviour dataset. Each data point was imputed twice. This calibration allowed us to estimate the misclassification rate. We applied statistical correction for the misclassification to estimate the relative risk of dying within 1 year of diagnosis for each of the imputed behaviour variables. Subgroup analyses were conducted for adenocarcinoma and squamous cell carcinoma separately.

Results

Simulated survival data confirmed that accurate estimates of true relative risks could be retrieved for health behaviours with greater than 5% prevalence, although confidence intervals were wide. Applied to real datasets, the estimated relative risks were largely consistent with current knowledge. For example, tobacco smoking status 5 years prior to diagnosis was associated with an increased age-adjusted risk of all cause death within 1 year of diagnosis for oesophageal squamous cell carcinoma (RR = 1.99 95% CI 1.24,3.12) but not oesophageal adenocarcinoma RR = 1.61, 95% CI 0.79,2.57).

Conclusions

We have demonstrated a novel imputation-based algorithm for augmenting cancer registry data for epidemiological research which can be used when there are no cases in common between data sets. The algorithm allows investigation of research questions which could not be addressed through direct data linkage.

Validation of a food frequency questionnaire as a tool for assessing dietary intake in cardiovascular disease research and surveillance in Bangladesh

BACKGROUND

Cardiovascular disease (CVD) has emerged as a major public health concern in Bangladesh. Diet is an established risk factor for CVD but a tool to assess dietary intake in Bangladesh is lacking. This study aimed to validate a food frequency questionnaire (FFQ) using the 24-h dietary recall method and corresponding nutritional biological markers among rural and urban populations of Bangladesh.

METHOD

Participants of both genders aged 18-60 years were included in the analysis (total n = 146, rural n = 94 and urban n = 52). Two FFQs of 166 items were administered three-months apart, during which time three 24-h dietary recalls were also completed. Participants were asked to recall their frequency of consumption over the preceding 3 months. Urine and blood samples were collected for comparison between FFQ-estimates of nutrients and their corresponding biomarkers. Methods were compared using unadjusted, energy-adjusted, de-attenuated correlation coefficients, 95% limits of agreement (LOA) and quartile classification.

RESULTS

Fair to moderate agreement for ranking energy, macro and micronutrients into quartiles was observed (weighted k value ranged from 0.22 to 0.58; p < 0.001 for unadjusted data) except for vitamin D (weighted k - 0.05) and zinc (weighted k 0.09). Correlation coefficients of crude energy, macronutrients and common micronutrients including vitamin E, thiamine, riboflavin, niacin, pyridoxine, folate, iron, magnesium, phosphorus, potassium, and sodium were moderately good, ranging from 0.42 to 0.78; p < 0.001 but only fair for vitamin A, β carotene and calcium (0.31 to 0.38; p < 0.001) and poor for vitamin D and zinc (0.02 and 0.16; p = ns, respectively). Energy-adjusted correlations were generally lower except for fat and vitamin E, and in range of - 0.017 (for calcium) to 0.686 (for fat). De-attenuated correlations were higher than unadjusted and energy- adjusted, and significant for all nutrients except for vitamin D (0.017) to 0.801 (for carbohydrate). The Bland Altman tests demonstrated that most of the coefficients were positive which indicated that FFQ provided a greater overestimation at higher intakes. More than one in three participants appeared to overestimate their food consumption based on the ratio of energy intake to basal metabolic rate cut points suggested by Goldberg. Absolute intake of macronutrients was 1.5 times higher and for micronutrients it ranged from 1.07 (sodium) to 26 times (Zinc). FFQ estimates correlated well for sodium (0.32; p < 0.001), and vitamin D (0.20; p = 0.017) with their corresponding biomarkers and iron (0.25; p = 0.003) with serum ferritin for unadjusted data. Folate, iron (with haemoglobin) and total protein showed inverse association; and fat and potassium showed poor correlation with their corresponding biomarkers for unadjusted data. However, folate showed significant positive correlation (0.189; p = 0.025) with biomarker after energy adjustment.

CONCLUSION

Although FFQ showed overestimation for absolute intake in comparison with 24-h recalls, the validation study demonstrated acceptable agreement for ranking dietary intakes from FFQ with 24-h recall methods and some biomarkers and therefore could be considered as a tool to measure dietary intake for research and CVD risk factors surveillance in Bangladesh. The instrument may not be appropriate for monitoring population adherence to recommended intakes because of the overestimation.

Using estimated probability of pre-diagnosis behavior as a predictor of cancer survival time: an example in esophageal cancer

Background

Information on the associations between pre-diagnosis health behavior and post-diagnosis survival time in esophageal cancer could assist in planning health services but can be difficult to obtain using established study designs. We postulated that, with a large data set, using estimated probability for a behavior as a predictor of survival times could provide useful insight as to the impact of actual behavior.

Methods

Data from a national health survey and logistic regression were used to calculate the probability of selected health behaviors from participant’s demographic characteristics for each esophageal cancer case within a large cancer registry data base. The associations between survival time and the probability of the health behaviors were investigated using Cox regression.

Results

Observed associations include: a 0.1 increase in the probability of smoking 1 year prior to diagnosis was detrimental to survival (Hazard Ratio (HR) 1.21, 95% CI 1.19,1.23); a 0.1 increase in the probability of hazardous alcohol consumption 10 years prior to diagnosis was associated with decreased survival in squamous cell cancer (HR 1.29, 95% CI 1.07, 1.56) but not adenocarcinoma (HR 1.08, 95% CI 0.94,1.25); a 0.1 increase in the probability of physical activity outside the workplace is protective (HR 0.83, 95% CI 0.81,0.84).

Conclusions

We conclude that probability for health behavior estimated from demographic characteristics can provide an initial assessment of the association between pre-diagnosis health behavior and post-diagnosis health outcomes, allowing some sharing of information across otherwise unrelated data collections.

Seasonal Variations in Physical Activity Domains among Rural and Urban Bangladeshis Using a Culturally Relevant Past Year Physical Activity Questionnaire (PYPAQ)

While the effect of weather and seasons on physical activity (PA) is well documented for leisure-time physical activities in western countries, scant information is available for developing countries where lifestyle PA is the major source of energy expenditure (EE). In Bangladesh, the traditional calendar divides the year to six seasons that last two months each: summer, rainy, autumn, late autumn, winter, and spring. We developed the Past Year Physical Activity Questionnaire to record culturally relevant physical activities and to help assess the seasonal variation in total and domain-specific PA in Bangladesh. We have applied this tool to 162 men and women aged 18-60 years residing in Dhaka city and in the northern rural district of Thakurgaon. Repeated measures analysis of variance (RMANOVA) was used to test for evidence of variation in PA between place and seasons. The age- and gender-adjusted model revealed significantly lower levels of EE in urban residents compared to rural residents across all seasons and domains. We also found evidence of seasonal variations in moderate-to-vigorous physical activity (MVPA) MET-min/weekamong rural participants only; for total PA (ranging from 3192 in autumn to 4124 in winter; p = 0.0001) and for two domains: the occupation domain (ranging from 935 in autumn to 1645 in winter; p = 0.0001) and the leisure time domain(ranging from 229 in late autumn to 272 in rainy season; p = 0.005). Seasonality in gardening was also noted (ranging from 2.46 in late autumn to 29.28 in rainy season; p = 0.0001). There were no seasonal differences of total and domain-specific MVPA in urban except household-related PA. Among rural participants, PA was higher in the summer, rainy, and winter seasons and lower in autumn and late autumn. The most common leisure-time physical activities were walking, bicycling, and swimming with higher participation in the rural area. Leisure-time physical activity needs to be promoted to urban residents all year long but more focused on autumn, late autumn, and spring in rural areas.

Predictors of and barriers to adherence in a 16-week randomised controlled trial of Bikram yoga in stressed and sedentary adults

BACKGROUND

Bikram yoga may enhance health outcomes in healthy adults and those at risk for chronic disease, however, challenges remain in achieving optimal adherence to this practice. This study investigated factors influencing adherence to a 16-week Bikram yoga intervention in stressed and sedentary adults.

METHODS

Experimental group participants (n = 29) were instructed to attend 3-5 Bikram yoga classes weekly for 16 weeks. Baseline demographics, behaviours and health measures were investigated as predictors of adherence. Barriers were assessed via documentation of adverse events, and exit survey responses.

RESULTS

Participants (38.2 ± 10.1 years) were predominantly overweight-obese (83%), female (79%), and attended 27 ± 18 classes. Higher adherence was associated with older age (p = 0.094), less pain (p = 0.011), fewer physical limitations (p = 0.011), poorer blood lipid profile, and higher heart rate variability (HRV; total power, (p = 0.097)). In multi-variable analysis, three variables: age (β = 0.492, p = 0.006), HRV (β = 0.413, p = 0.021) and pain (β = 0.329, p = 0.048) remained predictors of adherence. Difficulty committing to the trial, lack of enjoyment and adverse events were barriers to adherence.

CONCLUSIONS

These findings should be considered in the development of future Bikram yoga trials to facilitate higher levels of adherence, which may enhance health outcomes and inform community practice. Future trials should investigate and address additional barriers and facilitators of Bikram yoga practice.

Effect of a 16-week Bikram yoga program on perceived stress, self-efficacy and health-related quality of life in stressed and sedentary adults: A randomised controlled trial

OBJECTIVES

The purpose of this study was to investigate the effect of 16 weeks of Bikram yoga on perceived stress, self-efficacy and health related quality of life (HRQoL) in sedentary, stressed adults.

DESIGN

16 week, parallel-arm, randomised controlled trial with flexible dosing.

METHODS

Physically inactive, stressed adults (37.2±10.8 years) were randomised to Bikram yoga (three to five classes per week) or control (no treatment) group for 16 weeks. Outcome measures, collected via self-report, included perceived stress, general self-efficacy, and HRQoL. Outcomes were assessed at baseline, midpoint and completion.

RESULTS

Individuals were randomised to the experimental (n=29) or control group (n=34). Average attendance in the experimental group was 27±18 classes. Repeated measure analyses of variance (intention-to-treat) demonstrated significantly improved perceived stress (p=0.003, partial η²=0.109), general self-efficacy (p=0.034, partial η²=0.056), and the general health (p=0.034, partial η²=0.058) and energy/fatigue (p=0.019, partial η²=0.066) domains of HRQoL in the experimental group versus the control group. Attendance was significantly associated with reductions in perceived stress, and an increase in several domains of HRQoL.

CONCLUSIONS

16 weeks of Bikram yoga significantly improved perceived stress, general self-efficacy and HRQoL in sedentary, stressed adults. Future research should consider ways to optimise adherence, and should investigate effects of Bikram yoga intervention in other populations at risk for stress-related illness.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry ACTRN12616000867493. Registered 04 July 2016. URL: http://www.anzctr.org.au/ACTRN12616000867493.aspx.

Effect of a 16-week Bikram yoga program on heart rate variability and associated cardiovascular disease risk factors in stressed and sedentary adults: A randomized controlled trial

Background

Chronic activation of the stress-response can contribute to cardiovascular disease risk, particularly in sedentary individuals. This study investigated the effect of a Bikram yoga intervention on the high frequency power component of heart rate variability (HRV) and associated cardiovascular disease (CVD) risk factors (i.e. additional domains of HRV, hemodynamic, hematologic, anthropometric and body composition outcome measures) in stressed and sedentary adults.

Methods

Eligible adults were randomized to an experimental group (n = 29) or a no treatment control group (n = 34). Experimental group participants were instructed to attend three to five supervised Bikram yoga classes per week for 16 weeks at local studios. Outcome measures were assessed at baseline (week 0) and completion (week 17).

Results

Sixty-three adults (37.2 ± 10.8 years, 79% women) were included in the intention-to-treat analysis. The experimental group attended 27 ± 18 classes. Analyses of covariance revealed no significant change in the high-frequency component of HRV (p = 0.912, partial η² = 0.000) or in any secondary outcome measure between groups over time. However, regression analyses revealed that higher attendance in the experimental group was associated with significant reductions in diastolic blood pressure (p = 0.039; partial η² = 0.154), body fat percentage (p = 0.001, partial η² = 0.379), fat mass (p = 0.003, partial η² = 0.294) and body mass index (p = 0.05, partial η² = 0.139).

Conclusions

A 16-week Bikram yoga program did not increase the high frequency power component of HRV or any other CVD risk factors investigated. As revealed by post hoc analyses, low adherence likely contributed to the null effects. Future studies are required to address barriers to adherence to better elucidate the dose-response effects of Bikram yoga practice as a medium to lower stress-related CVD risk.

Trial registration

Retrospectively registered with Australia New Zealand Clinical Trials Registry ACTRN12616000867493. Registered 04 July 2016.

The influence of neighbourhood green space on children's physical activity and screen time: findings from the longitudinal study of Australian children

OBJECTIVE

It is often hypothesised that neighbourhood green space may help prevent well-known declines in physical activity and increases in sedentary behaviour that occur across childhood. As most studies in this regard are cross-sectional, the purpose of our study was to use longitudinal data to examine whether green space promotes active lifestyles as children grow older.

METHODS

Data came from participants (n = 4983; age = 4-5) of the Longitudinal Study of Australian Children, a nationally representative study on health and child development. Physical activity and screen time were measured biennially (2004-2012) using questionnaires and time use diaries. Quantity of neighbourhood green space was objectively measured using Australian Bureau of Statistics mesh block data for each participant's statistical area level 2. Multilevel regression was used to test for associations between physical activity and screen time with green space quantity, adjusting for socio-economic confounders.

RESULTS

Boys living in areas with 10% more neighbourhood green space had a: 7% (95% CI = 1.02, 1.13) greater odds of choosing physically active pastimes; 8% (95 % CI = 0.85, 1.00) lower odds of not enjoying physical activity; 2.3 min reduction in weekend television viewing (95% CI = -4.00, -0.69); and 7% (95% CI = 1.02; 1.12) and 9% (95% CI = 1.03; 1.15) greater odds of meeting physical activity guidelines on weekdays and weekends, respectively. No statistically (or practically) significant results were observed for girls.

CONCLUSION

Current provisions of neighbourhood green space may be more amenable to promoting active lifestyles among boys than girls. Research is needed to explore what types of green space promote active lifestyles in all children.

Green Space and Child Weight Status: Does Outcome Measurement Matter? Evidence from an Australian Longitudinal Study

OBJECTIVE

To examine whether neighbourhood green space is beneficially associated with (i) waist circumference (WC) and (ii) waist-to-height ratio (WtHR) across childhood.

METHODS

Gender-stratified multilevel linear regressions were used to examine associations between green space and objective measures of weight status in the Longitudinal Study of Australian Children, a nationally representative source of data on 4,423 children aged 6 y to 13 y. WC and WtHR were measured objectively. Percentage green space within the local area of residence was calculated. Effect modification by age was explored, adjusting for socioeconomic confounding.

RESULTS

Compared to peers with 0-5% green space locally, boys and girls with >40% green space tended to have lower WC (β boys  -1.15, 95% CI -2.44, 0.14; β girls  -0.21, 95% CI -1.47, 1.05) and WtHR (β boys  -0.82, 95% CI -1.65, 0.01; β girls  -0.32, 95% CI -1.13, 0.49). Associations among boys were contingent upon age (p  valuesage∗green  space < 0.001) and robust to adjustment for socioeconomic variables. The benefits of greener neighbourhoods appeared from age 7, with mean WC and WtHR for boys aged 13 y with >40% green space at 73.85 cm and 45.75% compared to those with 0-5% green space at 75.18 cm and 46.62%, respectively.

CONCLUSIONS

Greener neighbourhoods appear beneficial to alternative child weight status measures, particularly among boys.

Outcomes and opportunities: a nurse-led model of chronic disease management in Australian general practice

The Australian government’s commitment to health service reform has placed general practice at the centre of its agenda to manage chronic disease. Concerns about the capacity of GPs to meet the growing chronic disease burden has stimulated the implementation and testing of new models of care that better utilise practice nurses (PN). This paper reports on a mixed-methods study nested within a larger study that trialled the feasibility and acceptability of a new model of nurse-led chronic disease management in three general practices. Patients over 18 years of age with type 2 diabetes, hypertension or stable ischaemic heart disease were randomised into PN-led or usual GP-led care. Primary outcomes were self-reported quality of life and perceptions of the model’s feasibility and acceptability from the perspective of patients and GPs. Over the 12-month study quality of life decreased but the trend between groups was not statistically different. Qualitative data indicate that the PN-led model was acceptable and feasible to GPs and patients. It is possible to extend the scope of PN care to lead the routine clinical management of patients’ stable chronic diseases. All GPs identified significant advantages to the model and elected to continue with the PN-led care after our study concluded.

The influence of prediagnostic demographic and lifestyle factors on esophageal squamous cell carcinoma survival

Demographic and lifestyle factors, in particular tobacco smoking and alcohol, are well established causes of esophageal squamous cell carcinoma (ESCC); however, little is known about the effect of these factors on survival. We included all 301 patients with incident ESCC, recruited into a population-based case-control study of esophageal cancer in Australia. Detailed information about demographic and lifestyle factors was obtained at diagnosis, and deaths were identified using the National Death Index. Median follow-up for all-cause mortality was 6.4 years. Hazard ratios (HRs) and 95% confidence intervals (95% CI) were calculated from Cox proportional hazards models, adjusted for age, sex, pretreatment AJCC tumor stage, treatment and presence of comorbidities. Two hundred and thirteen patients (71%) died during follow-up. High lifetime alcohol consumption was independently associated with poor survival. Relative to life-long nondrinkers and those consuming<1 drink/week, the HRs for those with average consumption of 7-20 drinks/week or ≥21 drinks/week were 2.21 (95% CI=1.27-3.84) and 2.08 (95% CI=1.18-3.69), respectively. There was a suggestion of worse survival among current smokers (HR=1.42, 95% CI=0.89-2.28); however, the risk of early death was greatest among current smokers who reported regularly (≥7 drinks/week) consuming alcohol (HR=3.84, 95% CI=2.02-7.32). Other lifestyle factors putatively associated with risk of developing ESCC were not associated with survival. In addition to increasing disease risk, heavy alcohol consumption may be independently associated with worse survival among patients with ESCC. Future clinical follow-up studies should consider alcohol as a potential prognosticator, in addition to known clinicopathologic factors.

Medical practitioners and health promotion: results from a community survey in Sydney's western suburbs

A health survey of 484 persons aged 14 to 89 years was conducted in Sydney's western suburbs in May 1987. Its aims included a description of preventive activities undertaken by medical practitioners and an assessment of the community's perception of the doctor's role in health promotion. Ninety-three per cent reported visiting a doctor in the previous year and 31 per cent of respondents reported having contact with a general practitioner the fortnight before the survey, either for their own health or that of another. Eighty per cent of respondents reported having had their blood pressure measured in the previous year and 63 per cent of female respondents aged 18 years and over who had not had a hysterectomy reported having had a Pap smear in the last five years. However, few respondents reported receiving any lifestyle-related advice at their most recent doctor visit and 77 per cent said that the food they ate was rarely or never discussed with their doctor. Despite this low level of advice, doctors and nurses were perceived to be the most important source of health information by nearly half the respondents. Strategies for increasing the involvement of doctors in health promotion are discussed.

Long-term survival of surgically treated hip fracture in an Australian regional hospital

This study was undertaken to identify factors influencing outcome in elderly patients operated for hip fracture. In particular, this study examined factors related to mortality at least 30 months post-fracture. Hospital records and death registrations were analysed for 463 patients aged 60 or more years treated for hip fracture at a Queensland regional hospital between 1997 and 2001. The overall mortality for surgically treated patients was 13.7% at 100 days and 24.9% at one year Patient factors including age, gender, health status and place of residence were the predominant influences on mortality. Non-patient and process factors including delay to surgery, type of operation and type of anaesthetic had minimal impact on mortality. No major determinants of length of hospital stay were identified. Patient health status was the main determinant for surgical delay. Our results confirm the persistently high mortality in this group of patients, and suggest that the main determinants of outcome are patient- rather than process-related.

Monitoring postoperative pulmonary embolisms in Australia--II. Variation within hospitals

Clinical indicator data can be analysed quickly and efficiently within hospitals to provide quality review staff with monthly or quarterly reports on their own hospital's performance relative to national or regional normative statistics. The statistical tools used are indirect standardisation to correct for casemix differences between institutions and control charts, and cumulative sum charts for the analysis and presentation of findings. Routinely collected postoperative pulmonary embolism data are used to illustrate these approaches.

Monitoring postoperative pulmonary embolisms in Australia--I. Variation between hospitals

Information on inter-hospital variation in clinical outcomes can be extracted from routinely collected morbidity data in Australia. Postoperative pulmonary embolism rates, one of seven clinical performance indicators now subject to review during Australian hospitals' quality accreditation surveys, is used as an example throughout. Using indirect statistical standardisation and Poisson models of random variation, we were able to identify five hospitals which recorded statistically significantly higher pulmonary embolism rates than average and three which recorded lower than expected rates. The application of these methods to all hospital outcome measures will assist in objectively monitoring the quality of patient care.

Objective decision-making following a portal film: the results of a pilot study

PURPOSE

To discriminate between random and systematic treatment setup errors using portal films.

METHODS AND MATERIALS

A bi-dimensional analytic techniques using multiple analyses of variance based on Hotelling's T2 statistics to derive numerical and graphical measures of daily portal film accuracy and precision has been trialed using 88 daily portal films from seven patients' treatment.

RESULTS

A demonstration is provided of how a reasonable approximation of random variation from the intended (Simulator) field center, and systematic displacement of the mean position of the portal film centers may be derived from a minimum number of portal films. If a random error as great as 10 mm exists, at least six or seven portal films are considered necessary to reliably detect and quantify the size of a systematic error.

CONCLUSION

Our results suggest that a modest systematic error could go undetected until the end of a 5 or 6 week course of treatment if only one portal film is obtained each week. A greater number of portal films should be performed during the first week of treatment to reduce the frequency of such errors. Efforts to separate and quantify both random and systematic errors in setup are worthwhile and will lead to improvements in outcome at the individual patient level and at a departmental level in the development of quality assurance programs.

Cardiovascular disease-related knowledge and attitudes in a high-risk Australian population

The population of Sydney's western suburbs has higher-than-average mortality rates of heart disease and has raised prevalence rates of the associated risk factors. To enquire into the cardiovascular disease-related knowledge, attitudes and behaviours of this population, a survey that used a multistage area-probability sampling method was conducted in May 1987. A total of 484 subjects was interviewed. The self-reported prevalence rates of angina, heart attacks, strokes and diabetes all were high compared with the rates from the Australia-wide National Heart Foundation's Risk Factor Prevalence Study in 1983. The rates of smoking, hypertension, high blood-lipid levels and sedentary life-style also were raised. Awareness of cardiovascular disease-related issues was high but detailed knowledge often was deficient. The majority of respondents reported having attempted to change their health-related behaviours. Of special note was the finding that 80% of current smokers had tried to quit smoking. The high level of awareness of the importance of making life-style changes, and the frequency with which attempts at behavioural changes were reported, suggest that improvements in the health of the population of Sydney's western suburbs will require two complementary strategies: the teaching of the skills that are needed to maintain healthy behaviours successfully and environmental changes to facilitate healthy life-style choices.

The Western Sydney Health Study: results of the shopping-centre survey

The Western Sydney Health Study is a two-phase descriptive study that is designed to provide data on the health-related knowledge, attitudes and behaviour of persons in the Western Metropolitan health region, which has higher-than-average death rates of many disorders that are associated with life-style. In the first phase of the study, 2164 respondents were interviewed in six shopping centres in the region. The prevalence rates of self-reported cardiovascular disease and diabetes were about twice those that were found in the Australia-wide National Heart Foundation Risk Factor Prevalence Study in 1983. The prevalence rates of smoking and self-reported raised blood lipid levels were also high. Doctors and nurses were the main sources of health information, and the media was less important as a source of health information than was found in the Better Health Commission's national survey in 1985. Over 80% of respondents believed that a lowering of the dietary fat intake and an increase in exercise were health-enhancing behaviours. Given this high level of health knowledge, the major aims for health promotion in the region should be a social change to facilitate choices towards healthy behaviour and the provision of skills to enable individual behavioural changes.

Agreement between two measures of alcohol consumption

Responses on the Quantity-Frequency Questionnaire (QF) were compared with those on the self-report diary. The QF was administered to 778 general practice patients prior to their consultation and the same patients completed the diary at home within 24 hours. The diary overestimated the number of nondrinkers in the population relative to the QF and classified a higher proportion of patients as heavy drinkers. The QF failed to detect 78% of heavy drinkers identified by the diary. Significantly (p less than .001) more alcohol was reported to be consumed overall on the diary (mean, 10.51 drinks/week) than on the QF (mean, 6.87 drinks/week). The relationship between responses on the two measures was nonlinear. At low consumption levels patients indicated drinking twice as much on the diary as on the QF, but the magnitude of the reported consumption difference decreased with increasing consumption levels. The results are discussed in terms of their implications for self-report measures of alcohol consumption.

Detection of patients with high alcohol intake by general practitioners

General practitioners have the potential to treat patients with alcohol problems effectively. Despite the medical implications of excessive alcohol intake, it appears that general practitioners are not sufficiently aware of the drinking habits of their patients. The aim of the study was to investigate the accuracy of 56 randomly chosen general practitioners in detecting which of their patients had a high alcohol intake. Altogether, 2081 patients were recruited in general practitioners' waiting rooms, where they answered questions about their drinking habits. After the consultations general practitioners were asked to indicate the patients' levels of alcohol intake. The results showed that general practitioners correctly identified only 27.5% of patients who were classified as "high risk" drinkers, using Australian Medical Association criteria. They correctly identified only 45.2% of patients who were classified as "moderate to heavy" drinkers, defined by them as drinkers who consume four or more standard drinks a day. These findings have important implications for clinical practice since they indicate that general practitioners are failing to perform adequately in an important area of preventive medicine. This issue needs to be addressed in undergraduate and postgraduate medical education.