Developmental trajectories of socio-emotional outcomes of children and young people in out-of-home care - Insights from data of Pathways of Care Longitudinal Study (POCLS)

BACKGROUND

There has been a limited understanding of the longitudinal trajectory and determinants of socio-emotional outcomes among children in out-of-home care (OOHC).

OBJECTIVES

This study aimed to examine child socio-demographics, pre-care maltreatment, placement, and caregiver factors associated with trajectories of socio-emotional difficulties of children in OOHC.

PARTICIPANTS AND SETTING

The study sample (n = 345) included data from the Pathways of Care Longitudinal Study (POCLS), a prospective longitudinal cohort of children aged 3-17 years who entered the OOHC system in New South Wales (NSW) Australia, between 2010 and 2011.

METHODS

Group-based trajectory models were used to identify distinct socio-emotional trajectory groups based on the Child Behaviour Check List (CBCL) Total Problem T-scores completed at all four Waves 1-4. Modified Poisson regression analysis was conducted to assess the association (risk ratios) of socio-emotional trajectory group membership with pre-care maltreatment, placement, and caregiver-related factors.

RESULTS

Three trajectories of socio-emotional development were identified: 'persistently low difficulties' (average CBCL T-score changed from 40 to 38 over time), normal (average CBCL T-score changed from 52 to 55 over time), and clinical (average CBCL T-score remained at 68 over time) trajectories. Each trajectory presented a stable trend over time. Relative/kinship care, as compared with foster care, was associated with the "persistently low" socio-emotional trajectory. Being male, exposure to ≥8 pre-care substantiated risk of significant harm (ROSH) reports, placement changes, and caregiver's psychological distress (more than two-fold increased risk) were associated with the clinical socio-emotional trajectory.

CONCLUSIONS

Early intervention to ensure children have a nurturing care environment and psychological support to caregivers are vital for positive socio-emotional development over time among children in long-term OOHC.

The effect of the 'Swim Reaper' program on water safety awareness, drowning mortality and morbidity among males aged 15-34 years in Aotearoa, New Zealand

BACKGROUND AND OBJECTIVE

To increase water safety awareness among young males New Zealand introduced the Swim Reaper program in 2016. The program ran annually over summer and in 2018/19 an evaluation was conducted. The objective of this study was to evaluate the impact of the 2018/19 Swim Reaper social media-based campaign on self-reported water safety awareness and identify changes in fatal and nonfatal drowning rates for New Zealand resident males aged 15-34 years before and after the 2016 Swim Reaper program.

METHODS

Online surveys pre (December-2018) and post (February-March-2019) Swim Reaper campaign were used to estimate water safety awareness post-campaign relative to pre-campaign using negative binomial regression adjusted for potential confounders. Interrupted time series (ITS) analysis, adjusted for seasonality, explored changes in drowning mortality, hospital admissions and Accident Compensation Corporation (ACC) claims pre and post program introduction (2016).

RESULTS

A total of 518 males responded (50.6% post-campaign). There were significant improvements (post vs. pre-campaign) in self-reported water safety awareness. ITS analysis showed a reduction in drowning related hospital admissions post relative to pre-program (RR = 0.47; [95%CI: 0.24-0.90]; p = 0.02).

DISCUSSION

Young males are an at-risk cohort for drowning and creating behavior change among this group can be challenging. Using a unique, humor-based approach the Swim Reaper program appears to be having some impact on self-reported water safety behaviors, as well as unintentional drowning-related hospitalization rates. Further evaluation, more clearly linked to campaign themes, is required to ascertain direct impact of the program.

CONCLUSION

The novelty and reach of the campaign within the context of a prevailing downward trend in drownings may provide support for social media-based programs targeting this hard-to-reach demographic.

Readmission to a non-index hospital following total joint replacement

Aims

It is unclear whether mortality outcomes differ for patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) surgery who are readmitted to the index hospital where their surgery was performed, or to another hospital.

Methods

We analyzed linked hospital and death records for residents of New South Wales, Australia, aged ≥ 18 years who had an emergency readmission within 90 days following THA or TKA surgery between 2003 and 2022. Multivariable modelling was used to identify factors associated with non-index readmission and to evaluate associations of readmission destination (non-index vs index) with 90-day and one-year mortality.

Results

Of 394,248 joint arthroplasty patients (THA = 149,456; TKA = 244,792), 9.5% (n = 37,431) were readmitted within 90 days, and 53.7% of these were admitted to a non-index hospital. Non-index readmission was more prevalent among patients who underwent surgery in private hospitals (60%). Patients who were readmitted for non-orthopaedic conditions (62.8%), were more likely to return to a non-index hospital compared to those readmitted for orthopaedic complications (39.5%). Factors associated with non-index readmission included older age, higher socioeconomic status, private health insurance, and residence in a rural or remote area. Non-index readmission was significantly associated with 90-day (adjusted odds ratio (aOR) 1.69; 95% confidence interval (CI) 1.39 to 2.05) and one-year mortality (aOR 1.31; 95% CI 1.16 to 1.47). Associations between non-index readmission and mortality were similar for patients readmitted with orthopaedic and non-orthopaedic complications (90-day mortality aOR 1.61; 95% CI 0.98 to 2.64, and aOR 1.67; 95% CI 1.35 to 2.06, respectively).

Conclusion

Non-index readmission was associated with increased mortality, irrespective of whether the readmission was for orthopaedic complications or other conditions.

Enriching Data Science and Health Care Education: Application and Impact of Synthetic Data Sets Through the Health Gym Project

Large-scale medical data sets are vital for hands-on education in health data science but are often inaccessible due to privacy concerns. Addressing this gap, we developed the Health Gym project, a free and open-source platform designed to generate synthetic health data sets applicable to various areas of data science education, including machine learning, data visualization, and traditional statistical models. Initially, we generated 3 synthetic data sets for sepsis, acute hypotension, and antiretroviral therapy for HIV infection. This paper discusses the educational applications of Health Gym's synthetic data sets. We illustrate this through their use in postgraduate health data science courses delivered by the University of New South Wales, Australia, and a Datathon event, involving academics, students, clinicians, and local health district professionals. We also include adaptable worked examples using our synthetic data sets, designed to enrich hands-on tutorial and workshop experiences. Although we highlight the potential of these data sets in advancing data science education and health care artificial intelligence, we also emphasize the need for continued research into the inherent limitations of synthetic data.

Software Application Profile: The daggle app-a tool to support learning and teaching the graphical rules of selecting adjustment variables using directed acyclic graphs

MOTIVATION

Directed acyclic graphs (DAGs) are used in epidemiological research to communicate causal assumptions and guide the selection of covariate adjustment sets when estimating causal effects. For any given DAG, a set of graphical rules can be applied to identify minimally sufficient adjustment sets that can be used to adjust for bias due to confounding when estimating the causal effect of an exposure on an outcome. The daggle app is a web-based application that aims to assist in the learning and teaching of adjustment set identification using DAGs.

GENERAL FEATURES

The application offers two modes: tutorial and random. The tutorial mode presents a guided introduction to how common causal structures can be presented using DAGs and how graphical rules can be used to identify minimally sufficient adjustment sets for causal estimation. The random mode tests this understanding by presenting the user with a randomly generated DAG-a daggle. To solve the daggle, users must correctly identify a valid minimally sufficient adjustment set.

IMPLEMENTATION

The daggle app is implemented as an R shiny application using the golem framework. The application builds upon existing R libraries including pcalg to generate reproducible random DAGs, dagitty to identify all valid minimal adjustment sets and ggdag to visualize DAGs.

AVAILABILITY

The daggle app can be accessed online at [http://cbdrh.shinyapps.io/daggle]. The source code is available on GitHub [https://github.com/CBDRH/daggle] and is released under a Creative Commons CC BY-NC-SA 4.0 licence.

An interactive geographic information system to inform optimal locations for healthcare services

Large health datasets can provide evidence for the equitable allocation of healthcare resources and access to care. Geographic information systems (GIS) can help to present this data in a useful way, aiding in health service delivery. An interactive GIS was developed for the adult congenital heart disease service (ACHD) in New South Wales, Australia to demonstrate its feasibility for health service planning. Datasets describing geographic boundaries, area-level demographics, hospital driving times, and the current ACHD patient population were collected, linked, and displayed in an interactive clinic planning tool. The current ACHD service locations were mapped, and tools to compare current and potential locations were provided. Three locations for new clinics in rural areas were selected to demonstrate the application. Introducing new clinics changed the number of rural patients within a 1-hour drive of their nearest clinic from 44·38% to 55.07% (79 patients) and reduced the average driving time from rural areas to the nearest clinic from 2·4 hours to 1·8 hours. The longest driving time was changed from 10·9 hours to 8·9 hours. A de-identified public version of the GIS clinic planning tool is deployed at https://cbdrh.shinyapps.io/ACHD_Dashboard/. This application demonstrates how a freely available and interactive GIS can be used to aid in health service planning. In the context of ACHD, GIS research has shown that adherence to best practice care is impacted by patients' accessibility to specialist services. This project builds on this research by providing opensource tools to build more accessible healthcare services.

Uptake of Team Care Arrangements for adults newly diagnosed with cancer

BACKGROUND

Medicare-subsidised Team Care Arrangements (TCAs) support Australian general practitioners to implement shared care between collaborating health professionals for patients with chronic medical conditions and complex needs. We assessed the prevalence of TCAs, factors associated with TCA uptake and visits to TCA-subsidised allied health practitioners, for adults newly diagnosed with cancer in New South Wales, Australia.

METHODS

We carried out a retrospective individual patient data linkage study with 13 951 45 and Up Study participants diagnosed with incident cancer during 2006-16. We used a proportional hazards model to estimate the factors associated with receipt of a TCA after cancer diagnosis.

RESULTS

In total, 6630 patients had a TCA plan initiated (47.5%). A TCA was more likely for patients aged ≥65years, those with higher service utilisation 4-15months prior to cancer diagnosis, a higher number of comorbidities, lower self-rated overall health status, living in areas of greater socio-economic disadvantage, lower educational attainment and those with no private health insurance. A total of 4084 (61.6%) patients with a TCA had at least one TCA-subsidised allied health visit within 24months of the TCA.

CONCLUSIONS

TCAs appear to be well targeted at cancer patients with chronic health conditions and lower socioeconomic status. Nevertheless, not all patients with a TCA subsequently attended a TCA-subsidised allied healthcare professional. This suggests either a misunderstanding of the plan, the receipt of allied health via other public schemes, a low prioritisation of the plan compared to other health care, or suboptimal availability of these services.

Estimating incidence rates of periprosthetic joint infection after hip and knee arthroplasty for osteoarthritis using linked registry and administrative health data

AIMS

The aim of this study was to estimate the 90-day periprosthetic joint infection (PJI) rates following total knee arthroplasty (TKA) and total hip arthroplasty (THA) for osteoarthritis (OA).

METHODS

This was a data linkage study using the New South Wales (NSW) Admitted Patient Data Collection (APDC) and the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), which collect data from all public and private hospitals in NSW, Australia. Patients who underwent a TKA or THA for OA between 1 January 2002 and 31 December 2017 were included. The main outcome measures were 90-day incidence rates of hospital readmission for: revision arthroplasty for PJI as recorded in the AOANJRR; conservative definition of PJI, defined by T84.5, the PJI diagnosis code in the APDC; and extended definition of PJI, defined by the presence of either T84.5, or combinations of diagnosis and procedure code groups derived from recursive binary partitioning in the APDC.

RESULTS

The mean 90-day revision rate for infection was 0.1% (0.1% to 0.2%) for TKA and 0.3% (0.1% to 0.5%) for THA. The mean 90-day PJI rates defined by T84.5 were 1.3% (1.1% to 1.7%) for TKA and 1.1% (0.8% to 1.3%) for THA. The mean 90-day PJI rates using the extended definition were 1.9% (1.5% to 2.2%) and 1.5% (1.3% to 1.7%) following TKA and THA, respectively.

CONCLUSION

When reporting the revision arthroplasty for infection, the AOANJRR substantially underestimates the rate of PJI at 90 days. Using combinations of infection codes and PJI-related surgical procedure codes in linked hospital administrative databases could be an alternative way to monitor PJI rates.Cite this article: Bone Joint J 2022;104-B(9):1060-1066.

Children's Relative Age and Medicine Treatment for Attention-Deficit/Hyperactivity Disorder Across Australian Jurisdictions with Different School Enrolment Policies

Background: Children who are relatively young for their school grade are more likely to receive treatment for attention-deficit/hyperactivity disorder (ADHD). It is unclear whether the phenomenon also exists across Australia or is impacted by the school enrolment policy in place. Objective: We evaluated the association between children's relative age and initiation of ADHD medicines across Australian jurisdictions with different school enrolment policies and rates of delayed school entry. Methods: We used Australia-wide dispensing data for a 15% random sample of children 4-9 years of age in 2013-2017 to create a nationwide cohort. Due to high rates of delayed school entry in New South Wales (NSW), we used linked prescribing and education data for a cohort of NSW residents starting school in 2009 and 2012. We estimated incidence rate ratios (IRRs) for ADHD medicine across children's birth month, sex, and jurisdiction. We used asthma medicines as a negative control. Results: For girls, we observed a relative age effect in three out of five jurisdictions, with an IRR ranging from 1.3 to 2.8, comparing the youngest versus oldest birth month thirds. We observed more modest effects among boys, ranging from null to 1.5-fold. In NSW, the relatively youngest boys were less likely to initiate stimulant medicines than the oldest (IRR = 0.5, 95% confidence interval 0.29-0.78). We did not observe a relative age effect for initiation of asthma medicines. Conclusions: In jurisdictions with low rates of delayed entry, relatively young children were more likely to initiate ADHD medicines than their older classmates. We observed the inverse association in NSW where delayed entry was highest, likely reflecting the characteristics and needs of children who delay school entry for 1 year and become the oldest children in the grade. Increased awareness around children's maturity differences and school readiness may enhance appropriate diagnosis and treatment of ADHD.

557Outcomes of Indigenous multifetal and singleton pregnancies: complications, medical care, birth experience and infant health

Background

Perinatal outcomes for singleton pregnancies are poorer, on average, for Aboriginal people than non-Aboriginal people, but little is known about Aboriginal multifetal pregnancies. Yet multifetal pregnancies and births are often more complicated and have poorer outcomes than singleton pregnancies. We describe the pregnancies, births and outcomes for Aboriginal twins born in Western Australia (WA) and New South Wales (NSW) with comparisons to Aboriginal singletons (WA and NSW) and non-Aboriginal births (NSW).

Methods

Whole-population birth and hospital records were linked for births during 2000-2013 (WA) and 2002-2008 (NSW). Descriptive statistics are reported for demographics, maternal health, pregnancy complications, births and infant outcomes.

Results

Pregnancy complications were more common among mothers of Aboriginal twins than Aboriginal singletons (e.g. 17% of mothers of WA twins had hypertension/pre-eclampsia/eclampsia vs 8% for singletons) but similar to mothers of NSW non-Aboriginal twins. Most Aboriginal twins were born in principal referral, women’s or large public hospitals. The hospitals were often far from the mother’s home (e.g. 31% of mothers of WA Aboriginal twins gave birth at hospitals located >3 hours by road from their home). Outcomes were worse for Aboriginal liveborn twins than Aboriginal singletons and non-Aboriginal twins (e.g. 58% of NSW Aboriginal twins were preterm versus 9% of Aboriginal singletons and 49% non-Aboriginal twins).

Conclusions

Mothers of Aboriginal twins faced significant challenges during the pregnancy, birth and the postnatal period in hospital.

Key messages

In addition to accessible specialist medical care, these mothers may need extra practical and psychosocial support throughout their journey.

Vaccinating Australia: How long will it take?

The Australian Government began to roll out the national COVID-19 vaccination program in late February 2021, with the initial aim to vaccinate the Australian adult population by the end of October 2021. The task of vaccinating some 20 million people presents considerable logistic challenges, but a rapid rollout is essential to allow for the reopening of borders and is especially urgent as new more transmissible variants arise. Here, we run a series of projections to estimate how long it will take to vaccinate the Australian population under different assumptions about the rate of vaccine administration, the schedule for vaccine eligibility and prevalence of vaccine hesitancy. Our analysis highlights the number of vaccine doses that can be administered per day as the key factor determining the duration of the vaccine rollout. A rate of 200,000 doses per day would achieve 90% population coverage by the end of 2021; 80,000 doses a day would see the rollout extended until mid-2023. Vaccine hesitancy has the potential to greatly slow down the rollout and becomes the main limiting factor when the supply of vaccine doses is high. Speed is of the essence when it comes vaccinating populations against COVID-19: a rapid rollout will minimise the risk of sporadic and costly lockdowns and the potential for small, local clusters getting out of control and sparking new epidemic waves. In order to achieve rapid population coverage, the Australian government must ramp up vaccine administration to at least 200,000 doses per day as quickly as possible, while also promoting vaccine willingness in the community through clear public health messaging, especially to known hesitant demographics.

Pregnancy and birth characteristics of Aboriginal twins in two Australian states: a data linkage study

Introduction

Perinatal outcomes for singleton pregnancies are poorer, on average, for Aboriginal people than non-Aboriginal people, but little is known about Aboriginal multifetal pregnancies. Yet multifetal pregnancies and births are often more complicated and have poorer outcomes than singleton pregnancies. We describe the pregnancies, births and perinatal outcomes for Aboriginal twins born in Western Australia (WA) and New South Wales (NSW) with comparisons to Aboriginal singletons in both states and to non-Aboriginal births in NSW.

Materials and methods

Whole-population birth records and birth and death registrations were linked for all births during 2000–2013 (WA) and 2002–2008 (NSW). Hospital records and the WA Register of Developmental Anomalies - Cerebral Palsy were linked for all WA births and hospital records for a subset of NSW births. Descriptive statistics are reported for maternal and child demographics, maternal health, pregnancy complications, births and perinatal outcomes.

Results

Thirty-four thousand one hundred twenty-seven WA Aboriginal, 32,352 NSW Aboriginal and 601,233 NSW non-Aboriginal births were included. Pregnancy complications were more common among mothers of Aboriginal twins than Aboriginal singletons (e.g. 17% of mothers of WA twins had hypertension/pre-eclampsia/eclampsia vs 8% of mothers of singletons) but similar to mothers of NSW non-Aboriginal twins. Most Aboriginal twins were born in a principal referral, women’s or large public hospital. The hospitals were often far from the mother’s home (e.g. 31% of mothers of WA Aboriginal twins gave birth at hospitals located more than 3 h by road from their home). Outcomes were worse for Aboriginal liveborn twins than Aboriginal singletons and non-Aboriginal twins (e.g. 58% of NSW Aboriginal twins were preterm compared to 9% of Aboriginal singletons and 49% non-Aboriginal twins).

Conclusions

Mothers of Aboriginal twins faced significant challenges during the pregnancy, birth and the postnatal period in hospital and, in addition to accessible specialist medical care, these mothers may need extra practical and psychosocial support throughout their journey.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03945-9.

Preschool attendance and developmental outcomes at age five in Indigenous and non-Indigenous children: a population-based cohort study of 100 357 Australian children

BACKGROUND

Policies to increase Australian Indigenous children's participation in preschool aim to reduce developmental inequities between Indigenous and non-Indigenous children. This study aims to understand the benefits of preschool participation by quantifying the association between preschool participation in the year before school and developmental outcomes at age five in Indigenous and non-Indigenous children.

METHODS

We used data from perinatal, hospital, birth registration and school enrolment records, and the Australian Early Development Census (AEDC), for 7384 Indigenous and 95 104 non-Indigenous children who started school in New South Wales, Australia in 2009/2012. Preschool in the year before school was recorded in the AEDC. The outcome was developmental vulnerability on ≥1 of five AEDC domains, including physical health, emotional maturity, social competence, language/cognitive skills and communication skills/general knowledge.

RESULTS

5051 (71%) Indigenous and 68 998 (74%) non-Indigenous children attended preschool. Among Indigenous children, 33% of preschool attenders and 44% of the home-based care group were vulnerable on ≥1 domains, compared with 17% of preschool attenders and 33% in the home-based care group among non-Indigenous children. In the whole population model, the adjusted risk difference for developmental vulnerability among preschool attenders was -7.9 percentage points (95% CI, -9.8 to -6.1) in non-Indigenous children and -2.8 percentage points (95% CI -4.8 to -0.7) in Indigenous children, compared with Indigenous children in home-based care.

CONCLUSIONS

Our findings suggest a likely beneficial effect of preschool participation on developmental outcomes, although the magnitude of the benefit was less among Indigenous compared with non-Indigenous children.

Outcomes of Indigenous Twin and Singleton Pregnancies: Complications, Medical Care, Birth Experience and Infant Health

IntroductionMultifetal pregnancies and births tend to be more complicated and have poorer outcomes than singleton pregnancies. Singleton pregnancies and perinatal outcomes are worse, on average, for Indigenous people than non-Indigenous people, but little is known about Indigenous multifetal pregnancies. Objectives and ApproachWe comprehensively describe and compare Indigenous twin and singleton pregnancies and births in Western Australia (WA) and New South Wales (NSW) and compare to NSW non-Indigenous pregnancies and births. Birth records and infant and maternal hospital records were linked for births during 2000-2013 (WA) and 2002-2008 (NSW). Time travelled for the birth was based on the distance from the hospital to the centroid of the mother’s geographical residential area. ResultsIn the Indigenous populations, mothers of twins had poorer health than mothers of singletons (e.g. in WA, 19% of mothers of twins had hypertension/pre-eclampsia/eclampsia vs 9% of mothers of singletons). They were more likely to have antenatal care during the first trimester (e.g. 69% vs 64% in NSW), though less likely than non-Indigenous mothers of both twins (80%) and singletons (75%).The majority of Indigenous twins were born in a hospital with a neonatal intensive care unit (NICU) (e.g. 66% vs 26% in WA) and many mothers of twins travelled further for the birth (e.g. 8% of mothers of Indigenous twins in NSW travelled 3 hours or more vs 4% of mothers of singletons). In both jurisdictions, outcomes were worse for twins than singletons (e.g. 67% of twins in WA were preterm vs 13% of singletons and 30% of twins were admitted to a NICU vs 6% of singletons). Conclusion / ImplicationsMothers of Indigenous twins faced significant challenges during the pregnancy, birth and the postnatal period in hospital and, in addition to accessible specialist medical care, these mothers may need practical and psychosocial support throughout their journey.

Cumulative Incidence of Child Protection Services Involvement Before Age 5 Years in 153 670 Australian Children

This study examines the incidence of notifications to and investigations, substantiations, and out-of-home care placements by child protection services for children aged 0 to 5 years in New South Wales, Australia.

Medications used disproportionately during pregnancy: Priorities for research on the risks and benefits of medications when used during pregnancy

PURPOSE

To identify medications used disproportionately more or less among pregnant women relative to women of childbearing age.

METHODS

Medication use among pregnant women in New South Wales, Australia was identified using linked perinatal and pharmaceutical dispensing data from 2006 to 2012. Medication use in women of childbearing age (including pregnant women) was identified using pharmaceutical dispensing data for a 10% random sample of the Australian population. Pregnant social security beneficiaries (n = 111 612) were age-matched (1:3) to female social security beneficiaries in the 10% sample. For each medication, the risk it was dispensed during pregnancy relative to being dispensed during an equivalent time period among matched controls was computed. Medications were mapped to Australian pregnancy risk categories.

RESULTS

Of the 181 included medications, 35 were statistically significantly more commonly dispensed to pregnant women than control women. Of these, 23 are categorised as posing no increased risk to the foetus. Among medications suspected of causing harm or having insufficient safety data, the strongest associations were observed for hydralazine, ondansetron, dalteparin sodium and ranitidine. Use was less likely during pregnancy than control periods for 127 medications, with the strongest associations observed for hormonal contraceptives and progestogens.

CONCLUSIONS

Most medications found to be used disproportionately more by pregnant women are indicated for pregnancy-related problems. A large number of medications were used disproportionately less among pregnant women, where avoidance of some of these medications may pose a greater risk of harm. For many other medications avoided during pregnancy, current data are insufficient to inform this risk-benefit assessment.

Role of maternal age at birth in child development among Indigenous and non-Indigenous Australian children in their first school year: a population-based cohort study

BACKGROUND

Indigenous Australian children are twice as likely to score poorly on developmental outcomes at age 5 years than their non-Indigenous peers. Indigenous children are also more likely to be born to younger mothers. We aimed to quantify the relationship between maternal age at childbirth and early childhood development outcomes in Indigenous and non-Indigenous children.

METHODS

In this population-based, retrospective cohort study, we used data from the Australian Early Development Census (AEDC) that were probabilistically linked by the New South Wales (NSW) Centre for Health Record Linkage to several NSW administrative datasets, including the Perinatal Data Collection, the Register of Births, Deaths and Marriages (for birth registrations), the Admitted Patient Data Collection, and public school enrolment records, as part of the Seeding Success study. The resulting data resource comprises a cohort of 166 278 children born in NSW whose first year of school was reported in a 2009 or 2012 AEDC record (which were the years of AEDC data available at the time of data linkage). The primary outcome was the aggregate outcome of developmental vulnerability (scores in the bottom decile, according to the 2009 benchmark, on one or more of the five AEDC domains, which include physical, social, emotional, language and cognitive, and communication development). This outcome was measured in singleton children without special needs recorded on the AEDC, in those with available developmental data. As a secondary outcome analysis, we also repeated the main analyses on the outcome of developmental vulnerability on the individual domains. We estimated the absolute risk of developmental vulnerability by maternal age in Indigenous and non-Indigenous populations, and we also estimated the risk difference and relative risk between Indigenous and non-Indigenous children by use of modified Poisson regression.

FINDINGS

Of 166 278 children in the cohort, 107 666 (64·8%) children were enrolled in a public school in NSW in 2009 or 2012, of whom 7994 (7·4%) children were Indigenous (ie, they, or either parent, were recorded as Aboriginal or Torres Strait Islander on one or more birth records) and 99 672 (92·6%) children were not Indigenous. After exclusions, the final study population included 99 530 children (7206 [7·2%] Indigenous and 92 324 [92·8%] non-Indigenous). Of those for whom developmental outcome data were available, 2581 (35·9%) of 7180 Indigenous children and 18 071 (19·7%) of 91 835 non-Indigenous children were developmentally vulnerable on one domain or more. The risk of developmental vulnerability decreased with maternal ages between 15 and 39 years, but the decrease in risk with maternal age was significantly steeper in non-Indigenous than Indigenous children.

INTERPRETATION

Developmental vulnerability is most common in Indigenous and non-Indigenous children born to young mothers; however, Indigenous children have an increased risk of this outcome across most of the maternal age range. Policies that improve the socioeconomic circumstances of Indigenous children and families could promote better developmental outcomes among Indigenous children. Culturally appropriate support for Indigenous children, including those born to young mothers and disadvantaged families, could also reduce early childhood developmental inequalities.

FUNDING

The Australian National Health and Medical Research Council, Manitoba Centre for Health Policy.

Demographic and clinical characteristics of hospitalised unintentional poisoning in Aboriginal and non-Aboriginal preschool children in New South Wales, Australia: a population data linkage study

OBJECTIVES

To investigate differences in demographic and clinical characteristics of Aboriginal and non-Aboriginal children aged 0-4 years hospitalised for unintentional poisoning in New South Wales (NSW), Australia.

DESIGN AND SETTING

Retrospective whole-of-population cohort analysis of linked hospital and mortality data for 2000-2014.

PARTICIPANTS

All children (Aboriginal and non-Aboriginal) under the age of 5 years who were born in a hospital in NSW from 2000 to 2009.

OUTCOMES

The primary outcome was hospitalisation for unintentional poisoning. Logistic regression was used to estimate odds of poisoning hospitalisation for Aboriginal and non-Aboriginal children. Poisoning agents and clinical outcomes were compared by Aboriginality.

RESULTS

The cohort included 767 119 children, including 28 528 (3.7%) Aboriginal children. Aboriginal children had approximately three times higher rates of hospitalised poisoning (1.34%) compared with non-Aboriginal children (0.41%). Poisoning incidence peaked at 2-3 years of age. Male sex, socioeconomic disadvantage and geographical remoteness were associated with higher odds of poisoning hospitalisation for Aboriginal and non-Aboriginal children, but associations with disadvantage and remoteness were statistically significant only for non-Aboriginal children. Most (83%) poisonings were caused by pharmaceutical agents. Few Aboriginal and non-Aboriginal children had repeat admissions for poisoning; most had a length of stay of 1 day or less. Only 8% of poisoning admissions involved contact with a social worker.

CONCLUSION

Commonly used medications in the general population contribute to poisonings among both Aboriginal and non-Aboriginal preschool-aged children. This study highlights a need to develop culturally safe poisoning prevention strategies and policies.

Developmental vulnerability at age five among children who enter and progress through the child protection system in New South Wales, Australia: a cross-sectoral data linkage study

IntroductionA recent independent review of the child protection system in New South Wales (NSW), Australia, highlighted the need for whole-of-government reform to improve outcomes for children at risk of, or experiencing, maltreatment. Population-level evidence on outcomes of children who enter and progress through the child protection system is currently lacking. Objectives and ApproachWe aimed to quantify developmental vulnerability at age five among children who enter and progress through the child protection system during early childhood to demonstrate the value of cross-sectoral data linkage to inform and evaluate policy at a population-level. We used Australian Early Development Census (AEDC) data linked to cross-sectoral population datasets in NSW, including birth registrations, perinatal, and child protectionnotification and out-of-home care (OOHC) placement data. Linked AEDC data, collected in 2009 and 2012, areavailable for 153,670 NSW children. Socio-demographic and perinatal characteristics available in the linked data were used to characterise the population. Results21,179 (13.9%) children had ≥1 ‘screened in’ notification, 4927 (3.2%) had ≥1 substantiated abuse and neglect notification, and 2177 (1.4%) had ≥1 OOHC placement before their fifth birthday. Indicators of disadvantage and adverse birth outcomes were more common among children who progressed to higher levels of the child protection system. The proportion developmentally vulnerable on ≥1 domains of the AEDC increased for children who entered and progressed through the child protection system; from 21% of children with no contact with child protection before age five, to 39% of children with ≥1 ‘screened in’ notification, 50% with ≥1 substantiated notification, and 54% with ≥1 OOHC placement before their fifth birthday. Comparison of findings from other Australian jurisdictions with similar data will be discussed. Conclusion/ImplicationsThis study demonstrates there is scope to improve developmental outcomes through targeted interventions among children who become known to child protection during early childhood in NSW. Moreover, it illustrates that cross-sectoral data linkage can be used to inform and evaluate policy reforms to drive better outcomes for vulnerable children.

Maternal age and offspring developmental vulnerability at age five: A population-based cohort study of Australian children

BACKGROUND

In recent decades, there has been a shift to later childbearing in high-income countries. There is limited large-scale evidence of the relationship between maternal age and child outcomes beyond the perinatal period. The objective of this study is to quantify a child's risk of developmental vulnerability at age five, according to their mother's age at childbirth.

METHODS AND FINDINGS

Linkage of population-level perinatal, hospital, and birth registration datasets to data from the Australian Early Development Census (AEDC) and school enrolments in Australia's most populous state, New South Wales (NSW), enabled us to follow a cohort of 99,530 children from birth to their first year of school in 2009 or 2012. The study outcome was teacher-reported child development on five domains measured by the AEDC, including physical health and well-being, emotional maturity, social competence, language and cognitive skills, and communication skills and general knowledge. Developmental vulnerability was defined as domain scores below the 2009 AEDC 10th percentile cut point. The mean maternal age at childbirth was 29.6 years (standard deviation [SD], 5.7), with 4,382 children (4.4%) born to mothers aged <20 years and 20,026 children (20.1%) born to mothers aged ≥35 years. The proportion vulnerable on ≥1 domains was 21% overall and followed a reverse J-shaped distribution according to maternal age: it was highest in children born to mothers aged ≤15 years, at 40% (95% CI, 32-49), and was lowest in children born to mothers aged between 30 years and ≤35 years, at 17%-18%. For maternal ages 36 years to ≥45 years, the proportion vulnerable on ≥1 domains increased to 17%-24%. Adjustment for sociodemographic characteristics significantly attenuated vulnerability risk in children born to younger mothers, while adjustment for potentially modifiable factors, such as antenatal visits, had little additional impact across all ages. Although the multi-agency linkage yielded a broad range of sociodemographic, perinatal, health, and developmental variables at the child's birth and school entry, the study was necessarily limited to variables available in the source data, which were mostly recorded for administrative purposes.

CONCLUSIONS

Increasing maternal age was associated with a lesser risk of developmental vulnerability for children born to mothers aged 15 years to about 30 years. In contrast, increasing maternal age beyond 35 years was generally associated with increasing vulnerability, broadly equivalent to the risk for children born to mothers in their early twenties, which is highly relevant in the international context of later childbearing. That socioeconomic disadvantage explained approximately half of the increased risk of developmental vulnerability associated with younger motherhood suggests there may be scope to improve population-level child development through policies and programs that support disadvantaged mothers and children.

Gestational Age and Child Development at Age Five in a Population-Based Cohort of Australian Aboriginal and Non-Aboriginal Children

BACKGROUND

Preterm birth and developmental vulnerability are more common in Australian Aboriginal compared with non-Aboriginal children. We quantified how gestational age relates to developmental vulnerability in both populations.

METHODS

Perinatal datasets were linked to the Australian Early Development Census (AEDC), which collects data on five domains, including physical, social, emotional, language/cognitive, and general knowledge/communication development. We quantified the risk of developmental vulnerability on ≥1 domains at age 5, according to gestational age and Aboriginality, for 97 989 children born in New South Wales, Australia, who started school in 2009 or 2012.

RESULTS

Seven thousand and seventy-nine children (7%) were Aboriginal. Compared with non-Aboriginal children, Aboriginal children were more likely to be preterm (5% vs. 9%), and developmentally vulnerable on ≥1 domains (20% vs. 36%). Overall, the proportion of developmentally vulnerable children decreased with increasing gestational age, from 44% at ≤27 weeks to 20% at 40 weeks. Aboriginal children had higher risks than non-Aboriginal children across the gestational age range, peaking among early term children (risk difference [RD] 19.0, 95% confidence interval [CI] 16.3, 21.7; relative risk [RR] 1.91, 95% CI 1.77, 2.06). The relation of gestational age to developmental outcomes was the same in Aboriginal and non-Aboriginal children, and adjustment for socio-economic disadvantage attenuated the risk differences and risk ratios across the gestational age range.

CONCLUSIONS

Although the relation of gestational age to developmental vulnerability was similar in Aboriginal and non-Aboriginal children, Aboriginal children had a higher risk of developmental vulnerability at all gestational ages, which was largely accounted for by socio-economic disadvantage.

Association between respiratory syncytial viral disease and the subsequent risk of the first episode of severe asthma in different subgroups of high-risk Australian children: a whole-of-population-based cohort study

OBJECTIVE

To determine the contribution of respiratory syncytial virus (RSV) to the subsequent development of severe asthma in different subgroups of children at risk of severe RSV disease.

SETTINGS

The study was conducted in New South Wales (NSW), Australia.

PARTICIPANTS

The study comprised all children born in NSW between 2000 and 2010 with complete follow-up till 31 December 2011. The cohort was divided into three subgroups: (1) non-Indigenous high-risk children: non-Indigenous children born preterm or born with a low birth weight; (2) Indigenous children: children of mothers whose Indigenous status was recorded as Aboriginal and/or Torres Strait Islander and (3) non-Indigenous standard risk children: all other non-Indigenous term children.

PRIMARY OUTCOME MEASURE

Risk of development of severe asthma in different subgroups of children who had RSV hospitalisation in the first 2 years of life compared with those who did not.

DESIGN

We performed a retrospective cohort analysis using population-based linked administrative data. Extended Cox model was used to determine HR and 95% CI around the HR for first asthma hospitalisation in different subgroups of children.

RESULTS

The cohort comprised 847 516 children born between 2000 and 2010. In the adjusted Cox model, the HR of first asthma hospitalisation was higher and comparable across all subgroups of children who had RSV hospitalisation compared with those who did not. The HR (95% CI) was highest in children aged 2-3 years; 4.3 (95% CI 3.8 to 4.9) for high-risk, 4.0 (95% CI 3.3 to 4.8) for Indigenous and 3.9 (95% CI 3.7 to 4.1) for non-Indigenous standard risk children. This risk persisted beyond 7 years of age.

CONCLUSION

This large study confirms a comparable increased risk of first asthma hospitalisation following RSV disease in the first 2 years of life across different subgroups children at risk.

Preschool attendance and early childhood development outcomes in the first year of school for Aboriginal and non-Aboriginal children in New South Wales, Australia

ABSTRACT ObjectivesA key target to reduce the gap in early childhood outcomes between Australian Aboriginal and non-Aboriginal children has been to increase preschool enrolment rates, particularly in remote communities. However, there is little population-based information on preschool attendance and its impact on child development for Aboriginal children specifically. This study aims to examine: (i) the characteristics of children, families and areas associated with preschool attendance; and (ii) the association between preschool attendance and childhood development in the first year of school for Aboriginal and non-Aboriginal children in Australia’s most populous state, New South Wales (NSW). ApproachRoutinely-collected birth registration, perinatal, health and education data were used to create a linked dataset consisting of an almost complete population of children known as the ‘Seeding Success’ cohort. These children were born in NSW and had an Australian Early Development Census (AEDC) checklist completed by their teacher in their first year of school in NSW in 2009 and 2012 (n=154,936). Multilevel Poisson regression modelling was used to determine child-, family- and area-level characteristics associated with preschool attendance in the year before starting school. The association between preschool attendance and childhood development in the first year of school, as measured across five AEDC developmental domains, was also examined. Results71% of Aboriginal children attended preschool in the year before school (95% CI: 70% to 72%) compared with 76% of non-Aboriginal children (95% CI: 76% to 77%). The prevalence of preschool attendance was lower in major cities compared with regional and remote areas, with 65% of Aboriginal children attending preschool in major cities compared with 73% in outer regional and 79% in remote areas. Factors associated with preschool attendance in the year before starting school included being non-Aboriginal, speaking English as a first language, having a mother with a partner, having fewer older siblings, living in a more remote area and living in a less socioeconomically disadvantaged area. After adjusting for potentially confounding factors, Aboriginal children who attended preschool were more likely to be developmentally ‘on track’ compared with Aboriginal children who did not attend preschool, in four of the five AEDC domains. ConclusionThe barriers to preschool attendance for Aboriginal children living in major cities should be further explored. Targeted support for families and areas where preschool attendance is lower is likely required to ensure children have access to the apparent benefits of preschool education.

Phase III Randomized Trial of Intravenous Cisplatin Plus a 24- or 96-Hour Infusion of Paclitaxel in Epithelial Ovarian Cancer: A Gynecologic Oncology Group Study

Purpose

This study was undertaken to assess if prolonged paclitaxel administration in combination with cisplatin improves overall survival (OS) in epithelial ovarian cancer (EOC).

Patients and Methods

Eligible patients with suboptimal stage III or IV EOC, fallopian tube, or primary peritoneal cancer were randomly allocated to receive six cycles of cisplatin 75 mg/m2 and either paclitaxel 135 mg/m2 during 24 hours (arm 1) or paclitaxel 120 mg/m2 during 96 hours (arm 2).

Results

Planned accrual was 324 patients; 293 were enrolled before the study was closed as a result of a scheduled interim futility analysis. There were 13 ineligible patients; thus, 140 patients in each arm were assessable. In arm 1, 80% of patients completed all six cycles compared with 83% of patients in arm 2. Grade 4 granulocytopenia was more common in arm 1 (79% v 54%; P < .001) whereas grade 3 or worse anemia was more severe in arm 2 (6% v 18%; P < .003). The median progression-free survival was 1.03 years for arm 1 versus 1.05 years for arm 2. The median OS was 2.49 and 2.54 years for arms 1 and 2, respectively. There have been 237 reported deaths. The relative death rate was approximately 12% greater in arm 2 (hazard ratio, 1.12; 95% CI, 0.860 to 1.45).

Conclusion

Patients with advanced EOC have a relatively poor prognosis. The results of treatment with cisplatin and paclitaxel are not significantly improved by prolonging the paclitaxel infusion from 24 to 96 hours.

Acantholytic Variant of Squamous Cell Carcinoma of the Breast: A Case Report

Primary squamous cell carcinoma of the breast is a rare clinical entity. Two large review series found only five cases out of a total of 8351 breast malignancies. This case report presents a patient with metaplastic, pseudoangiosarcomatous carcinoma or acantholytic variant of a squamous cell carcinoma of the breast. This diagnosis was based on the histological finding of highly atypical, acantholytic squamous cells. Because the tumor stained positive for keratin and negative for factor VIII, the diagnosis of angiosarcoma was ruled out. Although only scattered case reports have been published on this histological variant, these tumors tend to follow an aggressive course.

Acantholytic variant of squamous cell carcinoma of the breast: a case report

Primary squamous cell carcinoma of the breast is a rare clinical entity. Two large review series found only five cases out of a total of 8351 breast malignancies. This case report presents a patient with metaplastic, pseudoangiosarcomatous carcinoma or acantholytic variant of a squamous cell carcinoma of the breast. This diagnosis was based on the histological finding of highly atypical, acantholytic squamous cells. Because the tumor stained positive for keratin and negative for factor VIII, the diagnosis of angiosarcoma was ruled out. Although only scattered case reports have been published on this histological variant, these tumors tend to follow an aggressive course.

Leiomyosarcoma of the colon: a second malignant neoplasm after treatment for a Wilms' tumor

Leiomyosarcoma of the colon is a rare malignancy. We report the case of a 33-year-old woman with a leiomyosarcoma of the colon occurring as an intussusception 30 years after receiving abdominal irradiation for a Wilms' tumor. A review of the prior and current treatment for Wilms' tumor is discussed, as well as the association between second malignancies and abdominal irradiation. Leiomyosarcoma of the colon usually presents in the fifth and sixth decades of life and is more common in men. The most common symptom is pain. Ninety per cent are diagnosed at surgery for treatment of bleeding, perforation, or obstruction. Surgery remains the primary treatment. Leiomyosarcomas of the gastrointestinal tract are radioresistant, and adjuvant chemotherapy has shown no survival benefit. The overall prognosis is poor, with mean 5-year survival of 28 per cent. General surgeons need to be aware of the possibility of second malignant neoplasms after primary treatment of childhood cancers. Proper reporting is essential to study the long-term effects of early treatment of childhood cancers and in predicting the best treatment outcomes for these patients.

Leiomyosarcoma of the Colon: A Second Malignant Neoplasm after Treatment for a Wilms’ Tumor

Leiomyosarcoma of the colon is a rare malignancy. We report the case of a 33-year-old woman with a leiomyosarcoma of the colon occurring as an intussusception 30 years after receiving abdominal irradiation for a Wilms’ tumor. A review of the prior and current treatment for Wilms’ tumor is discussed, as well as the association between second malignancies and abdominal irradiation. Leiomyosarcoma of the colon usually presents in the fifth and sixth decades of life and is more common in men. The most common symptom is pain. Ninety per cent are diagnosed at surgery for treatment of bleeding, perforation, or obstruction. Surgery remains the primary treatment. Leiomyosarcomas of the gastrointestinal tract are radioresistant, and adjuvant chemotherapy has shown no survival benefit. The overall prognosis is poor, with mean 5-year survival of 28 per cent. General surgeons need to be aware of the possibility of second malignant neoplasms after primary treatment of childhood cancers. Proper reporting is essential to study the long-term effects of early treatment of childhood cancers and in predicting the best treatment outcomes for these patients.

Jejunal cirsoid aneurysm: a rare cause of massive lower gastrointestinal hemorrhage

Diverticulosis and angiodysplasia are the most common causes of massive lower gastrointestinal hemorrhage. Lower gastrointestinal hemorrhage frequently resolves without determination of a definitive source. An uncommon cause of lower gastrointestinal tract hemorrhage is the small intestinal submucosal aneurysm. This poorly described entity, more commonly recognized as Dieulafoy's disease in the gastric mucosa, has been documented only rarely in the jejunum. We describe a case report of a 27-year-old man with a massive lower gastrointestinal hemorrhage. Diagnostic evaluation failed to identify the source on initial admission. The patient re-presented to the emergency room with recurrent bleeding, anemia, and hypotension. During a period of active bleeding, a number of diagnostic studies ultimately revealed the source to be the proximal jejunum. Inspection of the resected specimen identified a submucosal aneurysm on the mesenteric border. Histologic evaluation identified the pathologic entity as a cirsoid aneurysm.

Aspergillus: a rare primary organism in soft-tissue infections

Nonclostridial necrotizing soft-tissue infections are usually polymicrobial, with greater than 90 per cent involving beta-hemolytic streptococci or coagulase-positive staphylococci. The remaining 10 per cent are usually due to Gram-negative enteric pathogens. We describe the case of a 46-year-old woman with bilateral lower extremity fungal soft tissue infections. She underwent multiple surgical debridements of extensive gangrenous necrosis of the skin and subcutaneous fat associated with severe acute arteritis. Histopathological examination revealed Aspergillus niger as the sole initial pathogen. Despite aggressive surgical debridement, allografts, and intravenous amphotericin B, her condition clinically deteriorated and she ultimately died of overwhelming infection. Treatment for soft-tissue infections include surgical debridement and intravenous antibiotics. More specifically, Aspergillus can be treated with intravenous amphotericin B, 5-fluorocytosine, and rifampin. Despite these treatment modalities, necrotizing fascitis is associated with a 60 per cent mortality rate. Primary fungal pathogens should be included in the differential diagnosis of soft-tissue infections.

Massive ovarian enlargement in primary hypothyroidism

OBJECTIVE

To report a case of ovarian cyst formation and myxedematous infiltration of the ovary in a subject with primary hypothyroidism.

DESIGN

Retrospective case report.

SETTING

University hospital.

PATIENT(S)

A 16-year-old female adolescent with pelvic pain, galactorrhea, irregular menses, and ovarian cysts on pelvic examination.

INTERVENTION(S)

Laparotomy with bilateral ovarian wedge resection and thyroid replacement therapy.

MAIN OUTCOME MEASURE(S)

Ovarian histopathology, thyroid function tests, and menstrual history.

RESULT(S)

Resolution of patient's pain, galactorrhea, and resumption of normal menses.

CONCLUSION(S)

Ovarian cyst formation may accompany primary hypothyroidism in the child with accelerated or delayed sexual maturation. To date, the underlying pathophysiology of the morphological changes in the ovary remain enigmatic. This case report provides the first insight into the actual histologic changes that occur in ovaries of subjects with primary hypothyroidism without secondary ovarian pathology such as torsion. There is clear evidence of myxedematous infiltration into the ovarian stroma without luteinization of the theca interna. These microscopic findings suggest that local changes occurring independent of gonadotropin stimulation may contribute significantly to altered morphology of the ovaries in primary hypothyroidism.

Polarity-sensitive perceptual adaptation to temporal sawtooth modulation of luminance

Exposure to a large uniform field modulated in luminance by a sawtooth function, repeating between 1 and 5 times per second, raised the threshold for detection of a test stimulus of similar waveform by a factor of 2 to 4.5. In comparison, the threshold elevation for a test stimulus of the inverse waveform was only half as great. This polarity-sensitive adaptation fits with Jung's hypothesis that separate channels signal 'brightening' and 'darkening' in the human visual system. Introduction of spatial contrast such as random noise does not affect adaptation to temporal luminance gradients, but does lead to some interocular transfer. The transferred component, however, shows no sensitivity to the polarity of the test stimulus.