High-volume surgeons with ⩾250 radical prostatectomies provide superior oncological outcomes as evidenced by a lower rate of PSA recurrence (PSAR). The financial benefits of performing ...prostatectomies at high-volume centers (HVC) are unexplored.
A base case--referent scenario--where the share of prostatectomies at high- and low-volume centers were evenly divided at 50% was defined. Additional scenarios with increasing shares of prostatectomies at HVC with 10% increments were also modeled. Using a lower probability of PSAR as the only advantage of more experienced surgeons, the savings that would result from fewer recurrences, avoidance of salvage radiation therapy (SRT) and management of fewer men with metastatic cancer were calculated.
The savings associated with performing 80% of radical prostatectomy at HVC were $177, $357 and $559 per prostatectomy at 5, 10 and 20 years, respectively. These savings would offset referral costs of up to $1833 per prostatectomy referral at no additional total societal costs. Given the longer average biochemical failure-free survival with prostatectomies at HVC, referral costs of more than $1833 may be cost effective.
Under the conservative assumption of accounting for lower rates of PSAR as the only benefit of surgery in an HVC, performing prostatectomies at an HVC was associated with savings that may offset part of the initial referral costs.
Objective
To identify successes to date and opportunities for improvement in the implementation of a complex health systems intervention aiming to improve prenatal and postpartum care and health ...outcomes for women with hyperglycemia in pregnancy in regional and remote Australia.
Methods
A qualitative evaluation, underpinned by the RE‐AIM framework (reach, effectiveness, adoption, implementation, maintenance), was conducted mid‐intervention. Semi‐structured interviews were conducted with the participants, who included clinicians, regional policymakers and managers, and study implementation staff.
Results
Interviewees (n = 45) reported that the early phase of the intervention had resulted in the establishment of a clinician network, increased clinician awareness of hyperglycemia in pregnancy, and improvements in management, including earlier referral for specialist care and a focus on improving communication with women. Enablers of implementation included existing relationships with stakeholders and alignment of the intervention with health service priorities. Challenges included engaging remote clinicians and the labor‐intensive nature of maintaining a clinical register of women with hyperglycemia in pregnancy.
Conclusion
The early phase of this health systems intervention has had a positive perceived impact on systems of care for women with hyperglycemia in pregnancy. Findings have informed modifications to the intervention, including the development of a communication and engagement strategy.
Synopsis
A complex health systems intervention resulted in perceived improvements in systems of care for women with hyperglycemia in pregnancy in regional and remote Australia.
Hypertension is a major risk factor for death and cardiovascular disease (CVD) in patients undergoing chronic haemodialysis (HD), but there is uncertainty surrounding the effects of blood pressure ...(BP) lowering on this high-risk patient group.
In a multicenter, prospective, randomized, open-label, blinded-endpoint trial, 469 patients with chronic HD and elevated BP (140-199/90-99 mmHg) were assigned to receive the angiotensin receptor blockade (ARB) olmesartan (at a dose of 10-40 mg daily; n = 235) or another treatment that does not include angiotensin receptor blockers and angiotensin-converting enzyme (ACE) inhibitors (n = 234). The primary outcomes were the following: (i) composite of death, nonfatal stroke, nonfatal myocardial infarction and coronary revascularization and (ii) all-cause death.
During a mean follow-up of 3.5 years, the mean BP was 0.9/0.0 mmHg lower in the olmesartan group than in the control group (not significant). A total of 68 patients (28.9%) in the olmesartan group and 67 patients (28.6%) in the control group had subsequent primary composite endpoints hazard ratio (HR) in the olmesartan group 1.00, 95% confidence interval (CI) 0.71-1.40, P = 0.99. All-cause deaths occurred in 38 patients (16.2%) in the olmesartan group and 39 (16.7%) in the control group (HR, 0.97; 95% CI, 0.62-1.52, P = 0.91). Olmesartan did not alter the risks of serious adverse events.
BP-lowering treatment with an ARB did not significantly lower the risks of major cardiovascular events or death among patients with hypertension on chronic HD. (Cochrane Renal Group Prospective Trial Register number CRG010600030).
•Aboriginal women experience more social disadvantage and diabetes in pregnancy than Europid women.•Smoking in pregnancy associated with preserved skinfold adiposity and reduced lean body ...mass.•Limiting intake of ‘fast’ foods in pregnancy will likely improve offspring adiposity.•Skinfold measures may identify risk for early onset obesity.•Socio-economic inequity likely to have important influence on neonatal adiposity.
Australian Indigenous women experience high rates of social disadvantage and type 2 diabetes (T2D) in pregnancy, but it is not known how social factors and maternal behaviours impact neonatal adiposity in offspring of women with hyperglycaemia in pregnancy.
Participants were Indigenous (n = 404) and Europid (n = 240) women with gestational diabetes mellitus (GDM) or T2D in pregnancy and their offspring in the Pregnancy and Neonatal Diabetes Outcomes in Remote Australia (PANDORA) study. Social, economic factors, and maternal behaviours were measured in pregnancy and six neonatal anthropometric outcomes were examined after birth.
On univariate analysis, maternal education < 12 years (p = 0.03), unemployment (p = 0.001), welfare income vs no welfare income (p = 0.001), lower area based socio-economic score (p < 0.001), and fast food intake > 2 times/week (p = 0.002) were associated with increased sum of skinfolds (SSF) in offspring. Smoking was significantly associated with a reduction in anthropometric measures, except SSF. In multivariable models adjusted for ethnicity, BMI and hyperglycaemia, social and economic factors were no longer significant predictors of neonatal outcomes. Smoking was independently associated with a reduction in length, head circumference and fat free mass. Frequent fast food intake remained independently associated with SSF (β-coefficient 1.08 mm, p = 0.02).
In women with hyperglycaemia in pregnancy, social factors were associated with neonatal adiposity, particularly skinfold measures. Promoting smoking cessation and limited intake of energy-dense, nutrient-poor foods in pregnancy are important to improve neonatal adiposity and lean mass outcomes. Addressing inequities in social and economic factors are likely to be important, particularly for Indigenous women or women experiencing social disadvantage.
There is conflicting evidence on the benefits of foods rich in vitamin E (α-tocopherol), n-3 polyunsaturated fatty acids (PUFA), and their pharmacological substitutes. We investigated the effects of ...these substances as supplements in patients who had myocardial infarction.
From October, 1993, to September, 1995, 11 324 patients surviving recent (≤3 months) myocardial infarction were randomly assigned supplements of n-3 PUFA (1 g daily, n=2836), vitamin E (300 mg daily, n=2830), both (n=2830), or none (control, n=2828) for 3·5 years. The primary combined efficacy endpoint was death, non-fatal myocardial infarction, and stroke. Intention-to-treat analyses were done according to a factorial design (two-way) and by treatment group (four-way).
Treatment with n-3 PUFA, but not vitamin E, significantly lowered the risk of the primary endpoint (relativerisk decrease 10% 95% CI 1–18 by two-way analysis, 15% 2–26 by four-way analysis). Benefit was attributable to a decrease in the risk of death (14% 3–24 two-way, 20% 6–33 four-way) and cardiovascular death (17% 3–29 two-way, 30% 13–44 four-way). The effect of the combined treatment was similar to that for n-3 PUFA for the primary endpoint (14% 1–26) and for fatal events (20% 5–33).
Dietary supplementation with n-3 PUFA led to a clinically important and satistically significant benefit. Vitamin E had no benefit. Its effects on fatal cardiovascular events require further exploration.
Palmar hand burns continue to be a common injury in the pediatric population, with long-term implications for function, hand rehabilitation, and psychosocial well-being in a growing child. Debate ...over the choice of full-thickness skin grafts (FTSG) and split skin grafts (SSG) for optimal subsequent functional and cosmetic outcomes continues. This study prospectively evaluated children who required skin grafting of palmar burns at our institution between January 2008 and December 2009. A clinical assessment of the grafted area and donor site using the Vancouver Scar Scale, together with assessment of sensation, hair growth, and the development of contracture was performed by an independent clinician. Thirty-four (16%) of 214 palm burns that presented to our institution during this period required grafting, of which 26 (77%) agreed to participate in this study. At a mean 13.5 months postsurgery, pliability was significantly enhanced in FTSG compared with SSG (P < .001). Although not statistically significant, vascularity and height of SSGs were preferred. There was no difference in sensation between the two types of graft or donor site outcomes, although hair growth was significantly (P = .002) more prominent in FTSG. There were an equal number of contractures in the two groups, with grafts of either type that extended from the palm onto the volar aspect of digits more commonly affected. These data suggest an improved outcome in children with deep palm burns after FTSG, although with the exception of scar pliability these differences were small.
Indigenous Australians experience a heavy burden of CKD. To address this burden, the eGFR Follow-Up Study recruited and followed an Indigenous Australian cohort from regions of Australia with the ...greatest ESRD burden. We sought to better understand factors contributing to the progression of kidney disease. Specific objectives were to assess rates of progression of eGFR in Indigenous Australians with and without CKD and identify factors associated with a decline in eGFR.
This observational longitudinal study of Indigenous Australian adults was conducted in >20 sites. The baseline cohort was recruited from community and primary care clinic sites across five strata of health, diabetes status, and kidney function. Participants were then invited to follow up at 2-4 years; if unavailable, vital status, progression to RRT, and serum creatinine were obtained from medical records. Primary outcomes were annual eGFR change and combined renal outcome (first of ≥30% eGFR decline with follow-up eGFR<60 ml/min per 1.73 m(2), progression to RRT, or renal death).
Participants (n=550) were followed for a median of 3.0 years. Baseline and follow-up eGFR (geometric mean 95% confidence interval, 83.9 (80.7 to 87.3) and 70.1 (65.9 to 74.5) ml/min per 1.73 m(2), respectively. Overall mean annual eGFR change was -3.1 (-3.6 to -2.5) ml/min per 1.73 m(2). Stratified by baseline eGFR (≥90, 60-89, <60 ml/min per 1.73 m(2)), annual eGFR changes were -3.0 (-3.6 to -2.4), -1.9 (-3.3 to -0.5), and -5.0 (-6.5 to -3.6) ml/min per 1.73 m(2). Across baseline eGFR categories, annual eGFR decline was greatest among adults with baseline albumin-to-creatinine ratio (ACR) >265 mg/g (30 mg/mmol). Baseline determinants of the combined renal outcome (experienced by 66 participants) were higher urine ACR, diabetes, lower measured GFR, and higher C-reactive protein.
The observed eGFR decline was three times higher than described in nonindigenous populations. ACR was confirmed as a powerful predictor for eGFR decline across diverse geographic regions.
Aim The aim of this study was to measure resting energy expenditure (REE) and energy intake in children with quadriplegic cerebral palsy (CP), to relate these to anthropometric measurements, and to ...determine the influence of nutritional rehabilitation on REE.
Methods Fifty‐six children (20 females, 36 males; age range 3y 11mo–18y; mean age 10y; SD 3y 11mo) with CP (Gross Motor Function Classification System level V) participated in this cross‐sectional study. Children were excluded if they had a known metabolic disorder, genetic syndrome, or chromosomal abnormality. Thirty‐three of the children were tube fed and 23 were fed orally. A comparison group comprised 111 (42 females, 69 males) healthy children who had undergone anthropometric and REE measurements and were of similar age to the children with CP (4–19y). REE was measured by indirect calorimetry and energy intake was determined from weighed food records.
Results The REE in the children with CP was low (79.5%) compared with that predicted and highly variable (SD 38.4%). Fat‐free mass was the strongest predictor of REE, accounting for 27% of the variation. Energy intake as a percentage of REE in was greatly overestimated in oral‐fed children with CP (293%). In a subset of children with CP (n=14), an increased energy intake by gastrostomy tube feeding resulted in an increase in REE from 70.0% to 101.9% of that predicted.
Interpretation The REE of children with CP is low and variable and is not strongly related to any one anthropometric measurement. Food records in oral‐fed children with CP are of little value owing to their inaccuracy. This study provided support for the hypothesis that the low REE found in malnourished children with CP is partly due to a low energy intake.
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