Few studies have examined psychological adjustment for cancer survivors in late treatment and early survivorship stages. Our study investigated the prevalence and short-term trajectories of anxiety, ...depression, and comorbid anxiety-depression among adult cancer survivors, and identified the individual, disease, health behavior, psychological, and social predictors of chronic and late psychological morbidity.
A heterogeneous sample of adult cancer survivors was recruited from two state-based cancer registries. A total of 1,154 survivors completed self-report questionnaires at 6 (Time 1) and 12 months (Time 2) postdiagnosis. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale with cases identified by a subscale cutoff score ≥ 8. Logistic regression analyses identified Time 1 characteristics associated with anxiety and/or depression at Time 2.
The point prevalence of anxiety (Time 1, 22%; Time 2, 21%), depression (13% at both timepoints) and comorbid anxiety-depression (9% at both timepoints) was similar at 6 and 12 months postdiagnosis. The most prevalent Time 1 to Time 2 trajectory was noncase for anxiety (70%), depression (82%), and comorbid anxiety-depression (87%). While psychological morbidity at Time 1 was the strongest predictor of psychological morbidity at Time 2, being diagnosed with lung cancer and health risk behaviors (smoking, insufficient physical activity) were also strong predictors.
Targeted psychological screening of vulnerable survivors and early intervention may prevent the onset and/or reduce the severity of psychological morbidity in early survivorship. Trials of risk reduction interventions targeting psychological functioning and health risk behaviors seem warranted.
Mobile phones are gradually becoming an integral part of healthcare services worldwide. We assessed the association between Aponjon mobile phone based messaging services and practices regarding ...childbirth and care of mother and neonates in selected areas in Bangladesh.
In early 2014, 476 subscriber mothers whose last born child's age was between 3 and 18 months, were recruited to the study by Dnet from selected areas of Bangladesh. One group of mothers received the early warning messages from Aponjon during pregnancy (exposed; n = 210) while the other group of new mothers did not receive the messages during pregnancy as they had enrolled in the service after childbirth (non-exposed; n = 266). We undertook regression analyses to investigate the relationship between timing of exposure to Aponjon messages and socio-economic factors and outcomes of safe delivery, immediate breastfeeding post birth, delayed bathing of the neonate, and number of postnatal care (PNC) visits.
Women reported delivering babies at home without a skilled birth attendant (SBA) (n = 58, 12%), at home with SBA (n = 111, 23%) and at health facilities (n = 307, 65%). Most (n = 443, 93%) women breastfed babies immediately post birth. Babies were bathed after 72 h (n = 294, 62%), between 48 and 72 (n = 100, 21%) and between 0 and 47 (n = 80, 17%) hours after birth. PNC frequencies were reported as none (n = 273, 57%), 1 (n = 79, 17%), 2 (n = 54, 11%), 3 (n = 34, 7%) and 4 (n = 36, 8%). There was no significant association between exposure to Aponjon messages during pregnancy and presence of a SBA at birth, breastfeeding practices, and postnatal care visits, although delayed bathing up to 48 h was significant at the 10% but not 5% level (RRR 1.7; 95% CI 0.93-3.0; p = 0.083). Women with higher education, from higher income, older in age, with birth order 1 or 2 were more likely to birth at health facilities. Facility based delivery was an independent factor for delayed bathing and having postnatal care visits.
Low cost mobile phone messages may have the potential to positively influence maternal and child healthcare behaviours, such as delayed timing of first bath, in resource-poor settings. Further studies are needed, with adequate sample size to detect significant change.
Summary Background We assessed patient outcomes 90 days after hospital admission for stroke following a multidisciplinary intervention targeting evidence-based management of fever, hyperglycaemia, ...and swallowing dysfunction in acute stroke units (ASUs). Methods In the Quality in Acute Stroke Care (QASC) study, a single-blind cluster randomised controlled trial, we randomised ASUs (clusters) in New South Wales, Australia, with immediate access to CT and on-site high dependency units, to intervention or control group. Patients were eligible if they spoke English, were aged 18 years or older, had had an ischaemic stroke or intracerebral haemorrhage, and presented within 48 h of onset of symptoms. Intervention ASUs received treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction with multidisciplinary team building workshops to address implementation barriers. Control ASUs received only an abridged version of existing guidelines. We recruited pre-intervention and post-intervention patient cohorts to compare 90-day death or dependency (modified Rankin scale mRS ≥2), functional dependency (Barthel index), and SF-36 physical and mental component summary scores. Research assistants, the statistician, and patients were masked to trial groups. All analyses were done by intention to treat. This trial is registered at the Australia New Zealand Clinical Trial Registry (ANZCTR), number ACTRN12608000563369. Findings 19 ASUs were randomly assigned to intervention (n=10) or control (n=9). Of 6564 assessed for eligibility, 1696 patients' data were obtained (687 pre-intervention; 1009 post-intervention). Results showed that, irrespective of stroke severity, intervention ASU patients were significantly less likely to be dead or dependent (mRS ≥2) at 90 days than control ASU patients (236 42% of 558 patients in the intervention group vs 259 58% of 449 in the control group, p=0·002; number needed to treat 6·4; adjusted absolute difference 15·7% 95% CI 5·8–25·4). They also had a better SF-36 mean physical component summary score (45·6 SD 10·2 in the intervention group vs 42·5 10·5 in the control group, p=0·002; adjusted absolute difference 3·4 95% CI 1·2–5·5) but no improvement was recorded in mortality (21 4% of 558 in intervention group and 24 5% of 451 in the control group, p=0·36), SF-36 mean mental component summary score (49·5 10·9 in the intervention group vs 49·4 10·6 in the control group, p=0·69) or functional dependency (Barthel Index ≥60: 487 92% of 532 patients vs 380 90% of 423 patients; p=0·44). Interpretation Implementation of multidisciplinary supported evidence-based protocols initiated by nurses for the management of fever, hyperglycaemia, and swallowing dysfunction delivers better patient outcomes after discharge from stroke units. Our findings show the possibility to augment stroke unit care. Funding National Health & Medical Research Council ID 353803, St Vincent's Clinic Foundation, the Curran Foundation, Australian Diabetes Society-Servier, the College of Nursing, and Australian Catholic University.
A pilot validation recommended defining polytrauma as patients with an Abbreviated Injury Scale (AIS) score greater than 2 in at least two Injury Severity Score (ISS) body regions (2 × AIS score > ...2). This study aimed to validate this definition on larger data set. We hypothesized that patients defined by the 2 × AIS score > 2 cutoff have worse outcomes and use more resources than those without 2 × AIS score > 2 and that this would therefore be a better definition of polytrauma.
Patients injured between 2009 and 2011, with complete documentation of AIS by New South Wales Trauma Registry and 16 years and older were selected. Age and sex were obtained in addition to outcomes of ISS, hospital length of stay (LOS), intensive care unit (ICU) admission, ICU LOS, and mortality. We compared demographic characteristics and outcomes between patients with ISS greater than 15 who did and did not meet the 2 × AIS score > 2 definition. We then undertook regression analyses (logistic regression for binary outcomes ICU admission and death and linear regression for hospital and ICU LOS) to compare outcomes for patients with and without 2 × AIS score > 2, adjusting for sex and age categories.
In the adjusted analyses, patients with 2 × AIS score > 2 had twice the odds of being admitted to the ICU compared with those without 2 × AIS score > 2 (odds ratio, 2.5; 95% confidence interval CI, 2.2-2.8) and 1.7 times the odds of dying (95% CI, 1.4-2.0; p < 0.001 for both models). Patients with 2 × AIS score > 2 also had a mean difference of 1.5 days longer stay in the hospital compared with those without 2 × AIS score > 2 (95% CI, 1.4-1.7) and 1.6 days longer ICU stay (95% CI, 1.4-1.8; p < 0.001 for all models).
Patients with 2 × AIS score > 2 had higher mortality, more frequent ICU admissions, and longer hospital and ICU stay than those without 2 × AIS score > 2 and represents a superior definition to the definitions for polytrauma currently in use.
Diagnostic test/ criteria, level III.
Summary Background Androgen-deprivation therapy is offered to men with prostate cancer who have a rising prostate-specific antigen after curative therapy (PSA relapse) or who are considered not ...suitable for curative treatment; however, the optimal timing for its introduction is uncertain. We aimed to assess whether immediate androgen-deprivation therapy improves overall survival compared with delayed therapy. Methods In this randomised, multicentre, phase 3, non-blinded trial, we recruited men through 29 oncology centres in Australia, New Zealand, and Canada. Men with prostate cancer were eligible if they had a PSA relapse after previous attempted curative therapy (radiotherapy or surgery, with or without postoperative radiotherapy) or if they were not considered suitable for curative treatment (because of age, comorbidity, or locally advanced disease). We used a database-embedded, dynamically balanced, randomisation algorithm, coordinated by the Cancer Council Victoria, to randomly assign participants (1:1) to immediate androgen-deprivation therapy (immediate therapy arm) or to delayed androgen-deprivation therapy (delayed therapy arm) with a recommended interval of at least 2 years unless clinically contraindicated. Randomisation for participants with PSA relapse was stratified by type of previous therapy, relapse-free interval, and PSA doubling time; randomisation for those with non-curative disease was stratified by metastatic status; and randomisation in both groups was stratified by planned treatment schedule (continuous or intermittent) and treatment centre. Clinicians could prescribe any form and schedule of androgen-deprivation therapy and group assignment was not masked. The primary outcome was overall survival in the intention-to-treat population. The trial closed to accrual in 2012 after review by the independent data monitoring committee, but data collection continued for 18 months until Feb 26, 2014. It is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12606000301561) and ClinicalTrials.gov ( NCT00110162 ). Findings Between Sept 3, 2004, and July 13, 2012, we recruited 293 men (261 with PSA relapse and 32 with non-curable disease). We randomly assigned 142 men to the immediate therapy arm and 151 to the delayed therapy arm. Median follow-up was 5 years (IQR 3·3–6·2) from the date of randomisation. 16 (11%) men died in the immediate therapy arm and 30 (20%) died in the delayed therapy arm. 5-year overall survival was 86·4% (95% CI 78·5–91·5) in the delayed therapy arm versus 91·2% (84·2–95·2) in the immediate therapy arm (log-rank p=0·047). After Cox regression, the unadjusted HR for overall survival for immediate versus delayed arm assignment was 0·55 (95% CI 0·30–1·00; p=0·050). 23 patients had grade 3 treatment-related adverse events. 105 (36%) men had adverse events requiring hospital admission; none of these events were attributable to treatment or differed between treatment-timing groups. The most common serious adverse events were cardiovascular, which occurred in nine (6%) patients in the delayed therapy arm and 13 (9%) in the immediate therapy arm. Interpretation Immediate receipt of androgen-deprivation therapy significantly improved overall survival compared with delayed intervention in men with PSA-relapsed or non-curable prostate cancer. The results provide benchmark evidence of survival rates and morbidity to discuss with men when considering their treatment options. Funding Australian National Health and Medical Research Council and Cancer Councils, The Royal Australian and New Zealand College of Radiologists, Mayne Pharma Australia.
Self-reported weight and height is frequently used to quantify overweight and obesity. It is however, associated with limitations such as bias and poor agreement, which may be a result of social ...desirability or difficulties with recall. Methods to reduce these biases would improve the accuracy of assessment of overweight and obesity using patient self-report. The level of agreement between self-reported and measured weight and height has not been widely examined in general practice patients.
Consenting patients, presenting for care within four hour sessions, were randomly allocated to the informed or uninformed group. Participants were notified either a) prior to (informed group), or b) after (uninformed group) reporting their weight and height using a touchscreen computer questionnaire, that they would be measured. The differences in accuracy of self-report between the groups were examined by comparing mean differences, intraclass correlations (ICCs), Bland Altman plot with limits of agreement (LOAs) and Cohen's kappa. Overall agreement was assessed using similar statistical methods.
Of consenting participants, 32% were aged between 18-39 years, 42% between 40-64 years and 25% were 65 years and above. The informed group (n = 172) did not report their weight and height more accurately than the uninformed group (n = 160). Mean differences between self-reported and measured weight (p = 0.4004), height (p = 0.5342) and body mass index (BMI) (p = 0.4409) were not statistically different between the informed and uninformed group. Overall, there were small mean differences (-1.2 kg for weight, 0.8 for height and -0.6 kg/m2 for BMI) and high ICCs (>0.9) between self-reported and measured values. A substantially high kappa (0.70) was obtained when using self-reported weight and height relative to measured values to quantify the proportion underweight, normal weight, overweight or obese. While the average bias of self-reported weight and height as estimates of the measured quantities is small, the LOAs indicate that substantial discrepancies occur at the individual level.
Informing patients that their weight and height would be measured did not improve accuracy of reporting. The use of self-reported weight and height for surveillance studies in this setting appears acceptable; however this measure needs to be interpreted with care when used for individual patients.
Summary Background The TROG 96.01 trial assessed whether 3-month and 6-month short-term neoadjuvant androgen deprivation therapy (NADT) decreases clinical progression and mortality after radiotherapy ...for locally advanced prostate cancer. Here we report the 10-year results. Methods Between June, 1996, and February, 2000, 818 men with T2b, T2c, T3, and T4 N0 M0 prostate cancers were randomly assigned to receive radiotherapy alone, 3 months of NADT plus radiotherapy, or 6 months of NADT plus radiotherapy. The radiotherapy dose for all groups was 66 Gy, delivered to the prostate and seminal vesicles (excluding pelvic nodes) in 33 fractions of 2 Gy per day (excluding weekends) over 6·5–7·0 weeks. NADT consisted of 3·6 mg goserelin given subcutaneously every month and 250 mg flutamide given orally three times a day. NADT began 2 months before radiotherapy for the 3-month NADT group and 5 months before radiotherapy for the 6-month NADT group. Primary endpoints were prostate-cancer-specific mortality and all-cause mortality. Treatment allocation was open label and randomisation was done with a minimisation technique according to age, clinical stage, tumour grade, and initial prostate-specific antigen concentration (PSA). Analysis was by intention-to-treat. The trial has been closed to follow-up and all main endpoint analyses are completed. The trial is registered with the Australian New Zealand Clinical Trials Registry , number ACTRN12607000237482. Findings 802 men were eligible for analysis (270 in the radiotherapy alone group, 265 in the 3-month NADT group, and 267 in the 6-month NADT group) after a median follow-up of 10·6 years (IQR 6·9–11·6). Compared with radiotherapy alone, 3 months of NADT decreased the cumulative incidence of PSA progression (adjusted hazard ratio 0·72, 95% CI 0·57–0·90; p=0·003) and local progression (0·49, 0·33–0·73; p=0·0005), and improved event-free survival (0·63, 0·52–0·77; p<0·0001). 6 months of NADT further reduced PSA progression (0·57, 0·46–0·72; p<0·0001) and local progression (0·45, 0·30–0·66; p=0·0001), and led to a greater improvement in event-free survival (0·51, 0·42–0·61, p<0·0001), compared with radiotherapy alone. 3-month NADT had no effect on distant progression (0·89, 0·60–1·31; p=0·550), prostate cancer-specific mortality (0·86, 0·60–1·23; p=0·398), or all-cause mortality (0·84, 0·65–1·08; p=0·180), compared with radiotherapy alone. By contrast, 6-month NADT decreased distant progression (0·49, 0·31–0·76; p=0·001), prostate cancer-specific mortality (0·49, 0·32–0·74; p=0·0008), and all-cause mortality (0·63, 0·48–0·83; p=0·0008), compared with radiotherapy alone. Treatment-related morbidity was not increased with NADT within the first 5 years after randomisation. Interpretation 6 months of neoadjuvant androgen deprivation combined radiotherapy is an effective treatment option for locally advanced prostate cancer, particularly in men without nodal metastases or pre-existing metabolic comorbidities that could be exacerbated by prolonged androgen deprivation. Funding Australian Government National Health and Medical Research Council, Hunter Medical Research Institute, AstraZeneca, and Schering-Plough.
Aims: To compare prisoners' self-reported history of TBI associated with hospital attendance with details extracted from relevant hospital medical records and to identify factors associated with the ...level of agreement between the two sources.
Methods: From a sample of prison entrants, this study obtained a history of TBIs for which medical attention was sought at a hospital. Audit tools were developed for data extraction relevant to any possible TBI from records at a total of 23 hospitals located within New South Wales, Australia. The level of agreement between self-report and hospital records was compared in relation to demographic, psychological and criminographic characteristics.
Results: Of the 200 participants in the study, 164 (82%) reported having sustained a past TBI giving a total of 420 separate TBI incidents. Of these, 156 (37%) were alleged to have resulted in attendance at a hospital emergency department including 112 (72%) at a hospital accessible for the validation exercise. For 93/112 (83%) of reported TBIs, a corresponding hospital medical record was located of which 78/112 (70%) supported the occurrence of a TBI. Lower education and a lifetime history of more than seven TBIs were associated with less agreement between self-report and medical record data with regard to specific details of the TBI.
Conclusions: Overall, these findings suggest that prisoners' self-report of TBI is generally accurate when compared with the 'gold standard' of hospital medical record. This finding is contrary to the perception of this group as 'dishonest' and 'unreliable'.
As with many Indigenous peoples, smoking rates among Aboriginal Australians are considerably higher than those of the non-Indigenous population. Approximately 50% of Indigenous women smoke during ...pregnancy, a time when women are more motivated to quit. Antenatal care providers are potentially important change agents for reducing the harms associated with smoking, yet little is known about their knowledge, attitudes or skills, or the factors associated with providing smoking cessation advice.
This paper aimed to explore the knowledge and attitudes of health care providers caring for pregnant Australian Aboriginal women with regard to smoking risks and cessation; and to identify factors associated with self-reported assessment of smoking. A cross-sectional survey was undertaken with 127 staff providing antenatal care to Aboriginal women from two jurisdictions: the Northern Territory and New South Wales, Australia. Measures included respondents' estimate of the prevalence of smoking among pregnant women; optimal and actual assessment of smoking status; knowledge of risks associated with antenatal smoking; knowledge of smoking cessation; attitudes to providing cessation advice to pregnant women; and perceived barriers and motivators for cessation for pregnant women.
The median provider estimate of the smoking prevalence was 69% (95%CI: 60,70). The majority of respondents considered assessment of smoking status to be integral to antenatal care and a professional responsibility. Most (79%) indicated that they assess smoking status in 100% of clients. Knowledge of risks was generally good, but knowledge of cessation was poor. Factors independently associated with assessing smoking status among all women were: employer service type (p = 0.025); cessation knowledge score (p = 0.011); and disagreeing with the statement that giving advice is not worth it given the low level of success (p = 0.011).
Addressing knowledge of smoking risks and cessation counselling is a priority and should improve both confidence and ability, and increase the frequency and effectiveness of counselling. The health system must provide supports to providers through appropriate policy and resourcing, to enable them to address this issue.
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