Longitudinal associations between socioeconomic position and overall health of children with chronic kidney disease and their carers

BACKGROUND

Disadvantaged socioeconomic position (SEP) is an important predictor of poor health in children with chronic kidney disease (CKD). The time course over which SEP influences the health of children with CKD and their carers is unknown.

METHODS

This prospective longitudinal study included 377 children, aged 6-18 years with CKD (stages I-V, dialysis, and transplant), and their primary carers. Mixed effects ordinal regression was performed to assess the association between SEP and carer-rated child health and carer self-rated health over a 4-year follow-up.

RESULTS

Adjusted for CKD stage, higher family household income (adjusted odds ratio (OR) (95% CI) 3.3, 1.8-6.0), employed status of primary carers (1.7, 0.9-3.0), higher carer-perceived financial status (2.6, 1.4-4.8), and carer home ownership (2.2, 1.2-4.0) were associated with better carer-rated child health. Household income also had a differential effect on the carer's self-rated health over time (p = 0.005). The predicted probabilities for carers' overall health being 'very good' among lower income groups at 0, 2, and 4 years were 0.43 (0.28-0.60), 0.34 (0.20-0.51), and 0.25 (0.12-0.44), respectively, and 0.81 (0.69-0.88), 0.84 (0.74-0.91), and 0.88 (0.76-0.94) for carers within the higher income group.

CONCLUSIONS

Carers and their children with CKD in higher SEP report better overall child and carer health compared with those in lower SEP. Carers of children with CKD in low-income households had poorer self-rated health compared with carers in higher-income households at baseline, and this worsened over time. These cumulative effects may contribute to health inequities between higher and lower SEP groups over time. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information.

Integrated Text Messaging (ITM) for people attending cardiac and pulmonary rehabilitation: A multicentre randomised controlled trial

BACKGROUND

People living with cardiac and respiratory disease require improved post-hospital support that is readily available and efficient.

OBJECTIVES

To 1) test the effectiveness of an automated, semi-personalised text message support program on clinical and lifestyle outcomes amongst people attending cardiac and pulmonary rehabilitation. Also, 2) to evaluate the program's acceptability and utility using patient-reported outcome and experience measures.

METHODS

Multicentre randomised controlled trial (3:1, intervention:control) amongst cardiac and pulmonary rehabilitation attendees. Control received usual care (no message program). Intervention also received a 6-month text message lifestyle and support program. Primary outcome was 6-minute walk distance (6MWD). Secondary outcomes included clinical measures, lifestyle, patient-reported outcome and experience measures, medication adherence and rehabilitation attendance.

RESULTS

A total of 316 participants were recruited. They had a mean age of 66.7 (SD 10.1) years. Sixty percent were male (190/316) and 156 were cardiac rehabilitation participants. The cohort's mean baseline 6MWD was higher in the intervention than the control group. At 6 months, 6MWD improved in both groups; it was significantly greater amongst intervention than control participants (unadjusted mean difference of 43.4 m, 95 % CI 4.3 to 82.4; P = 0.0296). After adjustment for baseline values, there was no significant difference between intervention and control groups for 6MWD (adjusted mean difference 2.2 m, -21.2 to 25.6; P = 0·85), medication adherence, or cardiovascular risk factors. At 6-month follow-up, intervention participants reported significantly lower depression scores (adjusted mean difference -1.3, 95 % CI -2.2 to -0.3; P = 0.0124) and CAT scores (adjusted mean difference -3.9, 95 % CI -6.6 to -1.3; P = 0.0038), and significantly lower anxiety (adjusted mean difference -1.1, 95 %CI -2.1 to 0; P = 0.0456). Most participants (86 %) read most of their messages and strongly/agreed that the intervention was easy to understand (99 %) and useful (86 %).

CONCLUSIONS

An educational and supportive text message program for cardiac and pulmonary rehabilitation attendees improved anxiety and depression plus program attendance. The program was acceptable to, and useful for, participants and would be suitable for implementation alongside rehabilitation programs.

TRIAL REGISTRATION NUMBER

ACTRN12616001167459.

Differences in weight status among Australian children and adolescents from priority populations: a longitudinal study

BACKGROUND AND SIGNIFICANCE

Australia has a high level of cultural and linguistic diversity, including Aboriginal and Torres Strait Islander peoples. Children from specific cultural and ethnic groups may be at greater risk of overweight and obesity and may bear the additional risk of socioeconomic disadvantage. Our aim was to identify differences in body-mass index z-score (zBMI) by: (1) Cultural and ethnic groups and; (2) Socioeconomic position (SEP), during childhood and adolescence.

SUBJECTS/METHODS

We used data from the Longitudinal Study of Australian children (n = 9417) aged 2-19 years with 50870 longitudinal measurements of zBMI. Children were classified into 9 cultural and ethnic groups, based on parent and child's country of birth and language spoken at home. These were: (1) English-speaking countries; (2) Middle East & North Africa; (3) East & South-East Asia; (4) South & Central Asia; (5) Europe; (6) Sub-Saharan Africa; (7) Americas; (8) Oceania. A further group (9) was defined as Aboriginal and Torres Strait Islander from self-reported demographic information. Longitudinal cohort analyses in which exposures were cultural and ethnic group and family socioeconomic position, and the outcome was zBMI estimated using multilevel mixed linear regression models. We stratified our analyses over three periods of child development: early childhood (2-5 years); middle childhood (6-11 years); and adolescence (12-19 years).

RESULTS

Across all three periods of child development, children from the Middle East and North Africa, the Americas and Oceania were associated with higher zBMI and children from the two Asian groups were associated with lower zBMI, when compared to the referent group (English). zBMI was socioeconomically patterned, with increasingly higher zBMI associated with more socioeconomic disadvantage.

CONCLUSIONS

Our findings identified key population groups at higher risk of overweight and obesity in childhood and adolescence. Prevention efforts should prioritize these groups to avoid exacerbating inequalities in healthy weight in childhood.

T-cell lymphoma involving the rectum of a dog

A mediastinal mass was diagnosed in a 7-year-4-month-old neutered female mixed breed dog following a 3-week history of lethargy, hyporexia and pyrexia. Bi-cavitary imaging, needle aspirate cytology and flow cytometry confirmed WHO clinical stage IVb, intermediate to large T-cell lymphoma involving the mediastinum, liver and spleen. The dog initially responded to a multidrug chemotherapy protocol but clinical deterioration occurred 3 months later. The dog presented with anorexia, vomiting and diarrhoea, associated with marked faecal tenesmus and haematochezia, initially believed by the primary care practitioner to be related to chemotherapy toxicity. However, rectal examination revealed multiple sessile and pedunculated masses. Further diagnostic imaging, cytology and flow cytometry confirmed progressive disease, including T-cell lymphoma of the rectum. Histology and immunohistochemistry confirmed an infiltrate of intermediate-sized CD3-positive neoplastic cells that expanded the rectal mucosa. Rectal lymphoma is uncommon in dogs and previous cases have been B cell in origin. In this report we describe the clinical presentation and macro- and microscopic findings of a case of canine T-cell lymphoma involving the rectum.

Psychometric Evaluation of the PedsQL GCS and CHU9D in Australian Children and Adolescents with Common Chronic Health Conditions

BACKGROUND

Generic instruments such as the Pediatric Quality of Life Inventory™ v4.0 Generic Core Scales (PedsQL GCS) and Child Health Utility 9D (CHU9D) are widely used to assess health-related quality of life (HRQOL) of the general childhood population, but there is a paucity of information about their psychometric properties in children with specific health conditions. This study assessed psychometric properties, including acceptability, reliability, validity, and responsiveness, of the PedsQL GCS and the CHU9D in children and adolescents with a range of common chronic health problems.

METHODS

We used data from the Longitudinal Study of Australian Children (LSAC), for children aged 10-17 years with at least one of the following six parent-reported health conditions: asthma, anxiety/depression, attention deficit hyperactivity disorder (ADHD), autism/Asperger's, epilepsy, and type 1 diabetes mellitus. The LSAC used parent proxy-reported PedsQL GCS and child self-reported CHU9D assessments. The performance of each instrument (PedsQL GCS and CHU9D) for each psychometric property (acceptability, reliability, validity, and responsiveness) was assessed against established criteria.

RESULTS

The study sample included 7201 children and adolescents (mean age = 14 years; range 10.1-17.9 years; 49% female) with 15,568 longitudinal observations available for analyses. Across the six health conditions, acceptability of the PedsQL GCS was high, while acceptability for the CHU9D was mixed. Both the PedsQL GCS and CHU9D showed strong internal consistency (Cronbach's alpha range: PedsQL GCS = 0.70-0.95, CHU9D = 0.76-0.84; item-total correlations range: PedsQL GCS = 0.35-0.84, CHU9D = 0.32-0.70). However, convergent validity for both the PedsQL GCS and CHU9D was generally weak (Spearman's correlations ≤ 0.3). Known group validity was strong for the PedsQL GCS (HRQOL differences were detected for children with and without asthma, anxiety/depression, ADHD, autism/Asperger's, and epilepsy). CHU9D was only able to discriminate between children with and without anxiety/depression, ADHD, and autism/Asperger's. The responsiveness of both the PedsQL GCS and CHU9D was variable across the six conditions, and most of the estimated effect sizes were relatively small (< 0.5).

CONCLUSION

This study expands the evidence base of psychometric performance of the PedsQL GCS and CHU9D and can aid in appropriate HRQOL instrument selection for the required context by researchers and clinicians.

Twelve-month effectiveness of telephone and SMS support to mothers with children aged 2 years in reducing children's BMI: a randomized controlled trial

BACKGROUND/OBJECTIVES

Few quality intervention studies have assessed whether a combined telephone and short message service (SMS) intervention to mothers is effective in reducing BMI and obesity risk behaviors of children at 3 years of age. This study aimed to assess effectiveness of telephone and SMS support in reducing children's body mass index (BMI) and obesity risk behaviors.

SUBJECTS/METHODS

A randomized controlled trial (RCT) with 662 women of 2-year-old children (with the proportion of overweight and obesity being similar to the general population) was conducted in Sydney, Australia, March 2019-October 2020. The mothers in the intervention group received three telephone support sessions plus SMS messages and mailed-intervention-booklets over a 12 months period i.e., 24-26, 28-30, and 32-34 months of the child's age. Mothers in the control group received usual care and two mailed booklets on information not related to the intervention. The primary outcome was child's BMI at 3 years of age. Secondary outcomes were children's dietary and activity behaviors. All outcome measures were based on mothers' self-report using standardized tools due to COVID-19 pandemic restrictions.

RESULTS

537 (81%) mothers completed the post-intervention assessment at 3 years with only 470 (71%) children having weight and height measures. Multiple imputation analysis showed no statistically significant difference in mean BMI between the groups. Children in the intervention group were more likely not to eat in front of the TV [AOR 1.79 (95% CI 1.17-2.73), P = 0.008], more likely to meet the dietary recommendations [AOR 1.73 (95% CI 0.99-3.02), P = 0.054] and meet the activity recommendations [AOR 1.72 (95% CI 1.11-2.67), P = 0.015] than those in the control group respectively. Among those with an annual household income (

CONCLUSIONS

A staged telephone and SMS support intervention to mothers with children aged 2 years was associated with improved dietary and activity behaviors. The intervention was also associated with reduced children's BMI at age 3 years only for those from lower income households.

TRIAL REGISTRATION

The trial is registered with the Australian Clinical Trial Registry (ACTRN12618001571268).

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Key Words

• epidemiology
• risk factors

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MESH Headings

• Female
• Humans
• Child, Preschool
• Mothers
• Body Mass Index
• Australia/epidemiology
• COVID-19
• Obesity/epidemiology
• Weight Loss
• Telephone

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Affiliation(s)

Li Ming Wen Health Promotion Unit, Population Health Research & Evaluation Hub, Sydney Local Health District, Sydney, NSW, Australia. Sydney School of Public Health, Faculty of Medicine and Health, and Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia. NHMRC Centre of Research Excellence in the Early Prevention of Obesity in Childhood (EPOCH), Sydney, NSW, Australia. Sydney Institute for Women, Children and Their Families, Sydney Local Health District, Sydney, NSW, Australia.
Huilan Xu Health Promotion Unit, Population Health Research & Evaluation Hub, Sydney Local Health District, Sydney, NSW, Australia Sydney Institute for Women, Children and Their Families, Sydney Local Health District, Sydney, NSW, Australia
Philayrath Phongsavan Sydney School of Public Health, Faculty of Medicine and Health, and Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
Chris Rissel Sydney School of Public Health, Faculty of Medicine and Health, and Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia College of Medicine and Public Health, Rural and Remote Health, South Australia and Northern Territory, Flinders University, Bedford Park, SA, Australia
Alison Hayes Sydney School of Public Health, Faculty of Medicine and Health, and Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia NHMRC Centre of Research Excellence in the Early Prevention of Obesity in Childhood (EPOCH), Sydney, NSW, Australia
Sarah Taki Health Promotion Unit, Population Health Research & Evaluation Hub, Sydney Local Health District, Sydney, NSW, Australia Sydney School of Public Health, Faculty of Medicine and Health, and Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia NHMRC Centre of Research Excellence in the Early Prevention of Obesity in Childhood (EPOCH), Sydney, NSW, Australia Sydney Institute for Women, Children and Their Families, Sydney Local Health District, Sydney, NSW, Australia
Limin Buchanan Health Promotion Unit, Population Health Research & Evaluation Hub, Sydney Local Health District, Sydney, NSW, Australia Sydney Institute for Women, Children and Their Families, Sydney Local Health District, Sydney, NSW, Australia
Lisa Simone Health Promotion Unit, Population Health Research & Evaluation Hub, Sydney Local Health District, Sydney, NSW, Australia
Renee Moreton Population Health, Sydney Local Health District, Sydney, NSW, Australia
Louise A Baur Sydney School of Public Health, Faculty of Medicine and Health, and Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia NHMRC Centre of Research Excellence in the Early Prevention of Obesity in Childhood (EPOCH), Sydney, NSW, Australia Specialty of Child and Adolescent Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia

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Exploring the Effects of Offline Paradigms and Feature Extraction Techniques on Performance of Motor Imagery Brain-Computer Interface: Longitudinal Pilot Study

Motor Imagery (MI) Brain-Computer Interface (BCI) is a popular way of allowing disabled and healthy individuals to use brain signals to communicate with their environment, despite the technical and human factor challenges that affect MI BCI classification performance. This study explored the influence of paradigm choice and phase synchronization-based features on classification performance by comparing primary datasets to older supplemental datasets. Area Under the Curve (AUC) Receiver Operating Characteristics (ROC) curve was the metric for classification performance. Results showed that using both advanced paradigms and features significantly improved both classification and usability; TD-CSP-wPLI (16-30Hz) and S-CSP-wPLI (12-15Hz) frequency bands produced the most noticeable change in performance.

Modelled Distributional Cost-Effectiveness Analysis of Childhood Obesity Interventions: A Demonstration

OBJECTIVE

To demonstrate how distributional cost-effectiveness analyses of childhood obesity interventions could be conducted and presented for decision makers.

METHODS

We conducted modelled distributional cost-effectiveness analyses of three obesity interventions in children: an infant sleep intervention (POI-Sleep), a combined infant sleep, food, activity and breastfeeding intervention (POI-Combo) and a clinician-led treatment for primary school-aged children with overweight and obesity (High Five for Kids). For each intervention, costs and socioeconomic position (SEP)-specific effect sizes were applied to an Australian child cohort (n = 4898). Using a purpose-built microsimulation model we simulated SEP-specific body mass index (BMI) trajectories, healthcare costs and quality-adjusted life years (QALYs) from age 4 to 17 years for control and intervention cohorts. We examined the distribution of each health outcome across SEP and determined the net health benefit and equity impact accounting for opportunity costs and uncertainty due to individual-level heterogeneity. Finally, we conducted scenario analyses to test the effect of assumptions about health system marginal productivity, the distribution of opportunity costs and SEP-specific effect sizes. The results of the primary analyses, uncertainty analyses and scenario analyses were presented on an efficiency-equity impact plane.

RESULTS

Accounting for uncertainty, POI-Sleep and High Five for Kids were found to be 'win-win' interventions, with a 67% and 100% probability, respectively, of generating a net health benefit and positive equity impact compared with control. POI-Combo was found to be a 'lose-lose' intervention, with a 91% probability of producing a net health loss and a negative equity impact compared with control. Scenario analyses indicated that SEP-specific effect sizes were highly influential on equity impact estimates for POI-Combo and High Five for Kids, while health system marginal productivity and opportunity cost distribution assumptions primarily influenced the net health benefit and equity impact of POI-Combo.

CONCLUSIONS

These analyses demonstrated that distributional cost-effectiveness analyses using a fit-for-purpose model are appropriate for differentiating and communicating the efficiency and equity impacts of childhood obesity interventions.

Economic evaluation of digitally enabled aged and neurological rehabilitation care in the Activity and MObility UsiNg Technology (AMOUNT) trial

OBJECTIVE

To investigate the trial-based cost-effectiveness of the addition of a tailored digitally enabled exercise intervention to usual care shown to be clinically effective in improving mobility in the Activity and MObility UsiNg Technology (AMOUNT) rehabilitation trial compared to usual care alone.

DESIGN

Economic evaluation alongside a pragmatic randomized controlled trial.

PARTICIPANTS

300 people receiving inpatient aged and neurological rehabilitation were randomized to the intervention (n = 149) or usual care control group (n = 151).

MAIN MEASURES

Incremental cost effectiveness ratios were calculated for the additional costs per additional person demonstrating a meaningful improvement in mobility (3-point in Short Physical Performance Battery) and quality-adjusted life years gained at 6 months (primary analysis). The joint probability distribution of costs and outcomes was examined using bootstrapping.

RESULTS

The mean cost saving for the intervention group at 6 months was AU$2286 (95% Bootstrapped cost CI: -$11,190 to $6410) per participant; 68% and 67% of bootstraps showed the intervention to be dominant (i.e. more effective and cost saving) for mobility and quality-adjusted life years, respectively. The probability of the intervention being cost-effective considering a willingness to pay threshold of AU$50,000 per additional person with a meaningful improvement in mobility or quality-adjusted life year gained was 93% and 77%, respectively.

CONCLUSIONS

The AMOUNT intervention had a high probability of being cost-effective if decision makers are willing to pay AU$50,000 per meaningful improvement in mobility or per quality-adjusted life year gained, and a moderate probability of being cost-saving and effective considering both outcomes at 6 months post randomization.

Reliability, acceptability, validity and responsiveness of the CHU9D and PedsQL in the measurement of quality of life in children and adolescents with overweight and obesity

BACKGROUND

The Paediatric Quality of life Inventory (PedsQL^TM) Generic Core Scales and the Child Health Utilities 9 Dimensions (CHU9D) are two paediatric health-related quality of life (HRQoL) measures commonly used in overweight and obesity research. However, no studies have comprehensively established the psychometric properties of these instruments in the context of paediatric overweight and obesity. The aim of this study was to assess the reliability, acceptability, validity and responsiveness of the PedsQL and the CHU9D in the measurement of HRQoL among children and adolescents living with overweight and obesity.

SUBJECTS/METHODS

Subjects were 6544 child participants of the Longitudinal Study of Australian Children, with up to 3 repeated measures of PedsQL and CHU9D and aged between 10 and 17 years. Weight and height were measured objectively by trained operators, and weight status determined using World Health Organisation growth standards. We examined reliability, acceptability, known group and convergent validity and responsiveness, using recognised methods.

RESULTS

Both PedsQL and CHU9D demonstrated good internal consistency reliability, and high acceptability. Neither instrument showed strong convergent validity, but PedsQL appears to be superior to the CHU9D in known groups validity and responsiveness. Compared with healthy weight, mean (95%CI) differences in PedsQL scores for children with obesity were: boys -5.6 (-6.2, -4.4); girls -6.7 (-8.1, -5.4) and differences in CHU9D utility were: boys -0.02 (-0.034, -0.006); girls -0.035 (-0.054, -0.015). Differences in scores for overweight compared with healthy weight were: PedsQL boys -2.2 (-3.0, -1.4) and girls -1.3 (-2.0, -0.6) and CHU9D boys: no significant difference; girls -0.014 (-0.026, -0.003).

CONCLUSION

PedsQL and CHU9D overall demonstrated good psychometric properties, supporting their use in measuring HRQoL in paediatric overweight and obesity. CHU9D had poorer responsiveness and did not discriminate between overweight and healthy weight in boys, which may limit its use in economic evaluation.

Potential cost-effectiveness of e-health interventions for treating overweight and obesity in Australian adolescents

BACKGROUND

E-health, defined as the use of information and communication technologies to improve healthcare delivery and health outcomes, has been promoted as a cost-effective strategy to treat adolescent overweight and obesity. However, evidence supporting this claim is lacking.

OBJECTIVES

Assess the potential cost-effectiveness of a hypothetical e-health intervention for adolescents with overweight and obesity.

METHODS

The costs and effect size (BMI reduction) of the hypothetical intervention were sourced from recent systematic reviews. Using a micro-simulation model with a lifetime time horizon, we conducted a modelled cost-utility analysis of the intervention compared to a 'do-nothing' approach. To explore uncertainty, we conducted bootstrapping on individual-level costs and quality-adjusted life years (QALYs) and performed multiple one-way sensitivity analyses.

RESULTS

The incremental cost-effectiveness ratio (ICER) for the e-health intervention was dominant (cheaper and more effective), with a 96% probability of being cost-effective at a willingness-to-pay (WTP) of $50 000/QALY. The ICER remained dominant in all sensitivity analyses except when using the lower bounds of the hypothetical intervention effect size, which reduced the probability of cost-effectiveness at a WTP of $50 000/QALY to 51%.

CONCLUSION

E-health interventions for treatment of adolescent overweight and obesity demonstrate very good cost-effectiveness potential and should be considered by healthcare decision makers. However, further research on the efficacy of such interventions is warranted to strengthen the case for investment.

Longitudinal assessment of the health-related quality of life of children and adolescents with chronic kidney disease

In this multi-center longitudinal cohort study conducted in Australia and New Zealand, we assessed the trajectories of health-related quality of life (HRQoL) in children with chronic kidney disease (CKD) over time. A total of 377 children (aged 6-18 years) with CKD stages 1-5 (pre-dialysis), dialysis, or transplant, were followed biennially for four years. Multi Attribute Utility (MAU) scores of HRQoL were measured at baseline and at two and four years using the McMaster Health Utilities Index Mark 3 tool, a generic multi-attribute, preference-based system. A multivariable linear mixed model was used to assess the trajectories of HRQoL over time in 199 children with CKD stage 1-5, 43 children receiving dialysis and 135 kidney transplant recipients. An interaction between CKD stage at baseline and follow-up time indicated that the slopes of the HRQoL scores differed between children by CKD stage at inception. Over half of the cohort on dialysis at baseline had received a kidney transplant by the end of year four and the MAU scores of these children increased by a meaningful amount averaging 0.05 (95% confidence interval 0.01 to 0.09) per year in comparison to those who were transplant recipients at baseline. The mean difference between baseline and year two MAU scores was 0.09 (95% confidence interval -0.05, 0.23), (Cohen's d effect size 0.31). Thus, improvement in HRQoL over time of children on dialysis at baseline was likely to have been driven by their transition from dialysis to transplantation. Additionally, children with CKD stage 1-5 and transplant recipients at baseline had no changes in their disease stage or treatment modality and experienced stable HRQoL over time.

Is the cost-effectiveness of an early-childhood sleep intervention to prevent obesity affected by socioeconomic position?

OBJECTIVE

This study aimed to determine whether the cost-effectiveness of an infant sleep intervention from the Prevention of Overweight in Infancy (POI) trial was influenced by socioeconomic position (SEP).

METHODS

An SEP-specific economic evaluation of the sleep intervention was conducted. SEP-specific intervention costs and effects at age 5 years, derived from the trial data, were applied to a representative cohort of 4,898 4- to 5-year-old Australian children. Quality-adjusted life years and health care costs were simulated until age 17 years using a purpose-built SEP-specific model. Incremental cost-effectiveness ratios and acceptability curves were derived for each SEP group.

RESULTS

The incremental cost-effectiveness ratios, in Australian dollars per quality-adjusted life year gained, were smaller in the low- ($23,010) and mid-SEP ($18,206) groups compared with the high-SEP group ($31,981). The probability that the intervention was cost-effective was very high in the low- and mid-SEP groups (92%-100%) and moderately high in the high-SEP group (79%).

CONCLUSIONS

An infant sleep intervention is more cost-effective in low- and mid-SEP groups compared with high-SEP groups. Targeting this intervention to low-SEP groups would not require trade-offs between efficiency and equity.

Estimation and feasibility of correction modelling for mother-reported child height and weight at 2 years using data from the Australian CHAT trial

Correction modelling using reported BMI values has been employed in adolescent and adult populations to improve the accuracy of self-reporting. This study aimed to evaluate the feasibility of establishing correction modelling for mother-reported child height and weight at 2 years using data from an Australian trial in 2019. Correction modelling for BMI was conducted using mother-reported and objectively measured height and weight of 2-year-olds. Mother-reported height, weight and BMI values of 2-year-old children were adjusted based on objectively measured anthropometric data using linear regression models. 'Direct' and 'indirect' corrections were applied to the correction of BMI values. We defined the direct collection as using corrected BMI values that were predicted directly by the model and indirect correction as using corrected weight and height values to calculate corrected BMI values. Corrected BMI values via the indirect correction showed higher sensitivity or similar specificity in predicting overweight status, compared to the direct correction, and also showed higher agreement with measured values compared to the mother-reported measures. Corrected self-reported measures via an indirect correction had a better accuracy and agreement with the objectively measured data in the BMI values and classification of overweight, compared to the mother-reported values.

Economic evaluation of the Communicating Healthy Beginnings Advice by Telephone trial for early childhood obesity prevention

OBJECTIVE

This study aimed to conduct an economic evaluation of the Communicating Healthy Beginnings Advice by Telephone (CHAT) trial to prevent childhood obesity.

METHODS

Cost-effectiveness analyses were conducted for the telephone and short message service (SMS) delivery of Healthy Beginnings advice, compared with usual care, which included child health services unrelated to Healthy Beginnings. Costs were valued in 2018 Australian dollars, and costs and outcomes were discounted at 5% per year. The costs of upscaling both delivery modes to all yearly births in New South Wales, Australia, were estimated and compared with the original Healthy Beginnings home-visiting intervention.

RESULTS

At child age 2 years, the SMS delivery was more cost-effective ($5154 per unit BMI and $979 per 0.1 BMI z score units avoided) than the telephone delivery ($10,665 per unit BMI and $2017 per 0.1 BMI z score units avoided). The costs of upscaling the SMS ($7.64 million) and the telephone delivery modes ($37.65 million) were lower than the home-visiting intervention ($108.45 million).

CONCLUSIONS

SMS delivery of Healthy Beginnings advice was more cost-effective than telephone delivery but less cost-effective than the original home-visiting approach ($4230 per unit BMI avoided, as calculated in an earlier study). Both the SMS and telephone interventions were more affordable than the home-visiting approach.

Cost-effectiveness of scaling up a whole-of-community intervention: The Romp & Chomp early childhood obesity prevention intervention

BACKGROUND

Given the high prevalence of early childhood overweight and obesity, more evidence is required to better understand the cost-effectiveness of community-wide interventions targeting obesity prevention in children aged 0-5 years.

OBJECTIVES

To assess the cost-effectiveness of the Romp & Chomp community-wide early childhood obesity prevention intervention if delivered across Australia in 2018 from a funder perspective, against a no-intervention comparator.

METHODS

Intervention costs were estimated in 2018 Australian dollars. The annual Early Prevention of Obesity in Childhood micro-simulation model estimated body mass index (BMI) trajectories to age 15 years, based on end of trial data at age 3.5 years. Results from modelled cost-effectiveness analyses were presented as incremental cost-effectiveness ratios (ICERs): cost per BMI unit avoided, and cost per quality-adjusted life year (QALY) gained at age 15 years.

RESULTS

All Australian children aged 0-5 years (n = 1 906 075) would receive the intervention. Total estimated intervention cost and annual cost per participant were AUD178 million and AUD93, respectively, if implemented nationally. The ICERs were AUD1 126 per BMI unit avoided and AUD26 399 per QALY gained (64% probability of being cost-effective measured against a AUD50 000 per QALY threshold).

CONCLUSIONS

Romp & Chomp has a fair probability of being cost-effective if delivered at scale.

Compassion Focused Group Therapy for People With a Diagnosis of Bipolar Affective Disorder: A Feasibility Study

Background

Compassion focused therapy (CFT) is an evolutionary informed, biopsychosocial approach to mental health problems and therapy. It suggests that evolved motives (e.g., for caring, cooperating, competing) are major sources for the organisation of psychophysiological processes which underpin mental health problems. Hence, evolved motives can be targets for psychotherapy. People with certain types of depression are psychophysiologically orientated towards social competition and concerned with social status and social rank. These can give rise to down rank-focused forms of social comparison, sense of inferiority, worthlessness, lowered confidence, submissive behaviour, shame proneness and self-criticism. People with bipolar disorders also experience elevated aspects of competitiveness and up rank status evaluation. These shift processing to a sense of superiority, elevated confidence, energised behaviour, positive affect and social dominance. This is the first study to explore the feasibility of a 12 module CFT group, tailored to helping people with a diagnosis of bipolar disorder understand the impact of evolved competitive, status-regulating motivation on their mental states and the value of cultivating caring and compassion motives and their psychophysiological regulators.

Methods

Six participants with a history of bipolar disorder took part in a CFT group consisting of 12 modules (over 25 sessions) as co-collaborators to explore their personal experiences of CFT and potential processes of change. Assessment of change was measured via self-report, heart rate variability (HRV) and focus groups over three time points.

Results

Although changes in self-report scales between participants and across time were uneven, four of the six participants consistently showed improvements across the majority of self-report measures. Heart rate variability measures revealed significant improvement over the course of the therapy. Qualitative data from three focus groups revealed participants found CFT gave them helpful insight into: how evolution has given rise to a number of difficult problems for emotion regulation (called tricky brain) which is not one's fault; an evolutionary understanding of the nature of bipolar disorders; development of a compassionate mind and practices of compassion focused visualisations, styles of thinking and behaviours; addressing issues of self-criticism; and building a sense of a compassionate identity as a means of coping with life difficulties. These impacted their emotional regulation and social relationships.

Conclusion

Although small, the study provides evidence of feasibility, acceptability and engagement with CFT. Focus group analysis revealed that participants were able to switch from competitive focused to compassion focused processing with consequent improvements in mental states and social behaviour. Participants indicated a journey over time from 'intellectually' understanding the process of building a compassionate mind to experiencing a more embodied sense of compassion that had significant impacts on their orientation to (and working with) the psychophysiological processes of bipolar disorder.

Percutaneous cryoablation for desmoid fibromatosis: initial experience at a UK centre

AIM

To report the first UK experience of cryoablation in desmoid fibromatosis (DF) with particular focus on technique, safety, and efficacy.

MATERIALS AND METHODS

Patients were selected at multidisciplinary tumour board meetings at a specialist cancer hospital. Radiation dose, procedure duration, and number of cryoprobes were compared for small versus large tumours (>10 cm long axis). Response at magnetic resonance imaging (MRI) was evaluated using different criteria, and percentage agreement with clinical response as assessed in oncology clinic calculated.

RESULTS

Thirteen procedures were performed in 10 patients (eight women, median age 51 years, IQR 42-69 years) between February 2019 and August 2021. Procedures for large tumours had higher radiation dose (2,012 ± 1,012 versus 1,076 ± 519 mGy·cm, p=0.048) used more cryoprobes (13 ± 7 versus 4 ± 2, p=0.009), and were more likely to have residual unablated tumour (38 ± 37% versus 7.5 ± 10%, p=0.045). Adverse events were minor apart from one transient radial nerve palsy. Eight of 10 patients had symptomatic benefit at clinical follow-up (median 353 days, IQR 86-796 days), and three started systemic therapy mean 393 days later. All patients who had complete ablation demonstrated symptomatic response, with no instances of repeat treatment, recurrence, or need for systemic therapy during the study period. All progression occurred outside ablation zones.

CONCLUSION

Cryoablation for symptomatic DF is a reproducible technique with low, transient toxicity, where one or two treatments can achieve a meaningful response. Where possible, the ablation ice ball should fully cover DF tumours.

Reducing household air pollution exposure to improve early child growth and development; a randomized control trial protocol for the "Poriborton-Extension: The CHANge trial"

Background

Globally, household air pollution (HAP) is a leading environmental cause of morbidity and mortality. Our trial aims to assess the impact of liquefied petroleum gas (LPG) for cooking to reduce household air pollution exposure on child health outcomes, compared to usual cooking practices in Bangladesh. The primary aim is to evaluate if reduced exposure to HAP through the provision of LPG for cooking from early gestation through to age 2 improves child anthropometry, health, and neuro-cognitive developmental outcomes, compared to children exposed to emissions from usual practice.

Methods

Two-arm parallel cluster randomized controlled trial (cCRT). We will extend the intervention and follow-up of our existing “Poriborton” trial. In a subset of the original surviving participants, we will supply LPG cylinders and LPG stoves (intervention) compared to usual cooking practices and extend the follow-up to 24 months of age. The expected final sample size, for both (intervention and control) is 1854 children with follow-up to 2 years of age available for analysis.

Discussion

This trial will answer important research gaps related to HAP and child health and neuro-cognitive developmental outcomes. This evidence will help to understand the impact of a HAP intervention on child health to inform policies for the adoption of clean fuel in Bangladesh and other similar settings.

Trial registration

The Poriborton: Change trial: Household Air Pollution and Perinatal and early Neonatal mortality is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618001214224, original trial registered on 19th July 2018, extension approved on 23rd June 2021. www.anzctr.org.au.

Demographic Predictors of Mothers' Willingness to Vaccinate Young Children Against COVID-19, Get Tested and Isolate: A Cross-Sectional Survey Before and During the Greater Sydney Lockdown 2021, Australia

Background and Objectives

Having a COVID-19 vaccination, getting tested, and self-isolating if symptomatic are some of the most important mitigation strategies for preventing the spread of COVID-19. This study aimed to investigate whether demographic factors are associated with mothers' willingness to vaccinate their 4-year-old children against COVID-19 if a suitable vaccine becomes available or to get tested and self-isolate if they themselves have COVID-19 symptoms and whether the willingness could be influenced by the Greater Sydney lockdown 2021.

Methods

A cross-sectional telephone survey was conducted between 24th February and 26th October 2021. Questions from the NSW Adult Population Health Survey and from previously published studies were used to assess family demographics, mothers' willingness to vaccinate their young children, and willingness to get tested and self-isolate if symptomatic. The survey involved 604 mothers of children aged 4 years who participated in an existing trial in Sydney, Australia.

Results

Mothers were more willing to vaccinate their children when the child's father had a tertiary education or higher, with an adjusted odds ratio (AOR) of 2.60 (95% CI 1.67–4.04). Mothers who were older than 30 years or who completed the survey during the lockdown were more willing to get tested if symptomatic, with AOR 2.50 (95% CI 1.17–5.36) and AOR 3.36 (95% CI 1.41–8.02), respectively. Mothers who were married or had de-facto partners were more willing to self-isolate if symptomatic [AOR 17.15 (95% CI 3.56–82.65)].

Conclusion

Fathers' educational level, mothers' age, and marital status were associated with mothers' willingness to vaccinate their young children if a suitable vaccine were available, to get tested, and self-isolate if symptomatic respectively. The promotion of mitigation strategies for tackling the COVID-19 pandemic needs to take into account specific family demographics.

Protocol for a cluster randomised controlled trial of LPG cookstoves compared to usual cooking practices to reduce perinatal mortality and morbidity in rural Bangladesh called Poriborton: the CHANge trial

Background

Household air pollution is a leading health risk for global morbidity and mortality and a major health risk in South Asia. However, there are no prospective investigations of the impact of household air pollution on perinatal morbidity and mortality. Our trial aims to assess the impact of liquefied petroleum gas (LPG) for cooking to reduce household air pollution exposure on perinatal morbidity and mortality compared to usual cooking practices in Bangladesh.

Hypothesis

In a community-based cluster randomised controlled trial of pregnant women cooking with LPG throughout pregnancy, perinatal mortality will be reduced by 35% compared with usual cooking practices in a rural community in Bangladesh.

Methods

A two-arm community-based cluster randomised controlled trial will be conducted in the Sherpur district, Bangladesh. In the intervention arm, pregnant women receive an LPG cookstove and LPG in cylinders supplied throughout pregnancy until birth. In the control or usual practice arm, pregnant women continue their usual cooking practices, predominately traditional stoves with biomass fuel. Eligible women are pregnant women with a gestational age of 40–120 days, aged between 15 and 49 years, and permanent residents of the study area. The primary outcome is the difference in perinatal mortality between the LPG arm and the usual cooking arm. Secondary outcomes include (i) preterm birth and low birth weight, (ii) personal level exposure to household air pollution, (iii) satisfaction and acceptability of the LPG stove and stove use, and (iv) cost-effectiveness and cost-utility in reducing perinatal morbidity and mortality. We follow up all women and infants to 45 days after the birth. Personal exposure to household air pollution is assessed at three-time points in a sub-sample of the study population using the MicroPEM™. The total required sample size is 4944 pregnant women.

Discussion

This trial will produce evidence of the effectiveness of reduced exposure to household air pollution through LPG cooking to reduce perinatal morbidity and mortality compared to usual cooking practices. This evidence will inform policies for the adoption of clean fuel in Bangladesh and other similar settings.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12618001214224. Prospectively registered on 19 July 2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06146-7.

Systematic Review of Conceptual, Age, Measurement and Valuation Considerations for Generic Multidimensional Childhood Patient-Reported Outcome Measures

BACKGROUND AND AIMS

Patient-reported outcome measures (PROMs) for children (aged ≤ 18 years) present methodological challenges. PROMs can be categorised by their diverse underlying conceptual bases, including functional, disability and health (FDH) status; quality of life (QoL); and health-related quality of life (HRQoL). Some PROMs are designed to be accompanied by preference weights. PROMs should account for childhood developmental differences by incorporating age-appropriate health/QoL domains, guidance on respondent type(s) and design. This systematic review aims to identify generic multidimensional childhood PROMs and synthesise their characteristics by conceptual basis, target age, measurement considerations, and the preference-based value sets that accompany them.

METHODS

The study protocol was registered in the Prospective Register of Systematic Reviews (CRD42021230833), and reporting followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We conducted systematic database searches for generic multidimensional childhood PROMs covering the period 2012-2020, which we combined with published PROMs identified by an earlier systematic review that covered the period 1992-2011. A second systematic database search identified preference-based value sets for generic multidimensional PROMs. The PROMs were categorised by conceptual basis (FDH status, QoL and HRQoL) and by target age (namely infants and pre-schoolers aged < 5 years, pre-adolescents aged 5-11, adolescents aged 12-18 and multi-age group coverage). Descriptive statistics assessed how PROM characteristics (domain coverage, respondent type and design) varied by conceptual basis and age categories. Involvement of children in PROM development and testing was assessed to understand content validity. Characteristics of value sets available for the childhood generic multidimensional PROMs were identified and compared.

RESULTS

We identified 89 PROMs, including 110 versions: 52 FDH, 29 QoL, 12 HRQoL, nine QoL-FDH and eight HRQoL-FDH measures; 20 targeted infants and pre-schoolers, 29 pre-adolescents, 24 adolescents and 37 for multiple age groups. Domain coverage demonstrated development trajectories from observable FDH aspects in infancy through to personal independence and relationships during adolescence. PROMs targeting younger children relied more on informant report, were shorter and had fewer ordinal scale points. One-third of PROMs were developed following qualitative research or surveys with children or parents for concept elicitation. There were 21 preference-based value sets developed by 19 studies of ten generic multidimensional childhood PROMs: seven were based on adolescents' stated preferences, seven were from adults from the perspective of or on behalf of the child, and seven were from adults adopting an adult's perspective. Diverse preference elicitation methods were used to elicit values. Practices with respect to anchoring values on the utility scale also varied considerably. The range and distribution of values reflect these differences, resulting in value sets with notably different properties.

CONCLUSION

Identification and categorisation of generic multidimensional childhood PROMs and value sets by this review can aid the development, selection and interpretation of appropriate measures for clinical and population research and cost-effectiveness-based decision-making.

Investigating socioeconomic inequalities in BMI growth rates during childhood and adolescence

BACKGROUND

Many countries report socioeconomic inequalities in childhood obesity, but when they develop is not well-characterised. Studies rarely isolate BMI growth rates from overall BMI, perhaps overlooking an important precursor to the observed inequalities in obesity. The objective of this study was to determine the age at which inequalities in BMI growth rates develop in children and whether they are similar across the BMI spectrum.

METHODS

Using the Longitudinal Study of Australian Children (n = 9024), a cohort study, we measured socioeconomic inequalities in annual BMI growth from age 2 to 17 years by age, sex and weight status. We fit a linear model using generalised estimating equations (GEE) to estimate simultaneously the effects of age and weight status on inequalities in BMI growth rate.

RESULTS

The slope (SII) and relative (RII) indexes of inequality for annual BMI growth were greatest in middle childhood (age 4-11 years) (SII 0.25, RII 1.83 (boys) 1.78 (girls)) and were moderate during adolescence (age 10-17 years) (SII 0.11, RII 1.16 [boys] 1.15 [girls]). In early childhood, there was little evidence of inequality in annual BMI growth except in children with obesity. In middle childhood and adolescence, inequalities were greater at higher weight status. The GEE indicated that both weight status (P < 0.001) and age period (P < 0.001) affected inequalities in BMI growth rates.

CONCLUSIONS

Inequalities in annual BMI growth were strongest in middle childhood, and widest in children at the upper end of the BMI spectrum. This could signify a key age bracket to intervene clinically and at a public health level and improve inequalities in childhood obesity.

Multimodal Treatment of a Canine Lingual Melanoma Using a Combination of Immunotherapy and a Tyrosine Kinase Inhibitors

A 9-year-old female neutered Miniature Schnauzer was diagnosed with a lingual malignant melanoma on the basis of incisional biopsy and histopathology. The patient was initially given a guarded prognosis of a few months’ survival as surgical treatment options were declined by the owner. In order to control the disease a combination treatment of immunotherapy and tyrosine kinase inhibitors was initiated. The mass showed a marked and sustained reduction in size, whilst preserving quality of life for the patient, with a survival at the time of writing of 15 months since diagnosis. This experience suggests that combination therapy for oral malignant melanoma using immunotherapy and tyrosine kinase inhibitors may be successful in some patients and warrants further investigation.

Relationship between obesity and school absenteeism in Australian children: Implications for carer productivity

BACKGROUND

Economic evaluations of childhood obesity interventions are often used to assist decision making when presented with alternative course of action. Including indirect costs related to productivity losses is recommended; in children this would include school absenteeism. Our aim was to determine the association between school absenteeism and weight status among Australian children and estimate the indirect costs of this.

METHODS

We used data from a nationally representative sample of 8551 Australian children in the Longitudinal study of Australian Children (LSAC) with follow-up between 2006 and 2018. A mixed-effects negative binomial regression model was used to investigate the relationship between school absenteeism and weight status, controlling for age, sex, socio-economic position, indigenous status, rural/remote status and long-term medical conditions. We used average daily wages for the year 2018 to value the indirect costs of school absenteeism (through caregiver lost productivity).

RESULTS

Australian children with obesity aged 6-13 years missed on average an extra day of school annually compared to children of a healthy weight (p = 0.004), while adolescents with obesity aged 14-17 years missed on average an extra 0.69 days of school annually (p = 0.006). The estimated national cost for children with obesity aged 6-13 years was approximately $64 million AUD ($43 million USD) or $338 AUD ($230 USD) per child through caregiver lost productivity in 2018.

CONCLUSIONS

There is a small but significant association between school absenteeism and childhood obesity in Australia which is estimated to generate a considerable national cost through caregiver productivity losses. Our results will assist health economists evaluating childhood obesity interventions capture the full extent of the associated costs with this condition.

Estimating risk factor progression equations for the UKPDS Outcomes Model 2 (UKPDS 90)

OBJECTIVES

To estimate 13 equations that predict clinically plausible risk factor time paths to inform the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model version 2 (UKPDS-OM2).

METHODS

Data from 5102 UKPDS participants from the 20-year trial, and the 4031 survivors with 10 years further post-trial follow-up, were used to derive equations for the time paths of 13 clinical risk factors: HbA_1c , systolic blood pressure, LDL-cholesterol, HDL-cholesterol, BMI, micro- or macro-albuminuria, creatinine, heart rate, white blood cell count, haemoglobin, estimated glomerular filter rate, atrial fibrillation and peripheral vascular disease (PVD). The incidence of events and death predicted by the UKPDS-OM2 when informed by the new risk factor equations was compared with the observed cumulative rates up to 25 years.

RESULTS

The new equations were based on 24 years of follow-up and up to 65,252 person-years of data. Women were associated with higher values of all continuous risk factors except for haemoglobin. Older age and higher BMI at diagnosis were associated with higher rates of PVD (HR 1.06 and 1.02), atrial fibrillation (HR 1.10 and 1.08) and micro- or macro-albuminuria (HR 1.01 and 1.18). Smoking was associated with higher rates of developing PVD (HR 2.38) and micro- and macro-albuminuria (HR 1.39). The UKPDS-OM2, informed by the new risk factor equations, predicted event rates for complications and death consistent with those observed.

CONCLUSIONS

The new equations allow risk factor time paths beyond observed data, which should improve modelling of long-term health outcomes for people with type 2 diabetes when using the UKPDS-OM2 or other models.

The role of estrogens in osteosarcopenia: from biology to potential dual therapeutic effects

Osteoporosis and sarcopenia are two conditions associated with aging and characterized by a simultaneous decline in bone and muscle mass, respectively. These conditions share common risk factors (genetic, endocrine, nutritional and lifestyle factors) and biological pathways that often co-exist in a syndrome known as osteosarcopenia. Among the endocrine causes, estrogens play a critical role, especially in women. Estrogens have been demonstrated to exert a positive effect on bone and muscle development and maintenance. For this reason, menopause is characterized by a loss in bone mineral density and skeletal muscle quality and quantity. To date, studies indicate a positive effect of hormonal therapy on the prevention and management of osteoporosis, to the point that estrogen is prescribed as a first-line treatment for osteoporosis by the major international authorities. While results on sarcopenia are still disputable, such that estrogens are not recommended to prevent muscle loss in postmenopausal women, increased response to anabolic stimuli with estrogen therapy suggests similar beneficial effects on muscle as seen with bone, particularly when combined with resistance exercise.

Breast Angiosarcoma Surveillance Study: UK national audit of management and outcomes of angiosarcoma of the breast and chest wall

BACKGROUND

Breast angiosarcomas are rare tumours of vascular origin. Secondary angiosarcoma occurs following radiotherapy for breast cancer. Angiosarcomas have high recurrence and poor survival rates. This is concerning owing to the increasing use of adjuvant radiotherapy for the treatment of invasive breast cancer and ductal cancer in situ (DCIS), which could explain the rising incidence of angiosarcoma. Outcome data are limited and provide a poor evidence base for treatment. This paper presents a national, trainee-led, retrospective, multicentre study of a large angiosarcoma cohort.

METHODS

Data for patients with a diagnosis of breast/chest wall angiosarcoma between 2000 and 2015 were collected retrospectively from 15 centres.

RESULTS

The cohort included 183 patients with 34 primary and 149 secondary angiosarcomas. Median latency from breast cancer to secondary angiosarcoma was 6 years. Only 78.9 per cent of patients were discussed at a sarcoma multidisciplinary team meeting. Rates of recurrence were high with 14 of 28 (50 per cent ) recurrences in patients with primary and 80 of 124 (64.5 per cent ) in those with secondary angiosarcoma at 5 years. Many patients had multiple recurrences: total of 94 recurrences in 162 patients (58.0 per cent). Median survival was 5 (range 0-16) years for patients with primary and 5 (0-15) years for those with secondary angiosarcoma. Development of secondary angiosarcoma had a negative impact on predicted breast cancer survival, with a median 10-year PREDICT prognostic rate of 69.6 per cent, compared with 54.0 per cent in the observed cohort.

CONCLUSION

A detrimental impact of secondary angiosarcoma on breast cancer survival has been demonstrated. Although not statistically significant, almost all excess deaths were attributable to angiosarcoma. The increased use of adjuvant radiotherapy to treat low-risk breast cancer and DCIS is a cause for concern and warrants further study.

Effectiveness and acceptability of a text message intervention (DTEXT) on HbA1c and self-management for people with type 2 diabetes. A randomized controlled trial

OBJECTIVE

Determine the effectiveness and acceptability of a text message intervention (DTEXT) on HbA1c and self-management behaviors for Australian adults with type 2 diabetes.

METHODS

Using intention to treat analysis and generalized estimating equations, this randomized controlled trial of 395 adults determined change in HbA1c at 3 and 6 months between the intervention and control group. Secondary outcomes included change in nutrition, physical activity, blood lipid profile, body mass index, quality of life, self-efficacy, medication taking and program acceptability.

RESULTS

No significant difference was observed between the intervention or control group for HbA1c at 3 months (P = 0.23) or 6 months (P = 0.22). Significant improvements were seen in consumption of vegetables at 3 months (P < 0.001) and 6 months (P = 0.04); fruit at 3 months (P = 0.046) and discretionary sweet foods at 3 months (P = 0.02). No other significant effects seen. The intervention demonstrated high rates of acceptability (94.0%) and minimal withdrawal (1.5%).

CONCLUSIONS

DTEXT was an acceptable text message intervention that improved some nutritional behaviors in people with type 2 diabetes, but did not significantly improve HbA1c or other outcomes. Further research is required to optimize DTEXT.

PRACTICE IMPLICATIONS

DTEXT provides an acceptable, feasible form of self-management support that may complement existing diabetes care.

Utility Decrements Associated with Adult Overweight and Obesity in Australia: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim was to conduct a systematic review and meta-analysis of health state utility decrements associated with overweight and obesity in adults 18 years and over, for use in modelled economic evaluations in Australia.

METHODS

A systematic review was conducted in nine databases to identify studies that reported health state utility values by weight status. Random-effects meta-analysis was used to synthesise average utility decrements (from healthy weight) associated with overweight, all obesity and obesity classes 1, 2 and 3. Heterogeneity surrounding utility decrements was assessed via sub-group analysis, random-effects meta-regression and sensitivity analyses.

RESULTS

Twelve studies were found for which data were used to synthesise utility decrements, estimated as overweight = 0.020 (95% confidence interval 0.010-0.030), all obesity = 0.055 (0.034-0.076), obesity class 1 = 0.047 (0.017-0.077), class 2 = 0.072 (0.028-0.116) and class 3 = 0.084 (0.039-0.130). There was considerable heterogeneity in our results, which could be accounted for by the different ages and utility instruments used in the contributing studies.

CONCLUSIONS

Our results demonstrate that elevated weight status is associated with small but statistically significant reductions in utility compared with healthy weight, which will result in reduced quality-adjusted life years when extrapolated across time and used in economic evaluations.

Cost comparison of five Australasian obesity prevention interventions for children aged from birth to two years

BACKGROUND

In the absence of rigorous evidence of cost-effectiveness for early childhood obesity prevention interventions, the next-best option may be for decision-makers to consider the relevant costs of interventions when allocating resources.

OBJECTIVES

This study aimed to estimate systematically the cost of five obesity prevention interventions in children aged 0-2 years, undertaken in research settings in Australia and New Zealand.

METHODS

A standardised costing protocol informed the costing methodology, ensuring comparability of results across interventions. Micro-costing was undertaken, with intervention costs defined from the funder perspective and valued in 2018 Australian dollars using unit costs from the trials or market rates.

RESULTS

Interventions varied widely in their resource use. The total cost per participant ranged from $80 for the CHAT SMS intervention arm (95% UI $77-$82) to $1135 for the Healthy Beginnings intervention (95% UI $1059-$1189). Time costs of personnel delivering interventions contributed >50% of total intervention costs for all included studies.

CONCLUSIONS

An understanding of the costs associated with intervention delivery modes is important, alongside effectiveness. Telephone delivery may include unexpected costs associated with connection to intervention participants at convenient times. A SMS-based intervention had the lowest delivery cost in this study.

Impact of overweight and obesity on life expectancy, quality-adjusted life years and lifetime costs in the adult population of Ghana

INTRODUCTION

Prior studies have revealed the increasing prevalence of obesity and its associated health effects among ageing adults in resource poor countries. However, no study has examined the long-term and economic impact of overweight and obesity in sub-Saharan Africa. Therefore, we quantified the long-term impact of overweight and obesity on life expectancy (LE), quality-adjusted life years (QALYs) and total direct healthcare costs.

METHODS

A Markov simulation model projected health and economic outcomes associated with three categories of body mass index (BMI): healthy weight (18.5≤BMI <25.0); overweight (25.0≤BMI < 30.0) and obese (BMI ≥30.0 kg/m2) in simulated adult cohorts over a 50-year time horizon from age fifty. Costs were estimated from government and patient perspectives, discounted 3% annually and reported in 2017 US$. Mortality rates from Ghanaian lifetables were adjusted by BMI-specific all-cause mortality HRs. Published input data were used from the 2014/2015 Ghana WHO Study on global AGEing and adult health data. Internal and external validity were assessed.

RESULTS

From age 50 years, average (95% CI) remaining LE for females were 25.6 (95% CI: 25.4 to 25.8), 23.5 (95% CI: 23.3 to 23.7) and 21.3 (95% CI: 19.6 to 21.8) for healthy weight, overweight and obesity, respectively. In males, remaining LE were healthy weight (23.0; 95% CI: 22.8 to 23.2), overweight (20.7; 95% CI: 20.5 to 20.9) and obesity (17.6; 95% CI: 17.5 to 17.8). In females, QALYs for healthy weight were 23.0 (95% CI: 22.8 to 23.2), overweight, 21.0 (95% CI: 20.8 to 21.2) and obesity, 19.0 (95% CI: 18.8 to 19.7). The discounted total costs per female were US$619 (95% CI: 616 to 622), US$1298 (95% CI: 1290 to 1306) and US$2057 (95% CI: 2043 to 2071) for healthy weight, overweight and obesity, respectively. QALYs and costs were lower in males.

CONCLUSION

Overweight and obesity have substantial health and economic impacts, hence the urgent need for cost-effective preventive strategies in the Ghanaian population.

Can Reducing Childhood Obesity Solve the Obesity Crisis in Australia?

OBJECTIVE

Childhood obesity prevention has been identified as a key strategy to address the obesity crisis, with considerable investment by governments internationally. This study modeled the implications of entering adulthood at a lower or higher BMI (a consequence of changes in childhood obesity) and modeled how this would influence future numbers of adults with obesity in Australia.

METHODS

In this study, a dynamic population model was used to investigate how obesity prevention in children could impact the future number of adults with obesity in Australia from 2015 to 2040. The base population was a nationally representative data set of 14,256 individuals (representing approximately 17 million adults) from the Australian Health Survey 2014-2015. Each year, a new 20-year-old cohort was added to the simulated population, reflecting the transition to adulthood under scenarios of stable, increasing, or decreasing childhood obesity.

RESULTS

Targeting and reducing childhood obesity will have only a small and delayed effect on adult obesity levels, with approximately 280,000 fewer adults with obesity by 2040.

CONCLUSIONS

These findings highlight the importance of investing in and implementing obesity prevention programs across all ages, particularly in young adults, to successfully reduce the prevalence of adult obesity in Australia.

Estimating Age- and Sex-Specific Utility Values from the CHU9D Associated with Child and Adolescent BMI z-Score

OBJECTIVE

Our objective was to identify age- and sex-specific utilities for children and adolescents by body mass index (BMI) z-score.

METHODS

We used data from 6822 participants and 12,094 observations from two cohorts and two waves of interviews from the Longitudinal Study of Australian Children. We fit linear models using generalised estimating equations to investigate associations between Child Health Utility 9D and BMI z-score in girls and boys aged 10-17 years. We initially fit models for each sex, fully adjusted for known predictors of health-related quality of life, including socioeconomic position, long-term medical condition and maternal smoking status and also included an interaction between age and BMI z-score to examine age-specific effects. Finally, we derived a minimal model for each sex by eliminating interaction terms with P > 0.01 and predictors with P > 0.05.

RESULTS

Our adjusted results show different utility patterns in girls and boys. In girls, utility decrements for each unit increase in BMI z-score changed with age (P < 0.01 for interaction between age and BMI z-score). At age 10 years, the mean utility decrement for each unit increase in BMI z-score was 0.002 (95% confidence interval [CI] 0.011 decrement to 0.006 increment), but, by age 17 years, this utility decrement was 0.023 (95% CI 0.013 to 0.032). In boys, small non-significant decrements were found in utility for each unit increase in BMI z-score, with no observable change with age.

CONCLUSION

Our analyses demonstrated that age and sex should be considered when attributing utility values and decrements to BMI z-scores.

A European multicentre evaluation of detection and typing methods for human enteroviruses and parechoviruses using RNA transcripts

Polymerase chain reaction (PCR) detection has become the gold standard for diagnosis and typing of enterovirus (EV) and human parechovirus (HPeV) infections. Its effectiveness depends critically on using the appropriate sample types and high assay sensitivity as viral loads in cerebrospinal fluid samples from meningitis and sepsis clinical presentation can be extremely low. This study evaluated the sensitivity and specificity of currently used commercial and in-house diagnostic and typing assays. Accurately quantified RNA transcript controls were distributed to 27 diagnostic and 12 reference laboratories in 17 European countries for blinded testing. Transcripts represented the four human EV species (EV-A71, echovirus 30, coxsackie A virus 21, and EV-D68), HPeV3, and specificity controls. Reported results from 48 in-house and 15 commercial assays showed 98% detection frequencies of high copy (1000 RNA copies/5 µL) transcripts. In-house assays showed significantly greater detection frequencies of the low copy (10 copies/5 µL) EV and HPeV transcripts (81% and 86%, respectively) compared with commercial assays (56%, 50%; P = 7 × 10^-5 ). EV-specific PCRs showed low cross-reactivity with human rhinovirus C (3 of 42 tests) and infrequent positivity in the negative control (2 of 63 tests). Most or all high copy EV and HPeV controls were successfully typed (88%, 100%) by reference laboratories, but showed reduced effectiveness for low copy controls (41%, 67%). Stabilized RNA transcripts provide an effective, logistically simple and inexpensive reagent for evaluation of diagnostic assay performance. The study provides reassurance of the performance of the many in-house assay formats used across Europe. However, it identified often substantially reduced sensitivities of commercial assays often used as point-of-care tests.

Weight status and health-related quality of life during childhood and adolescence: effects of age and socioeconomic position

BACKGROUND

Overweight and obesity in children is associated with poor health-related quality of life (HRQoL), but the nuances of this relationship across different age and socio-demographic groups are not well-established. The aim of this study is to examine how the association between weight status and HRQoL changes with age and socioeconomic position (SEP) throughout childhood and adolescence.

METHODS

We used data from the Longitudinal Study of Australian Children (LSAC), a cohort study in which children were interviewed biennially from ages 4 to 17 years over seven waves of data. Measurements of HRQoL (using PedsQL^TM), body mass index (BMI), and socio-demographic characteristics were collected at each interview. Of the 4983 children recruited into the study, we included data from 4083 children (a total of 24,446 observations). We used generalised estimating equations to assess whether age and SEP modified the association between weight status and HRQoL, after controlling for sex, long-term medical condition, language spoken to child and maternal smoking status.

RESULTS

Age was a significant modifier of the association between weight status and HRQoL, with adjustment for known predictors of HRQoL (P < 0.001). At age 4, children with obesity had, on average, a 0.99 (95% CI 0.02-1.96) point lower PedsQL total score than children at healthy weight. This difference became clinically important by age 9 at 4.50 (95% CI 3.86-5.13) points and increased to 6.69 (95% CI 5.74-7.64) points by age 17. There was no evidence that SEP modified the relationship between weight status and HRQoL (P > 0.05).

CONCLUSIONS

Our results demonstrate that the relationship between overweight and obesity status and poor HRQoL is strengthened with increasing age through childhood and adolescence, but is not affected by SEP. Paediatricians, researchers and carers of children with obesity should acknowledge HRQoL outcomes, particularly for older children and adolescents.

Intercontinental collaborative experience with abdominal, retroperitoneal and pelvic schwannomas

Background

Schwannomas are rare tumours that pose a significant management challenge in the abdomen, retroperitoneum and pelvis. No data are available to inform management strategy.

Methods

A collaborative international cohort study, across specialist sarcoma units, was conducted to include adults presenting between 2000 and 2017 with histopathologically confirmed schwannomas within the abdomen, retroperitoneum or pelvis.

Results

Of 485 patients across 12 centres, 38 (7·8 per cent) were discharged without follow-up, 199 (41·0 per cent) underwent early resection and 248 (51·1 per cent) had radiological monitoring. Of these 248 patients, 96 (38·7 per cent) eventually had surgery, giving an overall resection rate of 60·8 per cent (295 of 485). At baseline, median tumour volume was 90·1 (i.q.r. 26·5–262·0) cm3. The estimated growth rate was 10·5 (95 per cent c.i. 9·4 to 11·6) per cent per year, and was consistent in the short term (within 2 years of diagnosis) and long term (beyond 2 years) (ρ = 0·405, P = 0·021). A decision to operate was more common in symptomatic patients (P &lt; 0·001) and for rapidly growing tumours (growth rate more than 20 per cent per year) (P = 0·025). R0/R1 resection was achieved in 91·6 per cent of patients (263 of 287). Kaplan–Meier long-term recurrence rates after R0/R1 resection were 2·3 and 6·7 per cent at 3 and 5 years respectively.

Conclusion

Specific recommendations include: indications for early surgery, prediction of growth from radiological monitoring, promotion of selective submacroscopic resection and cessation of postoperative imaging surveillance.

The potential for long-term cost-effectiveness of obesity prevention interventions in the early years of life

BACKGROUND

Early childhood obesity prevention is gaining increasing importance, as the prevalence of children with overweight and obesity aged 5 years and under increases worldwide. Along with understanding the effectiveness of obesity interventions, it is important to understand the cost-effectiveness of interventions over time.

OBJECTIVES

To estimate the long-term health benefits and health care cost-savings of reductions in BMI for the Australian population of children aged between 2 and 5 years.

METHODS

A proportional multistate, multiple cohort lifetable model estimated the health benefits and health care cost-savings related to hypothetical reductions in BMI, informed by a scoping review of systematic reviews reporting the effectiveness of obesity prevention interventions in preschool aged children.

RESULTS

Results suggest significant potential for cost-effectiveness of obesity prevention interventions in preschool-aged children if intervention effect can be maintained. A relatively small population level reduction in BMI z-score (-0.13 BMIz) in children aged 2 to 5 years would result in 36 496 health-adjusted life years saved (95% uncertainty interval [UI], 30 283-42 945) and health care cost-savings of approximately $301 million (95% UI $234 million-$369 million) if modelled over the lifetime.

CONCLUSIONS

Scenario results highlight the importance of obesity intervention in the early years of life.

Socioeconomic inequalities in obesity: modelling future trends in Australia

OBJECTIVES

To develop a model to predict future socioeconomic inequalities in body mass index (BMI) and obesity.

DESIGN

Microsimulation modelling using BMI data from adult participants of Australian Health Surveys, and published data on the relative risk of mortality in relation to BMI and socioeconomic position (SEP), based on education.

SETTING

Australia.

PARTICIPANTS

74 329 adults, aged 20 and over from Australian Health Surveys, 1995-2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were BMI trajectories and obesity prevalence by SEP for four birth cohorts, born 10 years apart, centred on 1940, 1950, 1960 and 1970.

RESULTS

Simulations projected persistent or widening socioeconomic inequality in BMI and obesity over the adult life course, for all birth cohorts. Recent birth cohorts were predicted to have greater socioeconomic inequality by middle age, compared with earlier cohorts. For example, among men, there was no inequality in obesity prevalence at age 60 for the 1940 birth cohort (low SEP 25% (95% CI 17% to 34%); high SEP 26% (95% CI 19% to 34%)), yet for the 1970 birth cohort, obesity prevalence was projected to be 51% (95% CI 43% to 58%) and 41% (95% CI 36% to 46%) for the low and high SEP groups, respectively. Notably, for more recent birth cohorts, the model predicted the greatest socioeconomic inequality in severe obesity (BMI >35 kg/m²) at age 60.

CONCLUSIONS

Lower SEP groups and more recent birth cohorts are at higher risk of obesity and severe obesity, and its consequences in middle age. Prevention efforts should focus on these vulnerable population groups in order to avoid future disparities in health outcomes. The model provides a framework for further research to investigate which interventions will be most effective in narrowing the gap in socioeconomic disparities in obesity in adulthood.

DTEXT - text messaging intervention to improve outcomes of people with type 2 diabetes: protocol for randomised controlled trial and cost-effectiveness analysis

BACKGROUND

Diabetes prevalence is rapidly increasing, with type 2 diabetes predicted to be the leading contributor of non-communicable disease in Australia by 2020. It is anticipated that rates of type 2 diabetes will continue to increase if factors such as overweight and obesity, low physical activity and poor nutrition are not addressed. The majority of Australians with type 2 diabetes do not meet the guidelines for optimal diabetes management, and access to diabetes education is limited. This highlights the need for new interventions that can reduce existing barriers to diabetes education, attain greater population reach and support self-management strategies for people with type 2 diabetes. Mobile phone text messages have shown promising results as an intervention for people with chronic disease. They have the ability to achieve high levels of engagement and broad population reach, whilst requiring minimal resources. There is however, no evidence on the effect of text messaging to improve the health of people with type 2 diabetes in Australia.

METHODS/DESIGN

This randomised controlled trial aims to investigate if a 6 month text message intervention (DTEXT) can lead to improvements in glycated haemoglobin (HbA1c) and diabetes self-management among Australian residents in New South Wales (NSW) with type 2 diabetes. Community dwelling adults (n = 340) will be recruited with the primary outcome being change in HbA1c at 6 months. Secondary outcomes include behaviour change for diabetes self-management, self-efficacy, quality of life and intervention acceptability. An economic evaluation will be conducted using a funder plus patient perspective.

DISCUSSION

This study will provide evidence on the effectiveness and cost effectiveness of a text message intervention to reduce HbA1c and enhance self-management of type 2 diabetes in the Australian population. If successful, this intervention could be used as a model to complement and extend existing diabetes care in the Australian health care system.

TRIAL REGISTRATION

The study has been registered with the Australian New Zealand Clinical Trials Registry, Trial ID: ACTRN12617000416392 . Registered: 23 March 2017.

ITM support for patients with chronic respiratory and cardiovascular diseases: a protocol for a randomised controlled trial

INTRODUCTION

Simple and scalable strategies are needed to improve 'out-of-hospital' support and management for people living with cardiovascular disease (CVD) and respiratory disease. Text messaging via mobile phones has been shown to be effective in helping promote lifestyle change and is supported by quantitative and qualitative evidence. The aim of this study is to test the effectiveness and implementation of a 6-month text messaging support programme for people with CVD and respiratory disease as an addition to cardiac and pulmonary outpatient rehabilitation.

METHODS AND ANALYSIS

Pragmatic randomised controlled trial (n=310) to test the effectiveness of a 6-month text message support programme on clinical outcomes in people with CVD and chronic respiratory disease who are attending outpatient cardiac and pulmonary rehabilitation. The study includes a nested process evaluation to inform scalability and implementation across settings. The intervention group will receive a text message support programme comprising five messages per week for 26 weeks and the control group will continue with standard care. The primary outcome is exercise capacity (6 min walk distance). Secondary outcomes include clinical measures (proportion of people meeting the Australian guideline-recommended blood pressure and cholesterol targets), lifestyle outcomes (smoking rates, achievement of national guidelines for nutrition and physical activity), quality of life, mood (Hospital Anxiety and Depression Scale), medication adherence and attendance at and completion of rehabilitation.

ETHICS AND DISSEMINATION

Primary ethics approval was received from the Sydney Local Health District Hospital Human Research Ethics Committee and associated Governance committees at sites. Results will be disseminated via the usual scientific forums including peer-reviewed publications and presentations at international conferences. At its conclusion, the study will determine the effectiveness and implementation of a simple programme that aims to improve health outcomes and attendance at rehabilitation for people with CVD and chronic respiratory disease.

TRIAL REGISTRATION NUMBER

ACTRN12616001167459.

Dietary intervention in patients with age-related macular degeneration: protocol for a randomised controlled trial

INTRODUCTION

Age-related macular degeneration (AMD) is a leading cause of blindness. After smoking, nutrition is the key modifiable factor in reducing AMD incidence and progression, and no other preventative treatments are currently available. At present, there is an evidence-practice gap of dietary recommendations made by eye care practitioners and those actually practised by patients with AMD. To address this gap, a telephone-delivered dietary intervention tailored to patients with AMD will be piloted. The study aims to improve dietary intake and behaviours in patients with AMD. This type of nutrition-focused healthcare is currently not considered in the long-term management of AMD and represents the first empirical evaluation of a telephone-supported application encouraging adherence to dietary recommendations for AMD.

METHODS AND ANALYSIS

140 participants with AMD will be recruited for this randomised controlled trial. Those lacking English fluency; unwilling to engage in the intervention or provide informed consent were excluded. Following the completion of the baseline questionnaire, participants will be randomised into one of two arms: intervention or wait-list control (70 each in the intervention and control groups). Intervention participants will receive a detailed mail-delivered workbook containing information on healthy eating behaviours that promote optimal macular health, as well as scheduled phone calls over 4 months from an accredited practising dietitian. Descriptive statistics and multivariate stepwise linear regressions analyses will be used to summarise and determine the changes in dietary intakes, respectively. Economic analysis will be conducted to determine intervention feasibility and possibility of a large-scale rollout.

ETHICS AND DISSEMINATION

The study was approved by the University of Sydney Human Research Ethics Committee (HREC) (Reference: HREC 2018/219). Study findings will be disseminated via presentations at national/international conferences and peer-reviewed journal articles.

TRIAL REGISTRATION NUMBER

ACTRN12618000527268; Pre-results.

Establishing an Operational Definition of Sarcopenia in Australia and New Zealand: Delphi Method Based Consensus Statement

BACKGROUND

Globally there are several operational definitions for sarcopenia, complicating clinical and research applications.

OBJECTIVE

The objective of the Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) Task Force on Diagnostic Criteria for Sarcopenia was to reach consensus on the operational definition of sarcopenia for regional use by clinicians and researchers.

METHOD

A four-Phase modified Delphi process was undertaken in which 24 individuals with expertise or a recognised interest in sarcopenia from different fields across Australia and New Zealand were invited to be Task Force members. An initial face-to-face meeting was held in Adelaide, South Australia, in November 2017, followed by two subsequent online Phases conducted by electronic surveys. A final Phase was used to approve the final statements. Responses were analysed using a pre-specified strategy. The level of agreement required for consensus was 80%.

RESULTS

In Phase 2, 94.1% of Task Force respondents voted in favour of adopting an existing operational definition of sarcopenia. In Phase 3, 94.4% of respondents voted in favour of adopting the European Working Group on Sarcopenia in Older People (EWGSOP) definition as the operational definition for sarcopenia in Australia and New Zealand.

CONCLUSION

With consensus achieved, the ANZSSFR will adopt, promote and validate the EWGSOP operational definition of sarcopenia for use by clinicians and researchers in Australia and New Zealand.