U.S. trainees' experiences of ethical challenges during research in low- and middle-income countries: A mixed methods study

High-income country (HIC) trainees are participating in research in low- and middle-income countries (LMIC) in increasing numbers, yet the ethical challenges they face have not been well described. We conducted a mixed methods study of U.S. graduate and undergraduate students who conducted research in LMIC, including an online survey and semi-structured interviews. Among 123 online survey respondents, 31% reported ethical challenges and nearly two-thirds of respondents did not feel well prepared to deal with ethical challenges. Qualitative analysis of the 17 semi-structure interviews and narrative survey responses revealed many themes of 'ethics in practice': challenges in setting research priorities, navigating relationships with host country partners, scope of research practice, and human subject protections. Respondents reported that pre-departure trainings were not reflective of ethical frameworks or research contexts in LMIC, and few described seeking host mentor help in addressing ethical challenges. These results suggest a need for improvements in training, oversight and mentorship of trainee researchers, and to further engage both HIC and LMIC institutions, educators and researchers in addressing ethical issues.

Saving time in the radiotherapy procedures for COVID-19 pneumonia treatment. A single-institution experience

Background

The use of low dose radiotherapy (LD-RT) for the treatment of COVID-19 pneumonia is supported by biological rationale for its immunomodulatory effect. Some institutions have started to treat these patients showing encouraging results. To shorten procedure times is crucial for the comfort of symptomatic patients receiving respiratory support and to optimize institutional facilities.

Patients and methods

At our institution, LD-RT is offered to hospitalized patients with COVID-19 pneumonia and signs of early cytokine-released syndrome on behalf of a multicenter study. We designed a coordinated process flow starting from the patient transfer to the simulation CT-scan (first-step), to the end of the LD-RT treatment (last step). The times spent on each step of the process flow were evaluated.

Results

Mean age of treated patients was 83 (72–91) years-old. The timing parameters of the first 10 consecutive patients were analyzed. Except for the first (dummy run), patients were managed from the first to the last step in a median of 38 min (25–58, SD 10.67). The most time-consuming sub-process was the contouring of the treatment volumes and dosimetry.

Conclusions

LD-RT is not only an encouraging option for COVID-19 pneumonia patients, but a convenient and feasible procedure if performed in a coordinated way by reducing procedure times.

Suppression of the maize phytoglobin ZmPgb1.1 promotes plant tolerance against Clavibacter nebraskensis

Suppression of the maize phytoglobin ZmPgb1.1 enhances tolerance against Clavibacter nebraskensis by promoting hypersensitive response mechanisms mediated by ethylene and reactive oxygen species. Suppression of the maize phytoglobin, ZmPgb1.1, reduced lesion size and disease severity in leaves following inoculation with Clavibacter nebraskensis, the causal agent of Goss's bacterial wilt disease of corn. These effects were associated with an increase of the transcriptional levels of ethylene biosynthetic and responsive genes, which resulted in the accumulation of reactive oxygen species (ROS) and TUNEL-positive nuclei in the proximity of the inoculation site. An in vitro system, in which maize cells were treated with induced xylem sap, was employed to define the cause-effect relationship of these events. Phytoglobins (Pgbs) are hemoglobins able to scavenge nitric oxide (NO). Suppression of ZmPgb1.1 elevated the level of NO in cells exposed to the induced xylem sap causing a rise in the transcript levels of ethylene biosynthesis and response genes, as well as ethylene. Accumulation of ethylene in the same cells was sufficient to elevate the amount of reactive oxygen species (ROS), through the activation of the respiratory burst oxidase homologs (Rboh) genes, and trigger programmed cell death (PCD). The sequence of these events was demonstrated by manipulating the content of NO and ethylene in culture through pharmacological treatments. Collectively, our results illustrated that suppression of ZmPgb1.1 evokes tolerance against C. nebraskensis culminating in the execution of PCD, a key step of the hypersensitive response.

Anti-PSMA 124I-scFvD2B as a new immuno-PET tool for prostate cancer: preclinical proof of principle

Background

Prostate cancer (PCa) is the second leading cause of cancer-related death in the Western population. The use in oncology of positron emission tomography/computed tomography (PET/CT) with emerging radiopharmaceuticals promises accurate staging of primary disease, restaging of recurrent disease and detection of metastatic lesions. Prostate-specific membrane antigen (PSMA) expression, directly related to androgen-independence, metastasis and progression, renders this tumour associate antigen a good target for the development of new radiopharmaceuticals for PET. Aim of this study was to demonstrate in a preclinical in vivo model (PSMA-positive versus PSMA-negative tumours) the targeting specificity and sensitivity of the anti-PSMA single-chain variable fragment (scFv) labelled with ¹²⁴I.

Methods

The ¹²⁴I-labeling conditions of the antibody fragment scFvD2B were optimized and assessed for purity and immunoreactivity. The specificity of ¹²⁴I-scFvD2B was tested in mice bearing PSMA-positive and PSMA-negative tumours to assess both ex-vivo biodistribution and immune-PET.

Results

The uptake fraction of ¹²⁴I-scFvD2B was very high on PSMA positive cells (range 75–91%) and highly specific and immuno-PET at the optimal time point, defined between 15 h and 24 h, provides a specific localization of lesions bearing the target antigen of interest (PSMA positive vs PSMA negative tumors %ID/g: p = 0.0198 and p = 0.0176 respectively) yielding a median target/background ratio around 30–40.

Conclusions

Preclinical in vivo results of our immuno-PET reagent are highly promising. The target to background ratio is improved notably using PET compared to SPECT previously performed.

These data suggest that, upon clinical confirmation of sensitivity and specificity, our anti-PSMA ¹²⁴I-scFvD2B may be superior to other diagnostic modalities for PCa. The possibility to combine in patients our ¹²⁴I-scFvD2B in multi-modal systems, such as PET/CT, PET/MR and PET/SPECT/CT, will provide quantitative 3D tomographic images improving the knowledge of cancer biology and treatment.

Radioembolization of hepatocarcinoma with (90)Y glass microspheres: development of an individualized treatment planning strategy based on dosimetry and radiobiology

PURPOSE

The aim of this study was to optimize the dosimetric approach and to review the absorbed doses delivered, taking into account radiobiology, in order to identify the optimal methodology for an individualized treatment planning strategy based on (99m)Tc-macroaggregated albumin (MAA) single photon emission computed tomography (SPECT) images.

METHODS

We performed retrospective dosimetry of the standard TheraSphere® treatment on 52 intermediate (n = 17) and advanced (i.e. portal vein thrombosis, n = 35) hepatocarcinoma patients with tumour burden < 50% and without obstruction of the main portal vein trunk. Response was monitored with the densitometric radiological criterion (European Association for the Study of the Liver) and treatment-related liver decompensation was defined ad hoc with a time cut-off of 6 months. Adverse events clearly attributable to disease progression or other causes were not attributed to treatment. Voxel dosimetry was performed with the local deposition method on (99m)Tc-MAA SPECT images. The reconstruction protocol was optimized. Concordance of (99m)Tc-MAA and (90)Y bremsstrahlung microsphere biodistributions was studied in 35 sequential patients. Two segmentation methods were used, based on SPECT alone (home-made code) or on coregistered SPECT/CT images (IMALYTICS™ by Philips). STRATOS™ absorbed dose calculation was validated for (90)Y with a single time point. Radiobiology was used introducing other dosimetric variables besides the mean absorbed dose D: equivalent uniform dose (EUD), biologically effective dose averaged over voxel values (BEDave) and equivalent uniform biologically effective dose (EUBED). Two sets of radiobiological parameters, the first derived from microsphere irradiation and the second from external beam radiotherapy (EBRT), were used. A total of 16 possible methodologies were compared. Tumour control probability (TCP) and normal tissue complication probability (NTCP) were derived. The area under the curve (AUC) of the receiver-operating characteristic (ROC) curve was used as a figure of merit to identify the methodology which gave the best separation in terms of dosimetry between responding and non-responding lesions and liver decompensated vs non-decompensated liver treatment.

RESULTS

MAA and (90)Y biodistributions were not different (71% of cases), different in 23% and uncertain in 6%. Response correlated with absorbed dose (Spearman's r from 0.48 to 0.69). Responding vs non-responding lesion absorbed doses were well separated, regardless of the methodology adopted (p = 0.0001, AUC from 0.75 to 0.87). EUBED gave significantly better separation with respect to mean dose (AUC = 0.87 vs 0.80, z = 2.07). Segmentation on SPECT gave better separation than on SPECT/CT. TCP(50%) was at 250 Gy for small lesion volumes (<10 cc) and higher than 1,000 Gy for large lesions (>10 cc). Apparent radiosensitivity values from TCP were around 0.003/Gy, a factor of 3-5 lower than in EBRT, as found by other authors. The dose-rate effect was negligible: a purely linear model can be applied. Toxicity incidence was significantly larger for Child B7 patients (89 vs 14%, p < 0.0001), who were therefore excluded from dose-toxicity analysis. Child A toxic vs non-toxic treatments were significantly separated in terms of dose averaged on whole non-tumoural parenchyma (including non-irradiated regions) with AUC from 0.73 to 0.94. TD50 was ≈ 100 Gy. No methodology was superior to parenchyma mean dose, which therefore can be used for planning, with a limit of TD15 ≈ 75 Gy.

CONCLUSION

A dosimetric treatment planning criterion for Child A patients without complete obstruction of the portal vein was developed.

Infrastructures, treatment modalities, and workload of radiation oncology departments in Spain with special attention to prostate cancer

AIM

The purpose of the study was to describe infrastructures, treatment modalities, and workload in radiation oncology (RO) in Spain, referred particularly to prostate cancer (PC).

METHODS

An epidemiologic, cross-sectional study was performed during 2008-2009. A study-specific questionnaire was sent to the 108 RO-registered departments.

RESULTS

One hundred and two departments answered the survey, and six were contacted by telephone. Centers operated 236 treatment units: 23 (9.7 %) cobalt machines, 37 (15.7 %) mono-energetic linear accelerators, and 176 (74.6 %) multi-energy linear accelerators. Sixty-one (56.4 %) and 33 (30.5 %) departments, respectively, reported intensity-modulated radiation therapy (IMRT) and image-guided RT (IGRT) capabilities; three-dimensional-conformal RT was used in 75.8 % of patients. Virtual simulators were present in 95 departments (88.0 %), 35 use conventional simulators. Fifty-one departments (47.2 %) have brachytherapy units, 38 (35.2 %) perform prostatic implants. Departments saw a mean of 24.9 new patients/week; the number of patients treated annually was 102,054, corresponding to 88.4 % of patients with a RT indication. In 56.5 % of the hospitals, multidisciplinary teams were available to treat PC.

CONCLUSIONS

Results provide an accurate picture of current situation of RO in Spain, showing a trend toward the progressive introduction of new technologies (IMRT, IGRT, brachytherapy).

Dosimetry in 131I-mIBG therapy: moving toward personalized medicine

Internal dosimetry was developed as a basis for 131I-mIBG treatment at an early stage and has continued to develop for over the last 20 years. Whole-body dosimetry was introduced to prevent hematological toxicity. It will be the basis for a forthcoming European multicentre trial, in which the activity of a second administration is determined according to the results calculated from the first. Lesion dosimetry has also been performed in a small number of centres. The major goal of dosimetry now is to establish dose-effect correlation studies, which will be the basis for individualized treatment planning. The aim of this paper is to analyse previously published studies and to consider the potential for improvement in order to obtain a stronger predictive power of dosimetry. The intrinsic radiobiological limits of dosimetry are also illustrated. Due to the development and dissemination of methods of internal dosimetry and radiobiology over the last two decades, and to the increasing availability of quantitative 124I PET imaging, dosimetry could provide in the near future a more systematic basis for standardization and individualization of mIBG therapy. This will however require a number of multicentre trials which are performed under good instrumental and scientific methodology.

A dosimetric treatment planning strategy in radioembolization of hepatocarcinoma with 90Y glass microspheres

AIM

Our goal was to limit liver toxicity and to obtain good efficacy by developing a dosimetric treatment planning strategy. While several dosimetric evaluations are reported in literature, the main problem of the safety of the treatment is rarely addressed. Our work is the first proposal of a treatment planning method for glass spheres, including both liver toxicity and efficacy issues.

METHODS

Fifty-two patients (series 1) had been treated for intermediated/advanced hepatocellular carcinoma (HCC) with glass spheres, according to the Therasphere® prescription of 120 Gy averaged on the injected lobe. They were retrospectively evaluated with voxel dosimetry, adopting the local deposition hypothesis. Regions of interest on tumor and non tumor parenchyma were drawn to determine the parenchyma absorbed dose, averaged also on non irradiated voxels, excluding tumor voxels. The relationship between the mean non tumoral parenchyma absorbed dose D and observed liver decompensation was analyzed.

RESULTS

Basal Child-Pugh strongly affected the toxicity incidence, which was 22% for A5, 57% for A6, 89% for B7 patients. Restricting the analysis to our numerically richest class (basal Child-Pugh A5 patients), D median values were significantly different between toxic (median 90 Gy) and non toxic treatments (median 58 Gy) at a Mann-Withney test, (P=0.033). Using D as a marker for toxicity, the separation of the two populations in terms of area under ROC curve was 0.75, with 95% C.I. of [0.55-0.95]. The experimental Normal Tissue Complication Probability (NTCP) curve as a function of D resulted in the following values: 0%, 14%, 40%, 67% for D interval of [0-35] Gy, [35-70] Gy, [70-105] Gy, [105-140] Gy.

DISCUSSION

A limit of about 70 Gy for the mean absorbed dose to parenchyma was assumed for A5 patients, corresponding to a 14% risk of liver decompensation. This result is applicable only to our administration conditions: glass spheres after a decay interval of 3.75 days. Different safety limit (40 Gy) are published for resin spheres, characterized by higher number of particle per GBq (more uniform irradiation, bigger biological effect for the same absorbed dose).

CONCLUSION

As result of this study we suggest a constraint of about 70 Gy mean absorbed dose to liver non tumoral parenchyma, corresponding to about 15% probability of radioinduced liver decompensation while still aiming at achieving an absorbed of several hundreds of Gy to lesions.

Preoperative chemoradiotherapy with capecitabine and oxaliplatin in locally advanced rectal carcinoma: A phase II trial

4044

Background: The aim of this phase II trial was to assess the impact of preoperative external radiation therapy combined with Capecitabine and Oxaliplatin on pathologic tumor response, sphincter preservation and tumor control in patients with locally advanced rectal carcinoma. Methods: Sixty-seven patients with locally advanced rectal carcinoma (T3/T4 or N+) received radiotherapy (50.4 Gy/28 fractions) and chemotherapy with Capecitabine 825 mg/m2/12 hours on days 1–5 + Oxaliplatin 50 mg/m2 on day 1 every week (weeks 1–6). Surgery with TME was performed 6–7 weeks after the end of the treatment. Adjuvant chemotherapy was administered after surgery according investigator‘s crtiteria. Results: Patients have been recruited between February 2005 and June 2006. 47 male/20 female. Median age 67 years (range 38–79). Performance status (ECOG) 0 in 45 patients. Clinical stage (determined by EUS+CT or RMI): cT2 3p/cT3 58p/cT4 6p/cN+ 47p. Tumor location (from anal verge): = 5 cm in 27p. Median CEA level 3,69 ng/ml (0,7–391). Surgery (performed in 65 patients) consisted of low anterior resection in 37p, abdominal perineal resection in 28p. Tumor downstaging was observed in 52p (78%), 50 (76,9%) had negative lymph nodes, including 13p with complete pathological response (19,4%) and ten with only microfoci of tumor remaining (14,9%). 80% of the patients received adjuvant chemotherapy. Main adverse effects (NCI-CTC): diarrhea G3/4 25%, sensitive peripheral neurotoxicity G1 60%, skin G2 9%, skin G3 3%, nausea/vomiting G2 7.5%, fatigue G2 50%, fatigue G3 4%, neutropenia G3/4 4%. Conclusions: Those results show that preoperative chemoradiotherapy with capecitabine and oxaliplatin is a well tolerated regimen for locally advanced operable rectal cancer leading to a high probability of tumor downstaging.

No significant financial relationships to disclose.

Preoperative chemoradiotherapy with capecitabine and oxaliplatin in locally advanced rectal carcinoma: Preliminary results

13543

Background: Preoperative chemoradiotherapy has shown to improve local control and sphincter preservation with decreased acute toxicity compared with postoperative treatment in locally advanced rectal carcinoma. The primary endpoint of this phase II trial was pathologic tumor response. Secondary endpoints were sphincter preservation and toxicity. Methods: Inclusion criteria: rectal adenocarcinoma <12 cms from anal verge, clinical stage T3–4 and/or N+, adequate renal, hematological and liver function. Planned sample for this trial was 43 patients. Treatment scheme: pelvic radiotherapy (50.4 Gy/28 fractions) and chemotherapy: Capecitabine 825 mg/m2/12 hours on days 1–5 + Oxaliplatin 50 mg/m2 on day 1 every week (weeks 1–6). Surgery with TME was performed between 6–8 weeks after the end of the treatment. Adjuvant chemotherapy was administered after surgery according each center criteria. Results: 37 patients have been recruited between February and December 2005. 26 male/11 female. Median age 70 years (range 38–79). Clinical stage (determined by EUS+CT or RMI): cT2 1p/cT3 33p/cT4 3p/cN+ 27p. Tumor location (from anal verge): ≤ 5 cm in 15p, >5 cm in 22p. Surgery (performed in 26 patients) consisted of low anterior resection in 13p and abdominal-perineal resection in 13p. Tumor downstaging was observed in 17p (65%), 20 (77%) had negative lymph nodes, including 6p with complete pathological response (23%) and four with only microfoci of tumor remaining (15%). Main adverse effects (NCI-CTC): diarrhea G3–4 19%, sensitive peripheral neurotoxicity G1 38%, skin G2 11%, nausea/vomiting G2 11%, fatigue/malaise G3 4%, neutropenia G3 7%. Conclusions: Preliminary results show that preoperative chemoradiotherapy with capecitabine and oxaliplatin is a well tolerated regimen for locally advanced operable rectal cancer leading to a high probability of tumor downstaging.

No significant financial relationships to disclose.

A phase II trial of cisplatin and vinorelbine in patients with recurrent or metastatic squamous cell carcinoma of the head and neck

OBJECTIVE

We assessed the response rate and the toxicity of cisplatin plus vinorelbine in patients with this condition.

PATIENTS AND METHOD

Forty-two patients were included. Therapy consisted of cisplatin, 100 mg/m(2) on day 1, and vinorelbine, 25 mg/m(2) on days 1 and 8, given every 21 days. Therapy was continued up to six courses or progressive disease.

RESULTS

One hundred fifty-nine courses were given (median, three per patient). Dose reduction was applied in 13% of courses and 43% of patients. Grade 3 to 4 neutropenia appeared in 11% of courses and 35% of the patients. One patient died of febrile neutropenia. Ten percent of patients attained a complete response, and 23% attained a partial response (overall 33%, 95%CI 19%-47%). The median duration of response and median survival were 6 months. Twenty-four percent of patients remain alive at 1 year.

CONCLUSIONS

The combination of cisplatin and vinorelbine is moderately active in patients with recurrent or metastatic carcinomas of the head and neck and avoids the inconvenience of prolonged infusions of 5-fluorouracil.

Use of Medicare services related to diabetes care: the impact of rural isolation

This study used Medicare data for people living in New South Wales (NSW) (1993-1997) to examine the impact of rural isolation on the utilisation of diabetes health care services. The relative odds of attending a specialist was slightly higher for people in urban areas when compared to their rural counterparts but reached as high as 1.85 in regard to attendance to consultant physicians. Surveillance of diabetes parameters over the 5 year period showed greatest improvement in rural areas. The proportion of patients each year with glycaemic control assessed by quantification of glycosylated haemoglobin (HbA1c) or renal function and vascular risk by microalbuminuria estimation rose to 57.4% and 12.3%, respectively, in rural areas compared to 55.2% and 11.3% in major urban areas. This study has shown that the level of monitoring in rural areas is equal to urban areas, despite decreased access to medical care, highlighting the vital role GPs play in diabetes management in rural NSW.

An instrument for collecting problem oriented, problem linked data in primary medical care

AIM

To describe a new form for collecting problem oriented, problem linked data from primary care.

METHOD

A novel form is described which has been used to collect these data. These data were validated against secondary data collections.

RESULTS

The form has been used to record 10,937 encounters in a variety of primary care settings. The form was acceptable to general practitioners (GPs) and was completed on 87% of eligible patients in a one week data collection. Data captured provide descriptive data about the problems encountered and services provided during the consultation. These elements of the medical record are linked so that it is possible to address questions about patterns of service provision. Uncomplicated lower urinary tract infection is used as an example of how data from the form can be used to examine clinical practice and resource utilisation.

CONCLUSION

A method has been demonstrated to collect problem oriented, problem linked data which may be used for clinical costing and to demonstrate compliance with clinical practice guidelines.

Differential shared care for diabetes: does it provide the optimal partition between primary and specialist care?

AIMS

To establish whether a system of differential shared care between general practitioners and specialists is compatible with patients receiving the level of care they require.

METHODS

We sought to trace 200 shared care patients whose care had been kept at the general practitioner level after initial referral and compared them with a group of patients who had been re-referred to the Royal Prince Alfred Hospital Diabetes Centre for specialist review.

RESULTS

There were no significant differences in glycaemic, blood pressure and lipid levels of returned and non-returned patients at initial assessment. However, non-returned patients were less likely to have a history of macrovascular disease or risk factor (adjusted odds ratio (OR) 0.4; 95% confidence interval (CI) 0.2-0.6). Their referral letter was also more likely to emphasize their type and/or duration of diabetes (adjusted OR 4.6; 95% CI 2.5-8.4). Nearly half (47.1%) of the non-returned group changed their doctor in the years following their initial specialist review, increasing their likelihood of not being re-referred five-fold (adjusted OR 5.0; 95% CI 2.9-8.8). At initial assessment, non-returned patients were given less treatment recommendations (adjusted OR 0.5; 95% CI 0.3-0.7). Doctors registered with the Diabetes Shared Care Programme referred more patients than their non-shared care counterparts. However, a higher proportion of these doctors (52.5% vs. 21.3%; chi(2) = 16.5, 1 d.f., P = 0.00005) were selective in whom they re-referred.

CONCLUSION

Differential shared care encourages appropriate referral to specialist services, without compromise to standards of care. Diabet. Med. 18, 554-557 (2001)

Continuity of care in diabetes: to whom does it matter?

The Australian health care system allows patients to move around to seek medical treatment. This may impact negatively on continuity of care. To determine factors associated with continuity of care for persons with diabetes, the profiles of 479 patients attending the Diabetes Centre, Royal Prince Alfred Hospital, Sydney, Australia, were examined. The majority of patients (87.7%) attended only one general practitioner and had been under the care of the referring doctor for a median of 6.2 years. These patients were older (P=0.02), but were comparable with those attending multiple doctors in terms of their type, duration and treatment of diabetes as well as their clinical and complication profile. There was also a relationship between age and the length of time under the care of the referring doctor (P=0.0002). The HbA(1c), lipid, blood pressure and treatment profiles of patients attending the referring doctor short, medium or long-term were comparable. However, there was an upward trend in the proportion of patients with a history of cerebrovascular disease, ischaemic heart disease or any complication of diabetes with each incremental increase in length of time under the referring doctor. Appropriately, patients seek continuity of care as they age and their health needs become more complex.

Oranges are not the only fruit: the role of emergency departments in providing care to primary care patients

Effective and integrated primary health care services are seen world wide as the lynch pin of an equitable,efficient and high quality health care. Health services dominated by specialist care suffer either fromuncontainable costs (USA with 14% of GDP) or poor quality care (Russia and other former members of theSoviet bloc). Ierachi et al. (2000) argue that Australia should take the retrograde step of endorsing a servicewhich aims to "provide rapid, high quality and continuously accessible unscheduled care, for conditions coveringthe full spectrum of acute illness and injury" (emphasis added). They aim to provide care "for conditions", notfor people. General practice provides care for people, not just diseases or injuries.

Iron deficiency in Australian-born children of Arabic background in central Sydney

OBJECTIVES

To determine the prevalence of iron depletion and deficiency, and iron-deficiency anaemia, along with risk factors for iron depletion, in Australian-born children aged 12-36 months of Arabic-speaking background.

DESIGN

Community-based survey.

SETTING

Central Sydney Area Health Service (CSAHS), NSW, April to August, 1997.

PARTICIPANTS

All children born at five Sydney hospitals between 1 May 1994 and 30 April 1996, whose mothers gave an Arabic-speaking country of birth and resided in the area served by the CSAHS.

MAIN OUTCOME MEASURES

Full blood count (haemoglobin, mean corpuscular haemoglobin, mean corpuscular volume), plasma ferritin concentration, haemoglobin electrophoresis, potential risk factors for iron depletion.

RESULTS

Families of 641 of the 1,161 eligible children were able to be contacted, and 403 agreed to testing (response rate, 62.9% among those contacted). Overall, 6% of children had iron-deficiency anaemia, another 9% were iron deficient without anaemia, and 23% were iron depleted. Multiple logistic regression analysis showed three significant independent risk factors for iron depletion: <37 weeks' gestation (odds ratio [OR], 5.88, P=0.001); mother resident in Australia for less than the median time of 8.5 years (OR, 1.96, P=0.016); and daily intake of >600 mL cows' milk (OR, 3.89, P=<0.001).

CONCLUSION

Impaired iron status is common among children of Arabic background, and targeted screening is recommended for this group.

Immunization coverage of Australian-born children of Arabic-speaking background in Central Sydney

OBJECTIVES

To examine the immunization coverage rates of 12-36-month-old Australian-born children from an Arabic-speaking background in Central Sydney as determined by parental report and documentary evidence.

METHODOLOGY

Eligible children were identified by examination of the records of five hospitals. Eligibility criteria were that the mother gave an Arabic speaking country of birth and a Central Sydney post code (as her place of residence) and the child was born between 1 May 1994 and 30 April 1996. Parents of all eligible children were invited to participate, either by a special appointment to answer a structured questionnaire, or by telephone survey. Of the 1157 eligible children identified from hospital birth records, only 641 could be contacted, of whom 584 (91.1%) agreed to participate. Full information on age appropriate immunization rates, as reported by parents and documented in records, could be assessed for 403 children.

RESULTS

Parents reported that 97.6% of children were fully immunized. When the child's immunization status could be verified from either the child's personal health record and/or the service provider, the rate of full, age-appropriate immunization was 94.3% (95% confidence intervals 92.0-96.6) compared to a parent-reported rate of 98.0%. General practitioners provided 76.2% of immunizations.

CONCLUSION

While a substantial proportion of children identified from birth records could not be contacted, comparisons with census data and other analyses indicate that this sample is likely to be representative of the general population of 12-36-month-old Australian-born children from an Arabic-speaking background. This group appeared to be highly immunized. Further studies examining why the rates for this ethnic group are high in Central Sydney may determine strategies which will enhance immunization rates in other communities.

Serological survey of measles and rubella immunity in Sydney preschool children

OBJECTIVES

To estimate the prevalence of serological evidence of immunity to measles and rubella in preschool children in central and southern Sydney (NSW, Australia) and the prevalence of immunity in children with either documented or parentally reported immunization.

METHODS

Geographical cluster random sampling was used to select children aged between 18 and 60 months to participate in the present study. Standardized interviews obtained information on each child's reported (by parents) immunization status and documentary evidence of immunization was recorded from the Personal Health Record. Venous blood was collected, serum was separated and stored frozen until tested. Measles and rubella antibodies were measured using ELISA, with either immunofluorescence or haemagglutination inhibition being used to clarify equivocal results. The study was conducted from 1992 to 1994 in conjunction with surveys of blood lead concentrations, iron status and micronutrient status.

RESULTS

Parents of 726 of 953 children identified between 9 and 60 months of age agreed to participate in the lead, immunization, iron status and micronutrient studies. Sufficient blood for antibody testing was obtained from 580 children, aged 18 to 62 months at the time of collection. Parents reported that 94.7% (95% confidence interval (CI) 92.7-96.5%) of children had received a measles-mumps or measles-mumps-rubella (MMR) immunization. General practitioners administered 72.8% of these immunizations. The prevalence of serological evidence of immunity to measles and rubella was 88.8% (95% CI 86.2-91.4%) and 91.9% (95% CI 89.6-94.2%). respectively. There was documented evidence of measles and rubella immunization for 88.4% (95% CI 85.7-91.2%) and 86.4% (95% CI 83.4-89.3%) of children, respectively. Of children with documented measles immunization, 91.6% (95% CI 89.2-94.0%) had detectable measles antibody. Of children with documented rubella immunization 97.2% (95% CI 95.8-98.6%) had detectable rubella antibody.

CONCLUSIONS

Measles and rubella immunization rates in central and southern Sydney are relatively high and most of these immunizations are provided by the private sector. Immunity to rubella in children with documented rubella immunization is at the level that would be expected from seroconversion studies. Immunity to measles in children with documented measles immunization is slightly lower than expected from seroconversion studies, highlighting the need for the second MMR immunization in preschool children, as well as making near universal immunization imperative if this disease is to be eradicated.

The pattern of diabetes care in New South Wales: a five-year analysis using Medicare occasions of service data

OBJECTIVE

To use Medicare occasions of service data to establish the pattern and standard of care received by people with diabetes.

METHOD

Information about visits to medical practitioners as well as utilisation of diabetes related procedures for people living in New South Wales (NSW) for the individual years between 1993 to 1997 was retrieved using a Health Insurance Commission data file. Individuals were deemed to have diabetes if an HbA1c which can only be ordered for a person with known diabetes, had been performed over the five-year period.

RESULTS

On average over the study period, persons with diabetes accounted for 3.1% of the population but they used 5.5% of general practitioner services. A large proportion of patients also received care at the specialist and consultant physician level, 51.2% and 38.6% respectively, a three to four fold increase when compared with their non-diabetic counterparts. There was also a 1.3 to 1.8 fold increase in the mean number of attendances to the various medical practitioners. Surveillance of diabetes parameters was inadequate but small improvements were seen over the 5 year study period (proportion of persons with diabetes with a HbA1c performed: 48.8% to 56.8%; Lipids: 49.4% to 52.0%; HDL cholesterol: 18.3% to 18.8%; microalbuminuria: 4.7% to 11.6%).

CONCLUSION

This study has highlighted the heavy burden imposed by diabetes on our health care system.

IMPLICATIONS

The use of Medicare occasions of service data represents a cost efficient way of monitoring health service utilisation.

Can GP input into discharge planning result in better outcomes for the frail aged: results from a randomized controlled trial

OBJECTIVE

We aimed to assess whether GP input into discharge planning for high-risk aged in-patients admitted under the care of a geriatrician results in improved patient outcomes.

METHODS

We conducted a prospective randomized controlled trial in Sydney, Australia. The subjects were 364 patients aged 60 years and over. The main outcome measures included community service referral, accommodation changes, length of stay, readmission rate, length of time to first readmission and patient satisfaction with discharge arrangements.

RESULTS

No significant differences were found with regard to length of stay, readmission rates or time to first readmission. Test-group subjects were significantly more likely to be recommended for community services at discharge and to report that hospital personnel had discussed their discharge plan with them. Significantly more of the test group reported that their return home was well prepared.

CONCLUSIONS

Although GP pre-discharge visits did not alter the likelihood of 'hard outcomes such as risk of readmission', the results suggest that quality of care is enhanced amongst patients receiving a pre-discharge visit and that GPs can perform a key role in planning post-discharge care with other services.

[Temporary disability: analysis strategies]

OBJECTIVES

To apply different regression models to estimate rate ratios for temporary sick-leave (TSL) which may occur several times in the same individual during a period, and the frequency is not constant for the observation period.

SUBJECTS AND METHODS

All workers employed more than 30 days between January 1st of 1992 and June 1st of 1995 were included into the population study. The following period was 1,259 days and the total number of workers included in the study was 2,306. During that period 2,649 TSL episodes were notified, which meant 85,947 lost days. Poisson regression, Generalised Estimating Equations (GEE) and Andersen-Gill modification of Cox regression modify by Wei (WLW) were applied.

RESULTS

The highest TSL incidence rates were seen in women, lesser than 30 years old, cleaners, maintenance workers and auxiliary nurses, and those involved in shiftwork. This profile was not modified after applying GEE and WLW regression models, although confidence intervals were widened.

CONCLUSIONS

TSL data does not fit Poisson regression assumptions, but GEE and WLW regression models do not appear as alternatives. Other conditional regression models would need to be explored to suitably analyse this data.

Diabetes management: shared care or shared neglect

Shared care is increasingly being advocated as a way of managing patients with diabetes. While this approach has been supported by clinical trials, the success of shared care in 'real life' is not well established. If health care professionals leave undone what they think is done by others, shared care can become neglected care. Follow up of 200 'shared care' patients who had been referred to the Royal Prince Alfred Diabetes Centre, Sydney, Australia on two or more occasions between October 1995 and September 1998 showed that the majority of specialist recommendations regarding metabolic control (76%), referral to an ophthalmologist (73%) and blood pressure treatment (76%) had been implemented by the primary care physician; however, they were less likely to implement recommendations regarding lipid treatment (55%). The median HbA1c (7.6% vs. 8.4%; P = 0.04), cholesterol (5.6 vs. 6.8 mmol/l; P = 0.0005) and triglyceride (2.0 vs. 2.8 mmol/l; P = 0.05) levels for patients in whom recommendations had been implemented were significantly lower at the time of second referral. Doctors registered with the Diabetes Shared Care Programme and those who wrote longer letters were more likely to implement recommendations than their counterparts (87.2%, versus 70.9%; chi2 = 4.12, 1 df; P = 0.04 and 56 words (inter-quartile range (IQR): 36-71) versus 45 words (IQR: 23-59); P = 0.02, respectively). It therefore appears that diabetes care can be well provided by a shared care approach. However, further monitoring of different shared care models is warranted.

Information technology and general practice. A survey of general practitioner attitudes towards computerisation

AIM

General practitioners in the central Sydney area were surveyed to quantify the extent of, and attitudes towards, computerisation in Australian general practice.

METHOD

Two surveys were mailed to all GPs in the central Sydney area, first in 1994, and again in 1996. The majority of questions in both surveys were identical. The results were collated and descriptive and comparative statistics calculated.

RESULTS

There was an increase in the use of computers for clinical tasks and, GPs' attitudes towards computerised prescribing systems became more positive. There was a persistent negative attitude towards the actual costs of computerisation.

CONCLUSION

Methods are now required to transform the increased use of computers by GPs into improved outcomes for them and their patients.

The quality of communication between hospitals and general practitioners: an assessment

The objective of this study was to assess the quality of communications between hospitals and general practitioners (GPs). The proportion of medical records in which the patient's general practitioner (GP) was identified, the accuracy of medications recorded in the discharge summary, the proportion of GPs who received discharge summaries, and the timeliness of receipt of discharge summaries were all evaluated. Discussions were held with all stakeholders, the literature was reviewed and GPs were surveyed to identify potential measures of quality. These were then trialled to assess their utility and practicability. Timeliness, issues that required follow-up and treatment provided in hospital were of greatest importance to general practitioners. The GP's name was recorded in 88% of audited records. Few inaccuracies were detected in the medications recorded in the discharge summaries, and GPs received 77% of discharge summaries. Methods similar to those used in this study might be broadly applied to improve the quality of discharge communication throughout Australia.

Who should assess medical students' communication skills: their academic teachers or their patients?

The objective of this study was to compare the assessment of medical students communication skills made by their academic teachers, with the assessment made by their role-playing 'patients'. It was a cross-sectional study, conducted at the Department of General Practice, University of Sydney, Australia, and consisted of 519 undergraduate medical students. Teachers rated students' communication skills using ten specific criteria, each marked on a five-point Likert scale. Teachers then rated students' overall performance using a 10-point scale. Patients rated students' overall performance on the same 10-point Likert scale. Only two of the 10 criteria, as rated by the academic teachers, correlated with the role-playing patients' overall score, and all 10 criteria accounted for only 10.1% of the variance in that score. The academic assessors' overall score accounted for only 9.7% of the variance of the patients' overall score. The communications skills emphasized by academic teachers do not reflect the skills considered to be important by role-playing patients.

Opportunistic sampling from early childhood centres: a substitute for random sampling to determine lead and iron status of pre-school children?

This report compares the results from two sampling strategies used to determine the prevalence of elevated blood lead concentrations and iron status in 12-36 month old children in Central Sydney. The two methods were stratified random sampling using census collector districts and an opportunistic sampling strategy using client registers at Early Childhood Centres (ECCs). The response rates were 75.3% (n = 718 of whom 198 were aged 12-36 months) and 24.1% (n = 304) respectively. The geometric mean blood lead concentrations were 0.40 and 0.34 mumol/L respectively (p = 0.001). The traditional random sampling prevalence survey identified a significantly higher proportion of children with blood lead concentrations greater than 0.48 (OR = 0.61, 95% CI 0.40-0.93) and 0.72 mumol/L (OR = 0.44, 95% CI 0.21-0.92) compared to the simpler opportunistic survey. The median plasma ferritin concentration for both studies was 19 micrograms/L (p = 0.4). The prevalence of iron depletion, iron deficiency and iron deficiency anaemia was not significantly different between the two studies. In conclusion, opportunistic sampling through ECCs does not appear to be a substitute for the traditional random sampling prevalence surveys of determine the prevalence of elevated blood lead concentrations in pre-school children in Central Sydney. However, opportunistic sampling through ECCs may be an appropriate method for monitoring iron status, in particular iron depletion, in pre-school children in Central Sydney.

Age-specific reference intervals for plasma vitamins A, E and beta-carotene and for serum zinc, retinol-binding protein and prealbumin for Sydney children aged 9-62 months

Paediatric reference intervals for blood concentrations of certain nutrients are often based on either adult data or are derived from small samples of young children. Biochemical data were obtained from 467 randomly selected, healthy preschool children aged 9-62 months in Sydney, Australia. Data were obtained for plasma vitamins A, E and beta-carotene and for serum zinc, retinol-binding protein and prealbumin. Reference intervals based on the 2.5 and 97.5 centiles for age groups 9-23, 24-35, 36-47, 48-62 months and for the total group (9-62 months) were calculated. The 2.5-97.5 centiles for the whole group were: vitamin A, 0.7-1.8 mumol/l (20.05-51.56 micrograms/dl); vitamin E, 8-30 mumol/l (0.34-1.29 mg/dl); beta-carotene, 0.1-1.1 mumol/l (5.4-59.0 micrograms/dl); zinc, 9-19 mumol/l (58.8-124.2 micrograms/dl); retinol-binding protein, 14-36 mg/l; prealbumin, 104-264 mg/l. The reference intervals reported are consistent with the findings of a number of smaller studies and are likely to be an accurate reflection of the true intervals for healthy preschool children in western developed countries.