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1.  Ministernotomy or minithoracotomy for minimally invasive aortic valve replacement: a Bayesian network meta-analysis 
Establishing the relative merits of ministernotomy (MS) and minithoracotomy (MT) approaches to minimally invasive aortic valve replacement (MIAVR) is difficult given the limited available direct evidence. Network meta-analysis is a Bayesian approach that can combine direct and indirect evidence to better define the benefits and risks of MS and MT.
Electronic searches were performed using six databases from their inception to June 2014. Relevant studies utilizing a minimally invasive approach for aortic valve replacement were identified. Data were extracted and analyzed according to predefined clinical endpoints. Both traditional and Bayesian meta-analysis approaches were conducted.
Compared to full sternotomy, MT was associated with longer cardiopulmonary bypass (CPB) duration (WMD, 9.99; 95% CI, 3.91, 16.07; I2=55%; P=0.001) and cross-clamp duration (WMD, 7.64; 95% CI, 2.86, 12.42; P=0.002; I2=74%). When compared to MS using network meta-analysis, no significant difference in duration was detected. Postoperative outcomes including 30-day mortality, stroke, and reoperation for bleeding and wound infection were comparable between MS and MT using both traditional and Bayesian meta-analysis techniques.
The current evidence demonstrates that MIAVR via MS or MT is a safe and efficacious alternative to conventional median sternotomy. MT may be associated with longer CPB and cross-clamp durations, but has similar post-operative outcomes compared to MS. An individualized approach tailored to both the patient and surgical team is likely to provide optimal outcomes.
PMCID: PMC4311162
Aortic valve replacement; ministernotomy; minithoracotomy; Bayesian; network meta-analysis
2.  Meta-analysis of intentional sublobar resections versus lobectomy for early stage non-small cell lung cancer 
Annals of Cardiothoracic Surgery  2014;3(2):134-141.
Surgical resection is the preferred treatment modality for eligible candidates with non-small cell lung cancer (NSCLC). However, the selection of sublobar resection versus lobectomy for early-stage NSCLC remains controversial. Previous meta-analyses comparing these two procedures presented data without considering the significant differences in the patient selection processes in individual studies. The present study aimed to compare the overall survival (OS) and disease-free survival (DFS) outcomes of patients who underwent sublobar resections who were also eligible for lobectomy procedures with those who underwent lobectomy.
An electronic search was conducted using five online databases from their dates of inception to December 2013. Studies were selected according to predefined inclusion criteria and meta-analyzed using hazard ratio (HR) calculations.
Twelve studies met the selection criteria, including 1,078 patients who underwent sublobar resections and 1,667 patients who underwent lobectomies. From the available data, there was no significant differences in OS [HR 0.91; 95% confidence interval (CI) 0.64-1.29] or DFS (HR 0.82; 95% CI 0.60-1.12) between the two treatment arms. In addition, no significant OS difference was detected for patients who underwent segmentectomies compared to lobectomies (HR 1.04; 95% CI 0.66-1.63, P=0.86).
Using the available data in the current literature, patients who underwent sublobar resection for small, peripheral NSCLC after intentional selection rather than ineligibility for greater resections achieved similar long-term survival outcomes as those who underwent lobectomies. However, patients included for the present meta-analysis were a highly selected cohort and these results should be interpreted with caution. The importance of the patient selection process in individual studies must be acknowledged to avoid conflicting outcomes in future meta-analyses.
PMCID: PMC3988293  PMID: 24790836
Sublobar resection; segmentectomy; non-small cell lung cancer (NSCLC); meta-analysis
3.  A systematic review and meta-analysis on the safety and efficacy of the frozen elephant trunk technique in aortic arch surgery 
Annals of Cardiothoracic Surgery  2013;2(5):581-591.
The treatment of complex pathologies of the aortic arch and proximal descending aorta represents a significant challenge for cardiac surgeons. Various surgical techniques and prostheses have been implemented over the past several decades, all with varying degrees of success. The introduction of the frozen elephant trunk (FET) technique facilitates one-stage repair of such pathologies. The present systematic review and meta-analysis aims to assess the safety and efficacy of the FET approach in the current literature.
Electronic searches were performed using six databases from their inception to July 2013. Relevant studies utilizing the FET technique were identified. Data were extracted and analyzed according to predefined clinical endpoints.
Seventeen studies were identified for inclusion for qualitative and quantitative analyses, all of which were observational reports. Pooled mortality was 8.3%, while stroke and spinal cord injuries were 4.9% and 5.1% respectively. Cardiopulmonary bypass time, myocardial ischemia time, and circulatory arrest time strongly correlated with perioperative mortality in a linear relationship, while moderate correlations between cerebral perfusion time and mortality, and circulatory arrest time and spinal cord injury, were also identified. Five-year survival, reported in five studies, ranged between 63-88%.
Overall, results of the present systematic review and meta-analysis suggest that the FET procedure can be performed with acceptable mortality and morbidity risks.
PMCID: PMC3791206  PMID: 24109565
Frozen elephant trunk; hybrid procedure; aortic dissection; thoracic aneurysm; systematic review
4.  Gender differences in health-related quality of life of Australian chronically-ill adults: patient and physician characteristics do matter 
The aims of this study were to explore the health-related quality of life (HRQoL) in a large sample of Australian chronically-ill patients (type 2 diabetes and/or hypertension/ischaemic heart disease), to investigate the impact of characteristics of patients and their general practitioners on their HRQoL and to examine clinically significant differences in HRQoL among males and females.
This was a cross-sectional study with 193 general practitioners and 2181 of their chronically-ill patients aged 18 years or more using the standard Short Form Health Survey (SF-12) version 2. SF-12 physical component score (PCS-12) and mental component score (MCS-12) were derived using the standard US algorithm. Multilevel regression analysis (patients at level 1 and general practitioners at level 2) was applied to relate PCS-12 and MCS-12 to patient and general practitioner (GP) characteristics.
Employment was likely to have a clinically significant larger positive effect on HRQoL of males (regression coefficient (B) (PCS-12) = 7.29, P < 0.001, effect size = 1.23 and B (MCS-12) = 3.40, P < 0.01, effect size = 0.55) than that of females (B(PCS-12) = 4.05, P < 0.001, effect size = 0.78 and B (MCS-12) = 1.16, P > 0.05, effect size = 0.16). There was a clinically significant difference in HRQoL among age groups. Younger men (< 39 years) were likely to have better physical health than older men (> 59 years, B = −5.82, P < 0.05, effect size = 0.66); older women tended to have better mental health (B = 5.62, P < 0.001, effect size = 0.77) than younger women. Chronically-ill women smokers reported clinically significant (B = −3.99, P < 0.001, effect size = 0.66) poorer mental health than women who were non-smokers. Female GPs were more likely to examine female patients than male patients (33% vs. 15%, P < 0.001) and female patients attending female GPs reported better physical health (B = 1.59, P < 0.05, effect size = 0.30).
Some of the associations between patient characteristics and SF-12 physical and/or mental component scores were different for men and women. This finding underlines the importance of considering these factors in the management of chronically-ill patients in general practice. The results suggest that chronically ill women attempting to quit smoking may need more psychological support. More quantitative studies are needed to determine the association between GP gender and patient gender in relation to HRQoL.
PMCID: PMC3691728  PMID: 23800331
Quality of life; Patient and physician characteristics; SF-12 version 2; Physical component score; Mental component score; Multilevel regression analysis
5.  Risk factors for unintentional poisoning in children aged 1–3 years in NSW Australia: a case–control study 
BMC Pediatrics  2013;13:88.
Unintentional poisoning in young children is an important public health issue. Age pattern studies have demonstrated that children aged 1–3 years have the highest levels of poisoning risk among children aged 0–4 years, yet little research has been conducted regarding risk factors specific to this three-year age group and the methodologies employed varied greatly. The purpose of the current study is to investigate a broad range of potential risk factors for unintentional poisoning in children aged 1–3 years using appropriate methodologies.
Four groups of children, one case group (children who had experienced a poisoning event) and three control groups (children who had been ‘injured’, ‘sick’ or who were ‘healthy’), and their mothers (mother-child dyads) were enrolled into a case–control study. All mother-child dyads participated in a 1.5-hour child developmental screening and observation, with mothers responding to a series of questionnaires at home. Data were analysed as three case–control pairs with multivariate analyses used to control for age and sex differences between child cases and controls.
Five risk factors were included in the final multivariate models for one or more case–control pairs. All three models found that children whose mothers used more positive control in their interactions during a structured task had higher odds of poisoning. Two models showed that maternal psychiatric distress increased poisoning risk (poisoning-injury and poisoning-healthy). Individual models identified the following variables as risk factors: less proximal maternal supervision during risk taking activities (poisoning-injury), medicinal substances stored in more accessible locations in bathrooms (poisoning-sick) and lower total parenting stress (poisoning-healthy).
The findings of this study indicate that the nature of the caregiver-child relationship and caregiver attributes play an important role in influencing poisoning risk. Further research is warranted to explore the link between caregiver-child relationships and unintentional poisoning risk. Caregiver education should focus on the benefits of close interaction with their child as a prevention measure.
PMCID: PMC3682908  PMID: 23705679
Child; Poisoning; Risk factors; Odds ratios
6.  Nurses’ workarounds in acute healthcare settings: a scoping review 
Workarounds circumvent or temporarily ‘fix’ perceived workflow hindrances to meet a goal or to achieve it more readily. Behaviours fitting the definition of workarounds often include violations, deviations, problem solving, improvisations, procedural failures and shortcuts. Clinicians implement workarounds in response to the complexity of delivering patient care. One imperative to understand workarounds lies in their influence on patient safety. This paper assesses the peer reviewed empirical evidence available on the use, proliferation, conceptualisation, rationalisation and perceived impact of nurses’ use of workarounds in acute care settings.
A literature assessment was undertaken in 2011–2012. Snowballing technique, reference tracking, and a systematic search of twelve academic databases were conducted to identify peer reviewed published studies in acute care settings examining nurses’ workarounds. Selection criteria were applied across three phases. 58 studies were included in the final analysis and synthesis. Using an analytic frame, these studies were interrogated for: workarounds implemented in acute care settings by nurses; factors contributing to the development and proliferation of workarounds; the perceived impact of workarounds; and empirical evidence of nurses’ conceptualisation and rationalisation of workarounds.
The majority of studies examining nurses’ workarounds have been published since 2008, predominantly in the United States. Studies conducted across a variety of acute care settings use diverse data collection methods. Nurses’ workarounds, primarily perceived negatively, are both individually and collectively enacted. Organisational, work process, patient-related, individual, social and professional factors contribute to the proliferation of workarounds. Group norms, local and organisational culture, ‘being competent’, and collegiality influence the implementation of workarounds.
Workarounds enable, yet potentially compromise, the execution of patient care. In some contexts such improvisations may be deemed necessary to the successful implementation of quality care, in others they are counterproductive. Workarounds have individual and cooperative characteristics. Few studies examine nurses’ individual and collective conceptualisation and rationalisation of workarounds or measure their impact. The importance of displaying competency (image management), collegiality and organisational and cultural norms play a role in nurses’ use of workarounds.
PMCID: PMC3663687  PMID: 23663305
Workaround; Violation; Deviation; Short cut; First order problem solving; Patient safety; Procedural failure
7.  Systematic review and meta-analysis of transcatheter aortic valve implantation versus surgical aortic valve replacement for severe aortic stenosis 
Transcatheter aortic valve implantation (TAVI) has emerged as an acceptable treatment modality for patients with severe aortic stenosis who are deemed inoperable by conventional surgical aortic valve replacement (AVR). However, the role of TAVI in patients who are potential surgical candidates remains controversial.
A systematic review was conducted using five electronic databases, identifying all relevant studies with comparative data on TAVI versus AVR. The primary endpoint was all-cause mortality. A number of periprocedural outcomes were also assessed according to the Valve Academic Research Consortium endpoint definitions.
Fourteen studies were quantitatively assessed and included for meta-analysis, including two randomized controlled trials and eleven observational studies. Results indicated no significant differences between TAVI and AVR in terms of all-cause and cardiovascular related mortality, stroke, myocardial infarction or acute renal failure. A subgroup analysis of randomized controlled trials identified a higher combined incidence of stroke or transient ischemic attacks in the TAVI group compared to the AVR group. TAVI was also found to be associated with a significantly higher incidence of vascular complications, permanent pacemaker requirement and moderate or severe aortic regurgitation. However, patients who underwent AVR were more likely to experience major bleeding. Both treatment modalities appeared to effectively reduce the transvalvular mean pressure gradient.
The available data on TAVI versus AVR for patients at a higher surgical risk showed that major adverse outcomes such as mortality and stroke appeared to be similar between the two treatment modalities. Evidence on the outcomes of TAVI compared with AVR in the current literature is limited by inconsistent patient selection criteria, heterogeneous definitions of clinical endpoints and relatively short follow-up periods. The indications for TAVI should therefore be limited to inoperable surgical candidates until long-term data become available.
PMCID: PMC3741825  PMID: 23977554
Transcatheter aortic valve implantation (TAVI); transcatheter aortic valve replacement (TAVR); aortic valve replacement; aortic stenosis; meta-analysis; systematic review
8.  Under-reporting of birth registrations in New South Wales, Australia 
To determine the rates of birth registration over a five-year period in New South Wales (NSW) and explore the factors associated with the rate of registration.
This is a cross-sectional study using linked population databases. The study population included all births of NSW residents in NSW between 2001 and 2005.
Birth registration rates in NSW were 82.66% in the year of birth, 93.19% in the first year, 94.02% in the second, 94.56% in the third and 95.08% in the fourth year after birth. The non-registration of births was mainly associated with such factors as neonatal and postneonatal death (adjusted OR = 3.84, 95% CI: 3.23-4.57); being Indigenous (adjusted OR = 3.26, 95% CI: 3.10-3.43); maternal age <25 or >39 years (adjusted OR = 2.81, 95% CI: 2.72-2.90); low birthweight (<2,500 grams) (adjusted OR = 1.79, 95% CI: 1.69-1.90); living in remote areas (adjusted OR = 1.57, 95% CI: 1.52-1.63); being born after the first quarter of year (adjusted OR = 1.08-1.56, 95% CI between 1.03-1.12 and 1.49-1.64); mother having more pregnancies (adjusted OR = 1.85-7.29, 95% CI between1.78-1.93 and 6.87-7.73). Mothers who were born overseas were more likely to register their births than those born in Australia (adjusted OR = 0.72, 95% CI: 0.69-0.75). Multiple births were more likely to be registered than singleton births (adjusted OR = 0.84, 95% CI: 0.76-0.92). About one-third of the non-registrations of births in NSW were explained by the risk factors. The reasons for the remaining non-registrations need to be investigated.
Of birth in NSW, 4.92% were not registered by the fourth year after birth.
PMCID: PMC3562517  PMID: 23234578
Birth; Registration; Factor; Australia
9.  Quality of Life and Functional Health Status of Long-Term Meditators 
Background. There is very little data describing the long-term health impacts of meditation. Aim. To compare the quality of life and functional health of long-term meditators to that of the normative population in Australia. Method. Using the SF-36 questionnaire and a Meditation Lifestyle Survey, we sampled 343 long-term Australian Sahaja Yoga meditation practitioners and compared their scores to those of the normative Australian population. Results. Six SF-36 subscales (bodily pain, general health, mental health, role limitation—emotional, social functioning, and vitality) were significantly better in meditators compared to the national norms whereas two of the subscales (role limitation—physical, physical functioning) were not significantly different. A substantial correlation between frequency of mental silence experience and the vitality, general health, and especially mental health subscales (P < 0.005) was found. Conclusion. Long-term practitioners of Sahaja yoga meditation experience better functional health, especially mental health, compared to the general population. A relationship between functional health, especially mental health, and the frequency of meditative experience (mental silence) exists that may be causal. Evidence for the potential role of this definition of meditation in enhancing quality of life, functional health and wellbeing is growing. Implications for primary mental health prevention are discussed.
PMCID: PMC3352577  PMID: 22611427
10.  Improvement of maternal Aboriginality in NSW birth data 
The Indigenous population of Australia was estimated as 2.5% and under-reported. The aim of this study is to improve statistical ascertainment of Aboriginal women giving birth in New South Wales.
This study was based on linked birth data from the Midwives Data Collection (MDC) and the Registry of Births Deaths and Marriages (RBDM) of New South Wales (NSW). Data linkage was performed by the Centre for Health Record Linkage (CHeReL) for births in NSW for the period January 2001 to December 2005. The accuracy of maternal Aboriginal status in the MDC and RBDM was assessed by consistency, sensitivity and specificity. A new statistical variable, ASV, or Aboriginal Statistical Variable, was constructed based on Indigenous identification in both datasets. The ASV was assessed by comparing numbers and percentages of births to Aboriginal mothers with the estimates by capture-recapture analysis.
Maternal Aboriginal status was under-ascertained in both the MDC and RBDM. The ASV significantly increased ascertainment of Aboriginal women giving birth and decreased the number of missing cases. The proportion of births to Aboriginal mothers in the non-registered birth group was significantly higher than in the registered group.
Linking birth data collections is a feasible method to improve the statistical ascertainment of Aboriginal women giving birth in NSW. This has ramifications for the ascertainment of babies of Aboriginal mothers and the targeting of appropriate services in pregnancy and early childhood.
PMCID: PMC3314542  PMID: 22289717
Birth; Aboriginality; data; Australia
11.  Priorities for women with lymphoedema after treatment for breast cancer: population based cohort study  
Objective To explore the perceived unmet needs among women treated for breast cancer and in whom symptoms and signs indicate the presence of lymphoedema.
Design Population based cross sectional survey with a purpose designed questionnaire (60 items).
Setting Cancer registries of New South Wales, Victoria, and South Australia.
Participants 237 women with symptoms and signs indicative of lymphoedema from an initial 1930 eligible women.
Main outcome measure Unmet needs in the previous month across psychological, health system and information, physical and daily living, patient care and support, sexuality needs, body image, and financial domains.
Results The 10 items most commonly identified as a “moderate to high current need” included having their doctor and allied health workers being fully informed about lymphoedema, acknowledge the seriousness of the condition, and be willing to treat it. Women also wanted access to up to date treatments, both mainstream and alternative, and financial assistance for their garments. The three factors that explained most of the variance were: information and support (11 items), which accounted for 49% of the variance; body image and self esteem (seven items; 7% variance); and health system (seven items; 5% variance). Examination of these three factors showed that while the levels of need were generally low, they were common.
Conclusion To address the needs of women with lymphoedema and perhaps to prevent progression of lymphoedema, it is important that practitioners do not dismiss mild symptoms and that women are referred to an appropriate specialist.
PMCID: PMC3119382  PMID: 21693532
12.  A Review of the Urban Development and Transport Impacts on Public Health with Particular Reference to Australia: Trans-Disciplinary Research Teams and Some Research Gaps 
Urbanization and transport have a direct effect on public health. A transdisciplinary approach is proposed and illustrated to tackle the general problem of these environmental stressors and public health. Processes driving urban development and environmental stressors are identified. Urbanization, transport and public health literature is reviewed and environmental stressors are classified into their impacts and which group is affected, the geographical scale and potential inventions. Climate change and health impacts are identified as a research theme. From an Australian perspective, further areas for research are identified.
PMCID: PMC2697929  PMID: 19543407
Multi-disciplinary teams; urbanization and transport; environmental stressors; public health; research and policy interventions
13.  The Effects of Solvent Exposure on Memory and Motor Dexterity in Working Children 
Public Health Reports  2005;120(6):657-664.
Children working in vehicle spray-painting, mechanical, and other trade workshops are at significant risk of exposure to organic solvents and, as a result, may be at significant risk of developing clinical and subclinical signs of neurotoxicity. This study reports on the association between exposure to solvents and neurobehavioral performance on a number of non-computerized tests for working children exposed to solvents in comparison with nonexposed working children and nonexposed children at school.
A convenience cross-sectional sample of 300 male children aged 10–17 years was recruited for study. The exposed working group and the two nonexposed groups (working and nonworking school) were matched, as far as possible, on geographic location of residence and age. Neurotoxic effects were assessed through a questionnaire and the child's performance on a selection of neurobehavioral tests.
Exposed working children scored worse on the overall neurotoxicity symptoms score (mean=6.8; standard deviation [SD]=3.6) compared with the nonexposed working children (mean=1.3; SD=2.0) and school children (mean=1.2; SD=1.8). Analysis of the non-computerized neurobehavioral tests demonstrated that exposed working children performed significantly worse than the two nonexposed groups on the motor dexterity and memory tests. Results of the mood test showed that exposed working children were more angry and confused than the nonexposed groups.
There is an association between exposure to solvents and lower neurobehavioral performance, with significant neurobehavioral deficits among children exposed to solvents in comparison with working children not exposed to solvents and nonworking school children. Memory and motor dexterity appear to be particularly affected in solvent-exposed working children.
PMCID: PMC1497779  PMID: 16350336
16.  Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): randomised parallel trial 
Objectives To determine whether a lifestyle integrated approach to balance and strength training is effective in reducing the rate of falls in older, high risk people living at home.
Design Three arm, randomised parallel trial; assessments at baseline and after six and 12 months. Randomisation done by computer generated random blocks, stratified by sex and fall history and concealed by an independent secure website.
Setting Residents in metropolitan Sydney, Australia.
Participants Participants aged 70 years or older who had two or more falls or one injurious fall in past 12 months, recruited from Veteran’s Affairs databases and general practice databases. Exclusion criteria were moderate to severe cognitive problems, inability to ambulate independently, neurological conditions that severely influenced gait and mobility, resident in a nursing home or hostel, or any unstable or terminal illness that would affect ability to do exercises.
Interventions Three home based interventions: Lifestyle integrated Functional Exercise (LiFE) approach (n=107; taught principles of balance and strength training and integrated selected activities into everyday routines), structured programme (n=105; exercises for balance and lower limb strength, done three times a week), sham control programme (n=105; gentle exercise). LiFE and structured groups received five sessions with two booster visits and two phone calls; controls received three home visits and six phone calls. Assessments made at baseline and after six and 12 months.
Main outcome measures Primary measure: rate of falls over 12 months, collected by self report. Secondary measures: static and dynamic balance; ankle, knee and hip strength; balance self efficacy; daily living activities; participation; habitual physical activity; quality of life; energy expenditure; body mass index; and fat free mass.
Results After 12 months’ follow-up, we recorded 172, 193, and 224 falls in the LiFE, structured exercise, and control groups, respectively. The overall incidence of falls in the LiFE programme was 1.66 per person years, compared with 1.90 in the structured programme and 2.28 in the control group. We saw a significant reduction of 31% in the rate of falls for the LiFE programme compared with controls (incidence rate ratio 0.69 (95% confidence interval 0.48 to 0.99)); the corresponding difference between the structured group and controls was non-significant (0.81 (0.56 to 1.17)). Static balance on an eight level hierarchy scale, ankle strength, function, and participation were significantly better in the LiFE group than in controls. LiFE and structured groups had a significant and moderate improvement in dynamic balance, compared with controls.
Conclusions The LiFE programme provides an alternative to traditional exercise to consider for fall prevention. Functional based exercise should be a focus for interventions to protect older, high risk people from falling and to improve and maintain functional capacity.
Trial registration Australia and New Zealand Clinical Trials Registry 12606000025538.
PMCID: PMC3413733  PMID: 22872695

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