Tertiary Referral Hospital In Sydney Research Articles

Association between intravenous fluids during labor and primary postpartum hemorrhage: A retrospective cohort study.

There is a major research gap relating to the impact of intravenous (IV) fluids administration during labor on maternal and neonatal outcomes. It is biologically plausible that a relationship between volume of IV fluids and primary postpartum hemorrhage (PPH) exists. The primary objective of this study was to evaluate whether the administration of high-volume IV fluids during labor (≥ 2500 mL) increases the risk of primary PPH and other adverse outcomes for women with a term, singleton pregnancy, in comparison to low-volume IV fluids during labor (<2500 mL). A retrospective cohort study was conducted at a tertiary referral hospital in Sydney, Australia between 1st September 2021 and 31st October 2022. Inclusion criteria were: women with a live singleton fetus in a cephalic presentation; planning a vaginal birth; and admitted for labor and birth care between 37 and 42 week gestation. The study factor was IV fluids during labor and the primary outcome was primary PPH ≥500 mL. Secondary outcomes included cesarean section and major perineal injury. Pregnancy, birth, and postnatal data were obtained from the hospital's electronic clinical database, electronic medical records, and paper fluid order documentation. Multivariable logistic regression and multiple imputation were used to explore the relationship between volume of IV fluids in labor and PPH. A total of 1023 participants were included of which 339 had a primary PPH (33.1%). There was no association between high-volume IV fluids and PPH after adjusting for demographic and clinical factors (adjusted odds ratio [ORadj]1.02 95% confidence interval [95%CI] 0.72, 1.44). However, there was a positive association between high-volume IV fluids and cesarean section (ORadj 1.99; 95%CI 1.4, 2.8). The findings of this research are important to further knowledge relating to the administration of IV fluids during labor. The findings emphasize the importance of accurately documenting IV fluids administration and identifies research priorities to enable us to better understand the broader implications of IV fluids administration on pregnancy and perinatal outcomes.

A Double-blinded, Randomized, Placebo-controlled Trial of Antibiotic Prophylaxis in Elective Non-hysterectomy Laparoscopic Surgery for Benign Gynecologic Conditions: A Pilot Study

To determine the feasibility of a double-blinded randomized, placebo-controlled study in determining the efficacy of antibiotic prophylaxis in preventing postoperative infections (POIs) in elective nonhysterectomy laparoscopic procedures for benign gynecologic conditions. Double-blinded, randomized, placebo-controlled trial. University-affiliated tertiary referral hospital in Sydney, Australia. Women older than 18 years undergoing elective nonhysterectomy laparoscopic procedures for benign gynecologic conditions were eligible for the study and approached. Before surgery, participants were randomized to receive either 2-g cephazolin or placebo (10-mL normal saline) administered by the anesthetist. Participants and other research staff were blinded to group allocation. The primary outcome was study feasibility measured by recruitment rates, compliance rates of drug administration, compliance rates of delivery, maintenance of double blinding, and follow-up rates. Secondary outcomes included rate of POIs, length of hospitalization, readmission to hospital, unscheduled presentations to healthcare facilities, and antibiotic-related reactions. Between February 2019 and March 2021, 170 patients were approached with 117 participants (68.8%) recruited and randomized. The study had a high compliance rate of trial drug delivery (95.7%) and a high follow-up rate (99.1%). This pilot study has demonstrated feasibility of a large-scale study with a recruitment rate of 68% of patients approached and excellent trial drug delivery and follow-up rates. As anticipated, it is underpowered for identifying clinically significant findings for POI rates. A large-scale study is appropriate and essential to determine the health-related risks of antibiotic prophylaxis with an emphasis on antimicrobial stewardship. The sample size for a large-scale study is 1678 participants based on infection rates in this pilot study.

Uptake of osteoporosis treatment recommended by an orthogeriatrics service after hip fracture: Retrospective cohort study of prevalence and potential barriers and enablers at a tertiary referral hospital in Sydney.

The primary aim was to determine the 12-month period prevalence of and time to osteoporosis treatment following minimal trauma hip fractures in patients who were recommended treatment by an orthogeriatrics service. The secondary aim was to determine the factors associated with receiving treatment including the impact of osteoporosis clinic follow-up. A retrospective cohort study of patients with minimal trauma hip fractures admitted at a tertiary hospital in Sydney between 1 April 2017 and 31 March 2019 was performed. Baseline characteristics were collected from medical records. Osteoporosis treatment data were collected from patients and general practitioners. Univariate and multivariate logistic regression analyses were used to determine the factors associated with receiving osteoporosis treatment. There were 189 participants who consented to participate with a mean age of 84.6years. Most (76.7%) were females, 18.5% were nursing home residents, 70.9% had normal cognition, 20.6% were taking osteoporosis treatment prior to admission, 61.9% had osteoporosis treatment recommendations documented on the discharge summary, and 10.1% were followed up in the osteoporosis clinic. Ninety-eight patients (51.9%) received treatment within the first 12months after fracture with a median time to treatment of 90days. Factors associated with receiving osteoporosis treatment within 12months on multivariate analysis included normal cognition (p=0.03), taking osteoporosis treatment prior to admission (p<0.001), including treatment recommendations in the discharge summary (p=0.006) and osteoporosis clinic follow-up (p<0.001). Osteoporosis treatment after hip fracture remains suboptimal at this hospital. Patient and health service factors associated with treatment uptake could inform future quality improvement work.

Chronic Pulmonary Aspergillosis: Burden, Clinical Characteristics and Treatment Outcomes at a Large Australian Tertiary Hospital.

Chronic pulmonary aspergillosis (CPA) is a fungal lung infection associated with high morbidity and mortality. Yet, it remains under-recognized worldwide, with few Australian clinical data available. This retrospective study aimed to investigate CPA at a major tertiary referral hospital in Sydney. We identified patients having International Classification of Diseases (ICD-10) codes for “aspergillosis” and/or positive respiratory microbiology samples for Aspergillus species from January 2012–December 2018 at Westmead Hospital. Eligible cases were classified using European Respiratory Society 2016 CPA guidelines. We diagnosed 28 CPA patients: median age 60 years (IQR: 57–66), with 17 (60.7%) being males. Most had chronic cavitary pulmonary aspergillosis phenotype (n = 17, 60.7%). Twenty-three patients had outcomes data returned. Nineteen (82.6%) received antifungal therapy (median duration: 10.5 months (IQR: 6.5–20.7)). Eight (34.7%) patients received <6 months of antifungals, including three (38%) deaths. Two (13%) patients receiving ≥6 months of antifungals died. Chronic obstructive pulmonary disease (COPD) (n = 9, 32.1%) was the leading predisposing factor for CPA in our cohort. This contrasts with the global picture, where prior tuberculosis generally predominates, but is similar to findings from other high-income countries. Nevertheless, further larger-scale studies are required to determine whether these results are generalizable to the wider Australian population.

The administration of intravenous fluids to nulliparous women in labour: A retrospective clinical chart review and fluid balance documentation audit

BackgroundIn Australia, midwives are integral to providing safe and supportive care to women in labour. The administration of intravenous (IV) fluids is a frequent clinical intervention performed by midwives. At present, practices surrounding IV fluid administration to women during labour within Australia are largely undescribed and there is a limited amount of robust evidence available to guide practice. IV fluids do carry a risk of harm. To define and ensure safe IV fluid practices, research into practices surrounding the administration of IV fluids to women in labour is essential. AimsTo describe the current practice for registered midwives administering IV fluids to women during labour. DesignRetrospective clinical chart review and fluid balance documentation audit. MethodsA retrospective clinical chart review and audit of fluid balance documentation for 107 nulliparous women was conducted at a single metropolitan tertiary referral hospital in Sydney, New South Wales between 1 October 2016 and 22 March 2017. A 24-point tool was developed to audit fluid balance charts. ResultsEighty-eight percent of the 88 fluid balance charts available scored 50% or less using the 24-point fluid balance chart audit tool. Additionally, there was an estimated 18% completion rate for the NSW IV fluid order chart. ConclusionThis study found wide variation in clinical practice and incomplete fluid balance documentation at a single, metropolitan tertiary referral hospital. The findings highlight the difficulty of determining IV fluids practices in the context of incomplete fluid balance documentation. Additionally, there are patient safety and professional regulation concerns when fluid management documentation is missing and/or incomplete. Future research should examine barriers and facilitators for documentation.

Effect of Fractional Carbon Dioxide Laser vs Sham Treatment on Symptom Severity in Women With Postmenopausal Vaginal Symptoms

Postmenopausal vaginal symptoms are common and frequently detrimental to a woman's quality of life. Fractional carbon dioxide vaginal laser is increasingly offered as a treatment, but the efficacy remains unproven. To determine the efficacy of fractional carbon dioxide laser for treatment of vaginal symptoms associated with menopause. A double-blind, randomized, sham-controlled trial with 12-month follow-up was undertaken at a single tertiary referral hospital in Sydney, Australia. Enrollment commenced on September 19, 2016, with final follow-up on June 30, 2020. Participants were postmenopausal women with vaginal symptoms substantive enough to seek medical treatment. Of 232 participants approached, 85 were randomized. Three treatments using a fractional microablative carbon dioxide laser system performed 4 to 8 weeks apart, with 43 women randomized to the laser group and 42 to the sham group. The co-primary outcomes were symptom severity assessed using a visual analog scale (VAS; range, 0-100; 0 indicates no symptoms and 100 indicates the most severe symptoms) and the Vulvovaginal Symptom Questionnaire (VSQ; range, 0-20; 0 indicates no symptoms and 20 indicates the most severe symptoms) at 12 months. The minimal clinically important difference was specified as a 50% decrease in both VAS and VSQ severity scores. There were 5 prespecified secondary outcomes, including quality of life (range, 0-100; higher scores indicate better quality of life), the Vaginal Health Index Score (range, 5-25; higher scores indicate better health), and vaginal histology (premenopausal or postmenopausal status). Of 85 randomized participants (mean [SD] age, 57 [8] years), 78 (91.7%) completed the 12-month follow-up. From baseline to 12 months, there was no significant difference between the carbon dioxide laser group and the sham group in change in symptom severity (VAS score for overall vaginal symptoms: -17.2 vs -26.6; difference, 9.4 [95% CI, -28.6 to 47.5]; VAS score for the most severe symptom: -24.5 vs -20.4; difference -4.1 [95% CI, -32.5 to 24.3]; VSQ score: -3.1 vs -1.6; difference, -1.5 [95% CI, -5.9 to 3.0]). There were no significant differences between the laser and sham group in the mean quality of life score (6.3 vs 1.4; difference, 4.8 [95% CI, -3.9 to 13.5]) and Vaginal Health Index Score (0.9 vs 1.3; difference, -0.4 [95% CI, -4.3 to 3.6]) or in histological comparisons between laser and sham treatment groups. There were 16 adverse events in the laser group and 17 in the sham group, including vaginal pain/discomfort (44% vs 68%), spotting, discharge, and lower urinary tract symptoms. No severe adverse events were reported in either group. Among women with postmenopausal vaginal symptoms, treatment with fractional carbon dioxide laser vs sham treatment did not significantly improve vaginal symptoms after 12 months. Australian and New Zealand Clinical Trials Registry: ACTRN12616001403426.

From the sidelines: The indirect repercussions of COVID-19 on the delivery of hospital surgical services.

BackgroundDespite relatively few COVID‐19 cases within New South Wales, the uncertainty surrounding the pandemic has prevented a return to business as usual for the delivery of surgical services. This study aims to describe the evolving impact of COVID‐19 on surgical activity and patient outcomes at a major public tertiary referral hospital.MethodsA retrospective cohort study involving adult surgical patients treated at a large public tertiary referral hospital in Sydney, Australia. Surgical activity, surgical outcomes and patient demographics were compared across two time periods, including the ‘first wave’ (February–May 2020 vs. February–May 2019) and the ‘perseverance phase’ (June–September 2020 vs. June–September 2019). Variables across both groups were compared using an independent t test or chi‐squared test.ResultsA −32% reduction in surgical separations was observed in the ‘first wave’, including −20% emergency and −37% elective. In the ‘perseverance phase’, there was a −19% reduction in surgical activity, including 0% emergency and −27% elective. The average length of stay, intensive care admissions, postoperative complications and in‐hospital costs significantly increased in the ‘first wave’. The proportion of public patients increased marginally (3%) in the ‘first wave’.ConclusionThe impact of COVID‐19 was most severely experienced in the initial months of the pandemic and observed in the number of patients treated. Although there was an initial effect on surgical outcomes, overall, the standard of care remained safe. The delivery of elective surgery remains a challenge and reflects the ongoing system‐wide changes that are required to manage the COVID‐19 pandemic.

Nutritional status and quality of life in interstitial lung disease: a prospective cohort study

BackgroundMalnutrition and altered body composition are well-documented in chronic pulmonary diseases; however, investigation of nutritional status in interstitial lung disease (ILD) is limited. This study aimed to describe the nutritional status of ILD patients within three diagnostic groups and explore the relationship between nutritional status and quality of life (QoL).MethodsConsecutive patients attending an ILD clinic within a tertiary referral hospital in Sydney, Australia were studied. Weight, body-mass-index, anthropometrics, handgrip strength (HGS), subjective global assessment and QoL questionnaires (EQ-5D-5L and King’s-Brief Interstitial-Lung-Disease ‘K-BILD’) were collected. Associations between nutritional status and QoL were analysed.ResultsNinety participants were recruited and categorised: (1) Idiopathic Pulmonary Fibrosis (IPF) (2) Connective-Tissue Disease associated-ILD (CTD-ILD) or (3) Other (non-IPF/non-CTD ILD). Median age was 66.5 (18) years. Four-percent of patients were underweight and 50% were overweight or obese. Median HGS was 71%-(25.3) of predicted and was correlated to all measures of QoL including EQ-5D health-state index (r = 0.376, p < 0.0001), patient-reported EQ-5D-5L Visual Analogue Score (r = 0.367, p < 0.0001) and K-BILD total score (r = 0.346, p = 0.001). Twenty-three percent of the variance in K-BILD total score (F = 12.888, p < 0.0001) was explained by HGS (ß = 0.273, p = 0.006) and forced vital capacity % predicted (ß = 0.331, p = 0.001).ConclusionsAlthough a small number of ILD patients were malnourished, a large proportion of the cohort were overweight or obese. Handgrip strength was compromised and correlated to QoL. Future research with a larger cohort is required to explore the role of HGS as a predictor of QoL.

Detailed cost of robotic-assisted surgery in the Australian public health sector: from implementation to a multi-specialty caseload

BackgroundA barrier to the uptake of robotic-assisted surgery (RAS) continues to be the perceived high costs. A lack of detailed costing information has made it difficult for public hospitals in particular to determine whether use of the technology is justified. This study aims to provide a detailed description of the patient episode costs and the contribution of RAS specific costs for multiple specialties in the public sector.MethodsA retrospective descriptive costing review of all RAS cases undertaken at a large public tertiary referral hospital in Sydney, Australia from August 2016 to December 2018 was completed. This included RAS cases within benign gynaecology, cardiothoracic, colorectal and urology, with the total costs described utilizing various inpatient costing data, and RAS specific implementation, maintenance and consumable costs.ResultsOf 211 RAS patients, substantial variation was found between specialties with the overall median cost per patient being $19,269 (Interquartile range (IQR): $15,445 to $32,199). The RAS specific costs were $8828 (46%) made up of fixed costs including $4691 (24%) implementation and $2290 (12%) maintenance, both of which are volume dependent; and $1848 (10%) RAS consumable costs. This was in the context of 37% robotic theatre utilisation.ConclusionsThere is considerable variation across surgical specialties for the cost of RAS. It is important to highlight the different cost components and drivers associated with a RAS program including its dependence on volume and how it fits within funding systems in the public sector.

Prevalence and Factors Associated with Pelvic Girdle Pain During Pregnancy in Australian Women: A Cross-Sectional Study.

Cross-sectional study conducted between December 2017 and October 2019. To determine the prevalence and risk factors associated with pregnancy-related pelvic girdle pain (PPGP) in Australia. PPGP is a common condition worldwide yet the prevalence and associated risk factors are not known in Australia. A random sample of pregnant women (N = 780) of (mean [SD]) 31 (5) years of age between 14 and 38 weeks gestation attending ante-natal care in a tertiary referral hospital in Sydney, Australia was conducted. The main outcome measure was point-prevalence of PPGP as classified by recommended guidelines including a physical examination. A number of potential risk factors, including socio-demographic characteristics, country of birth, ethnicity, history of low back pain (LBP) and PPGP, family history of PPGP, occupational factors, and physical activity were investigated with logistic regression. The point-prevalence of PPGP in a random sample of 780 Australian women was 44% with the odds of having PPGP increasing with each additional week of gestation (odds ratio [OR]) (OR 1.02). Increasing parity (P = 0.03, OR 1.15), country of birth (P = 0.03), and greater duration of time spent standing (P = 0.009, OR 1.06) were associated with PPGP. The strongest predictors of PPGP were previous LBP and/or PPGP both pregnancy (P < 0.001, OR 4.35) and not pregnancy related (P < 0.001, OR 2.24), and a family history of PPGP (P < 0.001, OR 3.76). The prevalence of PPGP in Australian women was high with almost half the sample classified with PPGP, matching data reported worldwide. The identified risk factors associated with PPGP can be included in routine ante-natal care to screen women and identify those at risk of this common and disabling condition.Level of Evidence: 1.

Does volume or occupancy influence emergency access block? A multivariate time series analysis from a single emergency department in Sydney, Australia during the COVID-19 pandemic.

The study aims to determine whether ED presentation volume or hospital occupancy had a greater impact on ED performance before and during the COVID-19 health response at a tertiary referral hospital in Sydney, Australia. Single centre time series analysis using routinely collected hospital and ED data from January 2019 to September 2020. The primary outcome was ED access block measured by emergency treatment performance (ETP; i.e. percentage of patients who were discharged or transferred to a ward from ED within 4 h of ED arrival time). Secondary outcomes were hospital occupancy, elective theatre cases and ambulance ramping. Multivariate time series analysis was performed using vector autoregression, to model effects of changes in various endogenous and correlated variables on ETP. There was an increase in ETP, drop in ED presentations and decrease in hospital occupancy between April and June 2020. Elective surgery and hospital occupancy had significant effects up to 2 days prior on ETP, while there were no significant effects of either ED or ambulance presentations on ETP. Hospital occupancy itself increased with ED presentations after 2-4 days and decreased with elective surgery after 1 day. Shocks (a one standard deviation increase) in hospital occupancy had a peak impact nearly two times greater compared to ED presentations (-1.43, 95% confidence interval -1.92, -0.93 vs -0.73, 95% confidence interval -1.21, -0.25). The main determinants of the reduction of ED overcrowding and access block during the pandemic were associated with reductions in hospital occupancy and elective surgery levels, and more research is required to assess more complex associations beyond the scope of this manuscript.

Pharmacist review of high-risk haematology outpatients to improve appropriateness of antifungal prophylaxis.

Background Patients with haematological malignancies are at high risk of invasive fungal infections. However, there is a lack of information about the utilisation of the recommended Australian antifungal prophylaxis guidelines in haematology outpatients. Objective To assess the impact of a weekly pharmacist review of high-risk adult haematology outpatients on the utilisation of appropriate antifungal prophylaxis. Setting Outpatient cancer centre, tertiary referral hospital in Sydney, Australia. Method A 3-month pre-and post-interventional study was conducted. A retrospective audit was conducted to obtain baseline utilisation of antifungal guidelines in adult haematology outpatients with acute myeloid leukemia, acute lymphoblastic leukemia and myelodysplastic syndrome receiving chemotherapy. This was followed by a weekly pharmacist review over a 3-month period of all eligible outpatients assessing the appropriateness of antifungal agent, dose, use of therapeutic drug monitoring and presence of drug-interactions/contraindications. Recommendations to physicians were conveyed weekly and outcomes recorded. Main outcome measure Appropriate utilisation of antifungal prophylaxis guidelines in outpatient haematology patients before and after implementation of a 3-month weekly pharmacist review service. Results Forty patients were included in the retrospective group, equating to 348 reviews, while 42 patients equating to 269 reviews were included in the prospective group. Appropriate utilisation of antifungal prophylaxis guidelines increased from 31 to 54% post implementation of a pharmacist review (Odds Ratio = 2.44, 95% Confidence Interval: 1.07-5.58, p = 0.0344). The most common reason for nonadherence to guidelines in both groups was lack of therapeutic drug monitoring and failure to prescribe antifungal prophylaxis where indicated. The percentage of appropriate use of antifungal prophylaxis in patients with acute myeloid leukemia increased from 13 to 46% (p value < 0.01) after pharmacist intervention. The pharmacist made 153 recommendations from 269 reviews, with a percentage uptake of 40%. Moderate to severe drug interactions were identified in 19 reviews from 10 patients. One major azole antifungal-chemotherapy interaction was avoided. Conclusions Appropriate utilisation of antifungal prophylaxis guidelines can be improved through a regular pharmacist review. Future studies should identify whether improving adherence to antifungal guidelines leads to improved patient outcomes.

Cost-analysis of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal malignancy: An Australian perspective with global application

BackgroundCost-effective cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for treatment of patients with peritoneal malignancy remains an ongoing financial challenge for healthcare systems, hospitals and patients. This study aims to describe the detailed in-hospital costs of CRS and HIPEC compared with an Australian Activity Based Funding (ABF) system, and to evaluate how the learning curve, disease entities and surgical outcomes influence in-hospital costs. MethodsA retrospective descriptive costing review of all CRS and HIPEC cases undertaken at a large public tertiary referral hospital in Sydney, Australia from April 2017 to June 2019. In-hospital cost variables included staff, critical care, diagnosis, operating theatre, and other costs. Univariate and multivariate analyses were conducted to investigate the differences between actual cost and the provision of funding, and potential factors associated with these costs. ResultsOf the 118 CRS and HIPEC procedures included in the analyses, the median total cost was AU$130,804 (IQR: 105,744 to 153,972). Provision of funding via the ABF system was approximately one-third of the total CRS and HIPEC costs (p < 0.001). Surgical staff proficiency seems to reduce the total CRS and HIPEC costs. Surgical time, length of intensive care unit and hospital stay are the main predictors of total CRS and HIPEC costs. ConclusionDelivery of CRS and HIPEC is expensive with high variability. A standard ABF system grossly underestimates the specific CRS and HIPEC funding required with supplementation essential to sustaining this complex highly specialised service.

Nutritional management of patients with oesophageal cancer throughout the treatment trajectory: benchmarking against best practice.

Oesophageal cancer (OC) impacts nutritional status and outcomes. This study aims to benchmark the current nutrition management of patients with OC against best practice recommendations, identify critical points in the treatment trajectory where nutritional status is compromised, service gaps and opportunities for improvement. A retrospective audit collected demographic, medical and nutritional data from medical records of patients who received curative treatment for OC at a tertiary referral hospital in Sydney, Australia. Thirty-seven patient records were audited over the time period. Twenty-nine patients underwent nutrition screening on admission to the service. Eighteen out of 25 patients receiving neoadjuvant radiation therapy, all patients during surgical admission, and only 19 patients at postsurgical discharge were seen by a dietitian. All patients received tube feeding post-operatively; however, initiation within 24h only occurred for 14 patients. Weight significantly declined over the course of treatment (p < 0.001), whilst malnutrition during surgical admission (p = 0.004) and postsurgical discharge (p = 0.038) were both associated with significantly higher unplanned readmissions. Best practice recommendations were met for aspects of the immediate post-operative period; however, service gaps remain during pre-operative and post-discharge care. Findings from this study indicate that nutritional care is inconsistent across different treatment stages, and malnutrition impacts negatively on unplanned readmission. Research is needed to address evidence-practice gaps, assess appropriateness of recommendations and provide evidence for models of care during multimodality treatments and across different services.

A text message intervention to support women\u2019s physical and mental health after breast cancer treatments (EMPOWER-SMS): a randomised controlled trial protocol

BackgroundBreast cancer is the most common cancer diagnosed in women worldwide. In developed countries, 80–90% of women will survive five years after diagnosis but the transition from hospital-based care to health self-management and self-efficacy can be difficult. Text messaging programs offer a simple and proven way to provide support to people with chronic diseases. This study aims to test the effectiveness of a text message support program at improving women’s health self-efficacy, and physical and mental health outcomes after breast cancer treatments compared to usual care at 6-months and to understand the barriers and enablers to widespread implementation.MethodsSingle-blind randomised control trial (RCT; N = 160) comparing a text message support intervention to usual care in women with breast cancer (recruited from a large tertiary referral hospital in Sydney, Australia). The intervention group will receive a six-month text message support program, which consists of semi-personalised, supportive, lifestyle-focused text messages (4 messages/week) in addition to usual care. The control group will receive usual care without the text message program. Outcomes will be assessed at 6-months. The primary outcome is change in self-efficacy for managing chronic disease. Secondary outcomes include change in clinical outcomes (body mass index), lifestyle outcomes (physical activity levels, dietary behaviours), mood (depression and anxiety scales), quality of life, satisfaction with, and usefulness of the intervention. Analyses will be performed on the principle of intention-to-treat to examine differences between intervention and control groups.DiscussionThis study will test if a scalable and cost-effective text-messaging intervention is effective at improving women’s health self-efficacy, as well as physical and mental health outcomes. Moreover, this study will provide essential preliminary data to bolster a large multicentre RCT to helpsupport breast cancer survivors throughout recovery and beyond.Trial registrationAustralia New Zealand Clinical Trials Registry (ANZCTR) number ACTRN12618002020268, 17 December 2018

Continuous Epidural Infusion Versus Programmed Intermittent Epidural Bolus for Labor Analgesia: A Prospective, Controlled, Before-and-After Cohort Study of Labor Outcomes

(Br J Anaesth. 2018;121:432–437) Recent studies have shown that programmed intermittent epidural bolus (PIEB) may be more effective at achieving lower rates of motor block, shortened second stage of labor, improved patient satisfaction outcomes, and lower total local anesthetic dose for labor pain than standard techniques like continuous epidural infusion (CEI) or patient-controlled epidural analgesia (PCEA). Therefore, the authors of this prospective, controlled, before-and-after cohort study evaluated the effectiveness of PIEB+PCEA versus CEI for labor analgesia in a tertiary referral hospital in Sydney, New South Wales, Australia.

Maternal car driving capacity after birth: a pilot prospective study randomizing postnatal women to early verses late driving in a driving simulator

Background: Women are commonly advised to avoid driving following cesarean section (CS), however, this advice is based upon little evidence.Aims: We aimed to assess a woman’s capacity to drive a car postbirth using a driving simulator to objectively examine driving behavior and competencies.Materials and methods: We conducted a pilot, prospective, randomized study from a tertiary referral hospital in Sydney, Australia. Postnatal women who were regular drivers and had given birth by vaginal delivery (VD), elective cesarean section (ElCS) or emergency cesarean section (EmCS) were randomized to early (2–3 weeks post birth) or late (5–6 weeks post birth) driver simulator testing. Driving performance was measured by reaction time to simulated impediments, awareness, attention, braking ability, traffic infringements, and accidents. Analysis was by intention to treat. Outcomes were assessed using contingency analysis via two-sample t-tests and Wilcoxen rank-sum tests.Results: 66 women were randomized and 38 attended simulator testing (57.6%; 19 early, 19 late; 8 VD, 14 ElCS, 16 EmCS). There was no difference in reaction times, driver awareness, braking times, or traffic infringements by early versus late testing (all p > .05), nor by mode of birth (p > .05) amongst the women who completed driver testing. At 7–8 weeks, all women were driving, without an accident.Conclusions: Although the study is limited by small sample size, there was no difference in driving capability by early versus late driving time since birth, nor by mode of birth. Further research is needed, but we cannot provide evidence to discourage well women from driving from 2–3 weeks post birth.

The effect of a workplace violence training program for generalist nurses in the acute hospital setting: A quasi-experimental study

BackgroundWorkplace violence prevalence has attracted significant attention within the international nursing literature. Little attention to non-mental health settings and a lack of evaluation rigor have been identified within review literature. ObjectivesTo examine the effects of a workplace violence training program in relation to risk assessment and management practices, de-escalation skills, breakaway techniques, and confidence levels, within an acute hospital setting. DesignA quasi-experimental study of nurses using pretest-posttest measurements of educational objectives and confidence levels, with two week follow-up. SettingA 440 bed metropolitan tertiary referral hospital in Sydney, Australia. ParticipantsNurses working in specialties identified as a ‘high risk’ for violence. MethodA pre-post-test design was used with participants attending a one day workshop. The workshop evaluation comprised the use of two validated questionnaires: the Continuing Professional Development Reaction questionnaire, and the Confidence in Coping with Patient Aggression Instrument. Descriptive and inferential statistics were calculated. The paired t-test was used to assess the statistical significance of changes in the clinical behaviour intention and confidence scores from pre- to post-intervention. Cohen's d effect sizes were calculated to determine the extent of the significant results. ResultsSeventy-eight participants completed both pre- and post-workshop evaluation questionnaires. Statistically significant increases in behaviour intention scores were found in fourteen of the fifteen constructs relating to the three broad workshop objectives, and confidence ratings, with medium to large effect sizes observed in some constructs. A significant increase in overall confidence in coping with patient aggression was also found post-test with large effect size. ConclusionsPositive results were observed from the workplace violence training. Training needs to be complimented by a multi-faceted organisational approach which includes governance, quality and review processes.

Impact of serious mental illness on surgical patient outcomes.

People with comorbid mental illness have poorer health status and disparate access to healthcare. Several studies internationally have reported mixed findings regarding the association between mental illness and surgical patient outcomes. This study examines the surgical outcomes in people with decompensated serious mental illness (SMI) within the setting of the Australian universal healthcare system. Retrospective cohort study involving elective overnight surgical patients aged 18 years and above who attended a large public tertiary referral hospital in Sydney, Australia, between 2010 and 2014. Patients were identified using ICD-10-AM diagnosis codes. Outcomes measure including in-hospital mortality, post-operative complications, morbidity, admission and time in intensive care, length and cost of hospitalization, discharge destination and 28-day re-admission rates were examined. Of 23 343 surgical patient admissions, 451 (2%) patients had decompensated comorbid SMI with a subset of 47 (0.2%) having a specific psychotic illness. Patients with SMI comorbidity had significantly higher in-hospital mortality (2% versus 0%), post-operative complications (22% versus 8%), total comorbidity (7.6 versus 3.4 secondary codes), admissions (29% versus 9%) and time in intensive care (34.6 h versus 5.0 h), stay in hospital (12.2 days versus 4.6 days), admission costs ($24 162 versus $12 336), re-admission within 28 days (14% versus 10%) and discharges to another facility (11% versus 3%). Patients with comorbid SMI had significantly worse surgical outcomes and incur much higher costs compared with the general surgical population. These results strongly highlight that specific perioperative interventions are needed to proactively improve the identification, management and outcomes for these disadvantaged patients.

Is sonographically measured cervical length at 37 weeks of gestation associated with intrapartum cesarean section? A prospective cohort study.

Cesarean section rates continue to increase globally. Prediction of intrapartum cesarean section could lead to preventive measures. Our aim was to assess the association between sonographically measured cervical length at 37 weeks of gestation and cesarean section among women planning a vaginal birth. The population was women with a low-risk pregnancy or with gestational diabetes. This was a prospective cohort study conducted in a tertiary referral hospital in Sydney, Australia. In all, 212 women with a low-risk pregnancy or with gestational diabetes were recruited including 158 nulliparous and 54 parous women. Maternal demographic, clinical and ultrasound characteristics were collected at 37 weeks of gestation. Semi-Bayesian logistic regression and Markov chain Monte Carlo simulation were used to assess the relation between cervical length and cesarean section in labor. Rates of cesarean section were 5% (2/55) for cervical length ≤20 mm, 17% (17/101) for cervical length 20-32 mm, and 27% (13/56) for cervical length >32 mm. These rates were 4, 22 and 33%, respectively, in nulliparous women. In the semi-Bayesian analysis, the odds ratio for cesarean section was 6.2 (95% confidence interval 2.2-43) for cervical length 20-32 mm and 10 (95% confidence interval 4.8-74) for cervical length >32 mm compared with the lowest quartile of cervical length, after adjusting for maternal age, parity, height, prepregnancy body mass index, gestational diabetes, induction of labor, neonatal sex and birthweight centile. Cervical length at 37 weeks of gestation is associated with intrapartum cesarean section.