A systematic review of geographical differences in management and outcomes for colorectal cancer in Australia.

BACKGROUND: Australia and New Zealand have the highest incidence of colorectal cancer (CRC) in the world, presenting considerable health, economic, and societal burden. Over a third of the Australian population live in regional areas and research has shown they experience a range of health disadvantages that result in a higher disease burden and lower life expectancy. The extent to which geographical disparities exist in CRC management and outcomes has not been systematically explored. The present review aims to identify the nature of geographical disparities in CRC survival, clinical management, and psychosocial outcomes. METHODS: The review followed PRISMA guidelines and searches were undertaken using seven databases covering articles between 1 January 1990 and 20 April 2016 in an Australian setting. Inclusion criteria stipulated studies had to be peer-reviewed, in English, reporting data from Australia on CRC patients and relevant to one of fourteen questions examining geographical variations in a) survival outcomes, b) patient and cancer characteristics, c) diagnostic and treatment characteristics and d) psychosocial and quality of life outcomes. RESULTS: Thirty-eight quantitative, two qualitative, and three mixed-methods studies met review criteria. Twenty-seven studies were of high quality, sixteen studies were of moderate quality, and no studies were found to be low quality. Individuals with CRC living in regional, rural, and remote areas of Australia showed poorer survival and experienced less optimal clinical management. However, this effect is likely moderated by a range of other factors (e.g., SES, age, gender) and did appear to vary linearly with increasing distance from metropolitan centres. No studies examined differences in use of stoma, or support with stomas, by geographic location. CONCLUSIONS: Overall, despite evidence of disparity in CRC survival and clinical management across geographic locations, the evidence was limited and at times inconsistent. Further, access to treatment and services may not be the main driver of disparities, with individual patient characteristics and type of region also playing an important role. A better understanding of factors driving ongoing and significant geographical disparities in cancer related outcomes is required to inform the development of effective interventions to improve the health and welfare of regional Australians

Safety and Reactogenicity of Canarypox ALVAC-HIV (vCP1521) and HIV-1 gp120 AIDSVAX B/E Vaccination in an Efficacy Trial in Thailand

A prime-boost vaccination regimen with ALVAC-HIV (vCP1521) administered intramuscularly at 0, 4, 12, and 24 weeks and gp120 AIDSVAX B/E at 12 and 24 weeks demonstrated modest efficacy of 31.2% for prevention of HIV acquisition in HIV-uninfected adults participating in a community-based efficacy trial in Thailand.Reactogenicity was recorded for 3 days following vaccination. Adverse events were monitored every 6 months for 3.5 years, during which pregnancy outcomes were recorded. Of the 16,402 volunteers, 69% of the participants reported an adverse event any time after the first dose. Only 32.9% experienced an AE within 30 days following any vaccination. Overall adverse event rates and attribution of relatedness did not differ between groups. The frequency of serious adverse events was similar in vaccine (14.3%) and placebo (14.9%) recipients (p = 0.33). None of the 160 deaths (85 in vaccine and 75 in placebo recipients, p = 0.43) was assessed as related to vaccine. The most common cause of death was trauma or traffic accident. Approximately 30% of female participants reported a pregnancy during the study. Abnormal pregnancy outcomes were experienced in 17.1% of vaccine and 14.6% (p = 0.13) of placebo recipients. When the conception occurred within 3 months (estimated) of a vaccination, the majority of these abnormal outcomes were spontaneous or elective abortions among 22.2% and 15.3% of vaccine and placebo pregnant recipients, respectively (p = 0.08). Local reactions occurred in 88.0% of vaccine and 61.0% of placebo recipients (p<0.001) and were more frequent after ALVAC-HIV than AIDSVAX B/E vaccination. Systemic reactions were more frequent in vaccine than placebo recipients (77.2% vs. 59.8%, p<0.001). Local and systemic reactions were mostly mild to moderate, resolving within 3 days.The ALVAC-HIV and AIDSVAX B/E vaccine regimen was found to be safe, well tolerated and suitable for potential large-scale use in Thailand.ClinicalTrials.govNCT00223080

Ethnic determinants of skeletal health in female patients with fragility fracture in a culturally diverse population

Background: Low bone density leads to fragility fracture, with significant impact on morbidity and mortality. While ethnic differences in bone density have been observed in healthy subjects, this has not yet been explored in fragility fracture patients. Aims: To assess if ethnicity is associated with bone mineral density and serum markers of bone health in female patients who experience fragility fractures. Methods: 219 female patients presenting with at least one fragility fracture at a major tertiary hospital in Western Sydney Australia were studied. Western Sydney is a region with great cultural diversity, comprising people from over 170 ethnicities. Within this cohort, the three largest broad ethnic groups were Caucasians (62.1 %), Asians (22.8 %), and Middle Eastern patients (15.1 %). Location and nature of the presenting fracture and other relevant past medical history were obtained. Bone mineral density, measured by dual-energy X-ray absorptiometry, and bone-related serum markers were compared between ethnicities. Covariates (age, height, weight, diabetes, smoking, and at-risk drinking) were adjusted in multiple linear regression model. Results: Although Asian ethnicity was associated with lower bone mineral density at the lumbar spine in fragility fracture patients, this association was no longer significant after adjustment for weight. Ethnicity (Asian or Middle Eastern) was not a determinant of bone mineral density at any other skeletal site. Caucasians had lower estimated glomerular filtration rate compared to Asian and Middle Eastern subjects. Serum parathyroid hormone concentrations were significantly lower in Asians compared to other ethnicities. Conclusion: Asian ethnicity and Middle Eastern ethnicity were not major determinants of bone mineral density at the lumbar spine, femoral neck, or total hip

Modifying lifestyle behaviours to improve the prevention and management of cardiovascular disease

This handbook brings together the full weight of contemporary evidence bearing on what is now commonly termed “psycho-cardiology”