Prognostic limitations of donor t cell chimerism after myeloablative allogeneic stem cell transplantation for acute myeloid leukemia and myelodysplastic syndromes

Donor T cell chimerism is associated with relapse outcomes after allogeneic stem cell transplantation (alloSCT) for acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS). However, measures of statistical association do not adequately assess the performance of a prognostic biomarker, which is best characterized by its sensitivity and specificity for the chosen outcome. We analyzed donor T cell chimerism results at day 100 (D100chim) after myeloablative alloSCT for AML or MDS in 103 patients and determined its sensitivity and specificity for relapse-free survival at 6 months (RFS6) and 12 months (RFS12) post-alloSCT. The area under the receiver operating characteristic curve for RFS6 was .68, demonstrating only modest utility as a predictive biomarker, although this was greater than RFS12 at .62. Using a D100chim threshold of 65%, the specificity for RFS6 was 96.6%; however, sensitivity was poor at 26.7%. This equated to a negative predictive value of 88.5% and positive predictive value of 57.1%. Changing the threshold for D100chim to 75% or 85% modestly improved the sensitivity of D100chim for RFS6; however, this was at the expense of specificity. D100chim is specific but lacks sensitivity as a prognostic biomarker of early RFS after myeloablative alloSCT for AML or MDS. Caution is required when using D100chim to guide treatment decisions including immunologic manipulation, which may expose patients to unwarranted graft-versus-host disease

Working with CALD groups: testing the feasibility of an intervention to improve medication self-management in people with kidney disease, diabetes, and cardiovascular disease

Introduction: Australia is an ageing multicultural society with an increased prevalence of chronic conditions. The rise of coexisting diabetes, kidney disease and hypertension is placing a significant and increasing demand on Australian health services. Prescribed medications are a key component of reducing the disease burden of these coexisting conditions, and successful treatment is largely dependent on self-management of medications. Culturally and linguistically diverse (CALD) groups have an increased risk of medication mismanagement and are often excluded from intervention studies. We examined an intervention in this group and report on some of the difficulties and resource issues involved with studying CALD groups. Methods: Patients aged ≥18 years of age with chronic kidney disease, diabetes and cardiovascular disease whose preference it was to speak Greek, Italian or Vietnamese were recruited from nephrology outpatients\u27 clinics of two Australian metropolitan hospitals in 2009. A translated, multifactorial intervention, consisting of a medication review, a short PowerPoint presentation and motivational interviewing designed to improve medication self-efficacy and adherence, was tested in a randomised controlled trial (RCT) with 12 months follow-up post-baseline. People collecting data and assessing outcomes were blinded to group assignment. Results: Seventy-eight participants were recruited and 29 participants completed the study. There were no significant differences in medication self-efficacy or adherence between the intervention and control groups at three, six and 12 months post-baseline. Conclusion: The pilot study was not feasible due to high attrition rates. This work has highlighted difficulties with conducting research into CALD groups using interpreting services and health literacy issues affecting medicine self-management in this group

Supporting insulin initiation in type 2 diabetes in primary care: results of the Stepping Up pragmatic cluster randomised controlled clinical trial.

Objective To compare the effectiveness of a novel model of care ("Stepping Up") with usual primary care in normalising insulin initiation for type 2 diabetes, leading to improved glycated haemoglobin (HbA1c) levels.Design Cluster randomised controlled trial.Setting Primary care practices in Victoria, Australia, with a practice nurse and at least one consenting eligible patient (HbA1c ≥7.5% with maximal oral treatment).Participants 266 patients with type 2 diabetes and 74 practices (mean cluster size 4 (range 1-8) patients), followed up for 12 months.Intervention The Stepping Up model of care intervention involved theory based change in practice systems and reorientation of the roles of health professionals in the primary care diabetes team. The core components were an enhanced role for the practice nurse in leading insulin initiation and mentoring by a registered nurse with diabetes educator credentials.Main outcome measures The primary endpoint was change in HbA1c. Secondary endpoints included the proportion of participants who transitioned to insulin, proportion who achieved target HbA1c, and a change in depressive symptoms (patient health questionnaire, PHQ-9), diabetes specific distress (problem areas in diabetes scale, PAID), and generic health status (assessment of quality of life instrument, AQoL-8D).Results HbA1c improved in both arms, with a clinically significant between arm difference (mean difference -0.6%, 95% confidence interval -0.9% to -0.3%), favouring the intervention. At 12 months, in intervention practices, 105/151 (70%) of participants had started insulin, compared with 25/115 (22%) in control practices (odds ratio 8.3, 95% confidence interval 4.5 to 15.4, P<0.001). Target HbA1c (≤7% (53 mmol/mol)) was achieved by 54 (36%) intervention participants and 22 (19%) control participants (odds ratio 2.2, 1.2 to 4.3, P=0.02). Depressive symptoms did not worsen at 12 months (PHQ-9: -1.1 (3.5) v -0.1 (2.9), P=0.05). A statistically significant difference was found between arms in the mean change in mental health (AQoL mental component summary: 0.04 (SD 0.16) v -0.002 (0.13), mean difference 0.04 (95% confidence interval 0.002 to 0.08), P=0.04), favouring the intervention, but no significant difference in physical health (AQoL physical component summary: 0.03 (0.15) v 0.02 (0.13)) nor diabetes specific distress (5.6 (15.5) v -2.4 (15.4)). No severe hypoglycaemia events were reported.Conclusions The Stepping Up model of care was associated with increased insulin initiation rates in primary care, and improvements in glycated haemoglobin without worsening emotional wellbeing.Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12612001028897

Targeted ultrasound of the liver: Impact on scanning time of a new approach in chronic liver disease

Introduction: Targeted ultrasound of the liver (TUSL) has been proposed as a new approach in chronic liver disease to meet the increasing demands on ultrasound services in this patient population. This study analyses the impact of TUSL on examination time. Methods: Retrospective cohort analysis of time taken to perform liver ultrasound on consecutive chronic liver disease patients pre‐ (n = 230) and post‐ (n = 147) introduction of TUSL. Within each cohort, patients were subdivided into three categories based on the clinical indication: Group 1. hepatocellular carcinoma (HCC) surveillance; Group 2. detection of cirrhosis, fibrosis or fatty liver; Group 3. detection of portal hypertension. The primary outcome was difference in examination time in the pre‐ and post‐intervention groups. Results: Introduction of TUSL led to 49% reduction in examination time (median (Q1–Q3) 23.7 (16.7–36.2) min in pre‐TUSL period vs 12.1 (6.4–19.5) min in post, P < 0.001) and it was consistent across all three clinical indication groups (gr1: median 23.1 minutes vs 8.1 minutes (P < 0.001), gr2: 23.0 minutes vs 14.3 minutes (P < 0.001), gr3: 32.2 minutes vs 15.3 minutes (P = 0.006)). After the adjustment for clinical indication and sonographer's experience, impact of TUSL on time reduction remained significant with a 66.6% time reduction (95% CI 53.6 to 79.5). Conclusion: Targeted ultrasound of the liver improves efficiency of chronic liver disease ultrasound with halving of examination times and consequently has the potential to greatly improve resource utilization

Thyroid surgery and anticoagulation: Survey of practice of endocrine surgeons in Australia

Few studies specifically address management of venous thromboembolism (VTE) prophylaxis and bridging anticoagulation therapy in patients undergoing thyroid surgery. A survey about perioperative management of thromboprophylaxis was sent to Australian Endocrine Surgeons. Responses were tabulated and graphed; a p-value of < 0.05 was considered statistically significant. Survey responses showed a large broad spectrum of practice regarding thromboprophylaxis, bridging therapy and cessation of anticoagulant medication. While anticoagulant prophylaxis in thyroid surgery appears to be relatively safe, there is a theoretical risk of catastrophic bleeding complications; according to this survey of Australian Endocrine Surgeons, thromboembolic events are uncommon complications of thyroid surgery

Hurt feelings in women: the interaction of social and individual difference factors

Research into the causes of hurt feelings has generally examined the impact of single predictors. The current article builds on previous literature by examining the interactive effects of several key elements of hurtful events in predicting the intensity of hurt. Two studies using community samples of women examined interactions between the type of hurtful event, the importance of the perpetrator, and victim hurt-proneness in predicting variance in hurt intensity. Study 1 (<i>n</i> = 475) used a series of scenarios as the hurtful stimulus while Study 2 (<i>n</i> = 380) used a number of recalled hurtful events. Both studies replicated previous bivariate relationships between perpetrator importance and hurt-proneness and the intensity of hurt, while the first study also demonstrated a significant effect for type of hurtful event. Both studies also found a significant three-way interaction between these variables, indicating that victim hurt-proneness only predicted the intensity of hurt at lower levels of event severity and perpetrator importance. It is concluded that the experience of hurt is multidimensional and contextual. Future directions for research involving gender differences and interventions for individuals and couples are discussed

Evolution of surgical management for phaeochromocytoma over a 17-year period : An Australian perspective

Background Minimally invasive adrenalectomy and advances in anaesthetic techniques have transformed surgery for phaeochromocytoma. This 17-year review describes the evolution of phaeochromocytoma care in our unit. Methods We performed a retrospective cohort review of all patients who underwent adrenalectomy for phaeochromocytoma from 2000 to 2016. Patients were divided into three time periods, early: 2000–2005 (n = 17), middle: 2006–2010 (n = 15) and late: 2011–2016 (n = 24). The posterior retroperitoneoscopic adrenalectomy was introduced in 2011. Demographics and clinicopathological details were extracted. Median values for nominal data were compared using Mann–Whitney U-test. A chi-squared test was used to compare categorical data. Results Sixty-one adrenalectomies were performed on 56 patients: 19 open, 17 laparoscopic and 20 posterior retroperitoneoscopic adrenalectomies. The median length of operation decreased from 135 to 90 min from the early to the late time period (P > 0.05). Length of stay decreased from a median of 5 days in the early group to 1 day in the late group (P = 0.01). A total of 94.1% of the early period patients were admitted to the intensive care unit compared to 30.4% of the late group (P = <0.01). Need for post-operative vasopressors and blood transfusions was significantly reduced. Conclusion Over the 17-year period, the choice of operative technique has transitioned towards posterior retroperitoneoscopic adrenalectomy. Operative time, rate of intensive care unit admission, and admission length have all decreased without any increase in rates of complications

Symptom burden in malignant and non-malignant disease on admission to a palliative care unit

Background There is increasing recognition that patients with non-malignant diseases have comparable physical and psychosocial symptom burden to patients with cancer. There is currently limited data directly comparing symptom burden between these patient groups. Objective To investigate differences in symptom burden between patients with malignant and non-malignant conditions admitted to a palliative care unit (PCU). Method A cross-sectional study involving 186 patients admitted to a PCU was undertaken. Patients were dichotomised into malignant or non-malignant disease categories. Symptom burden at admission was assessed using the Symptom Assessment Scale and Palliative Care Problem Severity Score. Group differences in symptoms were analysed using univariate and multivariate approaches. Results One hundred patients (53.8%) had cancer, with upper gastrointestinal the most common type (18.0%). Among the 86 patients with non-malignant disease, neurological conditions were most prevalent (40.7%). Patients admitted with non-malignant diseases were older, more functionally impaired and more likely to be deteriorating or terminal. A malignant diagnosis was associated with a higher likelihood of clinician-assessed pain, patient-assessed pain, fatigue, psychological/spiritual symptoms and other symptoms. However, when adjusted for confounders, disease category ceased to be a significant predictor of symptom burden. Younger patients experienced worse pain and patients in terminal phase experienced less symptom burden. Conclusion Symptom burden was similar between patients with malignant and non-malignant disease after adjustment for confounders. Further research is needed to understand the palliative care needs of patients with non-malignant disease