To evaluate whether fatigue severity can serve as a cue to investigate the presence of depression... more To evaluate whether fatigue severity can serve as a cue to investigate the presence of depression in older adult patients with cancer. . Cross-sectional observational cohort study. . Seven hospitals and general practices in Belgium and the Netherlands. . 205 older adult patients with cancer and 436 older adults without cancer (aged 70 years or older). . The diagnostic accuracy of fatigue as a proxy for depression was evaluated using sensitivity, specificity, and predictive values. . Fatigue was measured with a visual analog scale, and depression was measured with the 15-item Geriatric Depression Scale. . Fifty-six percent of the population experienced fatigue, and 13% were depressed. For fatigue as a cue for depression, sensitivity was 82%, specificity was 47%, positive predictive value was 18%, and negative predictive value was 95%. . The data confirm that fatigue is a valuable cue to investigate the presence of depression because 82% of depressed participants were correctly iden...
Vaccines have been shown to cause differential expression of genes and increase antibody titers a... more Vaccines have been shown to cause differential expression of genes and increase antibody titers against antigens. Influenza vaccines may have an effect on unexplained disorders such as Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME). Immunological changes have been identified following immunization with trivalent influenza vaccine (TIV). The objective of this pilot study was to examine the consequences of TIV on cytokine and cytotoxic genes in CFS/ME. Peripheral blood mononuclear cells were preferentially isolated from whole blood of 7 CFS/ME patients and 8 controls. Following total RNA extraction and synthesis of cDNA, reverse transcriptase-quantitative polymerase chain reaction (RT-qPCR) was used to determine the expression levels of mRNAs for cytotoxic genes (perforin (PRF1), granzyme A (GZMA), granzyme B (GZMB) and cytokine genes. GZMB was significantly increased overall in the CFS/ME patients compared to the controls. GZMA was significantly increased 28 days after vaccination while PRF1 was reduced pre-vaccination but increased 14 days post-vaccination in the CFS/ME patients. There were no significant changes in cytokine genes pre or post vaccination. Administration of TIV may increase the expression of lytic genes in CFS/ME and this may contribute to the increase in cytotoxic activity we observed in these patients post vaccination.
Immune dysfunction is a hallmark of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME). ... more Immune dysfunction is a hallmark of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME). The purpose of this pilot study was to identify the effects of influenza vaccination on immune function in patients with CFS/ME. We included 7 patients meeting the Centre for Disease Control and Prevention criteria (CDC 1994) for ME/CFS and 8 control subjects. Bloods were collected from all participants prior to vaccination with Influvac, a trivalent inactivated influenza vaccine (TIV), 14 and 28 days following vaccination. The immune parameters examined include Natural Killer (NK) phenotypes, NK cytotoxic activity, FOXP3 and Th1/Th2/Th17 related cytokines. Flow cytometric protocols were employed. There was no significant difference in NK phenotypes and Tregs numbers between CFS/ME patients and healthy controls. However, NK activity was significantly decreased at baseline and at 28 days, while at 14 days it significantly increased in the CFS/ME patients compared to the healthy controls. Th1 pro-inflammatory cytokines increased considerably in the CFS/ME patients at 28 days compared to the non-fatigued controls. Only one Th2 cytokine, IL-4, increased in the CFS/ME participants. FOXP3 expressing Tregs only increased significantly at day 28 post vaccination in the CFS/ME patients compared to the healthy controls. Self-rated wellbeing was lower for patients at day 28 while at baseline and day 14 no differences were observed. In this pilot study immunization with influenza vaccine is accompanied by a degree of immune dysregulation in CFS/ME patients compared with controls. While vaccination may protect CFS/ME patients against influenza, it has the ability to increase cytotoxic activity and pro-inflammatory reactions post vaccination. The role of Tregs in promoting a toxic effect at 28 days post-vaccination in our patient group cannot be ruled out. The benefits of influenza vaccine still likely outweigh the risks CFS/ME patients experience following vaccination.
The Cochrane database of systematic reviews, Jan 25, 2015
Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated... more Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children with ADHD find it difficult to pay attention, they are hyperactive and impulsive.Methylphenidate is the drug most often prescribed to treat children and adolescents with ADHD but, despite its widespread use, this is the first comprehensive systematic review of its benefits and harms. To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD. In February 2015 we searched six databases (CENTRAL, Ovid MEDLINE, EMBASE, CINAHL, PsycINFO, Conference Proceedings Citations Index), and two trials registers. We checked for additional trials in the reference lists of relevant reviews and included trials. We contacted the pharmaceutical companies that manufacture methylphenidate to request published and unpublished data. We included all randomised controlled trials (RCTs) comparing methylphenidate v...
Background Increasing use of opioid analgesics (OA) has been reported worldwide. Objective To com... more Background Increasing use of opioid analgesics (OA) has been reported worldwide. Objective To compare the use of OA in two countries in order to better understand these trends. Setting Outpatient settings in Australia and The Netherlands. Method We analysed publicly available government data on outpatient OA dispensing over 15 years (2000-2014). We compared dispensing trends for specific OA and explored medical (national clinical guidelines), contextual and policy-related factors to explain differences in use between the two countries. Main outcome measure OA prescribing in Australia and The Netherlands, absolute volume of use, preferred types of opioids and changes over time. Results The average annual increase in OA prescribing was 10% in Australia and 8% in The Netherlands between 2000 and 2014. In 2014, the total use of OA was 10.0 daily defined doses (DDD)/1000 population/day in Australia and 9.4 DDD/1000 population/day in The Netherlands. In Australia, the most commonly prescribed opioids were oxycodone and tramadol, compared to fentanyl and tramadol in The Netherlands. We found differences in prescribing guidelines, culture of prescribing and regulatory frameworks that could explain some of the observed differences. Conclusion OA prescribing has increased remarkably in both countries between 2000 and 2014 but the types of prescribed OA vary. Differences in national evidence-based guidelines influenced the types of OA used. Prescribing culture as well as regulatory policies and costs, may also contribute to the different patterns of OA use.
People with intellectual disability experience difficulty forming intimate relationships and are ... more People with intellectual disability experience difficulty forming intimate relationships and are prone to sexual exploitation and abuse. This study sought information from people involved in the care of adults with intellectual disability regarding how they supported them in the areas of sexuality, relationships and abuse prevention. Semistructured interviews and focus groups were held with 28 family members and paid support workers caring for adults with intellectual disabilities. Interviews and focus groups were audio recorded, transcribed, coded and analysed qualitatively. Major themes emerging included views on sexuality and intellectual disability, consent and legal issues, relationships, sexual knowledge and education, disempowerment, exploitation and abuse, sexual health and parenting. People with intellectual disability were described as lonely, disempowered and vulnerable to abuse. The sex industry, internet and mobile telephones were identified as new forms of risk. While ...
Sexual abuse and abusive relationships are known to be especially common in people with intellect... more Sexual abuse and abusive relationships are known to be especially common in people with intellectual disability. This study explored how women with intellectual disability understand sex, relationships and sexual abuse, the effects of sexual abuse on their lives, and how successfully they protect themselves from abuse. Semistructured narrative interviews with nine women with mild intellectual disability in Queensland, Australia. Interviews were audio recorded, transcribed, coded and analysed qualitatively. Major themes that emerged were: sexual knowledge and sources of knowledge; negotiating sexual relationships; declining unwanted sexual contact; self protection strategies; sexual abuse experiences; and sequelae of sexual abuse. Most participants reported unwanted or abusive sexual experiences. They described sequelae such as difficulties with sex and relationships, and anxiety and depression. They described themselves as having inadequate self protection skills and difficulty repo...
Journal of Applied Research in Intellectual Disabilities, 2014
Background The vast health inequities experienced by people with intellectual disability remain i... more Background The vast health inequities experienced by people with intellectual disability remain indisputable. Persistent and contemporary challenges exist for primary healthcare providers and researchers working to contribute to improvements to the health and wellbeing of people with intellectual disability. Over two decades after the only review of supports for primary healthcare providers was published, this paper contributes to an evolving research agenda that aims to make meaningful gains in health-related outcomes for this group. Methods The present authors updated the existing review by searching the international literature for developments and evaluations of multinational models of care. Results Based on our review, we present three strategies to support primary healthcare providers: (i) effectively using what we know, (ii) considering other strategies that offer support to primary healthcare professionals and (iii) researching primary health care at the system level. Conclusions Strengthening primary care by supporting equitable provision of health-related care for people with intellectual disability is a much needed step towards improving health outcomes among people with intellectual disability. More descriptive quantitative and qualitative research, as well as intervention-based research underpinned by rigorous mixed-methods evaluating these strategies at the primary care level, which is sensitive to the needs of people with intellectual disability will assist primary care providers to provide better care and achieve better health outcomes.
Objectives: To determine the accuracy of routine identification of Aboriginal and Torres Strait I... more Objectives: To determine the accuracy of routine identification of Aboriginal and Torres Strait Islander womenconfining at King George V (KGV) Hospital, located in Sydney, Australia.Design: Interviewer-administered survey.Participants: Consecutive sample of women who delivered live, well infants from May to July 1999.Main Outcome Measure: Comparison of hospital documentation compared with confidential self-disclosureof Aboriginal or Torres Strait Islander status to a female Aboriginal health professional.Results: Of 536 women in our sample, 29 (5%) self-disclosed as being Aboriginal or Torres Strait Islander.Only 10 of these were identified as Aboriginal or Torres Strait Islander in hospital records (p<0.001). While specificity as determined by us was 100%, sensitivity was low (34.5%). Those Aboriginal and Torres Strait Islander women referred by another organisation were significantly more likely than those who self-referred to the hospital to be correctly identified (p=0.011). ...
Health Education in Practice: Journal of Research for Professional Learning
Purpose: To explore the association of Australian general practitioner (GP) registrars’ responses... more Purpose: To explore the association of Australian general practitioner (GP) registrars’ responses to uncertainty with their in-consultation information-, advice- and assistance-seeking.Design/methodology/approach: A cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) cohort study in four Australian states. In ReCEnT, GP registrars record details of 60 consecutive consultations, six-monthly, three times during training.Outcome factors in logistic regression models included whether the registrar sought in-consultation information or assistance from (i) their supervisor or (ii) an electronic or paper-based source. Independent variables were the four independent subscales of the Physicians’ Reaction to Uncertainty (PRU) instrument, as well as registrar, practice and consultation variables.Findings: 589 registrars contributed details of 70,412 consultations.On multivariable analysis, scores on the two ‘affective’ PRU subscales ‘anxiety regarding d...
ClinicoEconomics and Outcomes Research: CEOR, 2017
Background Chronic hepatitis C remains a major global health burden with serious long-term conseq... more Background Chronic hepatitis C remains a major global health burden with serious long-term consequences if left untreated. Recently the treatment standard of care has shifted to new interferon (IFN)-free drug regimens, which have been shown to be safe and effective. The aim of our study was to assess and compare medical resource utilization and costs of successfully treating patients with IFN-based and IFN-free therapies in Australia. Methods We performed a retrospective chart review of 30 HCV-infected patients successfully treated with IFN-based therapy between 2013 and 2015. We also generated a model for a virtual group of 100 genotype 1 (GT1) and 100 genotype 3 (GT3) patients treated with IFN-free therapy derived from national guidelines and clinical trial data. Results In comparison to virtual patients receiving IFN-free therapy, our IFN-treated patients on average had distinctively more liver clinic visits and blood tests. However, mean total cost per patient was $19,164 and $8...
Background: Advanced (50-99%) carotid stenosis (CS) causes about 10% of all strokes and affects a... more Background: Advanced (50-99%) carotid stenosis (CS) causes about 10% of all strokes and affects about 10% of people by their eighth decade (Abbott et al. 2007). The stroke risk associated with advanced asymptomatic CS has fallen over the last 3-4 decades by >65% using medical intervention alone (lifestyle modification and medication) (Abbott 2009; Abbott et al. 2017). Medical intervention alone is now best for asymptomatic CS with improved outcomes also expected for symptomatic persons and all at risk from arterial disease (Abbott 2009; Abbott et al. 2017). However, most guidelines do not reflect the necessary shift from carotid procedures to primary care services (Abbott et al. 2015). Further, medical intervention is a combined strategy targeting different risk factors. Relevant evidence has evolved over decades across many specialties causing confusion and uncertainty over what now constitutes best medical intervention. Aim/Objectives: To create a guideline in collaboration with the International Union of Angiology that overcomes procedural biases and objectively characterises current optimal medical intervention for arterial disease prevention. Methods: Methods to overcome guideline procedural biases consist of correcting the problems with existing guidelines (Abbott et al. 2015). Therefore, our methods include: (1) limiting procedural endorsements to subgroups which benefited in relevant randomised trials; (2) acknowledging all trials of carotid surgery (endarterectomy) are outdated; (3) acknowledging trans-aortic carotid stenting causes more harm than surgery, while variant methods of carotid stenting have not been tested against current optimal medical intervention; (4) including recommendations for proven medical interventions, not just for procedures; (5) using a fair way to rank evidence applicability at the point of care; all guidelines reviewed rank only randomised trial data as best, even if it is outdated or otherwise inadequate or unnecessary to address a clinical question (Abbott et al. 2015); (6) not using procedurally biased terminology; and (7) multinational , multi-stakeholder participation (including physicians, surgeons, policy advisors, consumers, pharmacists, nurses and general medical practitioners [GP]). GPs are particularly important in this guideline creation process given their traditional practice of referring people with CS directly to a proceduralist and their critical role in orchestrating non-invasive preventive therapies, and (8) open-access publication. Methods to characterise current optimal medical intervention include performing critical comparative audits of contemporary guidelines for each of the major arterial disease risk factors. Heterogeneity in recommendations will be sought and appropriateness of recommendations tested using guidelinecited and other evidence. This novel analytical method was used with guidelines regarding carotid procedures (Abbott et al. 2015). The process revealed the nature of current best practice and many ways in which guidelines need improvement now (Abbott et al. 2015). There is evidence that critical comparative audits regarding medical interventions will also show inappropriate heterogeneity and means to improvement. For example, sampled guidelines regarding atrial fibrillation (AF) do not limit anticoagulation recommendations to those with recent AND recurrent or persistent AF. This encourages over-treatment. Further, guideline-based automated risk stratification scores give different recommendations for starting lipid lowering medication for primary prevention for the same patient risk factor profiles (Bonner et al. 2018). This implies error in evidence interpretation. Implications: GPs are particularly important in this guideline creation process, and the work's subsequent utilisation, given (1) the traditional practice of many GPs to refer people with carotid arterial disease directly to a proceduralist, and (2) the critical role of GPs in orchestrating non-invasive iv Australian Journal of Primary Health AAAPC Abstracts arterial disease prevention therapies. My presentation will be about explaining my research findings, the translational opportunities offered by this guideline associated work and extending an invitation to GPs to collaborate. Expected benefits of this guideline associated work: (1) challenging the status quo (the 'dangerous' aspect); (2) longer, heathier living for Australians and others; (3) reduced inappropriate treatment, adverse events and hospital admissions; and (4) improved healthcare, research and guideline standards. References Abbott AL (2009) Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis.
Background: The Australian Government released a national strategy for antimicrobial resistance i... more Background: The Australian Government released a national strategy for antimicrobial resistance in 2015 that calls for a collaborative effort to change practices that have contributed to the development of drug-resistant infection and for the implementation of new initiatives to reduce antibiotic use. Although many achievements have been made in antimicrobial stewardship (AMS), particularly in the acute-care hospital setting, progress more broadly has been slow, and novel solutions are now required to improve clinical practice and community awareness. A facilitated workshop was undertaken at the 2019 National Australian Antimicrobial Resistance Forum to explore the complexity of AMS implementation in Australia and to prioritize future action. Methods: Participants engaged in rotating rounds of discussion using a world café format. The participants sat face-to-face at tables of 7 or fewer. At each table were 2 facilitators: one was a note taker and the other was the discussion leader...
Background Depression and anxiety are the most frequent indication for which antidepressants are ... more Background Depression and anxiety are the most frequent indication for which antidepressants are prescribed. Long-term antidepressant use is driving much of the internationally observed rise in antidepressant consumption. Surveys of antidepressant users suggest that 30% to 50% of long-term antidepressant prescriptions had no evidence-based indication. Unnecessary use of antidepressants puts people at risk of adverse events. However, high-certainty evidence is lacking regarding the e ectiveness and safety of approaches to discontinuing longterm antidepressants. Objectives To assess the e ectiveness and safety of approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults. Search methods We searched all databases for randomised controlled trials (RCTs) until January 2020. Selection criteria We included RCTs comparing approaches to discontinuation with continuation of antidepressants (or usual care) for people with depression or anxiety who are prescribed antidepressants for at least six months. Interventions included discontinuation alone (abrupt or taper), discontinuation with psychological therapy support, and discontinuation with minimal intervention. Primary outcomes were successful discontinuation rate, relapse (as defined by authors of the original study), withdrawal symptoms, and adverse events. Secondary outcomes were depressive symptoms, anxiety symptoms, quality of life, social and occupational functioning, and severity of illness. Data collection and analysis We used standard methodological procedures as expected by Cochrane. Approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults (Review)
Homeopathic preparations for preventing and treating acute upper respiratory tract infections in ... more Homeopathic preparations for preventing and treating acute upper respiratory tract infections in children: A systematic review and meta-analysis, Academic Pediatrics (2020), doi:
Background: Atopic dermatitis (AD) is a common presentation in the general practice (GP) setting.... more Background: Atopic dermatitis (AD) is a common presentation in the general practice (GP) setting. Implementation of appropriate referral pathways is instrumental for best patient care and is an essential skill for Australian GP registrars. Objectives: We aimed to explore the prevalence and associations of GP registrar referrals to specialists for AD management. Methods: A cross-sectional analysis utilizing data from the Registrar Clinical Encounters in Training (ReCEnT) project, an ongoing cohort study that documents in-consultation clinical and educational experience of Australian GP registrars. Registrar, patient, and consultation factors associated with referrals for AD were established using logistic regression. Results: A A total of 3,285 (0.55%) of 595,412 diagnoses managed were AD, of which 222 (6.8%) resulted in referral. Of these referrals, 70% were to dermatologists, 17% to allergists/immunologists, and 10% to pediatricians. Associations of referral included registrar fema...
ObjectiveLong-acting reversible contraception (LARC) is the most effective form of contraception ... more ObjectiveLong-acting reversible contraception (LARC) is the most effective form of contraception but use in Australia is low. Uptake of LARC prescribing by early-career general practitioners (GPs) has important implications for community reproductive health. We aimed to investigate the prevalence and associations of Australian GP registrars’ LARC prescribing.MethodsA cross-sectional analysis of the Registrar Clinical Encounters in Training (ReCEnT) cohort study 2010–2017. GP registrars collected data on 60 consecutive consultations on three occasions during their training. The outcome factor was prescription of LARC (compared with non-LARC). A secondary analysis was performed with problems involving prescription of LARC (compared with other problems). Associations with patient, practice, registrar and consultation independent variables were assessed by univariate and multivariable logistic regression.Results1737 registrars recorded 5382 problems/diagnoses involving women aged 12–55 ...
To evaluate whether fatigue severity can serve as a cue to investigate the presence of depression... more To evaluate whether fatigue severity can serve as a cue to investigate the presence of depression in older adult patients with cancer. . Cross-sectional observational cohort study. . Seven hospitals and general practices in Belgium and the Netherlands. . 205 older adult patients with cancer and 436 older adults without cancer (aged 70 years or older). . The diagnostic accuracy of fatigue as a proxy for depression was evaluated using sensitivity, specificity, and predictive values. . Fatigue was measured with a visual analog scale, and depression was measured with the 15-item Geriatric Depression Scale. . Fifty-six percent of the population experienced fatigue, and 13% were depressed. For fatigue as a cue for depression, sensitivity was 82%, specificity was 47%, positive predictive value was 18%, and negative predictive value was 95%. . The data confirm that fatigue is a valuable cue to investigate the presence of depression because 82% of depressed participants were correctly iden...
Vaccines have been shown to cause differential expression of genes and increase antibody titers a... more Vaccines have been shown to cause differential expression of genes and increase antibody titers against antigens. Influenza vaccines may have an effect on unexplained disorders such as Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME). Immunological changes have been identified following immunization with trivalent influenza vaccine (TIV). The objective of this pilot study was to examine the consequences of TIV on cytokine and cytotoxic genes in CFS/ME. Peripheral blood mononuclear cells were preferentially isolated from whole blood of 7 CFS/ME patients and 8 controls. Following total RNA extraction and synthesis of cDNA, reverse transcriptase-quantitative polymerase chain reaction (RT-qPCR) was used to determine the expression levels of mRNAs for cytotoxic genes (perforin (PRF1), granzyme A (GZMA), granzyme B (GZMB) and cytokine genes. GZMB was significantly increased overall in the CFS/ME patients compared to the controls. GZMA was significantly increased 28 days after vaccination while PRF1 was reduced pre-vaccination but increased 14 days post-vaccination in the CFS/ME patients. There were no significant changes in cytokine genes pre or post vaccination. Administration of TIV may increase the expression of lytic genes in CFS/ME and this may contribute to the increase in cytotoxic activity we observed in these patients post vaccination.
Immune dysfunction is a hallmark of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME). ... more Immune dysfunction is a hallmark of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME). The purpose of this pilot study was to identify the effects of influenza vaccination on immune function in patients with CFS/ME. We included 7 patients meeting the Centre for Disease Control and Prevention criteria (CDC 1994) for ME/CFS and 8 control subjects. Bloods were collected from all participants prior to vaccination with Influvac, a trivalent inactivated influenza vaccine (TIV), 14 and 28 days following vaccination. The immune parameters examined include Natural Killer (NK) phenotypes, NK cytotoxic activity, FOXP3 and Th1/Th2/Th17 related cytokines. Flow cytometric protocols were employed. There was no significant difference in NK phenotypes and Tregs numbers between CFS/ME patients and healthy controls. However, NK activity was significantly decreased at baseline and at 28 days, while at 14 days it significantly increased in the CFS/ME patients compared to the healthy controls. Th1 pro-inflammatory cytokines increased considerably in the CFS/ME patients at 28 days compared to the non-fatigued controls. Only one Th2 cytokine, IL-4, increased in the CFS/ME participants. FOXP3 expressing Tregs only increased significantly at day 28 post vaccination in the CFS/ME patients compared to the healthy controls. Self-rated wellbeing was lower for patients at day 28 while at baseline and day 14 no differences were observed. In this pilot study immunization with influenza vaccine is accompanied by a degree of immune dysregulation in CFS/ME patients compared with controls. While vaccination may protect CFS/ME patients against influenza, it has the ability to increase cytotoxic activity and pro-inflammatory reactions post vaccination. The role of Tregs in promoting a toxic effect at 28 days post-vaccination in our patient group cannot be ruled out. The benefits of influenza vaccine still likely outweigh the risks CFS/ME patients experience following vaccination.
The Cochrane database of systematic reviews, Jan 25, 2015
Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated... more Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children with ADHD find it difficult to pay attention, they are hyperactive and impulsive.Methylphenidate is the drug most often prescribed to treat children and adolescents with ADHD but, despite its widespread use, this is the first comprehensive systematic review of its benefits and harms. To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD. In February 2015 we searched six databases (CENTRAL, Ovid MEDLINE, EMBASE, CINAHL, PsycINFO, Conference Proceedings Citations Index), and two trials registers. We checked for additional trials in the reference lists of relevant reviews and included trials. We contacted the pharmaceutical companies that manufacture methylphenidate to request published and unpublished data. We included all randomised controlled trials (RCTs) comparing methylphenidate v...
Background Increasing use of opioid analgesics (OA) has been reported worldwide. Objective To com... more Background Increasing use of opioid analgesics (OA) has been reported worldwide. Objective To compare the use of OA in two countries in order to better understand these trends. Setting Outpatient settings in Australia and The Netherlands. Method We analysed publicly available government data on outpatient OA dispensing over 15 years (2000-2014). We compared dispensing trends for specific OA and explored medical (national clinical guidelines), contextual and policy-related factors to explain differences in use between the two countries. Main outcome measure OA prescribing in Australia and The Netherlands, absolute volume of use, preferred types of opioids and changes over time. Results The average annual increase in OA prescribing was 10% in Australia and 8% in The Netherlands between 2000 and 2014. In 2014, the total use of OA was 10.0 daily defined doses (DDD)/1000 population/day in Australia and 9.4 DDD/1000 population/day in The Netherlands. In Australia, the most commonly prescribed opioids were oxycodone and tramadol, compared to fentanyl and tramadol in The Netherlands. We found differences in prescribing guidelines, culture of prescribing and regulatory frameworks that could explain some of the observed differences. Conclusion OA prescribing has increased remarkably in both countries between 2000 and 2014 but the types of prescribed OA vary. Differences in national evidence-based guidelines influenced the types of OA used. Prescribing culture as well as regulatory policies and costs, may also contribute to the different patterns of OA use.
People with intellectual disability experience difficulty forming intimate relationships and are ... more People with intellectual disability experience difficulty forming intimate relationships and are prone to sexual exploitation and abuse. This study sought information from people involved in the care of adults with intellectual disability regarding how they supported them in the areas of sexuality, relationships and abuse prevention. Semistructured interviews and focus groups were held with 28 family members and paid support workers caring for adults with intellectual disabilities. Interviews and focus groups were audio recorded, transcribed, coded and analysed qualitatively. Major themes emerging included views on sexuality and intellectual disability, consent and legal issues, relationships, sexual knowledge and education, disempowerment, exploitation and abuse, sexual health and parenting. People with intellectual disability were described as lonely, disempowered and vulnerable to abuse. The sex industry, internet and mobile telephones were identified as new forms of risk. While ...
Sexual abuse and abusive relationships are known to be especially common in people with intellect... more Sexual abuse and abusive relationships are known to be especially common in people with intellectual disability. This study explored how women with intellectual disability understand sex, relationships and sexual abuse, the effects of sexual abuse on their lives, and how successfully they protect themselves from abuse. Semistructured narrative interviews with nine women with mild intellectual disability in Queensland, Australia. Interviews were audio recorded, transcribed, coded and analysed qualitatively. Major themes that emerged were: sexual knowledge and sources of knowledge; negotiating sexual relationships; declining unwanted sexual contact; self protection strategies; sexual abuse experiences; and sequelae of sexual abuse. Most participants reported unwanted or abusive sexual experiences. They described sequelae such as difficulties with sex and relationships, and anxiety and depression. They described themselves as having inadequate self protection skills and difficulty repo...
Journal of Applied Research in Intellectual Disabilities, 2014
Background The vast health inequities experienced by people with intellectual disability remain i... more Background The vast health inequities experienced by people with intellectual disability remain indisputable. Persistent and contemporary challenges exist for primary healthcare providers and researchers working to contribute to improvements to the health and wellbeing of people with intellectual disability. Over two decades after the only review of supports for primary healthcare providers was published, this paper contributes to an evolving research agenda that aims to make meaningful gains in health-related outcomes for this group. Methods The present authors updated the existing review by searching the international literature for developments and evaluations of multinational models of care. Results Based on our review, we present three strategies to support primary healthcare providers: (i) effectively using what we know, (ii) considering other strategies that offer support to primary healthcare professionals and (iii) researching primary health care at the system level. Conclusions Strengthening primary care by supporting equitable provision of health-related care for people with intellectual disability is a much needed step towards improving health outcomes among people with intellectual disability. More descriptive quantitative and qualitative research, as well as intervention-based research underpinned by rigorous mixed-methods evaluating these strategies at the primary care level, which is sensitive to the needs of people with intellectual disability will assist primary care providers to provide better care and achieve better health outcomes.
Objectives: To determine the accuracy of routine identification of Aboriginal and Torres Strait I... more Objectives: To determine the accuracy of routine identification of Aboriginal and Torres Strait Islander womenconfining at King George V (KGV) Hospital, located in Sydney, Australia.Design: Interviewer-administered survey.Participants: Consecutive sample of women who delivered live, well infants from May to July 1999.Main Outcome Measure: Comparison of hospital documentation compared with confidential self-disclosureof Aboriginal or Torres Strait Islander status to a female Aboriginal health professional.Results: Of 536 women in our sample, 29 (5%) self-disclosed as being Aboriginal or Torres Strait Islander.Only 10 of these were identified as Aboriginal or Torres Strait Islander in hospital records (p<0.001). While specificity as determined by us was 100%, sensitivity was low (34.5%). Those Aboriginal and Torres Strait Islander women referred by another organisation were significantly more likely than those who self-referred to the hospital to be correctly identified (p=0.011). ...
Health Education in Practice: Journal of Research for Professional Learning
Purpose: To explore the association of Australian general practitioner (GP) registrars’ responses... more Purpose: To explore the association of Australian general practitioner (GP) registrars’ responses to uncertainty with their in-consultation information-, advice- and assistance-seeking.Design/methodology/approach: A cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) cohort study in four Australian states. In ReCEnT, GP registrars record details of 60 consecutive consultations, six-monthly, three times during training.Outcome factors in logistic regression models included whether the registrar sought in-consultation information or assistance from (i) their supervisor or (ii) an electronic or paper-based source. Independent variables were the four independent subscales of the Physicians’ Reaction to Uncertainty (PRU) instrument, as well as registrar, practice and consultation variables.Findings: 589 registrars contributed details of 70,412 consultations.On multivariable analysis, scores on the two ‘affective’ PRU subscales ‘anxiety regarding d...
ClinicoEconomics and Outcomes Research: CEOR, 2017
Background Chronic hepatitis C remains a major global health burden with serious long-term conseq... more Background Chronic hepatitis C remains a major global health burden with serious long-term consequences if left untreated. Recently the treatment standard of care has shifted to new interferon (IFN)-free drug regimens, which have been shown to be safe and effective. The aim of our study was to assess and compare medical resource utilization and costs of successfully treating patients with IFN-based and IFN-free therapies in Australia. Methods We performed a retrospective chart review of 30 HCV-infected patients successfully treated with IFN-based therapy between 2013 and 2015. We also generated a model for a virtual group of 100 genotype 1 (GT1) and 100 genotype 3 (GT3) patients treated with IFN-free therapy derived from national guidelines and clinical trial data. Results In comparison to virtual patients receiving IFN-free therapy, our IFN-treated patients on average had distinctively more liver clinic visits and blood tests. However, mean total cost per patient was $19,164 and $8...
Background: Advanced (50-99%) carotid stenosis (CS) causes about 10% of all strokes and affects a... more Background: Advanced (50-99%) carotid stenosis (CS) causes about 10% of all strokes and affects about 10% of people by their eighth decade (Abbott et al. 2007). The stroke risk associated with advanced asymptomatic CS has fallen over the last 3-4 decades by >65% using medical intervention alone (lifestyle modification and medication) (Abbott 2009; Abbott et al. 2017). Medical intervention alone is now best for asymptomatic CS with improved outcomes also expected for symptomatic persons and all at risk from arterial disease (Abbott 2009; Abbott et al. 2017). However, most guidelines do not reflect the necessary shift from carotid procedures to primary care services (Abbott et al. 2015). Further, medical intervention is a combined strategy targeting different risk factors. Relevant evidence has evolved over decades across many specialties causing confusion and uncertainty over what now constitutes best medical intervention. Aim/Objectives: To create a guideline in collaboration with the International Union of Angiology that overcomes procedural biases and objectively characterises current optimal medical intervention for arterial disease prevention. Methods: Methods to overcome guideline procedural biases consist of correcting the problems with existing guidelines (Abbott et al. 2015). Therefore, our methods include: (1) limiting procedural endorsements to subgroups which benefited in relevant randomised trials; (2) acknowledging all trials of carotid surgery (endarterectomy) are outdated; (3) acknowledging trans-aortic carotid stenting causes more harm than surgery, while variant methods of carotid stenting have not been tested against current optimal medical intervention; (4) including recommendations for proven medical interventions, not just for procedures; (5) using a fair way to rank evidence applicability at the point of care; all guidelines reviewed rank only randomised trial data as best, even if it is outdated or otherwise inadequate or unnecessary to address a clinical question (Abbott et al. 2015); (6) not using procedurally biased terminology; and (7) multinational , multi-stakeholder participation (including physicians, surgeons, policy advisors, consumers, pharmacists, nurses and general medical practitioners [GP]). GPs are particularly important in this guideline creation process given their traditional practice of referring people with CS directly to a proceduralist and their critical role in orchestrating non-invasive preventive therapies, and (8) open-access publication. Methods to characterise current optimal medical intervention include performing critical comparative audits of contemporary guidelines for each of the major arterial disease risk factors. Heterogeneity in recommendations will be sought and appropriateness of recommendations tested using guidelinecited and other evidence. This novel analytical method was used with guidelines regarding carotid procedures (Abbott et al. 2015). The process revealed the nature of current best practice and many ways in which guidelines need improvement now (Abbott et al. 2015). There is evidence that critical comparative audits regarding medical interventions will also show inappropriate heterogeneity and means to improvement. For example, sampled guidelines regarding atrial fibrillation (AF) do not limit anticoagulation recommendations to those with recent AND recurrent or persistent AF. This encourages over-treatment. Further, guideline-based automated risk stratification scores give different recommendations for starting lipid lowering medication for primary prevention for the same patient risk factor profiles (Bonner et al. 2018). This implies error in evidence interpretation. Implications: GPs are particularly important in this guideline creation process, and the work's subsequent utilisation, given (1) the traditional practice of many GPs to refer people with carotid arterial disease directly to a proceduralist, and (2) the critical role of GPs in orchestrating non-invasive iv Australian Journal of Primary Health AAAPC Abstracts arterial disease prevention therapies. My presentation will be about explaining my research findings, the translational opportunities offered by this guideline associated work and extending an invitation to GPs to collaborate. Expected benefits of this guideline associated work: (1) challenging the status quo (the 'dangerous' aspect); (2) longer, heathier living for Australians and others; (3) reduced inappropriate treatment, adverse events and hospital admissions; and (4) improved healthcare, research and guideline standards. References Abbott AL (2009) Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis.
Background: The Australian Government released a national strategy for antimicrobial resistance i... more Background: The Australian Government released a national strategy for antimicrobial resistance in 2015 that calls for a collaborative effort to change practices that have contributed to the development of drug-resistant infection and for the implementation of new initiatives to reduce antibiotic use. Although many achievements have been made in antimicrobial stewardship (AMS), particularly in the acute-care hospital setting, progress more broadly has been slow, and novel solutions are now required to improve clinical practice and community awareness. A facilitated workshop was undertaken at the 2019 National Australian Antimicrobial Resistance Forum to explore the complexity of AMS implementation in Australia and to prioritize future action. Methods: Participants engaged in rotating rounds of discussion using a world café format. The participants sat face-to-face at tables of 7 or fewer. At each table were 2 facilitators: one was a note taker and the other was the discussion leader...
Background Depression and anxiety are the most frequent indication for which antidepressants are ... more Background Depression and anxiety are the most frequent indication for which antidepressants are prescribed. Long-term antidepressant use is driving much of the internationally observed rise in antidepressant consumption. Surveys of antidepressant users suggest that 30% to 50% of long-term antidepressant prescriptions had no evidence-based indication. Unnecessary use of antidepressants puts people at risk of adverse events. However, high-certainty evidence is lacking regarding the e ectiveness and safety of approaches to discontinuing longterm antidepressants. Objectives To assess the e ectiveness and safety of approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults. Search methods We searched all databases for randomised controlled trials (RCTs) until January 2020. Selection criteria We included RCTs comparing approaches to discontinuation with continuation of antidepressants (or usual care) for people with depression or anxiety who are prescribed antidepressants for at least six months. Interventions included discontinuation alone (abrupt or taper), discontinuation with psychological therapy support, and discontinuation with minimal intervention. Primary outcomes were successful discontinuation rate, relapse (as defined by authors of the original study), withdrawal symptoms, and adverse events. Secondary outcomes were depressive symptoms, anxiety symptoms, quality of life, social and occupational functioning, and severity of illness. Data collection and analysis We used standard methodological procedures as expected by Cochrane. Approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults (Review)
Homeopathic preparations for preventing and treating acute upper respiratory tract infections in ... more Homeopathic preparations for preventing and treating acute upper respiratory tract infections in children: A systematic review and meta-analysis, Academic Pediatrics (2020), doi:
Background: Atopic dermatitis (AD) is a common presentation in the general practice (GP) setting.... more Background: Atopic dermatitis (AD) is a common presentation in the general practice (GP) setting. Implementation of appropriate referral pathways is instrumental for best patient care and is an essential skill for Australian GP registrars. Objectives: We aimed to explore the prevalence and associations of GP registrar referrals to specialists for AD management. Methods: A cross-sectional analysis utilizing data from the Registrar Clinical Encounters in Training (ReCEnT) project, an ongoing cohort study that documents in-consultation clinical and educational experience of Australian GP registrars. Registrar, patient, and consultation factors associated with referrals for AD were established using logistic regression. Results: A A total of 3,285 (0.55%) of 595,412 diagnoses managed were AD, of which 222 (6.8%) resulted in referral. Of these referrals, 70% were to dermatologists, 17% to allergists/immunologists, and 10% to pediatricians. Associations of referral included registrar fema...
ObjectiveLong-acting reversible contraception (LARC) is the most effective form of contraception ... more ObjectiveLong-acting reversible contraception (LARC) is the most effective form of contraception but use in Australia is low. Uptake of LARC prescribing by early-career general practitioners (GPs) has important implications for community reproductive health. We aimed to investigate the prevalence and associations of Australian GP registrars’ LARC prescribing.MethodsA cross-sectional analysis of the Registrar Clinical Encounters in Training (ReCEnT) cohort study 2010–2017. GP registrars collected data on 60 consecutive consultations on three occasions during their training. The outcome factor was prescription of LARC (compared with non-LARC). A secondary analysis was performed with problems involving prescription of LARC (compared with other problems). Associations with patient, practice, registrar and consultation independent variables were assessed by univariate and multivariable logistic regression.Results1737 registrars recorded 5382 problems/diagnoses involving women aged 12–55 ...
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Papers by M. Van Driel