Publications by authors named "David Marco"

23 Publications

  • Page 1 of 1

End-of-life care in illicit drug users: mapping medication use.

BMJ Support Palliat Care 2021 May 17. Epub 2021 May 17.

Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.

Background: While clinical wisdom has long provided suggested guidance around caring for people who use illicit drugs (referred to as PWUD) at the end of life, there is striking paucity of empirical evidence underpinning these practices. Understanding medications and doses required to manage symptoms at the end of life is essential to provide effective end-of-life care for these patients. This study aimed to examine the type and dose of medications prescribed to hospitalised patients who use illicit drugs at the end of life, compared with patients without previous or current illicit drug use.

Method: A retrospective medical record review was conducted on consecutive patient deaths between 2012 and 2017 at a metropolitan hospital. PWUD were identified using the International Classification of Diseases 10th Revision codes for illicit drug use. Daily dosage of opioids, benzodiazepines and antipsychotics was documented for the last 3 days of life and compared with a matched comparator group.

Results: PWUD patients (n=55) received higher doses of opioids, midazolam and antipsychotics than comparator patients (n=55) for each day, significant for opioids in the last 24 hours (p=0.01). PWUD patients received a significantly higher total opioid dose (median=480.0 mg vs 255.0 mg) and midazolam (median=15.0 mg vs 5.0 mg) (both p<0.05). Rates of dose escalation did not differ.

Conclusions: Results suggest that PWUD require greater doses of symptom-controlling medications, particularly opioids and midazolam, at the end of life but that rates of dose escalation do not differ greatly. This study provides a foundation for future research to inform clinical guidelines for this cohort of palliative care patients.
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http://dx.doi.org/10.1136/bmjspcare-2021-002906DOI Listing
May 2021

Customized depolarization spatial patterns with dynamic retardance functions.

Sci Rep 2021 May 3;11(1):9415. Epub 2021 May 3.

Departamento de Física, Universitat Autònoma de Barcelona, 08193, Bellaterra, Spain.

In this work we demonstrate customized depolarization spatial patterns by imaging a dynamical time-dependent pixelated retarder. A proof-of-concept of the proposed method is presented, where a liquid-crystal spatial light modulator is used as a spatial retarder that emulates a controlled spatially variant depolarizing sample by addressing a time-dependent phase pattern. We apply an imaging Mueller polarimetric system based on a polarization camera to verify the effective depolarization effect. Experimental validation is provided by temporal integration on the detection system. The effective depolarizance results are fully described within a simple graphical approach which agrees with standard Mueller matrix decomposition methods. The potential of the method is discussed by means of three practical cases, which include non-reported depolarization spatial patterns, including exotic structures as a spirally shaped depolarization pattern.
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http://dx.doi.org/10.1038/s41598-021-88515-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8093234PMC
May 2021

Newly diagnosed seizures assessed at two established first seizure clinics: Clinic characteristics, investigations, and findings over 11 years.

Epilepsia Open 2021 03 13;6(1):171-180. Epub 2021 Jan 13.

Epilepsy Research Centre Department of Medicine (Austin Health) University of Melbourne Melbourne Australia.

Objective: 'First seizure' clinics (FSCs) aim to achieve early expert assessment for individuals with possible new-onset epilepsy. These clinics also have substantial potential for research into epilepsy evolution, outcomes, and costs. However, a paucity of FSCs details has implications for interpretation and utilization of this research.

Methods: We reviewed investigation findings over 11 years (2000-2010) from two established independent FSCs at Austin Health (AH) and Royal Melbourne Hospital (RMH), Australia. These adult clinics are in major public hospitals and operate with similar levels of expertise. Organizational differences include screening and dedicated administration at AH. Included were N = 1555 patients diagnosed with new-onset unprovoked seizures/epilepsy (AH n = 901, RMH n = 654). Protocol-driven interviews and investigations had been recorded prospectively and were extracted from medical records for study.

Results: Median patient age was 37 (IQR 26-52, range 18-94) years (AH 34 vs RMH 42 years;  < .001). Eighty-six percent of patients attended FSC within three weeks postindex seizure (median AH 12 vs RMH 25 days;  < .01). By their first appointment, 42% had experienced ≥2 seizures. An EEG was obtained within three weeks postindex seizure in 73% of patients, demonstrating epileptiform discharges in 25% (AH 33% vs RMH 15%). Seventy-six percent of patients had an MRI within 6 weeks. Of those with imaging (n = 1500), 19% had potentially epileptogenic abnormalities (RMH 28% vs AH 12%;  < .01). At both sites, changes due to previous stroke/hemorrhage were the commonest lesions, followed by traumatic brain injury. ≥WHO level 1 brain tumors diagnosed at presentation comprised a very small proportion (<1%) at each clinic. At both sites, epilepsy type could be determined in 60% of patients; RMH had more focal and AH more generalized epilepsy diagnoses.

Significance: Differences between the clinics' administrative and screening practices may contribute to differences in investigation findings. Insight into these differences will facilitate interpretation and utilization, and planning of future research.
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http://dx.doi.org/10.1002/epi4.12460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7918310PMC
March 2021

End of life in hospitalised prisoners: a group comparison of palliative medicine and hospital use.

BMJ Support Palliat Care 2021 Feb 18. Epub 2021 Feb 18.

Palliative Nexus, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Victoria, Australia.

Background: Providing optimal palliative and end-of-life care for people in prison with advanced progressive disease is a growing challenge. This study aimed to examine hospital and palliative care utilisation for people in prison who are hospitalised during the final 3 months of life and to compare with a disease-matched non-incarcerated patient cohort.

Methods: A retrospective cohort study of people in prison who died between 2009 and 2019 in an Australian public hospital that provides tertiary-level healthcare for 18% of Australia's prison population. Demographic, clinical and service use data were extracted from medical records of eligible patients experiencing incarceration (prison group) and a disease-matched, non-incarcerated patient comparator group (comparator group).

Results: At the time of death, patients in the prison group were aged a median of 20 years younger than the comparator group (median age 58 vs 78 years, p<0.01). The prison group experienced more than double the mean length of acute care hospital stay at the end of life. A higher proportion of patients in the prison group experienced an intensive care unit episode (22% vs 12%). More than two-thirds (71%) of the prison group patients were seen by palliative care prior to death, similar to the comparator group (p=0.44). Those transferred to the palliative care unit had a shorter length of stay and were admitted later, just prior to death (median 5 vs 8 days).

Conclusions: People in prison have prolonged acute care public hospital stays and are more likely to experience escalation of care at the end of life. Future opportunity may exist for increased access to formal subacute care settings for people in prison with life-limiting illness to receive optimal palliative and end-of-life care.
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http://dx.doi.org/10.1136/bmjspcare-2020-002703DOI Listing
February 2021

Measuring the spatial deformation of a liquid-crystal on silicon display with a self-interference effect.

Opt Lett 2020 Aug;45(16):4480-4483

We present a simple technique to characterize the spatial non-uniformity of a liquid-crystal on silicon (LCOS) spatial light modulator (SLM). It is based on illuminating the display with a wavelength out of the operation range, so there is a significant reflection at the output surface. As a consequence, a Gires-Tournois interferometer is directly created, without any alignment requirement and insensitive to vibrations. The beam reflected at the output surface is the reference beam, while the beam reflected at the silicon backplane is modulated with the addressed gray level in order to quantitatively derive its deformation. We provide an experimental demonstration using a LCOS-SLM designed to operate in the near-infrared range but illuminated with visible light.
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http://dx.doi.org/10.1364/OL.396105DOI Listing
August 2020

Complexities and Constraints in End-of-Life Care for Hospitalized Prisoner Patients.

J Pain Symptom Manage 2020 11 25;60(5):984-991.e1. Epub 2020 May 25.

Palliative Nexus, St Vincent's Hospital Melbourne, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Parkville Integrated Palliative Care Service, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Australia.

Context: Managing the care of an increasing and aging prisoner population, including providing palliative and end-of-life care, is a challenge worldwide. There is little known about the views of health professionals who provide palliative care to hospitalized prisoner patients.

Objectives: To explore experiences and perspectives of health professionals regarding the provision of palliative and end-of-life care for hospitalized prisoner patients.

Methods: A qualitative study involving semistructured focus groups and interviews with 54 medical, nursing, and allied health staff engaged in the care of hospitalized prisoner patients. Purposive sampling from a metropolitan teaching hospital responsible for providing secondary and tertiary health care for prisoners in Victoria, Australia, for 40 years was used to identify and seek perspectives of staff from a variety of clinical disciplines. Inductive thematic analysis was conducted by two researchers.

Results: Participants described significant constraints in how they provide palliative care to hospitalized prisoners. Key themes emerged describing constraints on prisoner health decisions, provision and place of care, patient advocacy, and how care is delivered in the last days of life. Participants highlighted a deep philosophical tension between prison constraints and the foundational principles of palliative care.

Conclusion: Clarity of correctional service processes, protocols, and aspects of security and related training for health professionals is needed to ensure improved care for prisoners with progressive and life-limiting illness. Further research is required to seek the views of prisoners facing end of life and their families.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.05.024DOI Listing
November 2020

A Simple Clinical Tool for Stratifying Risk of Clinically Significant CKD after Nephrectomy: Development and Multinational Validation.

J Am Soc Nephrol 2020 05 1;31(5):1107-1117. Epub 2020 Apr 1.

Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.

Background: Clinically significant CKD following surgery for kidney cancer is associated with increased morbidity and mortality, but identifying patients at increased CKD risk remains difficult. Simple methods to stratify risk of clinically significant CKD after nephrectomy are needed.

Methods: To develop a tool for stratifying patients' risk of CKD arising after surgery for kidney cancer, we tested models in a population-based cohort of 699 patients with kidney cancer in Queensland, Australia (2012-2013). We validated these models in a population-based cohort of 423 patients from Victoria, Australia, and in patient cohorts from single centers in Queensland, Scotland, and England. Eligible patients had two functioning kidneys and a preoperative eGFR ≥60 ml/min per 1.73 m. The main outcome was incident eGFR <45 ml/min per 1.73 m at 12 months postnephrectomy. We used prespecified predictors-age ≥65 years old, diabetes mellitus, preoperative eGFR, and nephrectomy type (partial/radical)-to fit logistic regression models and grouped patients according to degree of risk of clinically significant CKD (negligible, low, moderate, or high risk).

Results: Absolute risks of stage 3b or higher CKD were <2%, 3% to 14%, 21% to 26%, and 46% to 69% across the four strata of negligible, low, moderate, and high risk, respectively. The negative predictive value of the negligible risk category was 98.9% for clinically significant CKD. The statistic for this score ranged from 0.84 to 0.88 across derivation and validation cohorts.

Conclusions: Our simple scoring system can reproducibly stratify postnephrectomy CKD risk on the basis of readily available parameters. This clinical tool's quantitative assessment of CKD risk may be weighed against other considerations when planning management of kidney tumors and help inform shared decision making between clinicians and patients.
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http://dx.doi.org/10.1681/ASN.2019121328DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7217412PMC
May 2020

Author reply.

Intern Med J 2019 08;49(8):1056-1057

Centre for Palliative Care, St Vincent's Hospital, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1111/imj.14384DOI Listing
August 2019

Optimal triplicator design applied to a geometric phase vortex grating.

Opt Express 2019 May;27(10):14472-14486

In this work, a geometric phase liquid-crystal diffraction grating based on the optimal triplicator design is realized, i.e., a phase-only profile that generates three diffraction orders with equal intensity and maximum diffraction efficiency. We analyze the polarization properties of this special diffraction grating and then use embedded spiral phases to design geometric phase vortex diffraction gratings. Finally, the fabrication of a two-dimensional version of such a design using a micro-patterned half-wave retarder is demonstrated, where the phase distribution is encoded as the orientation of the fast axis of the retarder. This proof-of-concept element is made of liquid crystal on BK7 substrate where the orientation of the LC is controlled via photoalignment, using a commercially available fabrication facility. Experimental results demonstrate the parallel generation of vortex beams with different topological charge and different states of polarization.
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http://dx.doi.org/10.1364/OE.27.014472DOI Listing
May 2019

Incident Chronic Kidney Disease After Radical Nephrectomy for Renal Cell Carcinoma.

Clin Genitourin Cancer 2019 06 15;17(3):e581-e591. Epub 2019 Mar 15.

QIMR Berghofer Medical Research Institute, Brisbane, Australia; University of Queensland, Brisbane, Australia.

Background: Chronic kidney disease (CKD) after surgery for kidney cancer is common, and is associated with increased morbidity and mortality. This study aimed to identify factors associated with incident CKD in patients managed with radical nephrectomy.

Patients And Methods: All patients diagnosed with renal cell carcinoma between January 2012 and December 2013 were ascertained from state-based cancer registries in Queensland and Victoria. Information on patient, tumor, and health service characteristics was obtained via chart review. Multivariable logistic regression was used to evaluate exposures associated with incident CKD (estimated glomerular filtration rate [eGFR] <60 mL per minute per 1.73 m) at 12 months after nephrectomy.

Results: Older age (adjusted odds ratio [aOR] per 5-year increase, 1.5; 95% confidence interval [CI], 1.4-1.6), male sex (aOR, 1.4; 95% CI, 1.0-2.0), obese compared with not obese (aOR, 1.8; 95% CI, 1.2-2.7), rural compared with urban place of residence (aOR, 1.8; 95% CI, 1.1-3.0) were associated with a higher risk of incident CKD. Lower preoperative eGFR was also associated with a higher risk of incident CKD. Management in private compared with public hospitals was also associated with a higher risk of CKD (aOR, 1.6; 95% CI, 1.2-2.2). Factors related to tumor size and cancer severity were also associated with worse postoperative kidney function, although it is likely this was a consequence of selection bias.

Conclusion: Patient characteristics have the strongest associations with incident CKD after radical nephrectomy. Potential risk factors were reasonably similar to recognized CKD risk factors for the general population. Patients who undergo nephrectomy who have CKD risk factors might benefit from ongoing postoperative screening for deterioration of kidney function.
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http://dx.doi.org/10.1016/j.clgc.2019.02.011DOI Listing
June 2019

Recognising and managing dying patients in the acute hospital setting: can we do better?

Intern Med J 2019 Jan;49(1):119-122

Centre for Palliative Care, Victoria, Australia.

Healthcare professionals have limited formal end-of-life care training despite the large proportion of hospital deaths. A retrospective review of 201 acute hospital deaths revealed 166 (82.6%) had documentation to suggest the patient was dying but this was performed late with a median time between documentation and death of 0.84 days. Furthermore, 132 (66%) patients received an intervention in the final 48 h of life. This highlights the need to improve the recognition and management of dying patients in acute hospitals.
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http://dx.doi.org/10.1111/imj.14177DOI Listing
January 2019

The impact of cancer type, treatment, and distress on health-related quality of life: cross-sectional findings from a study of Australian cancer patients.

Support Care Cancer 2019 Sep 19;27(9):3421-3429. Epub 2019 Jan 19.

School of Psychology, Deakin University, Melbourne, Victoria, 3125, Australia.

Purpose: This study examined the mediating effects of cancer type, treatment, and distress on health-related quality of life (HRQoL) for early diagnosis cancer patients. Results were interpreted with respect to established thresholds for clinical meaningfulness.

Methods: A cross-sectional design was used. Patients completed surveys collecting demographics, cancer type, treatment, comorbid conditions, distress (HADS), and HRQoL (FACT-G). Hierarchical multivariate regressions examined associations between cancer type, treatment, and distress on HRQoL. Established minimum differences were used to identify clinically meaningful changes in HRQoL.

Results: Of the 1183 patients surveyed, 21% were classified as having elevated anxiety and 13% had elevated depression. Our sample reported significantly lower physical and emotional well-being compared to population norms. Patients with prostate, melanoma, gynaecological, and urological cancers had higher HRQoL scores than those with colorectal cancer. However, when effects for treatment type and distress were considered, differences between cancer types became non-significant. Anxiety and depression were associated with lower HRQoL scores as was chemotherapy. Only depression, anxiety, and chemotherapy were associated with clinically meaningful decreases in HRQoL scores.

Conclusions: While statistically significant differences in HRQoL were found between different cancer types, only chemotherapy, anxiety, and depression produced clinically meaningful poorer HRQoL scores. In practice, clinically meaningful differences could promote a shift in resources toward interventions where a positive effect on patient well-being is appreciated by both the patient and health professional.
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http://dx.doi.org/10.1007/s00520-018-4625-zDOI Listing
September 2019

Age at diagnosis and the surgical management of small renal carcinomas: findings from a cross-sectional population-based study.

BJU Int 2018 11;122 Suppl 5:50-61

QIMR Berghofer Medical Research Institute, Brisbane, Qld, Australia.

Objectives: To describe the use of partial nephrectomy (PN) for patients with stage T1a renal cell carcinoma (RCC) by age group (<65 and ≥65 years) in two Australian states.

Materials And Methods: All adults diagnosed with RCC in 2012 and 2013 were identified through population-based cancer registries in the Australian states of Queensland and Victoria. For each patient, research assistants extracted patient, tumour and treatment data from medical records. Percentages of patients treated by PN were determined for the two age groups. Multivariable logistic regression analyses examined factors associated with PN. Clinicians treating RCC were sent surveys to assess attitudes towards PN.

Results: Data were collected on 956 patients (Victoria: n = 548; Queensland: n = 404) with stage T1a RCC. Of those undergoing surgery (n = 865), PN was more common for those aged <65 years (61%) than for those aged ≥65 years (44%), with this difference significant after adjusting for patient, tumour (odds ratio 0.50, 95% confidence interval 0.36-0.70). There were significant interactions between age and treatment centre volume (P < 0.05) and residential state (P < 0.05). PN was less likely for younger patients treated at lower-volume hospitals (<24 patients a year) but hospital volume was not associated with PN for older patients. PN was less likely for older patients in Queensland than Victoria. In multivariable analyses, age was not related to laparoscopic surgery. Queensland clinicians were less likely than those from Victoria to agree that PN was the treatment of choice for most T1aN0M0 tumours (P < 0.001).

Conclusions: In Australia, patients aged > 65 years with small renal cancers were less likely to be treated by PN than younger patients. The variation in the surgical procedure used to treat older T1a RCC patients by state and hospital volume indicates that better evidence is needed to direct practice in this area.
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http://dx.doi.org/10.1111/bju.14585DOI Listing
November 2018

Predictors of new-onset chronic kidney disease in patients managed surgically for T1a renal cell carcinoma: An Australian population-based analysis.

J Surg Oncol 2018 Jun 22;117(7):1597-1610. Epub 2018 May 22.

QIMR Berghofer Medical Research Institute, Brisbane, Australia.

Background: New-onset chronic kidney disease (CKD) following surgical management of kidney tumors is common. This study evaluated risk factors for new-onset CKD after nephrectomy for T1a renal cell carcinoma (RCC) in an Australian population-based cohort.

Methods: There were 551 RCC patients from the Australian states of Queensland and Victoria included in this study. The primary outcome was new-onset CKD (eGFR <60 mL/min per 1.73 m ) and the secondary outcome was new-onset moderate-severe CKD (<45 mL/min per 1.73 m ). Multivariable logistic regression was used to evaluate associations between patient, tumor and health-service characteristics and these outcomes.

Results: Forty percent (219/551) of patients developed new-onset CKD, and 12% (68/551) experienced new-onset moderate-severe CKD. Risk factors for new-onset CKD were age, lower preoperative eGFR, tumor size >20 mm, radical nephrectomy, lower hospital caseloads (<20 cases/year), and rural place of residence. The associations between rural place of residence and low center volume were a consequence of higher radical nephrectomy rates.

Conclusion: Risk factors for CKD after nephrectomy generally relate to worse baseline health, or likelihood of undergoing radical nephrectomy. Surgeons in rural centres and hospitals with low caseloads may benefit from formalized integration with specialist centers for continued professional development and case-conferencing, to assist in management decisions.
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http://dx.doi.org/10.1002/jso.25037DOI Listing
June 2018

Integrating referral to community-based cancer information and support services in a hospital setting.

Support Care Cancer 2018 Mar 17;26(3):787-795. Epub 2017 Sep 17.

Cancer Council Victoria, 615 St Kilda Rd, Melbourne, VIC, 3004, Australia.

Purpose: To implement and evaluate a hospital-based referral mechanism to increase patient uptake of community-based cancer information and support services. Feasibility and acceptability of the intervention and education program was evaluated. Changes in usage of Cancer Council Victoria's cancer information and support telephone line were investigated.

Methods: A 6-month study was conducted in one metropolitan and one regional cancer treatment hospital. Clinicians attended an education session regarding referral mechanisms to Cancer Council support services. Clinicians completed a questionnaire, and consenting patients participated in a semi-structured telephone interview for the project evaluation. The number of calls made from patients at study sites was monitored.

Results: Fifty-two clinicians were trained and referred a total of 430 patients to the cancer information and support service during the study period. Calls from patients increased by up to 100% per month from baseline following the implementation of the referral mechanism. Staff evaluations showed support for the referral mechanism and its incorporation into routine practice. Interviews were conducted with 45 patients; most remembered receiving the referral and were positive towards the intervention. Common reasons patients gave for not acting on the referral included forgetting, lack of need, timing and burden of information.

Conclusions: There is preliminary evidence that this intervention increases awareness and uptake of community-based cancer information and support services. Ongoing clinician education and improvements in patient-clinician communication are important for effective translation from referral to service uptake. Consideration of the most appropriate time in a patients' care trajectory to introduce a referral is warranted.
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http://dx.doi.org/10.1007/s00520-017-3890-6DOI Listing
March 2018

The Role of Red Blood Cell Distribution Width for Predicting 1-year Mortality in Patients Admitted to the Emergency Department with Severe Dyspnoea.

J Med Biochem 2017 Jan 25;36(1):32-38. Epub 2017 Jan 25.

Section of Clinical Biochemistry, University of Verona, Verona, Piazzale LA Scuro, 37100 - Verona, Italy.

Background: Universally accepted and validated instruments for predicting the outcome of patients presenting to the emergency department (ED) with severe dyspnoea do not exist so far, nor are they regularly used by the emergency physicians. This study hence aimed to establish whether red blood cell distribution width (RDW) may be a predictive parameter of 1-year mortality in a population of patients admitted to the ED with severe dyspnoea attributable to different underlying disorders.

Methods: We retrospectively evaluated all the patients undergoing arterial blood gas analysis for severe dyspnoea (irrespective of the cause) during admission to ED of University Hospital of Verona from September 1, 2014 to November 31, 2014.

Results: The final study population consisted of 287 patients for whom complete clinical and laboratory information was available. Overall, 36 patients (12.5%) died after a 1-year follow-up. The RDW value was found to be considerably increased in patients who deceased during the follow-up compared to those who survived (17.2% versus 14.8%; p<0.001). In both univariate and multivariate analyses, the RDW value was found to be a significant predictor of 1-year mortality. In particular, patients with RDW ≥ 15.0% displayed a 72% increased risk of 1-year mortality after multiple adjustments.

Conclusions: The measurement of RDW, a very simple and inexpensive laboratory parameter, may represent an important factor for predicting medium-term mortality in patients presenting to the ED with severe dyspnoea.
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http://dx.doi.org/10.1515/jomb-2016-0026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5471657PMC
January 2017

Trends in the surgical management of stage 1 renal cell carcinoma: findings from a population-based study.

BJU Int 2017 11 9;120 Suppl 3:6-14. Epub 2017 Jun 9.

Cancer Council Victoria, Melbourne, Vic., Australia.

Objectives: To determine whether the use of nephron-sparing surgery (NSS) for treatment of stage 1 renal cell carcinoma (RCC) changed between 2009 and the end of 2013 in Australia.

Patients And Methods: All adult cases of RCC diagnosed in 2009, 2012 and 2013 were identified through the population-based Victorian Cancer Registry. For each identified patient, trained data-abstractors attended treating hospitals or clinician rooms to extract tumour and treatment data through medical record review. Multivariable logistic regression analyses were carried out to examine the significance of change in use of NSS over time, after adjusting for potential confounders.

Results: A total of 1 836 patients with RCC were identified. Of these, the proportion of cases with stage 1 tumours was 64% in 2009, 66% in 2012 and 69% in 2013. For T1a tumours, the proportion of patients residing in metropolitan areas receiving NSS increased from 43% in 2009 to 58% in 2012 (P < 0.05), and 69% in 2013 (P < 0.05). For patients residing in non-metropolitan areas, the proportion receiving NSS increased from 27% in 2009 to 49% in 2012, and 61% in 2013 (P < 0.01). Univariable logistic regression showed patients with moderate (odds ratio [OR] 0.57, 95% confidence interval [CI] 0.35-0.94) or severe comorbidities (OR 0.58, 95% CI 0.33-0.99), residing in non-metropolitan areas (OR 0.65, 95% CI 0.47-0.90), were less likely to be treated by NSS, while those attending high-volume hospitals (≥30 cases/year: OR 1.79, 95% CI 1.21-2.65) and those with higher socio-economic status (OR 1.45, 95% CI 1.02-2.07) were more likely to be treated by NSS. In multivariable analyses, patients with T1a tumours in 2012 (OR 2.00, 95% CI 1.34-2.97) and 2013 (OR 3.15, 95% CI 2.13-4.68) were more likely to be treated by NSS than those in 2009. For T1b tumours, use of NSS increased from 8% in 2009 to 20% in 2013 (P < 0.05).

Conclusion: This population-based study of the management of T1 renal tumours in Australia found that the use of NSS increased over the period 2009 to 2013. Between 2009 and 2013 clinical practice for the treatment of small renal tumours in Australia has increasingly conformed to international guidelines.
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http://dx.doi.org/10.1111/bju.13889DOI Listing
November 2017

Mind the gap: Multiple events and lengthy delays before presentation with a "first seizure".

Epilepsia 2015 Oct 31;56(10):1534-41. Epub 2015 Aug 31.

Department of Medicine, Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.

Objective: Up to half of patients assessed for suspected new-onset epileptic seizures report previous undiagnosed events. This suggests that delay to timely and expert assessment is a major issue. Very little is known about the degree of delay or nature of the undiagnosed events, impacting on our understanding of new-onset epilepsy. In this study we aimed to examine events that occur before presentation, as well as the extent and risk factors for delay to assessment.

Method: Included in this retrospective study were 220 patients diagnosed at the First Seizure Clinic (Austin Health, Australia) between 2003 and 2006 with an epileptic index seizure. Patients with a prior diagnosis of epileptic seizures were excluded. Chart review was undertaken, including detailed interviews conducted by an epileptologist at first assessment. Logistic regression assessed risk factors for delay from first event to presentation, including event characteristics, socioeconomic disadvantage, employment, and distance to medical facility.

Results: Forty-one percent (n = 90) of patients had one or more event before their index seizure. Of these, 50% had multiple or more than five prior events and 28% experienced one or more convulsive event before the index seizure. Of the total 220 patients, 36% had delayed presentation >4 weeks, 21% delayed >6 months, and 14% delayed >2 years. First events without convulsions or features likely to disrupt behaviour were strongly associated with delay (p = <0.001). Relative socioeconomic disadvantage was also associated with delay to presentation (p = 0.04).

Significance: Our findings suggest a gap in early diagnosis and care in a sizable proportion of new-onset cases, despite a "first world" urban environment and the availability of free basic medical care. Delay appears particularly likely when events are nonconvulsive or low-impact, suggesting that these seizure types may be underrepresented in studies of new-onset epilepsy. This has implications for our understanding of the incidence, evolution, impact, and treatment response of new-onset epilepsy.
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http://dx.doi.org/10.1111/epi.13127DOI Listing
October 2015

The musical environment and auditory plasticity: hearing the pitch of percussion.

Front Psychol 2013 24;4:768. Epub 2013 Oct 24.

Melbourne School of Psychological Sciences, The University of Melbourne Melbourne, VIC, Australia.

Although musical skills clearly improve with training, pitch processing has generally been believed to be biologically determined by the behavior of brain stem neural mechanisms. Two main classes of pitch models have emerged over the last 50 years. Harmonic template models have been used to explain cross-channel integration of frequency information, and waveform periodicity models have been used to explain pitch discrimination that is much finer than the resolution of the auditory nerve. It has been proposed that harmonic templates are learnt from repeated exposure to voice, and so it may also be possible to learn inharmonic templates from repeated exposure to inharmonic music instruments. This study investigated whether pitch-matching accuracy for inharmonic percussion instruments was better in people who have trained on these instruments and could reliably recognize their timbre. We found that adults who had trained with Indonesian gamelan instruments were better at recognizing and pitch-matching gamelan instruments than people with similar levels of music training, but no prior exposure to these instruments. These findings suggest that gamelan musicians were able to use inharmonic templates to support accurate pitch processing for these instruments. We suggest that recognition mechanisms based on spectrotemporal patterns of afferent auditory excitation in the early stages of pitch processing allow rapid priming of the lowest frequency partial of inharmonic timbres, explaining how music training can adapt pitch processing to different musical genres and instruments.
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http://dx.doi.org/10.3389/fpsyg.2013.00768DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3807563PMC
November 2013

Consonance and pitch.

J Exp Psychol Gen 2013 Nov 7;142(4):1142-58. Epub 2013 Jan 7.

School of Psychological Sciences.

To date, no consensus exists in the literature as to theories of consonance and dissonance. Experimental data collected over the last century have raised questions about the dominant theories that are based on frequency relationships between the harmonics of music chords. This study provides experimental evidence that strongly challenges these theories and suggests a new theory of dissonance based on relationships between pitch perception and recognition. Experiment 1 shows that dissonance does not increase with increasing numbers of harmonics in chords as predicted by Helmholtz's (1863/1954) roughness theory, nor does it increase with fewer pitch-matching errors as predicted by Stumpf's (1898) tonal fusion theory. Dissonance was strongly correlated with pitch-matching error for chords, which in turn was reduced by chord familiarity and greater music training. This led to the proposition that long-term memory templates for common chords assist the perception of pitches in chords by providing an estimate of the chord intervals from spectral information. When recognition mechanisms based on these templates fail, the spectral pitch estimate is inconsistent with the period of the waveform, leading to cognitive incongruence and the negative affect of dissonance. The cognitive incongruence theory of dissonance was rigorously tested in Experiment 2, in which nonmusicians were trained to match the pitches of a random selection of 2-pitch chords. After 10 training sessions, they rated the chords they had learned to pitch match as less dissonant than the unlearned chords, irrespective of their tuning, providing strong support for a cognitive mechanism of dissonance.
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http://dx.doi.org/10.1037/a0030830DOI Listing
November 2013

Pitch and plasticity: insights from the pitch matching of chords by musicians with absolute and relative pitch.

Brain Sci 2013 Dec 3;3(4):1615-34. Epub 2013 Dec 3.

Melbourne School of Psychological Sciences, The University of Melbourne, Victoria 3010, Australia.

Absolute pitch (AP) is a form of sound recognition in which musical note names are associated with discrete musical pitch categories. The accuracy of pitch matching by non-AP musicians for chords has recently been shown to depend on stimulus familiarity, pointing to a role of spectral recognition mechanisms in the early stages of pitch processing. Here we show that pitch matching accuracy by AP musicians was also dependent on their familiarity with the chord stimulus. This suggests that the pitch matching abilities of both AP and non-AP musicians for concurrently presented pitches are dependent on initial recognition of the chord. The dual mechanism model of pitch perception previously proposed by the authors suggests that spectral processing associated with sound recognition primes waveform processing to extract stimulus periodicity and refine pitch perception. The findings presented in this paper are consistent with the dual mechanism model of pitch, and in the case of AP musicians, the formation of nominal pitch categories based on both spectral and periodicity information.
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http://dx.doi.org/10.3390/brainsci3041615DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4061894PMC
December 2013

Pitch enumeration: failure to subitize in audition.

PLoS One 2012 2;7(4):e33661. Epub 2012 Apr 2.

School of Psychological Sciences, The University of Melbourne, Melbourne, Australia.

Background: Subitizing involves recognition mechanisms that allow effortless enumeration of up to four visual objects, however despite ample resolution experimental data suggest that only one pitch can be reliably enumerated. This may be due to the grouping of tones according to harmonic relationships by recognition mechanisms prior to fine pitch processing. Poorer frequency resolution of auditory information available to recognition mechanisms may lead to unrelated tones being grouped, resulting in underestimation of pitch number.

Methods, Results And Conclusion: We tested whether pitch enumeration is better for chords of full harmonic complex tones, where grouping errors are less likely, than for complexes with fewer and less accurately tuned harmonics. Chords of low familiarity were used to mitigate the possibility that participants would recognize the chord itself and simply recall the number of pitches. We found that accuracy of pitch enumeration was less than the visual system overall, and underestimation of pitch number increased for stimuli containing fewer harmonics. We conclude that harmonically related tones are first grouped at the poorer frequency resolution of the auditory nerve, leading to poor enumeration of more than one pitch.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0033661PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3317777PMC
July 2012

Robotic-assisted laparoscopic sacrocolpopexy for treatment of vaginal vault prolapse.

Urology 2004 Feb;63(2):373-6

Department of Urology, Mayo Clinic, Rochester, Minnesota 55901, USA.

Introduction: To describe and demonstrate the use and benefit of robotic-assisted laparoscopic sacrocolpopexy in the treatment of posthysterectomy vaginal vault prolapse.

Technical Considerations: The procedure combines the use of standard laparoscopy with the daVinci robotic system. The patient is placed in the dorsal lithotomy position. One camera port, two robotic ports, and two standard laparoscopic ports are placed transperitoneally. Standard laparoscopic dissection, in combination with an intravaginal retractor, is used for initial anterior and posterior vaginal mobilization and exposure of the sacral promontory. The daVinci robot is then docked and used to suture a silicone Y-shaped graft from the vagina to the sacral promontory. Culdoplasty, with plication of the uterosacral ligaments, is then performed, with the final step, retroperitonealization of the graft.

Conclusions: A total of 5 women have undergone this procedure, 3 with concomitant pubovaginal sling placement. All 5 women were discharged after 24 hours. No complications from the sacrocolpopexy were reported; however, 1 patient experienced transient vaginal bleeding related to the pubovaginal portion of the case. No recurrent anterior, posterior, or apical prolapse has occurred at mean of 4 months of follow-up. Using a robotic system for laparoscopic sacrocolpopexy facilitated precise intracorporeal suture placement so that the procedure could be done in a fashion similar to that of the open method. Robotic-assisted laparoscopic sacrocolpopexy may provide the same long-term durability of open sacrocolpopexy with the benefit of a minimally invasive approach.
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http://dx.doi.org/10.1016/j.urology.2003.09.033DOI Listing
February 2004