Publications by authors named "Emma Hamilton"

70 Publications

The State of Web Accessibility for People with Cognitive Disabilities: A Rapid Evidence Assessment.

Behav Sci (Basel) 2022 Jan 26;12(2). Epub 2022 Jan 26.

ARCOLA Research LLP, London E8 2NW, UK.

Increased digitisation of day-to-day activities was occurring prior to the COVID-19 pandemic. The pandemic only accelerated the virtual shift, making web accessibility an urgent issue, especially for marginalised populations. Despite decades of work to develop, refine, and implement web accessibility standards, people with cognitive disabilities regularly experience many barriers to web accessibility. To inform ongoing work to improve web accessibility for people with cognitive disabilities, a systematic review was conducted. The main question guiding this review is: what are the state-of-the-art of interventions that support web accessibility for citizens, 9 years of age and up, living with cognitive impairment? A set of 50 search strings were entered into three academic databases: SCOPUS, ProQuest, and Web of Science. Systematic screening procedures narrowed the search returns to a total of 45 included papers. A data analysis revealed themes associated with the lived experiences of people with cognitive disabilities, tools for improving web accessibility, and methodological best practices for involving people with cognitive disabilities in research. These findings have immediate implications for ongoing research and the development of meaningful solutions to the problem of web accessibility for people with cognitive disabilities.
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http://dx.doi.org/10.3390/bs12020026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8869505PMC
January 2022

Australian guideline on wound classification of diabetes-related foot ulcers: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease.

J Foot Ankle Res 2021 Dec 3;14(1):60. Epub 2021 Dec 3.

Department of Endocrinology, Royal Prince Alfred Hospital, Camperdown, Australia.

Background: Wound classification systems are useful tools to characterise diabetes-related foot ulcers (DFU) and are utilised for the purpose of clinical assessment, to promote effective communication between health professionals, and to support clinical audit and benchmarking. Australian guidelines regarding wound classification in patients with DFU are outdated. We aimed to adapt existing international guidelines for wound classification to develop new evidence-based Australian guidelines for wound classification in people with diabetes and DFU.

Methods: Recommended NHRMC procedures were followed to adapt suitable International Working Group on the Diabetic Foot (IWGDF) guidelines on wound classification to the Australian health context. Five IWGDF wound classification recommendations were evaluated and assessed according to the ADAPTE and GRADE systems. We compared our judgements with IWGDF judgements to decide if recommendations should be adopted, adapted or excluded in an Australian context. We re-evaluated the quality of evidence and strength of recommendation ratings, provided justifications for the recommendation and outlined any special considerations for implementation, subgroups, monitoring and future research in an Australian setting.

Results: After the five recommendations from the IWGDF 2019 guidelines on the classification of DFUs were evaluated by the panel, two were adopted and three were adapted to be more suitable for Australia. The main reasons for adapting, were to align the recommendations to existing Australian standards of care, especially in specialist settings, to maintain consistency with existing recommendations for documentation, audit and benchmarking and to be more appropriate, acceptable and applicable to an Australian context. In Australia, we recommend the use of the SINBAD system as a minimum standard to document the characteristics of a DFU for the purposes of communication among health professionals and for regional/national/international audit. In contrast to the IWGDF who recommend against usage, in Australia we recommend caution in the use of existing wound classification systems to provide an individual prognosis for a person with diabetes and a foot ulcer.

Conclusions: We have developed new guidelines for wound classification for people with diabetes and a foot ulcer that are appropriate and applicable for use across diverse care settings and geographical locations in Australia.
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http://dx.doi.org/10.1186/s13047-021-00503-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8641146PMC
December 2021

Reduction in femoral neck and total hip bone mineral density following hospitalisation for diabetes-related foot ulceration.

Sci Rep 2021 11 23;11(1):22742. Epub 2021 Nov 23.

Medical School, The University of Western Australia, Perth, Australia.

Management of diabetes-related foot ulceration (DFU) includes pressure offloading resulting in a period of reduced activity. The metabolic effects of this are unknown. This study aims to investigate changes in bone mineral density (BMD) and body composition 12 weeks after hospitalisation for DFU. A longitudinal, prospective, observational study of 22 people hospitalised for DFU was conducted. Total body, lumbar spine, hip and forearm BMD, and total lean and fat mass were measured by dual-energy X-ray absorptiometry (DXA) during and 12 weeks after hospitalisation for DFU. Significant losses in total hip BMD of the ipsilateral limb (- 1.7%, p < 0.001), total hip BMD of the contralateral limb (- 1.4%, p = 0.005), femoral neck BMD of the ipsilateral limb (- 2.8%, p < 0.001) and femoral neck BMD of the contralateral limb (- 2.2%, p = 0.008) were observed after 12 weeks. Lumbar spine and forearm BMD were unchanged. HbA1c improved from 75 mmol/mol (9.2%) to 64 mmol/mol (8.0%) (p = 0.002). No significant changes to lean and fat mass were demonstrated. Total hip and femoral neck BMD decreased bilaterally 12 weeks after hospitalisation for DFU. Future research is required to confirm the persistence and clinical implications of these losses.
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http://dx.doi.org/10.1038/s41598-021-02233-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8611081PMC
November 2021

Establishing the national top 10 priority research questions to improve diabetes-related foot health and disease: a Delphi study of Australian stakeholders.

BMJ Open Diabetes Res Care 2021 11;9(2)

Diabetes Feet Australia, Sydney, New South Wales, Australia.

Introduction: Diabetes-related foot disease is a large cause of the global disease burden yet receives very little research funding to address this large burden. To help address this gap, it is recommended to first identify the consensus priority research questions of relevant stakeholders, yet this has not been performed for diabetes-related foot disease. The aim of this study was to determine the national top 10 priority research questions for diabetes-related foot health and disease from relevant Australian stakeholders.

Research Design And Methods: A modified three-round Delphi online survey design was used to seek opinions from relevant Australian stakeholders including those with diabetes or diabetes-related foot disease or their carers (consumers), health professionals, researchers and industry. Participants were recruited via multiple public invitations and invited to propose three research questions of most importance to them (Round 1), prioritize their 10 most important questions from all proposed questions (Round 2), and then rank questions in order of importance (Round 3).

Results: After Round 1, a total of 226 unique questions were proposed by 210 participants (including 121 health professionals and 72 consumers). Of those participants, 95 completed Round 2 and 69 completed Round 3. The top 10 priority research questions covered a range of topics, including health economics, peripheral neuropathy, education, infection, technology, exercise, and nutrition. Consumers prioritized peripheral neuropathy and prevention-related questions. Health professionals prioritized management-related questions including Australia's First Peoples foot health, health economics and infection questions.

Conclusions: These priority research questions should guide future national research agendas, funding and projects to improve diabetes-related foot disease burdens in Australia and globally. Future research should focus on consumer priority research questions to improve the burden of diabetes-related foot disease on patients and nations. Further research should also investigate reasons for different priorities between consumers and health professionals.
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http://dx.doi.org/10.1136/bmjdrc-2021-002570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8587617PMC
November 2021

Management of diabetes-related foot disease in the outpatient setting during the COVID-19 pandemic.

Intern Med J 2021 Jul;51(7):1146-1150

Multidisciplinary Diabetes Foot Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia.

The use of telephone and/or video consultation in routine management of acute diabetes-related foot disease (DFD) before the coronavirus disease 2019 (COVID-19) pandemic at a tertiary hospital is unprecedented. In March 2020, the Diabetes Feet Australia (DFA) released a national guideline to inform DFD management during the COVID-19 pandemic. The present study aimed to describe the adherence to the DFA guideline of managing acute DFD using telephone and/or video consultation at a Western Australian tertiary hospital during this period. We found >80% adherence rate to the DFA guideline and the management of active DFD using telephone and/or video consultations was feasible and acceptable in carefully selected patients.
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http://dx.doi.org/10.1111/imj.15392DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8447054PMC
July 2021

Cognitive Impairment in People with Diabetes-Related Foot Ulceration.

J Clin Med 2021 Jun 25;10(13). Epub 2021 Jun 25.

Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Murdoch 6150, Australia.

Aims: To determine whether there is an excess of cognitive impairment in patients with type 2 diabetes and foot ulceration.

Methods: 55 patients with type 2 diabetes and foot ulcers attending Multidisciplinary Diabetes Foot Ulcer clinics (MDFU cohort) were compared with 56 patients with type 2 diabetes attending Complex Diabetes clinics (CDC cohort) using commonly used screening tests for cognitive impairment (Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MOCA)), as well as foot self-care, mood and health literacy. MMSE was also compared between the MDFU cohort and a historical community-based cohort of patients with type 2 diabetes (FDS2 cohort).

Results: Median MMSE scores were the same in all three groups (28/30). Median MOCA scores did not differ between the MDFU and CDC cohorts (25/30). There were no significant differences in the percentages of patients with MMSE ≤ 24 or MOCA ≤ 25 between MDFU and CDC cohorts (3.6% versus 10.7%, = 0.27 and 56.4% versus 51.8%, = 0.71, respectively), findings that did not change after adjustment for age, sex, education, diabetes duration, and random blood glucose.

Conclusions: Using conventionally applied instruments, patients with type 2 diabetes and foot ulceration have similar cognition compared with patients without, from either hospital-based clinic or community settings.
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http://dx.doi.org/10.3390/jcm10132808DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8268193PMC
June 2021

Wound healing with "spray-on" autologous skin grafting (ReCell) compared with standard care in patients with large diabetes-related foot wounds: an open-label randomised controlled trial.

Int Wound J 2022 Mar 22;19(3):470-481. Epub 2021 Jun 22.

Multidisciplinary Diabetes Foot Ulcer Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.

There is an urgent need for interventions that improve healing time, prevent amputations and recurrent ulceration in patients with diabetes-related foot wounds. In this randomised, open-label trial, participants were randomised to receive an application of non-cultured autologous skin cells ("spray-on" skin; ReCell) or standard care interventions for large (>6 cm ), adequately vascularised wounds. The primary outcome was complete healing at 6 months, determined by assessors blinded to the intervention. Forty-nine eligible foot wounds in 45 participants were randomised. An evaluable primary outcome was available for all wounds. The median (interquartile range) wound area at baseline was 11.4 (8.8-17.6) cm . A total of 32 (65.3%) index wounds were completely healed at 6 months, including 16 of 24 (66.7%) in the spray-on skin group and 16 of 25 (64.0%) in the standard care group (unadjusted OR [95% CI]: 1.13 (0.35-3.65), P = .845). Lower body mass index (P = .002) and non-plantar wounds (P = .009) were the only patient- or wound-related factors associated with complete healing at 6 months. Spray-on skin resulted in high rates of complete healing at 6 months in patients with large diabetes-related foot wounds, but was not significantly better than standard care (Australian New Zealand Clinical Trials Registry: ACTRN12618000511235).
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http://dx.doi.org/10.1111/iwj.13646DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8874115PMC
March 2022

Measuring Collateral Consequences Among Individuals Registered for a Sexual Offense: Development of the Sexual Offender Collateral Consequences Measure.

Sex Abuse 2022 Apr 9;34(3):259-291. Epub 2021 Jun 9.

Correctional Rehabilitation Services, LLC, Austin, TX, USA.

Collateral consequences faced by individuals convicted of a sexual offense have been widely referenced in the literature. There is yet to be a systematic examination of collateral consequences affecting individuals, however, due to measurement inconsistencies and the absence of a psychometrically validated instrument. The current study developed and validated a measure of collateral consequences faced by individuals convicted of a sexual offense. Specifically, this study investigated (a) the underlying factor structure of collateral consequences commonly endorsed by individuals convicted of a sexual offense through Exploratory Factor Analysis (EFA) procedures and (b) reliability and validity indicators of the aforementioned scale. Participants were 218 individuals convicted of and registered for a sexual offense in the state of Texas. Study measures included a pool of 66 collateral consequences items in addition to psychological self-report instruments addressing hopelessness, shame, social well-being, and discrimination. EFA results revealed a two-dimensional construct representing collateral consequences affecting areas of social and psychological well-being. The current measure demonstrated adequate reliability and validity. Limitations and future directions of findings are addressed.
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http://dx.doi.org/10.1177/10790632211019733DOI Listing
April 2022

Availability and service provision of multidisciplinary diabetes foot units in Australia: a cross-sectional survey.

J Foot Ankle Res 2021 Apr 7;14(1):27. Epub 2021 Apr 7.

Vascular Surgery Department, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia, 6150, Australia.

Background: With growing global prevalence of diabetes mellitus, diabetes-related foot disease (DFD) is contributing significantly to disease burden. As more healthcare resources are being dedicated to the management of DFD, service design and delivery is being scrutinised. Through a national survey, this study aimed to investigate the current characteristics of services which treat patients with DFD in Australia.

Methods: An online survey was distributed to all 195 Australian members of the Australian and New Zealand Society for Vascular Surgery investigating aspects of DFD management in each member's institution.

Results: From the survey, 52 responses were received (26.7%). A multidisciplinary diabetes foot unit (MDFU) was available in more than half of respondent's institutions, most of which were tertiary hospitals. The common components of MDFU were identified as podiatrists, endocrinologists, vascular surgeons and infectious disease physicians. Many respondents identified vascular surgery as being the primary admitting specialty for DFD patients that require hospitalisation (33/52, 63.5%). This finding was consistent even in centres with MDFU clinics. Less than one third of MDFUs had independent admission rights.

Conclusions: The present study suggests that many tertiary centres in Australia provide their diabetic foot service in a multidisciplinary environment however their composition and function remain heterogeneous. These findings provide an opportunity to evaluate current practice and, to initiate strategies aimed to improve outcomes of patients with DFD.
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http://dx.doi.org/10.1186/s13047-021-00471-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8028782PMC
April 2021

Temporal Trends in Incident Hospitalization for Diabetes-Related Foot Ulcer in Type 2 Diabetes: The Fremantle Diabetes Study.

Diabetes Care 2021 03 13;44(3):722-730. Epub 2021 Jan 13.

Medical School, University of Western Australia, Perth, Western Australia, Australia

Objective: To determine whether, reflecting trends in other chronic complications, incident hospitalization for diabetes-related foot ulcer (DFU) has declined over recent decades in type 2 diabetes.

Research Design And Methods: Participants with type 2 diabetes from the community-based Fremantle Diabetes Study phases I (FDS1; 1,296 participants, mean age 64.0 years, 48.6% males, recruited 1993-1996) and II (FDS2; 1,509 participants, mean age 65.4 years, 51.8% males, recruited 2008-2011) were followed from entry to first hospitalization for/with DFU, death, or 5 years (whichever came first). Incident rate ratios (IRRs) and incident rate differences (IRDs) were calculated for FDS2 versus FDS1 overall and in 10-year age-groups. Cox proportional hazards modeling determined independent predictors of first DFU hospitalization in the combined cohort.

Results: Incident DFU hospitalization (95% CI) was 1.9 (0.9-3.3)/1,000 person-years in FDS1 during 5,879 person-years of follow-up and 4.5 (3.0-6.4)/1,000 person-years in FDS2 during 6,915 person-years of follow-up. The crude IRR (95% CI) was 2.40 (1.17-5.28) ( = 0.013) and IRD 2.6 (0.7-4.5)/1,000 person-years ( = 0.010). The highest IR for any age-group was 23.6/1,000 person-years in FDS2 participants aged 31-40 years. Age at diabetes diagnosis (inverse), HbA, insulin use, height, ln(urinary albumin/creatinine), absence of any foot pulse, previous peripheral revascularization, and peripheral sensory neuropathy (PSN) were independent predictors of incident hospitalization for/with DFU.

Conclusions: Incident DFU hospitalizations complicating type 2 diabetes increased between FDS phases, especially in younger participants, and were more likely in those with PSN, peripheral arterial disease, and suboptimal glycemic control at baseline.
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http://dx.doi.org/10.2337/dc20-1743DOI Listing
March 2021

Toward a Focused Conceptualization of Collateral Consequences Among Individuals Who Sexually Offend: A Systematic Review.

Authors:
Emma Hamilton

Sex Abuse 2022 Feb 24;34(1):3-23. Epub 2020 Dec 24.

The University of Texas at Austin, USA.

Despite speculation regarding the role of collateral consequences of sexual offender policies in psychosocial and criminogenic outcomes, there has been no empirical analysis in the extant literature examining these links. Lack of conceptual underpinnings and no psychometrically valid measure of collateral consequences has limited study in this area. A systematic literature review was conducted to assess the state of measurement in terms of conceptual and operational definitions, populations sampled, domains assessed, items used, and scale properties reported. Nineteen studies met inclusion criteria. Themes emerged regarding commonly assessed collateral consequences, the misconnect between legal and psychological conceptualizations of collateral consequences, the division between external (i.e., social) and internal (i.e., affective) collateral consequences, as well as a trend toward emphasizing the psychological damages (in addition to discrete experiences of loss) associated with a sexual offense. Findings are discussed, and a unifying definition of collateral consequences is proposed to guide future scale development.
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http://dx.doi.org/10.1177/1079063220981906DOI Listing
February 2022

Provider-related barriers and enablers to the provision of hepatitis C treatment by general practitioners in Scotland: A behaviour change analysis.

J Viral Hepat 2021 03 7;28(3):528-537. Epub 2020 Dec 7.

School of Psychological Sciences and Health, University of Strathclyde, Glasgow, UK.

The ease of direct-acting antiviral (DAA) medications for hepatitis C virus (HCV) has provided an opportunity to decentralize HCV treatment into community settings. However, the role of non-specialist clinicians in community-based pathways has received scant attention to date. This study examined barriers and enablers to expanding the role of general practitioners (GPs) in HCV treatment provision, using simple behaviour change theory as a conceptual framework. A maximum variation sample of 22 HCV treatment providers, GPs and HCV support workers participated in semi-structured interviews. Data were inductively coded, and the resulting codes deductively mapped into three principal components of behaviour change: capability, opportunity and motivation (COM-B). By this process, a number of provider- and systemic-level barriers and enablers were identified. Key barriers included the pre-treatment assessment of liver fibrosis, GP capacity and the 'speciality' of HCV care. Enablers included the simplicity of the drugs, existing GP/patient relationships and the provision of holistic care. In addition to these specific factors, the data also exposed an overarching provider understanding of 'HCV treatment' as triumvirate in nature, incorporating the assessment of liver fibrosis, the provision of holistic support and the treatment of disease. This understanding imposes a further fundamental barrier to GP-led treatment as each of these three components needs to be individually addressed. To enable sustainable models of HCV treatment provision by GPs, a pragmatic re-examination of the 'HCV treatment triumvirate' is required, and a paradigm shift from the 'refer and treat' status quo.
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http://dx.doi.org/10.1111/jvh.13443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7898327PMC
March 2021

Spray on skin for diabetic foot ulcers: an open label randomised controlled trial.

J Foot Ankle Res 2019 15;12:52. Epub 2019 Nov 15.

9Department of Vascular Surgery, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150 Australia.

Background: One Australian loses a limb every 3 h as a result of infected diabetic foot ulcers (DFU). This common condition accounts for substantial morbidity and mortality for affected individuals and heavy economic costs for the health sector and the community. There is an urgent need to test interventions that improve wound healing time, prevent amputations and recurrent ulceration in patients presenting with DFU whilst improving quality of life and reducing health care costs.

Methods: One hundred and fifty eligible participants will be randomised to receive an autologous skin cell suspension, also termed 'spray-on' skin (ReCell®) or standard care interventions for their DFU. The primary outcome is complete wound healing at 6 months, but participants will be followed up for a total of 12 months to enable secondary outcomes including total overall costs, ulcer free days at 12 months and quality of life to be assessed.

Discussion: Outpatient costs for dressings, home nursing visits and outpatient appointments are key cost drivers for DFU. If spray-on skin is effective, large cost savings to WA Health will be realised immediately through a shortened time to healing, and through a higher proportion of patients achieving complete healing. Shortened healing times may enable participants to return to work earlier. Any economic benefits are likely to be amplified across Australia and other similar demographic settings where aging populations with increased diabetes rates are considered major future challenges.

Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12618000511235. Registered on 9 April 2018.
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http://dx.doi.org/10.1186/s13047-019-0362-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858641PMC
May 2020

Povidone-iodine Irrigation for Pediatric Perforated Appendicitis May Be Protective: A Bayesian Pilot Randomized Controlled Trial.

Ann Surg 2020 05;271(5):827-833

McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX.

Objectives: A randomized controlled trial was conducted to test the hypothesis that povidone-iodine (PVI) irrigation versus no irrigation (NI) reduces postoperative intra-abdominal abscess (IAA) in children with perforated appendicitis.

Methods: A 100 patient pilot randomized controlled trial was conducted. Consecutive patients with acute perforated appendicitis were randomized (1:1) to PVI or NI from April 2016 to March 2017 and followed for 1 year. Patients and postoperative providers were blinded to allocation. The primary endpoint was 30-day image-confirmed IAA. Secondary outcomes included initial and total 30-day length of stay (LOS), emergency department (ED) visits, and readmissions. Intention-to-treat analyses were performed to estimate the probability of clinical benefit using Bayesian regression models (an optimistic prior for the primary outcome and neutral priors for secondary outcomes). Frequentist statistics were also used.

Results: Baseline characteristics were similar between treatment arms. The PVI arm had 12% postoperative IAA versus 16% in the NI arm (relative risk 0.72, 95% credible interval 0.38-1.23). Bayesian analysis estimates 89% probability that PVI reduces IAA. High probability of benefit was seen in all secondary outcomes for the PVI arm: fewer ED visits and readmissions, and shorter initial and total 30-day LOS. The probability of benefit in reduction of total 30-day LOS in PVI patients was 96% and was significant (P = 0.05) on frequentist analysis.

Conclusions: PVI irrigation for perforated appendicitis in children demonstrated a strong probability of reduction in postoperative IAA with a high probability of decreased LOS. With the favorable probability of benefit in all outcomes, this pilot study serves as evidence to continue a definitive trial.
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http://dx.doi.org/10.1097/SLA.0000000000003398DOI Listing
May 2020

Evaluating the population impact of hepatitis C direct acting antiviral treatment as prevention for people who inject drugs (EPIToPe) - a natural experiment (protocol).

BMJ Open 2019 09 24;9(9):e029538. Epub 2019 Sep 24.

Glasgow Caledonian University, Glasgow, UK.

Introduction: Hepatitis C virus (HCV) is the second largest contributor to liver disease in the UK, with injecting drug use as the main risk factor among the estimated 200 000 people currently infected. Despite effective prevention interventions, chronic HCV prevalence remains around 40% among people who inject drugs (PWID). New direct-acting antiviral (DAA) HCV therapies combine high cure rates (>90%) and short treatment duration (8 to 12 weeks). Theoretical mathematical modelling evidence suggests HCV treatment scale-up can prevent transmission and substantially reduce HCV prevalence/incidence among PWID. Our primary aim is to generate empirical evidence on the effectiveness of HCV 'Treatment as Prevention' (TasP) in PWID.

Methods And Analysis: We plan to establish a natural experiment with Tayside, Scotland, as a single intervention site where HCV care pathways are being expanded (including specialist drug treatment clinics, needle and syringe programmes (NSPs), pharmacies and prison) and HCV treatment for PWID is being rapidly scaled-up. Other sites in Scotland and England will act as potential controls. Over 2 years from 2017/2018, at least 500 PWID will be treated in Tayside, which simulation studies project will reduce chronic HCV prevalence among PWID by 62% (from 26% to 10%) and HCV incidence will fall by approximately 2/3 (from 4.2 per 100 person-years (p100py) to 1.4 p100py). Treatment response and re-infection rates will be monitored. We will conduct focus groups and interviews with service providers and patients that accept and decline treatment to identify barriers and facilitators in implementing TasP. We will conduct longitudinal interviews with up to 40 PWID to assess whether successful HCV treatment alters their perspectives on and engagement with drug treatment and recovery. Trained peer researchers will be involved in data collection and dissemination. The primary outcome - chronic HCV prevalence in PWID - is measured using information from the Needle Exchange Surveillance Initiative survey in Scotland and the Unlinked Anonymous Monitoring Programme in England, conducted at least four times before and three times during and after the intervention. We will adapt Bayesian synthetic control methods (specifically the Causal Impact Method) to generate the cumulative impact of the intervention on chronic HCV prevalence and incidence. We will use a dynamic HCV transmission and economic model to evaluate the cost-effectiveness of the HCV TasP intervention, and to estimate the contribution of the scale-up in HCV treatment to observe changes in HCV prevalence. Through the qualitative data we will systematically explore key mechanisms of TasP real world implementation from provider and patient perspectives to develop a manual for scaling up HCV treatment in other settings. We will compare qualitative accounts of drug treatment and recovery with a 'virtual cohort' of PWID linking information on HCV treatment with Scottish Drug treatment databases to test whether DAA treatment improves drug treatment outcomes.

Ethics And Dissemination: Extending HCV community care pathways is covered by ethics (ERADICATE C, ISRCTN27564683, Super DOT C Trial clinicaltrials.gov: NCT02706223). Ethical approval for extra data collection from patients including health utilities and qualitative interviews has been granted (REC ref: 18/ES/0128) and ISCRCTN registration has been completed (ISRCTN72038467). Our findings will have direct National Health Service and patient relevance; informing prioritisation given to early HCV treatment for PWID. We will present findings to practitioners and policymakers, and support design of an evaluation of HCV TasP in England.
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http://dx.doi.org/10.1136/bmjopen-2019-029538DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6773339PMC
September 2019

Acute Exercise on Memory Reconsolidation.

J Clin Med 2019 Aug 11;8(8). Epub 2019 Aug 11.

Exercise & Memory Laboratory, Department of Health, Exercise Science and Recreation Management, The University of Mississippi, Oxford, MS 38677, USA.

Background And Objective: Once a memory is reactivated, it enters a labile state and, thus, is vulnerable to memory decay and/or distortion. Recent research demonstrates that acute, high-intensity exercise is associated with enhanced episodic memory function. Very limited research, however, has evaluated whether acute exercise can attenuate memory distortion from memory reactivation, which was the purpose of this study.

Methods: A between-subject randomized controlled intervention was employed. Participants (N = 80) were randomly assigned to one of four groups, including (1) reminder with exercise, (2) reminder, (3) no reminder, and (4) interference control. For the groups, participants completed three visits (Visit 1, 2, and 3), which all occurred 48 hours apart. An exception to this was the interference control group, which did not complete Visit 2. On Visit 2, the reminder with exercise group engaged in a 15 min bout of high-intensity exercise (80% of heart rate reserve) immediately after memory reactivation. On Visit 3, participants engaged in a free recall (4 trials) of the memory task encoded on Visit 1.

Results: In a 4 (groups) × 4 (learning trials) mixed-measures ANOVA, with the group as the between-subjects variable and the learning trials (1-4) as the within-subject variable, there was a significant main effect group, (3, 76) = 4.18, = 0.008, η = 0.14, and a significant main effect for the learning trials, (2.40, 182.59) = 49.25, < 0.001, η = 0.39, but there was no group by learning trials interaction, (7.20, 182.59) = 1.07, = 0.38, η = 0.04.

Conclusion: Our findings suggest that exercise may, potentially, attenuate memory distortion from memory reactivation. However, future work is needed to confirm these findings before any strong conclusions can be reached.
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http://dx.doi.org/10.3390/jcm8081200DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723489PMC
August 2019

Antimicrobial stewardship opportunities among inpatients with diabetic foot infections: microbiology results from a tertiary hospital multidisciplinary unit.

Intern Med J 2019 04;49(4):533-536

Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia.

Among 125 inpatients with diabetic foot infections managed by a multidisciplinary foot ulcer unit, knowledge of methicillin-resistant Staphylococcus aureus colonisation status assisted decision-making to prescribe appropriately or with-hold empiric anti-methicillin-resistant Staphylococcus aureus therapy. Despite adherence to national guidelines, apparent overuse of anti-pseudomonal therapy was frequent, providing potential antimicrobial stewardship opportunities.
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http://dx.doi.org/10.1111/imj.14251DOI Listing
April 2019

The Impact of Sociodemographic and Hospital Factors on Length of Stay Before and After Pyloromyotomy.

J Surg Res 2019 07 18;239:1-7. Epub 2019 Feb 18.

Department of Pediatric Surgery, McGovern Medical School, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, Department of Pediatric Surgery, McGovern Medical School, Houston, Texas. Electronic address:

Background: The aim of the study was to determine whether racial or ethnic and insurance disparities exist in pre- and post-operative length of stay (LOS) in patients with hypertrophic pyloric stenosis (HPS).

Materials And Methods: The Healthcare Cost and Utilization Project Kid's Inpatient Database database (years 2006, 2009, and 2012) was analyzed for patients aged <1 y with HPS with a primary procedure of pyloromyotomy. Multivariate logistic regression was performed to determine the association between race or ethnicity and insurance status with the primary outcomes of prolonged pre- and post-operative LOS (defined as >1 d). Odds ratios (ORs) and 95% confidence intervals (CIs) were tabulated using SPSS v24.

Results: A total of 13,706 cases were identified: 8503 (62%) non-Hispanic whites, 3143 (23%) Hispanics, 1007 (7%) non-Hispanic blacks (NHB), and 1053 (8%) non-Hispanic other race or ethnicity. NHB and Hispanics were 45% and 37%, respectively, more likely to have prolonged preoperative LOS compared with non-Hispanic whites (OR = 1.45, 95% CI: 1.19-1.77; OR = 1.37, 95% CI: 1.18-1.60, respectively). Children with public insurance had 21% increased odds of increased preoperative LOS (OR = 1.21, 95% CI: 1.06-1.38). All minority groups had increased odds of postoperative LOS (NHB OR 1.36, 95% CI: 1.17-1.54; Hispanic OR 1.14, 95% CI: 1.03-1.26; NHO OR 1.31, 95% CI: 1.15-1.51).

Conclusions: We conclude that NHB, Hispanics, and other race or ethnicity were more likely to have prolonged pre- and post-operative LOS. In addition, children with public insurance were more likely to have prolonged preoperative LOS. Further work is needed to better characterize and eliminate disparities in the management and outcomes of children with HPS.
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http://dx.doi.org/10.1016/j.jss.2019.01.003DOI Listing
July 2019

Development and Validation of a Simple Hip Fracture Risk Prediction Tool for Type 2 Diabetes: The Fremantle Diabetes Study Phase I.

Diabetes Care 2019 01 19;42(1):102-109. Epub 2018 Nov 19.

Medical School, The University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia

Objective: To develop a type 2 diabetes hip fracture risk tool in community-based patients, to validate it in an independent cohort, and to compare its performance against the only published prediction equation to include type 2 diabetes as a risk factor (QFracture).

Research Design And Methods: Hip fracture hospitalizations in 1,251 participants with type 2 diabetes aged 40-89 years from the longitudinal Fremantle Diabetes Study Phase I (FDS1) were ascertained between entry (1993-1996) and end-2012. Competing risk regression modeling determined independent predictors of time to first fracture over 10 years and the coefficients incorporated in a risk model. The model was validated in 286 participants with type 2 diabetes from the Busselton Health Study (BHS).

Results: Fifty FDS1 participants (4.0%) experienced a first hip fracture during 10,306 person-years of follow-up. Independent predictors of fracture were older age, female sex, lower BMI, peripheral sensory neuropathy, and estimated glomerular filtration rate <45 mL/min/1.73 m. The model-predicted mean 10-year incident fracture risk was 3.3% with good discrimination, calibration, and accuracy. For a 3% cutoff, sensitivity was 76.0%, specificity 71.9%, positive predictive value (PPV) 10.1%, and negative predictive value (NPV) 98.6%. Model performance in the small BHS sample was also good (sensitivity 66.7%, specificity 79.8%, PPV 6.2%, and NPV 99.2%). QFracture performed well in FDS1 but required availability of 25 variables.

Conclusions: The FDS1 hip fracture risk equation is a simple validated adjunct to type 2 diabetes management that uses variables that are readily available in routine care.
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http://dx.doi.org/10.2337/dc18-1486DOI Listing
January 2019

A 10-Year Prospective Study of Bone Mineral Density and Bone Turnover in Males and Females With Type 1 Diabetes.

J Clin Endocrinol Metab 2018 09;103(9):3531-3539

Medical School, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia.

Context: In a previous community-based, cross-sectional study, males with type 1 diabetes (T1D) had lower bone mineral density (BMD) than did matched people without diabetes but females with T1D had normal BMD.

Objective: To determine whether BMD in the males continued to decline, the neutral effect of T1D on BMD in females persisted, and whether temporal BMD changes reflected changes in bone turnover markers.

Design: Longitudinal observational study.

Setting: Urban community.

Patients: Forty-eight of the original 102 original cross-sectional study participants (20 males, 28 females) of mean age 42.0 years and median diabetes duration 14.6 years at baseline who were restudied a mean of 10.3 years later.

Main Outcome Measures: BMD at total hip, femoral neck, lumbar spine (L1 to L4), and distal forearm. Biochemical bone turnover markers.

Results: After adjustment for age, body mass index (BMI), and renal function, there was no temporal change in BMD at the hip or forearm in the males (P ≥ 0.12), but lumbar spine BMD increased (P = 0.009). Females exhibited no statistically significant change in BMD in similar multivariable models that also included postmenopausal status, except a mild increase at the forearm (P = 0.046). Age- and sex-related changes in bone turnover markers paralleled those in general population studies.

Conclusions: There is a reduction in BMD in males with T1D that occurs early in the course of the disease but then stabilizes. BMD in females with T1D remains similar to that expected for age, BMI, and postmenopausal status.
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http://dx.doi.org/10.1210/jc.2018-00850DOI Listing
September 2018

The impact of racial/ethnic disparities on survival for children and young adults with chest wall sarcoma: A population-based study.

J Pediatr Surg 2018 Aug 13;53(8):1621-1626. Epub 2018 Apr 13.

Department of Pediatric Surgery, McGovern Medical School, Houston, TX; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, Houston, TX; Division of Pediatrics, Children's Cancer Hospital at the University of Texas M.D. Anderson Cancer Center, Houston, TX; Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX. Electronic address:

Background: To determine whether there are racial/ethnic disparities in disease presentation, treatment and survival outcomes among children and young adults with chest wall sarcomas.

Methods: The Surveillance, Epidemiology and End Results (SEER) database was analyzed for patients 21 years old and younger with chest wall sarcoma. We performed multivariate logistic regression to investigate the association of race/ethnicity with advanced stage of disease at presentation and likelihood of undergoing surgical resection. Overall survival (OS) was evaluated using Cox regression modeling to calculate hazard ratios with 95% confidence intervals.

Results: A total of 669 patients were identified: 393 non-Hispanic whites (NHW) (59%), 151 Hispanics (23%), 64 non-Hispanic blacks (NHB) (11%), and 64 other race/ethnicity (9%). The 5- and 10-year OS rates for the entire cohort were 69% and 64%, respectively. NHB had significantly worse 5-year and 10-year OS compared to NHW based on the log rank test (61% versus 70%, 52% versus 66%, respectively; p = 0.037).). Most patients (80%) underwent surgical resection. However, NHB were less likely than NHW to undergo surgical resection by multivariate analysis (OR 0.43, 95% CI 0.22-0.82).

Conclusions: NHB children and young adults with chest wall sarcoma have decreased overall survival. In addition, NHB are less likely to undergo surgical resection which may contribute to survival disparities. It is paramount that health care providers work to close the treatment gap between racial/ethnic groups to improve survival in children and young adults with chest wall sarcoma.

Level Of Evidence: Level III Treatment Study.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.04.011DOI Listing
August 2018

Narrative Roles Among Contact Versus Noncontact Sexual Offenders.

Sex Abuse 2019 Oct 18;31(7):765-788. Epub 2018 Apr 18.

1 The University of Texas at Austin, USA.

The current study explored narrative roles among individuals convicted of a sexual offense. Narrative roles in a criminal context are defined as specific personal accounts utilized by offenders to justify illegal behavior. The chosen theoretical framework recognized four primary offender roles: Revengeful Mission/Romantic Quest, Professional, Victim, and Tragic Hero. A total of 23 interviews were conducted with individuals convicted of a sexual offense ( 11 contact, 12 noncontact) to explore and compare narrative roles between contact and noncontact offenders. Interviews were conducted using a phenomenological approach and coded via Framework Analysis, a qualitative data analytic method. Findings revealed a general pattern of narrative themes among offenders, along with a tendency for contact offenders to endorse Revengeful Mission/Romantic Quest narrative roles and noncontact offenders to endorse Tragic Hero narrative roles. Findings suggest that incorporating narrative roles into conceptualization and treatment of sexual offenders may help with tailoring treatments more effectively.
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http://dx.doi.org/10.1177/1079063218769651DOI Listing
October 2019

Retroperitoneal lymph node staging in paratesticular rhabdomyosarcoma-are we meeting expectations?

J Surg Res 2018 04 22;224:44-49. Epub 2017 Dec 22.

Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas; Department of Pediatric Patient Care, Children's Cancer Hospital, University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas. Electronic address:

Background: Staging retroperitoneal lymph node dissection (RPLND) for paratesticular rhabdomyosarcoma (RMS) is recommended for all patients aged ≥10 y. The purpose of this study was to evaluate adherence with surgical resection guidelines for RPLND in patients with paratesticular RMS as a measure for surgical quality.

Materials And Methods: All patients with paratesticular RMS were identified in the Surveillance, Epidemiology, and End Results database from 1973 to 2012. Patients were divided into two eras to reflect before (1973-2002) and after (2003-2012) the release and dissemination of the 2001 surgical guidelines for staging ipsilateral RPLND in all patients aged ≥10 y with paratesticular RMS. Survival outcomes associated with lymph node dissection were calculated using the Kaplan-Meier method and Cox proportional hazards analysis.

Results: Two hundred thirty-five patients with paratesticular RMS were identified and included in the study, among whom 111 were adolescents aged 10-20. RPLND did not significantly increase after 2003 among adolescents (45%-61%, P = 0.09). The benefit of RPLND on improved 5-y overall survival was evident among adolescents (92% versus 64%, P = 0.003). Adjusting for histology, age, stage at diagnosis, and race/ethnicity, RPLND was associated with improved overall survival among patients aged ≥10 y (hazard ratio 0.37, 95% confidence interval 0.17-0.83).

Conclusions: Despite surgical guidelines recommending RPLND in pediatric patients aged ≥10 y, nearly one-third of adolescent patients did not undergo RPLND. These findings are disturbing considering the survival benefit associated with RPLND among adolescent patients and indicate an opportunity for improvement in surgical quality.
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http://dx.doi.org/10.1016/j.jss.2017.11.051DOI Listing
April 2018

Pediatric melanoma: incidence, treatment, and prognosis.

Pediatric Health Med Ther 2017 18;8:39-45. Epub 2017 Apr 18.

Department of Pediatric Surgery, McGovern Medical School.

The purpose of this review is to outline recent advancements in diagnosis, treatment, and prevention of pediatric melanoma. Despite the recent decline in incidence, it continues to be the deadliest form of skin cancer in children and adolescents. Pediatric melanoma presents differently from adult melanoma; thus, the traditional asymmetry, border irregularity, color variegation, diameter >6 mm, and evolution (ABCDE) criteria have been modified to include features unique to pediatric melanoma (amelanotic, bleeding/bump, color uniformity, de novo/any diameter, evolution of mole). Surgical and medical management of pediatric melanoma continues to derive guidelines from adult melanoma treatment. However, more drug trials are being conducted to determine the specific impact of drug combinations on pediatric patients. Alongside medical and surgical treatment, prevention is a central component of battling the incidence, as ultraviolet (UV)-related mutations play a central role in the vast majority of pediatric melanoma cases. Aggressive prevention measures targeting sun safety and tanning bed usage have shown positive sun-safety behavior trends, as well as the potential to decrease melanomas that manifest later in life. As research into the field of pediatric melanoma continues to expand, a prevention paradigm needs to continue on a community-wide level.
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http://dx.doi.org/10.2147/PHMT.S115534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5774597PMC
April 2017

Variability of child access prevention laws and pediatric firearm injuries.

J Trauma Acute Care Surg 2018 04;84(4):613-619

From the Department of Pediatric Surgery (E.C.H., C.S.C., K.P.L., M.T.A.), Center for Surgical Trials and Evidence-Based Practice (E.C.H., K.P.L, M.T.A.), Department of Cardiothoracic and Vascular Surgery (C.C.M.), McGovern Medical School at The University of Texas Health Science Center at Houston; Children's Memorial Hermann Hospital (C.S.C., K.P.L., M.T.A.); and Department of Surgical Oncology (M.T.A.), The University of Texas M.D. Anderson Cancer Center, Houston, Texas.

Background: State-level child access prevention (CAP) laws impose criminal liability on adults who negligently allow children access to firearms. The CAP laws can be further divided into strong CAP laws which impose criminal liability for negligently stored firearms and weak CAP laws that prohibit adults from intentionally, knowingly, and/or recklessly providing firearms to a minor. We hypothesized that strong CAP laws would be associated with a greater reduction in pediatric firearm injuries than weak CAP laws.

Methods: We constructed a cross-sectional national study using the Healthcare Cost and Utilization Project-Kids Inpatient Database from 2006 and 2009 using weighted counts of firearm-related admissions among children younger than 18 years. Poisson regression was used to estimate the association of CAP laws with pediatric firearm injuries.

Results: After adjusting for race, sex, age, and socioeconomic income quartile, strong CAP laws were associated with a significant reduction in all (incidence rate ratio, 0.70; 95% confidence interval, 0.52-0.93), self-inflicted (incidence rate ratio, 0.46; 95% confidence interval, 0.26-0.79), and unintentional (incidence rate ratio, 0.56; 95% confidence interval, 0.43-0.74) pediatric firearm injuries. Weak CAP laws, which only impose liability for reckless endangerment, were associated with an increased risk of all pediatric firearm injuries.

Conclusion: The association of CAP laws on hospitalizations for pediatric firearm injuries differed greatly depending on whether a state had adopted a strong CAP law or a weak CAP law. Implementation of strong CAP laws by each state, which require safe storage of firearms, has the potential to significantly reduce pediatric firearm injuries.

Level Of Evidence: Prognostic and epidemiology study, level III.
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http://dx.doi.org/10.1097/TA.0000000000001786DOI Listing
April 2018

Spore forming bacteria infections and people who inject drugs: Implications for harm reduction.

Int J Drug Policy 2018 03 24;53:45-54. Epub 2017 Dec 24.

School of Media, Culture and Society, University of the West of Scotland, Paisley, PA1 2BE, Scotland, United Kingdom.

Background: There is no research on public health interventions that alert people who inject drugs (PWID) to clusters/outbreaks of severe bacterial infections. In Scotland, during the botulism cluster/outbreak of Dec 2014-July 2015 harm reduction (HR) messages detailed on a postcard (Botulism Postcard) were distributed to PWID between Feb-April 2015. We examined the impact of the Botulism Postcard on cluster/outbreak awareness, healthcare seeking and HR behaviours among PWID; and their views on such clusters/outbreaks.

Methods: The Botulism Postcard questionnaire survey was undertaken with 288 PWID recruited in Greater Glasgow and Clyde between May-August 2015. Multivariate logistic regression was undertaken. Between Oct 2015-January 2016 22 in-depth interviews were conducted with PWID in Glasgow and Edinburgh, these underwent thematic analysis.

Results: 38% (108/284) had never seen the postcard, 14% (40/284) had only seen it, 34% (98/284) read but not discussed it and 13% (38/284) had discussed it with service staff. Cluster/outbreak awareness was higher among those who had read (adjusted odds ratio (aOR) = 5.374, CI 2.394-11.349, p < 0.001) or discussed the postcard (aOR = 25.114, CI 3.188-190.550, p < 0.001); and symptom awareness was higher among those who had read (aOR = 2.664, CI 1.322-4.890, p < 0.001) or discussed the postcard (aOR = 6.707, CI 2.744 16.252, p < 0.001) than among those who had never seen it. The odds of introducing HR was higher among those who had discussed the postcard (AOR = 3.304 CI 1.425 7.660, p < 0.01) than those who had only read it. PWID learnt about clusters/outbreaks from several sources and despite concerns they continued to inject during such events.

Conclusion: More widespread exposure to the Botulism Postcard during the outbreak/cluster was needed. The Botulism Postcard distributed to PWID may raise awareness of such events, the symptoms, and may encourage HR particularly when used as a tool by frontline staff to initiate discussion. Acknowledging that people continue to inject during clusters/outbreaks of such infections necessitates a pragmatic HR approach.
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http://dx.doi.org/10.1016/j.drugpo.2017.12.001DOI Listing
March 2018

Are we missing the near misses in the OR?-underreporting of safety incidents in pediatric surgery.

J Surg Res 2018 01 20;221:336-342. Epub 2017 Oct 20.

Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas. Electronic address:

Background: Electronic hospital variance reporting systems used to report near misses and adverse events are plagued by underreporting. The purpose of this study is to prospectively evaluate directly observed variances that occur in our pediatric operating room and to correlate these with the two established variance reporting systems in our hospital.

Materials And Methods: Trained individuals directly observed pediatric perioperative patient care for 6 wk to identify near misses and adverse events. These direct observations were compared to the established handwritten perioperative variance cards and the electronic hospital variance reporting system. All observations were analyzed and categorized into an additional six safety domains and five variance categories. The chi-square test was used, and P-values < 0.05 were considered statistically significant.

Results: Out of 830 surgical cases, 211 were audited by the safety observers. During this period, 137 (64%) near misses were identified by direct observation, while 57 (7%) handwritten and 8 (1%) electronic variance were reported. Only 1 of 137 observed events was reported in the handwritten variance system. Five directly observed adverse events were not reported in either of the two variance reporting systems. Safety observers were more likely to recognize time-out and equipment variances (P < 0.001). Both variance reporting systems and direct observation identified numerous policy and process issues.

Conclusions: Despite multiple reporting systems, near misses and adverse events remain underreported. Identifying near misses may help address system and process issues before an adverse event occurs. Efforts need to be made to lessen barriers to reporting in order to improve patient safety.
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http://dx.doi.org/10.1016/j.jss.2017.08.005DOI Listing
January 2018

The impact of racial/ethnic disparities on survival for children and adolescents with extremity sarcomas: A population-based study.

J Pediatr Surg 2017 Oct 12. Epub 2017 Oct 12.

Department of Pediatric Surgery, McGovern Medical School, Houston, TX; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, Houston, TX; Division of Pediatrics, Children's Cancer Hospital at the University of Texas M.D. Anderson Cancer Center, Houston, TX; Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX. Electronic address:

Purpose: The purpose of this study was to determine whether racial/ethnic disparities exist in disease presentation, treatment, and survival among children and adolescents with extremity sarcoma.

Methods: The Surveillance, Epidemiology, and End Results (SEER) data were analyzed for patients <20years old with soft-tissue extremity sarcomas from 1973 to 2013. Multivariate logistic regression was performed to determine the association between race/ethnicity and disease stage at presentation and likelihood of surgical resection. Overall survival (OS) was evaluated using hazard ratios with 95% confidence intervals.

Results: 1261 cases were identified: 650 (52%) non-Hispanic whites (NHW), 313 (25%) Hispanics, 182 (14%) non-Hispanic blacks (NHB), and 116 (9%) other race/ethnicity. Logistic regression results showed that Hispanics and NHB were 51% and 44%, respectively, less likely to undergo surgical resection compared to NHW (OR=0.49, 95% CI: 0.30-0.80; OR=0.56, 95% CI: 0.32-0.98, respectively). Factors associated with failure to undergo surgical resection included histology, lower extremity site, tumor size, and distant metastases. OS based on race/ethnicity significantly differed using the log-rank test, with NHB having the worst survival (p<0.05).

Conclusions: We conclude that NHB, Hispanics, and other race/ethnicity were less likely to undergo surgical resection for extremity sarcoma. Further work is needed to better characterize and eliminate disparities in the management and outcomes of children with extremity sarcomas.

Type Of Study: Prognosis study.

Level Of Evidence: IV.
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http://dx.doi.org/10.1016/j.jpedsurg.2017.10.034DOI Listing
October 2017

Liver transplantation for primary hepatic malignancies of childhood: The UNOS experience.

J Pediatr Surg 2017 Oct 12. Epub 2017 Oct 12.

Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX. Electronic address:

Background/purpose: The purpose of this study was to determine factors associated with patient and graft survival following orthotopic liver transplantation (OLT) in children and adolescents with primary hepatic malignancies.

Methods: The United Network for Organ Sharing (UNOS) database was queried for all patients <18years old who received an OLT with a primary malignant liver tumor between 1987 and 2012 (n=544). Five-year patient and graft survival were determined using Kaplan-Meier methodology, and independent predictors of survival were determined using multivariate Cox proportional hazards model.

Results: The majority of patients were diagnosed with hepatoblastoma (HB) (n=376, 70%) with 84 (15%) hepatocellular carcinoma (HCC) and 84 (15%) other. HCC patients were older, more often hospitalized at the time of transplant, and more likely to receive a cadaveric organ compared to HB patients. Five-year patient and graft survival for the entire cohort was 73% and 74%, respectively, with the majority of deaths owing to malignancy. On multivariate analysis, independent predictors of 5-year patient and graft survival included diagnosis, transplant era, and medical condition at transplant.

Conclusions: In recent years, there has been significant improvement in posttransplant patient and graft survival for children and adolescents with primary hepatic malignancies. However, patients with HCC continue to have worse outcomes than those with other cancer types.

Type Of Study: Case series with no comparison group.

Level Of Evidence: IV.
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http://dx.doi.org/10.1016/j.jpedsurg.2017.10.035DOI Listing
October 2017
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