Parents Need More Support: A Qualitative Study of the Experiences of Australian Parents Who Are Waiting for Surgical Intervention for Their Children With Otitis Media.

OBJECTIVE: To explore the experiences, expectations, and motivations of parents/caregivers of children with otitis media who were booked to undergo tympanostomy tube insertion. METHOD: A cross-sectional cohort study was conducted using semistructured interviews with 39 parents. Interviews were conducted via telephone and analyzed for key themes. RESULTS: Three themes emerged that incorporated a range of subthemes: (1) the impact of the child's underlying condition on the family, (2) the cues and prompts that influenced parents to seek intervention, and (3) the parents' expectations of the health-care system. The child's otitis media disrupted the day-to-day functioning of the family and the child's well-being, but despite this, the families found ways to adapt and cope. Parents were influenced by their friends, family, and medical practitioners when making treatment decisions and had differing expectations of the health-care system. CONCLUSION: Parents need support during their child's illness to help with pressures placed on the family and also in making health-care decisions for their child. Clinicians should consider these issues when discussing treatment options with parents.

Gallbladder disease, cholecystectomy, and pancreatic cancer risk in the International Pancreatic Cancer Case-Control Consortium (PanC4).

BACKGROUND: The association among gallbladder disease, cholecystectomy, and pancreatic cancer is unclear. Moreover, time interval between gallbladder disease or cholecystectomy and pancreatic cancer diagnosis is not considered in most previous studies. AIM: To quantify the association among gallbladder disease, cholecystectomy, and pancreatic cancer, considering time since first diagnosis of gallbladder disease or cholecystectomy. METHODS: We used data from nine case-control studies within the Pancreatic Cancer Case-Control Consortium, including 5760 cases of adenocarcinoma of the exocrine pancreas and 8437 controls. We estimated pooled odds ratios and the corresponding 95% confidence intervals by estimating study-specific odds ratios through multivariable unconditional logistic regression models, and then pooling the obtained estimates using fixed-effects models. RESULTS: Compared with patients with no history of gallbladder disease, the pooled odds ratio of pancreatic cancer was 1.69 (95% confidence interval, 1.51-1.88) for patients reporting a history of gallbladder disease. The odds ratio was 4.90 (95% confidence interval, 3.45-6.97) for gallbladder disease diagnosed <2 years before pancreatic cancer diagnosis and 1.11 (95% confidence interval, 0.96-1.29) when ≥2 years elapsed. The pooled odds ratio was 1.64 (95% confidence interval, 1.43-1.89) for patients who underwent cholecystectomy, as compared to those without cholecystectomy. The odds ratio was 7.00 (95% confidence interval, 4.13-11.86) for a surgery <2 years before pancreatic cancer diagnosis and 1.28 (95% confidence interval, 1.08-1.53) for a surgery ≥2 years before. CONCLUSIONS: There appears to be no long-term effect of gallbladder disease on pancreatic cancer risk, and at most a modest one for cholecystectomy. The strong short-term association can be explained by diagnostic bias and reverse causation.

Menstrual and Reproductive Factors, Hormone Use, and Risk of Pancreatic Cancer: Analysis From the International Pancreatic Cancer Case-Control Consortium (PanC4).

OBJECTIVES: We aimed to evaluate the relation between menstrual and reproductive factors, exogenous hormones, and risk of pancreatic cancer (PC). METHODS: Eleven case-control studies within the International Pancreatic Cancer Case-control Consortium took part in the present study, including in total 2838 case and 4748 control women. Pooled estimates of odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated using a 2-step logistic regression model and adjusting for relevant covariates. RESULTS: An inverse OR was observed in women who reported having had hysterectomy (ORyesvs.no, 0.78; 95% CI, 0.67-0.91), remaining significant in postmenopausal women and never-smoking women, adjusted for potential PC confounders. A mutually adjusted model with the joint effect for hormone replacement therapy (HRT) and hysterectomy showed significant inverse associations with PC in women who reported having had hysterectomy with HRT use (OR, 0.64; 95% CI, 0.48-0.84). CONCLUSIONS: Our large pooled analysis suggests that women who have had a hysterectomy may have reduced risk of PC. However, we cannot rule out that the reduced risk could be due to factors or indications for having had a hysterectomy. Further investigation of risk according to HRT use and reason for hysterectomy may be necessary.

Visual evoked potential latencies of three-year-old children prenatally exposed to buprenorphine or methadone compared with non-opioid exposed children: The results of a longitudinal study.

This study compared the latency of pattern reversal visual evoked potentials (VEP) of 36-month old children exposed to opioid pharmacotherapy in utero to that of a group of non-exposed children. Pregnant women were enrolled as part of an open-label non-randomised flexible dosing longitudinal study. Participants were 21 children whose mothers were treated with buprenorphine- (n=11) or methadone-pharmacotherapy (n=10) during pregnancy, and 15 children not exposed to opioids in pregnancy. One-way between groups analyses of variance (ANOVA) were conducted to test the statistical significance of differences between the mean latencies of the peak response to two different sized checkerboard patterns (48' and 69' of retinal arc). Standard multiple regression analyses were conducted to determine whether there was a significant relationship between group status and VEP latencies after adjusting for the effect of covariates. VEP latencies ranged from 98 to 112 milliseconds (ms) for checks of 48' arc, and from 95 to 113ms for checks of 69' arc. Latencies were comparable across groups. After adjusting for covariates children prenatally exposed to methadone or buprenorphine did not differ significantly from non-opioid exposed children in their responses to either check size. Nor were there any significant differences in VEP latencies between children prenatally exposed to methadone and children prenatally exposed to buprenorphine. Head circumference (HC) was significantly associated with P100 latencies for both check sizes. Data from this controlled, non-randomised study suggest that neither buprenorphine nor methadone appear to have any long-term effects on visual maturity assessed at 36months of age.

The Minimum Duration of Sensor Data From Which Glycemic Variability Can Be Consistently Assessed.

Despite much discussion regarding the clinical relevance of glycemic variation (GV), little discourse has addressed the properties of the data set from which it is derived. We aimed to assess the minimum duration of data required using continuous glucose monitoring (CGM) that most closely approximates to a gold standard 90-day measure. Data from 20 children and adolescents with type 1 diabetes were examined. All participants had CGM data sets of 90 days duration, from which standard deviation (SD), coefficient of variation (CV), mean amplitude of glycemic action (MAGE), and continuous overlapping net glycemic action (CONGA1-8) were calculated for the overall period and then investigational periods of 2, 4, 6, 12, 18, 24, and 30 days. The percentage difference between each measure and the overall measure per time period was assessed. As the duration of the CGM data set increased, the percentage error continued to decrease, giving a metric approximating more closely toward the overall measure. Median SD and CV differed from the overall measure by <10% at 12 days duration. The frequency of interruptions to the CGM trace rendered MAGE and CONGA unreliable, hence SD and CV were reported. We suggest that data sets used to infer GV should be of a minimum duration of 12 days. MAGE and CONGA exhibit poor performance in the setting of frequent trace interruption.

Tracing the long-term legacy of childhood lead exposure: a review of three decades of the port Pirie cohort study.

Several prospective cohort studies have demonstrated that childhood lead levels show small but statistically significant adjusted associations with subsequent development in later childhood and adolescence. The Port Pirie Cohort study is one of the few prospective cohort studies to follow participants into adulthood. This paper reviews all childhood and adulthood findings of the Port Pirie Cohort study to date. Cohort members (initially, 723 infants born in/around the lead-smelting town of Port Pirie) showed a wide range of childhood blood lead levels, which peaked around 2 years old (M=21.3µg/dL, SD=1.2). At all childhood assessments, postnatal lead levels - particularly those reflecting cumulative exposure - showed small significant associations with outcomes including cognitive development, IQ, and mental health problems. While associations were substantially attenuated after adjusting for several childhood covariates, many remained statistically significant. Furthermore, average childhood blood lead showed small significant associations with some adult mental health problems for females, including anxiety problems and phobia, though associations only approached significance following covariate adjustment. Overall, there did not appear to be any age of greatest vulnerability or threshold of effect, and at all ages, females appeared more susceptible to lead-associated deficits. Together, these findings suggest that the associations between early childhood lead exposure and subsequent developmental outcomes may persist. However, as the magnitude of these effects was small, they are not discernible at the individual level, posing more of a population health concern. It appears that the combination of multiple early childhood factors best predicts later development. As such, minimising lead exposure in combination with improving other important early childhood factors such as parent-child interactions may be the best way to improve developmental outcomes.

Prospective associations between childhood low-level lead exposure and adult mental health problems: the Port Pirie cohort study.

Low-level environmental lead exposure during childhood is associated with poorer emotional/behavioural functioning in later childhood and adolescence. Scarce research has examined whether these apparent effects persist into adulthood. This study is the first to examine prospective associations between lead exposure across early childhood and several common adult mental health problems. Childhood data (including blood lead concentrations) and adult data (from mental health questionnaires and psychiatric interviews) were available for 210 participants (44% males, mean age=26.3 years) from the Port Pirie cohort study (1979-1982 birth cohort). Participants had a mean childhood (to 7 years) average blood lead concentration of 17.2µg/dL. Among females, childhood blood lead showed small significant positive associations with lifetime diagnoses of drug and alcohol abuse and social phobia, and with anxiety, somatic and antisocial personality problems. For example: for a 10µg/dL blood lead increase, females were 2.84 times (95% CI 1.10, 7.30) more likely to have an alcohol abuse diagnosis. However, adjustment for childhood covariates - particularly stimulation within the home environment - rendered these associations non-significant. No significant or sizeable unadjusted or adjusted associations were seen for males. The associations between early lead exposure and emotional/behavioural functioning in children might persist into adulthood, at least for females. However, it is unclear whether such results arise from residual confounding, or other mechanisms. Interventions that focus on improving the childhood home environment may have a long-term positive impact on adult mental health outcomes. However, more prospective research using large and representative samples is needed to substantiate these results.

Genetic and clinical contributions to cerebral palsy: a multi-variable analysis.

AIM: This study aims to examine single nucleotide polymorphism (SNP) associations with cerebral palsy in a multi-variable analysis adjusting for potential clinical confounders and to assess SNP-SNP and SNP-maternal infection interactions as contributors to cerebral palsy. METHODS: A case control study including 587 children with cerebral palsy and 1154 control children without cerebral palsy. Thirty-nine candidate SNPs were genotyped in both mother and child. Data linkage to perinatal notes and cerebral palsy registers was performed with a supplementary maternal pregnancy questionnaire. History of known maternal infection during pregnancy was extracted from perinatal databases. RESULTS: Both maternal and fetal carriage of inducible nitric oxide synthase SNP rs1137933 were significantly negatively associated with cerebral palsy in infants born at less than 32 weeks gestation after adjustment for potential clinical confounders and correction for multiple testing (odds ratio 0.55, 95% confidence interval 0.38-0.79; odds ratio 0.57, 95% confidence interval 0.4-0.82, respectively). Analysis did not show any statistically significant SNP-SNP or SNP-maternal infection interactions after correction for multiple testing. CONCLUSIONS: Maternal and child inducible nitric oxide synthase SNPs are associated with reduced risk of cerebral palsy in infants born very preterm. There was no evidence for statistically significant SNP-SNP or SNP-maternal infection interactions as modulators of cerebral palsy risk.

Resource factors for mental health resilience in early childhood: An analysis with multiple methodologies.

BACKGROUND: Given that relatively little is known about the development of resilience in early childhood, this longitudinal study aimed to identify preschool resource factors associated with young children's mental health resilience to family adversity. METHODS: A community sample of 474 young Australian children was assessed in preschool (mean age 4.59 years, 49% male), and again two years later after their transition into formal schooling. At each assessment, standard questionnaires were used to obtain ratings from both parents and teachers about the quality of children's relationships with parents and teachers, children's self-concept and self-control, mental health (Strengths and Difficulties Questionnaire), and family adversities (including stressful life events and socioeconomic disadvantage). RESULTS: Greater exposure to cumulative family adversities was associated with both greater teacher- and parent-reported child mental health difficulties two years later. Multiple methodologies for operationalizing resilience were used to identify resources associated with resilient mental health outcomes. Higher quality child-parent and child-teacher relationships, and greater child self-concept and self-control were associated with resilient mental health outcomes. With the exception of child-teacher relationships, these resources were also prospective antecedents of subsequent resilient mental health outcomes in children with no pre-existing mental health difficulties. Child-parent relationships and child self-concept generally had promotive effects, being equally beneficial for children facing both low- and high-adversity. Child self-control demonstrated a small protective effect on teacher-reported outcomes, with greater self-control conferring greater protection to children under conditions of high-adversity. CONCLUSIONS: Findings suggest that early intervention and prevention strategies that focus on fostering child-adult relationship quality, self-concept, and self-control in young children may help build children's mental health and their resilience to family adversities.

The case for retaining severe perineal tears as an indicator of the quality of obstetric care.

BACKGROUND: The incidence of severe perineal tears acquired during vaginal childbirth varies considerably across hospitals but its use as a safety and quality indicator is in jeopardy because of problems associated with accurate detection and recording. AIM: To understand and interpret time trends in the incidence of third- and fourth-degree perineal tears among women giving birth vaginally in 18 public maternity hospitals in South Australia, taking into account individualised risk factors for each birth. METHODS: The risk-adjusted probability of a third- and fourth-degree tear was estimated for each of 65,598 singleton vaginal births (2002-2008), using a previously published regression model. The risk factors for each birth included maternal age; parity and ethnicity; assistance with instruments and episiotomy; shoulder dystocia; and infant birthweight. Plots of 'excess' tears were generated to help identify maternity services where the observed incidence of severe trauma differed from the expectation estimated from the risk profiles. RESULTS: Three hospitals were identified at which there were systematically more tears than expected (given their risk profiles), and five hospitals were identified at which there were fewer tears. However, increased tearing at two hospitals coincided closely with improved advocacy for better detection and treatment of perineal tears (especially partial third-degree tears). CONCLUSION: Statistical process control methods provide a powerful means of investigating temporal variations in the incidence of outcomes like severe perineal tears. Third- or fourth- degree tears should be retained as a quality indicator of maternity services, but it is likely that many third-degree tears currently go undetected.

The IDEAL study: investigation of dietary advice and lifestyle for women with borderline gestational diabetes: a randomised controlled trial - study protocol.

BACKGROUND: The Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) showed that treatment of pregnant women with mild gestational diabetes mellitus is beneficial for both women and their infants. It is still uncertain whether there are benefits of similar treatment for women with borderline gestational diabetes.This trial aims to assess whether dietary and lifestyle advice and treatment given to pregnant women who screen for borderline gestational diabetes reduces neonatal complications and maternal morbidities. DESIGN: Multicentre, randomised controlled trial. INCLUSION CRITERIA: Women between 240 and 346 weeks gestation with a singleton pregnancy, a positive oral glucose challenge test (venous plasma glucose ≥7.8 mmol/L) and a normal oral 75 gram glucose tolerance test (fasting venous plasma glucose <5.5 mmol/L and a 2 hour glucose <7.8 mmol/L) with written, informed consent.Trial entry and randomisation: Women with an abnormal oral glucose tolerance test (fasting venous plasma glucose ≥5.5 mmol/L or 2 hour glucose ≥7.8 mmol/L) will not be eligible and will be offered treatment for gestational diabetes, consistent with recommendations based on results of the ACHOIS trial. Eligible women will be randomised into either the 'Routine Care Group' or the 'Intervention Group'.Study groups: Women in the 'Routine Care Group' will receive routine obstetric care reflecting current clinical practice in Australian hospitals. Women in the 'Intervention Group' will receive obstetric care, which will include dietary and lifestyle advice, monitoring of blood glucose and further medical treatment for hyperglycaemia as appropriate.Primary study outcome: Incidence of large for gestational age infants. SAMPLE SIZE: A sample size of 682 women will be sufficient to show a 50% reduction in the risk of large for gestational age infants (alpha 0.05 two-tailed, 80% power, 4% loss to follow up) from 14% to 7% with dietary and lifestyle advice and treatment. DISCUSSION: A conclusive trial outcome will provide reliable evidence of relevance for the care of women with borderline glucose intolerance in pregnancy and their infants. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry - ACTRN12607000174482.

Risk models for benchmarking severe perineal tears during vaginal childbirth: a cross-sectional study of public hospitals in South Australia, 2002-08.

BACKGROUND: The incidence of third- and fourth-degree perineal tears during vaginal childbirth is being increasingly used as an indicator of the safety and quality of maternity health care services. In order to make fair comparisons across hospitals it may be necessary to estimate a probability of severe perineal tears for every woman, taking into account her risk profile. METHODS: Logistic regression analysis was used to estimate the probabilities of third- and fourth-degree tears (n = 1582; 2.4%) in 65 598 vaginal births in publicly funded hospitals in South Australia, 2002-08. RESULTS: Maternal age ≥25 years, primiparity, instrument assistance, Asian or African ethnicity, shoulder dystocia and increasing birthweight were all identified as factors that are associated with an increased risk of perineal tears. In parous women, episiotomy, with or without instrument assistance, was associated with more tears; but among nulliparous women, episiotomy was associated with significantly fewer tears when forceps assistance was required, and showed little or no association with tearing in vacuum-assisted or unassisted (spontaneous) births. CONCLUSION: The probabilities of severe perineal tears in first-time mothers giving birth to a term singleton with cephalic presentation, may range from under 1% to over 40%, according to a minimalist model containing only predictors unrelated to clinical management. If instrument assistance and episiotomy are also incorporated into the modelling, the estimated probability of tearing may exceed 50% in high risk individuals. Such variation highlights the need for risk adjustment when comparing hospitals with respect to their incidence of third or fourth degree perineal tears.

Precise mid-trimester placenta localisation: does it predict adverse outcomes?

BACKGROUND: A low-lying placenta detected at the mid-pregnancy ultrasound is commonly reported to warn against potential morbidity associated with placenta praevia. There is no information on what distance away from the internal cervical os is safe. AIMS: We examined whether a low-lying placenta not overlapping the cervical os in the second trimester increases the risk of obstetric complications and whether there is a cut-off point at which that increase occurs. METHODS: Adverse perinatal outcomes were examined prospectively in a cohort of women with a placenta 0-30 mm from the internal cervical os ('low-lying') at the routine mid-trimester ultrasound and compared to those with a placenta further away. Two composite outcomes of 'major' and 'minor' adverse events were predefined as primary outcome measures, requiring a sample size of 480 women with a low-lying placenta. Chi-square and Fisher's exact tests were used for statistical analysis. RESULTS: In 1662 pregnancies ('low-lying': n = 484; 'normal': n = 1178), there was no increase in composite adverse outcomes with a low-lying placenta and no cut-off distance within 30 mm from the cervical os at which risks increased. Postpartum haemorrhage ≥ 1000 mL was more frequent with a low-lying placenta (7.6% vs 4.7%, P < 0.05). CONCLUSIONS: Women with a low-lying placenta, not overlapping the cervical os, in mid-pregnancy are at no higher risk of adverse outcomes than those with a normally located placenta, except postpartum haemorrhage. This suggests that the high-risk label can be removed from pregnancies with a low-lying placenta not overlapping the cervical os in mid-pregnancy, reducing anxiety and resource utilisation.

Stressful life events, social health issues and low birthweight in an Australian population-based birth cohort: challenges and opportunities in antenatal care.

BACKGROUND: Investment in strategies to promote 'a healthy start to life' has been identified as having the greatest potential to reduce health inequalities across the life course. The aim of this study was to examine social determinants of low birthweight in an Australian population-based birth cohort and consider implications for health policy and health care systems. METHODS: Population-based survey distributed by hospitals and home birth practitioners to >8000 women six months after childbirth in two states of Australia. Participants were women who gave birth to a liveborn infant in Victoria and South Australia in September/October 2007. Main outcome measures included stressful life events and social health issues, perceived discrimination in health care settings, infant birthweight. RESULTS: 4,366/8468 (52%) of eligible women returned completed surveys. Two-thirds (2912/4352) reported one or more stressful life events or social health issues during pregnancy. Women reporting three or more social health issues (18%, 768/4352) were significantly more likely to have a low birthweight infant (< 2500 grams) after controlling for smoking and other socio-demographic covariates (Adj OR = 1.77, 95% CI 1.1-2.8). Mothers born overseas in non-English speaking countries also had a higher risk of having a low birthweight infant (Adj OR = 1.85, 95% CI 1.2-2.9). Women reporting three or more stressful life events/social health issues were more likely to attend antenatal care later in pregnancy (OR = 2.06, 95% CI 1.3-3.1), to have fewer antenatal visits (OR = 2.17, 95% CI 1.4-3.4) and to experience discrimination in health care settings (OR = 2.69, 95% CI 2.2-3.3). CONCLUSIONS: There is a window of opportunity in antenatal care to implement targeted preventive interventions addressing potentially modifiable risk factors for poor maternal and infant outcomes. Developing the evidence base and infrastructure necessary in order for antenatal services to respond effectively to the social circumstances of women's lives is long overdue.

Calculating the mean amplitude of glycemic excursion from continuous glucose monitoring data: an automated algorithm.

BACKGROUND: Glycemic variability is currently under scrutiny as a possible predictor of the complications of diabetes. The manual process for estimating a now classical measure of glycemic variability, the mean amplitude of glycemic excursion (MAGE), is both tedious and prone to error, and there is a special need for an automated method to calculate the MAGE from continuous glucose monitoring (CGM) data. METHODS: An automated algorithm for identifying the peaks and nadirs corresponding to the glycemic excursions required for the MAGE calculation has been developed. The algorithm takes a column of timed glucose measurements and generates a plot joining the peaks and nadirs required for estimating the MAGE. It returns estimates of the MAGE for both upward and downward excursions, together with several other indices of glycemic variability. RESULTS: Details of the application of the algorithm to CGM data collected over a 48-h period are provided, together with graphical illustrations of the intermediate stages in identifying the peaks and nadirs required for the MAGE. Application of the algorithm to 104 CGM datasets (92 from children with diabetes and 12 from controls) generated plots that, on visual inspection, were all found to have identified the peaks, nadirs, and excursions correctly. CONCLUSIONS: The proposed algorithm eliminates the tedium and/or errors of manually identifying and measuring countable excursions in CGM data in order to estimate the MAGE. It can also be used to calculate the MAGE from "sparse" blood glucose measurements, such as those collected in home blood glucose monitoring.

The minimum frequency of glucose measurements from which glycemic variation can be consistently assessed.

AIMS: While there has been much debate about the clinical importance of glycemic variation (GV), little attention has been directed to the properties of data sets from which it is measured. The purpose of this study is to assess the minimum frequency of glucose measurements from which GV can be consistently and meaningfully measured. METHODS: Forty-eight 72 h continuous glucose monitoring traces from children with type 1 diabetes were assessed. Measures of GV included standard deviation (SD), mean amplitude of glycemic excursion (MAGE), and continuous overlapping net glycemic action (CONGA1-4). Measures of GV calculated using 5 min sampling were designated as the 100% or "best estimate" value. Calculations were then repeated for each patient using glucose values spaced at increasing intervals. For each of the specified sampling frequencies, the ratio (%) of the between-subject SD based on the reduced subset of data to the estimate of the SD based on the full 5 min sampling data set was calculated. RESULTS: As the interval between observations increased, so did the variability of the estimators of GV. Standard deviation exhibited the least systematic change at all measurement intervals, and MAGE exhibited the greatest systematic change. CONCLUSIONS: In patients with type 1 diabetes, GV as measured by SD or CONGA4, becomes unreliable if observations are more than 2-4 h apart, and estimates of MAGE become unreliable if glucose measurements are more than 1 h apart. MAGE is more unstable and prone to random measurement error than either SD or CONGA. The frequency of glycemic measurements is thus pivotal when selecting a parameter for measurement of GV.

Assessing glycemic variation: why, when and how?

In the post-Diabetes Control and Complications Trial (DCCT) and Epidemiology of Diabetes Interventions and Complications (EDIC) era of type 1 diabetes mellitus (T1DM) care, glycosylated hemoglobin (A1C) has enjoyed primacy as the clinical outcome variable (1). Metabolic control as defined by A1C, however, only defines approximately 25% of the risk of subsequent microvascular pathology (2) and, hence, other glycemic outcome variables are also being canvassed as being of potential significance. Transcription-regulating actions of glucose and the phenomenon of "metabolic memory" have recently become recognized (3,4). Simultaneously, ambulant continuous glucose monitoring (CGM) technologies have become available. The convergence of these factors has increased the interest in the impacts of fluctuations in glycemia, otherwise known as glycemic variation (GV). Initially, this interest was focused upon the effects of post-prandial glycemic excursions (5), but more recently, associations of GV and oxidative stress, microvascular pathology (6), and GV prediction associated with closedloop insulin delivery (7) have evolved. Notwithstanding this emerging interest in GV, there still remains a lack of consensus as to the importance of GV, in what circumstances it can be measured, and what GV metrics are best suited for various purposes. The aim of this review is to discuss these 3 key areas: Why measure GV? When can GV be meaningfully assessed?; How to measure to GV?.

The mental health and wellbeing of adolescents on remand in Australia.

OBJECTIVE: To compare the nature and prevalence of mental health problems, prevalence of suicidal ideation and behaviour, and health-related quality of life of 13-17-year-olds on remand with that of 13-17-year-olds in the general community. METHOD: Self reported questionnaires completed by 13-17-year-olds who were remanded in South Australia in 2008/9 (N = 159), 13-17-year-olds who participated in the Child and Adolescent Component of the National Survey of Mental Health and Well-being in Australia (N = 1283), and 13-17-year-olds who participated in the Western Australian Aboriginal Child Health Survey (N = 1100). Mental health problems were identified using the Youth Self-Report and the Strength and Difficulties Questionnaire. Health-related quality of life was assessed using the Child Health Questionnaire. RESULTS: A total of 50.0% (95% CI, 42.3-58.3) of adolescents on remand versus 18.9% of adolescents in the community scored above the recommended cut-off score on the Youth Self-Report. Among Indigenous adolescents, 55.8% (95% CI, 41.3-69.5) on remand versus 32.1% in the community scored above the recommended cut-off score on the Strength and Difficulties Questionnaire. Among those on remand, 19.1% (95% CI, 13.2-26.2) reported making a suicide attempt during the previous 12 months compared to 4.3% in the community. Health-related quality of life was significantly worse among adolescents on remand than adolescents in the community. These differences remained after adjusting for differences in the demographic characteristics of the two groups of adolescents. CONCLUSIONS: Compared with adolescents in the community, both Indigenous and non-Indigenous adolescents on remand experience a wide range of problems, including poorer mental and physical health, a higher prevalence of suicidal ideation and behaviour, greater family adversity, and poorer school attendance. This broad range of problems needs to be effectively addressed to enable adolescents on remand to become active and productive members of their communities.

The trouble with clinical indicators: Intact lower genital tract following childbirth in NSW Hospitals, 2003-2005.

BACKGROUND: The federal government wants outcomes of hospital care to be made publicly available. League tables based on single clinical indicators are misleading, largely because of their inability to take case-complexity into account. AIM: To demonstrate the application of a graphical tool (the risk-adjusted funnel plot) to the comparison of clinical outcomes across hospitals; and its advantages over league tables. METHODS: We looked at publicly available data on intact lower genital tract (ILGT), for all hospitals in New South Wales at which more than 200 births occurred in 2005. The 'excess' percentage of women at each hospital with an ILGT following a vaginal birth, was calculated after adjustment for instrumental assistance, the use of epidural analgesia/anaesthesia, the use of induction/augmentation, and the number of births per annum. RESULTS: In 2005, ILGT ranged from 13.1 to 55.8%. A plot of ILGT against vaginal births per annum (a funnel plot) revealed huge heterogeneity among hospitals, and an inverse association with the number of births per annum. A residual funnel plot, constructed from the differences between observed and expected ILGT identified four hospitals (three public and one private) with consistently better ILGT than expected - and four public hospitals with ILGT consistently worse than expected. Some of these hospitals were not located at the extremes of the league table. CONCLUSION: The risk-adjusted funnel plot is a useful graphical tool which may overcome the shortcomings of league tables. We need to become more sophisticated in our use of clinical indicators for comparing hospital performances.

Measuring glycaemic variation.

The measurement of glycaemic variation (GV) is conceived to be of clinical significance in determining diabetes outcomes. The debate as to the importance of GV has been complicated by studies using various metrics of GV in qualitatively different datasets. The purpose of this review is to discuss the properties of 8 of the more commonly used metrics (M-value, MAGE, "J"-index, CONGA, BG rate of change, ADRR, Lability/HYPO score and GRADE). Comparable metrics that can be used to measure continuous glycaemic measurements (CGM) (SDBGL, "J"-index, MAGE, CONGA, GRADE) were then compared in assessing diabetic and non-diabetic datasets. In non-diabetic conditions there was very close correlation (correlation coefficients >0.92) between SDBGL, MAGE and CONGA, however under diabetic conditions the correlation coefficients of the GV metrics diminished significantly. The varying GV metrics have varying inherent properties depending upon the purpose for which they were designed and should not be seen as being interchangeable. Investigators therefore need to be clear about the nature of their enquiry of GV and choose an appropriate metric.