Risk of COVID-19 death for people with a pre-existing cancer diagnosis prior to COVID-19-vaccination: A systematic review and meta-analysis.

While previous reviews found a positive association between pre-existing cancer diagnosis and COVID-19-related death, most early studies did not distinguish long-term cancer survivors from those recently diagnosed/treated, nor adjust for important confounders including age. We aimed to consolidate higher-quality evidence on risk of COVID-19-related death for people with recent/active cancer (compared to people without) in the pre-COVID-19-vaccination period. We searched the WHO COVID-19 Global Research Database (20 December 2021), and Medline and Embase (10 May 2023). We included studies adjusting for age and sex, and providing details of cancer status. Risk-of-bias assessment was based on the Newcastle-Ottawa Scale. Pooled adjusted odds or risk ratios (aORs, aRRs) or hazard ratios (aHRs) and 95% confidence intervals (95% CIs) were calculated using generic inverse-variance random-effects models. Random-effects meta-regressions were used to assess associations between effect estimates and time since cancer diagnosis/treatment. Of 23 773 unique title/abstract records, 39 studies were eligible for inclusion (2 low, 17 moderate, 20 high risk of bias). Risk of COVID-19-related death was higher for people with active or recently diagnosed/treated cancer (general population: aOR = 1.48, 95% CI: 1.36-1.61, I2 = 0; people with COVID-19: aOR = 1.58, 95% CI: 1.41-1.77, I2 = 0.58; inpatients with COVID-19: aOR = 1.66, 95% CI: 1.34-2.06, I2 = 0.98). Risks were more elevated for lung (general population: aOR = 3.4, 95% CI: 2.4-4.7) and hematological cancers (general population: aOR = 2.13, 95% CI: 1.68-2.68, I2 = 0.43), and for metastatic cancers. Meta-regression suggested risk of COVID-19-related death decreased with time since diagnosis/treatment, for example, for any/solid cancers, fitted aOR = 1.55 (95% CI: 1.37-1.75) at 1 year and aOR = 0.98 (95% CI: 0.80-1.20) at 5 years post-cancer diagnosis/treatment. In conclusion, before COVID-19-vaccination, risk of COVID-19-related death was higher for people with recent cancer, with risk depending on cancer type and time since diagnosis/treatment.

Recruiting and retaining general practitioners in rural practice: systematic review and meta-analysis of rural pipeline effects.

OBJECTIVE: To synthesise quantitative data on the effects of rural background and experience in rural areas during medical training on the likelihood of general practitioners practising and remaining in rural areas. STUDY DESIGN: Systematic review and meta-analysis of the effects of rural pipeline factors (rural background; rural clinical and education experience during undergraduate and postgraduate/vocational training) on likelihood of later general practice in rural areas. DATA SOURCES: MEDLINE (Ovid), EMBASE, Informit Health Collection, and ERIC electronic database records published to September 2018; bibliographies of retrieved articles; grey literature. DATA SYNTHESIS: Of 6709 publications identified by our search, 27 observational studies were eligible for inclusion in our systematic review; when appropriate, data were pooled in random effects models for meta-analysis. Study quality, assessed with the Newcastle-Ottawa scale, was very good or good for 24 studies, satisfactory for two, and unsatisfactory for one. Meta-analysis indicated that GPs practising in rural communities was significantly associated with having a rural background (odds ratio [OR], 2.71; 95% CI, 2.12-3.46; ten studies) and with rural clinical experience during undergraduate (OR, 1.75; 95% CI, 1.48-2.08; five studies) and postgraduate training (OR, 4.57; 95% CI, 2.80-7.46; eight studies). CONCLUSION: GPs with rural backgrounds or rural experience during undergraduate or postgraduate medical training are more likely to practise in rural areas. The effects of multiple rural pipeline factors may be cumulative, and the duration of an experience influences the likelihood of a GP commencing and remaining in rural general practice. These findings could inform government-led initiatives to support an adequate rural GP workforce. PROTOCOL REGISTRATION: PROSPERO, CRD42017074943 (updated 1 February 2018).

Parents' Expectations and Experiences of Antibiotics for Acute Respiratory Infections in Primary Care.

PURPOSE: Primary care visits for children with acute respiratory infections frequently result in antibiotic prescriptions, although antibiotics have limited benefits for common acute respiratory infections and can cause harms, including antibiotic resistance. Parental demands are often blamed for antibiotic prescription. We aimed to explore parents' beliefs about antibiotic necessity, quantify their expectations of antibiotic benefit, and report experiences of other management options and exposure to and preferences for shared decision making. METHODS: We conducted computer-assisted telephone interviews in an Australia-wide community sample of primary caregivers, hereafter referred to as parents, of children aged 1 to 12 years, using random digit dialing of household landline telephones. RESULTS: Of the 14,505 telephone numbers called, 10,340 were eligible numbers; 589 potentially eligible parents were reached, of whom 401 were interviewed. Most believed antibiotics provide benefits for common acute respiratory infections, especially for acute otitis media (92%), although not using them, particularly for acute cough and sore throat, was sometimes acceptable. Parents grossly overestimated the mean benefit of antibiotics on illness symptom duration by 5 to 10 times, and believed they reduce the likelihood of complications. The majority, 78%, recognized antibiotics may cause harm. Recalling the most recent relevant doctor visit, 44% of parents reported at least some discussion about why antibiotics might be used; shared decision making about antibiotic use was inconsistent, while 75% wanted more involvement in future decisions. CONCLUSIONS: Some parents have misperceptions about antibiotic use for acute respiratory infections, highlighting the need for improved communication during visits, including shared decision making to address overoptimistic expectations of antibiotics. Such communication should be one of several strategies that is used to reduce antibiotic use.

Preparing Parents to Make An Informed Choice About Antibiotic Use for Common Acute Respiratory Infections in Children: A Randomised Trial of Brief Decision Aids in a Hypothetical Scenario.

BACKGROUND: Childhood acute respiratory infections (ARIs) are one of the most common reasons for primary care consultations and for receiving an antibiotic. Public awareness of antibiotic benefit and harms for these conditions is low. To facilitate informed decision making, ideally in collaboration with their doctor, parents need clear communication about benefits and harms. Decision aids may be able to facilitate this process. OBJECTIVE: The aim of this study was to evaluate the effectiveness of three decision aids about antibiotic use for common ARIs in children. METHODS: Adult parents of children aged 1-16 years (n = 120) were recruited from community settings and then randomised using a computer-generated randomisation sequence to receive a decision aid (n = 60) or fact sheet (n = 60). Allocation was concealed and used sealed and opaque sequentially numbered envelopes. Participants self-completed questionnaires at baseline and immediately post-intervention. The primary outcome was informed choice (conceptual and numerical knowledge; attitudes towards, and intention to use, antibiotics for a future ARI). Secondary outcomes were decisional conflict, decisional self-efficacy, and material acceptability. RESULTS: After reading the information, significantly more intervention group participants made an informed choice [57%] compared with control group participants [29%] [difference 28, 95% confidence interval (CI) 11-45%, p < 0.01], and had higher total knowledge [mean difference (MD) 2.8, 95% CI 2.2-3.5, p < 0.01], conceptual knowledge (MD 0.7, 95% CI 0.4-1.1, p < 0.01) and numerical knowledge (MD 2.1, 95% CI 1.6-2.5, p < 0.01). Between-group differences in attitudes or intention to use antibiotics were not significant. Most intervention group participants found the information understandable and liked the aids' format and features. CONCLUSION: The decision aids prepared parents to make an informed choice about antibiotic use more than fact sheets, in a hypothetical situation. Their effect within a consultation needs to be evaluated. Clinical Trials Registration Number: ACTRN12615000843550.

Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care.

BACKGROUND: Shared decision making is an important component of patient-centred care. It is a set of communication and evidence-based practice skills that elicits patients' expectations, clarifies any misperceptions and discusses the best available evidence for benefits and harms of treatment. Acute respiratory infections (ARIs) are one of the most common reasons for consulting in primary care and obtaining prescriptions for antibiotics. However, antibiotics offer few benefits for ARIs, and their excessive use contributes to antibiotic resistance - an evolving public health crisis. Greater explicit consideration of the benefit-harm trade-off within shared decision making may reduce antibiotic prescribing for ARIs in primary care. OBJECTIVES: To assess whether interventions that aim to facilitate shared decision making increase or reduce antibiotic prescribing for ARIs in primary care. SEARCH METHODS: We searched CENTRAL (2014, Issue 11), MEDLINE (1946 to November week 3, 2014), EMBASE (2010 to December 2014) and Web of Science (1985 to December 2014). We searched for other published, unpublished or ongoing trials by searching bibliographies of published articles, personal communication with key trial authors and content experts, and by searching trial registries at the National Institutes of Health and the World Health Organization. SELECTION CRITERIA: Randomised controlled trials (RCTs) (individual level or cluster-randomised), which evaluated the effectiveness of interventions that promote shared decision making (as the focus or a component of the intervention) about antibiotic prescribing for ARIs in primary care. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted and collected data. Antibiotic prescribing was the primary outcome, and secondary outcomes included clinically important adverse endpoints (e.g. re-consultations, hospital admissions, mortality) and process measures (e.g. patient satisfaction). We assessed the risk of bias of all included trials and the quality of evidence. We contacted trial authors to obtain missing information where available. MAIN RESULTS: We identified 10 published reports of nine original RCTs (one report was a long-term follow-up of the original trial) in over 1100 primary care doctors and around 492,000 patients.The main risk of bias came from participants in most studies knowing whether they had received the intervention or not, and we downgraded the rating of the quality of evidence because of this.We meta-analysed data using a random-effects model on the primary and key secondary outcomes and formally assessed heterogeneity. Remaining outcomes are presented narratively.There is moderate quality evidence that interventions that aim to facilitate shared decision making reduce antibiotic use for ARIs in primary care (immediately after or within six weeks of the consultation), compared with usual care, from 47% to 29%: risk ratio (RR) 0.61, 95% confidence interval (CI) 0.55 to 0.68. Reduction in antibiotic prescribing occurred without an increase in patient-initiated re-consultations (RR 0.87, 95% CI 0.74 to 1.03, moderate quality evidence) or a decrease in patient satisfaction with the consultation (OR 0.86, 95% CI 0.57 to 1.30, low quality evidence). There were insufficient data to assess the effects of the intervention on sustained reduction in antibiotic prescribing, adverse clinical outcomes (such as hospital admission, incidence of pneumonia and mortality), or measures of patient and caregiver involvement in shared decision making (such as satisfaction with the consultation; regret or conflict with the decision made; or treatment compliance following the decision). No studies assessed antibiotic resistance in colonising or infective organisms. AUTHORS' CONCLUSIONS: Interventions that aim to facilitate shared decision making reduce antibiotic prescribing in primary care in the short term. Effects on longer-term rates of prescribing are uncertain and more evidence is needed to determine how any sustained reduction in antibiotic prescribing affects hospital admission, pneumonia and death.

A randomised non-inferiority controlled trial of a single versus a four intradermal sterile water injection technique for relief of continuous lower back pain during labour.

BACKGROUND: Almost one third of women suffer continuous lower back pain during labour. Evidence from three systematic reviews demonstrates that sterile water injections (SWI) provide statistically and clinically significant pain relief in women experiencing continuous lower back pain during labour. The most effective technique to administer SWI is yet to be determined. Therefore, the aim of this study is to determine if the single injection SWI technique is no less effective than the routinely used four injection SWI method in reducing continuous lower back pain during labour. METHODS/DESIGN: The trial protocol was developed in consultation with an interdisciplinary team of clinical researchers. We aim to recruit 319 women presenting at term, seeking analgesia for continuous severe lower back pain during labour. Participants will be recruited from two major maternity hospitals in Australia. Randomised participants are allocated to receive a four or single intradermal needle SWI technique. The primary outcome is the change in self-reported pain measured by visual analogue scale at baseline and thirty minutes post intervention. Secondary outcomes include VAS change scores at 10, 60, 90 and 120 min, analgesia use, mode of birth and maternal satisfaction. STATISTICAL ANALYSIS: Sample size was calculated to achieve 90% power at an alpha of 0.025 to detect a non-inferiority margin of ≤1 cm on the VAS, using a one-sided, two-sample t-test. Baseline demographic and clinical characteristics will be analysed for comparability between groups. Differences in primary (VAS pain score) and secondary outcomes between groups will be analysed by intention to treat and per protocol analysis using Student's t-test and ANOVA. CONCLUSION: This study will determine if a single intradermal SWI technique is no less effective than the routinely used four injection technique for lower back pain during labour. The findings will allow midwives to offer women requesting SWI during labour an evidence-based alternative technique more easily administered by staff and accepted by labouring women. TRIAL REGISTRATION: ACTRN12609000964213.

Rating access to health care: Are there differences according to geographical region?

OBJECTIVE: To report on satisfaction with access to health care in Queensland focussing on regional differences. METHODS: A sub-sample of 4440 respondents with no history of cancer from the Queensland Cancer Risk Study who completed a self-administered questionnaire was used for this study. MAIN OUTCOME MEASURES: Perceptions of overall difficulty gaining access to health care and ratings of access to various health care services by region. RESULTS: Queenslanders living outside major cities reported less satisfaction with access to various aspects of health care services. Age was associated with more favourable ratings of health care access. CONCLUSIONS: Despite public health efforts to increase service provision throughout Queensland, health care access is still rated relatively less favourably by Queenslanders in regional and remote parts of the state. IMPLICATIONS: Identifying which services are difficult to access and why will assist public health policy makers in improving health service accessibility.

Sexual abuse in childhood and sexual dysfunction in adulthood: an Australian population-based study.

This study examined self-reported adult sexual functioning in individuals reporting a history of childhood sexual abuse (CSA) in a representative sample of the Australian population. A sample of 1793 persons, aged 18-59 years, were randomly selected from the electoral roll for Australian states and territories in April 2000. Respondents were interviewed about their health status and sexual experiences, including unwanted sexual experiences before the age of 16 years. More than one-third of women and approximately one-sixth of men reported a history of CSA. Women were more likely than men to report both non-penetrative and penetrative experiences of CSA. For both sexes, there was a significant association between CSA and symptoms of sexual dysfunction. In assessing the specific nature of the relationship between sexual abuse and sexual dysfunction, statistically significant associations were, in general, evident for women only. CSA was not associated with the level of physical or emotional satisfaction respondents experienced with their sexual activity. The total number of lifetime sexual partners was significantly and positively associated with CSA for females, but not for males; however, the number of sexual partners in the last year was not related to CSA. CSA in the Australian population is common and contributes to significant impairment in the sexual functioning of adults, especially women. These consequences appear not to extend to the other areas of sexual activity considered in this study.