General Practice - Research Publications

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    Histopathologic indicators of breast cancer biology: insights from population mammographic screening
    Webster, LR ; Bilous, AM ; Willis, L ; Byth, K ; Burgemeister, FC ; Salisbury, ELC ; Clarke, CL ; Balleine, RL (NATURE PUBLISHING GROUP, 2005-04-25)
    Histopathologic features of breast cancer such as tumour size, grade and axillary lymph node (LN) status variably reflect tumour biology and time. Recent evidence suggests that the biological character of breast cancer is established at an early stage and has a major impact on clinical course. The aim of this study was to distinguish the impact of biology on breast cancer histopathology by comparing features of breast cancers diagnosed following population mammographic screening with prevalent vs incident detection and screening interval. Central histopathology review data from 1147 cases of ductal in situ and/or invasive breast cancer were examined. Size, grade and LN status of invasive cancers were positively correlated (P < 0.001). Prevalent invasive cancers were larger (P < 0.001) and more likely to be LN positive (P = 0.02) than incident cases, but grade was not associated with screening episode (P = 0.7). Screening interval for incident cancers was positively associated with invasive cancer size (P = 0.05) and LN status (P = 0.002) but not grade (P = 0.1). Together, these data indicate that biology and time both impact on size and LN status of invasive breast cancer, but grade reflects biology alone. In view of the clinical importance of breast cancer biology, grade as its most direct indicator assumes particular significance.
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    Variation in hospital rates of induction of labour: a population-based record linkage study
    Nippita, TA ; Trevena, JA ; Patterson, JA ; Ford, JB ; Morris, JM ; Roberts, CL (BMJ PUBLISHING GROUP, 2015-01-01)
    OBJECTIVES: To examine interhospital variation in rates of induction of labour (IOL) to identify potential targets to reduce high rates of practice variation. DESIGN: Population-based record linkage cohort study. SETTING: New South Wales, Australia, 2010-2011. PARTICIPANTS: All women with live births of ≥24 weeks gestation in 72 hospitals. PRIMARY OUTCOME MEASURE: Variation in hospital IOL rates adjusted for differences in case-mix, according to 10 mutually exclusive groups derived from the Robson caesarean section classification; groups were categorised by parity, plurality, fetal presentation, prior caesarean section and gestational age. RESULTS: The overall IOL rate was 26.7% (46,922 of 175,444 maternities were induced), ranging from 9.7% to 41.2% (IQR 21.8-29.8%) between hospitals. Nulliparous and multiparous women at 39-40 weeks gestation with a singleton cephalic birth were the greatest contributors to the overall IOL rate (23.5% and 20.2% of all IOL respectively), and had persisting high unexplained variation after adjustment for case-mix (adjusted hospital IOL rates ranging from 11.8% to 44.9% and 7.1% to 40.5%, respectively). In contrast, there was little variation in interhospital IOL rates among multiparous women with a singleton cephalic birth at ≥41 weeks gestation, women with singleton non-cephalic pregnancies and women with multifetal pregnancies. CONCLUSIONS: 7 of the 10 groups showed high or moderate unexplained variation in interhospital IOL rates, most pronounced for women at 39-40 weeks gestation with a singleton cephalic birth. Outcomes associated with divergent practice require determination, which may guide strategies to reduce practice variation.
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    Effectiveness of a Pragmatic Education Program Designed to Promote Walking Activity in Individuals With Impaired Glucose Tolerance A randomized controlled trial
    Yates, T ; Davies, M ; Gorely, T ; Bull, F ; Khunti, K (AMER DIABETES ASSOC, 2009-08-01)
    OBJECTIVE To investigate whether a pragmatic structured education program with and without pedometer use is effective for promoting physical activity and improving glucose tolerance in those with impaired glucose tolerance (IGT). RESEARCH DESIGN AND METHODS Overweight and obese individuals with IGT were recruited from ongoing screening studies at the University Hospitals of Leicester, U.K. Participants were randomly assigned to one of three groups. Group 1 received a 3-h group-based structured education program designed to promote walking activity using personalized steps-per-day goals and pedometers. Group 2 received a 3-h group-based structured education program designed to promote walking activity using generic time-based goals. Group 3 received a brief information leaflet (control condition). Outcomes included an oral glucose tolerance test, standard anthropometric measures, ambulatory activity, and psychological variables. Follow-up was conducted at 3, 6, and 12 months. RESULTS A total of 87 individuals (66% male, mean age 65 years) were included in this study. At 12 months, significant decreases in 2-h postchallenge glucose and fasting glucose of -1.31 mmol/l (95% CI -2.20 to -0.43) and -0.32 mmol/l (-0.59 to -0.03), respectively, were seen in the pedometer group compared with the control group. No significant improvements in glucose control were seen in those given the standard education program. CONCLUSIONS This study suggests that a pragmatic structured education program that incorporates pedometer use is effective for improving glucose tolerance in those with IGT. This result is likely to have important implications for future primary care-based diabetes prevention initiatives.
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    Supporting schools to create an inclusive environment for refugee students
    Block, K ; Cross, S ; Riggs, E ; Gibbs, L (ROUTLEDGE JOURNALS, TAYLOR & FRANCIS LTD, 2014-01-01)
    In a context of increasing numbers of refugees and asylum seekers globally, recognition of the importance of the school environment for promoting successful settlement outcomes and inclusion for refugee-background young people is growing. Yet schools may be poorly equipped to recognise and respond to the multiple challenges faced by children and young people who must learn a new language while grappling with unfamiliar educational and social systems. Refugee-background students often have minimal or significantly disrupted formal education prior to arrival in their new country. Young people, and sometimes their families, may lack literacy in first languages and many are coping with the impacts of trauma associated with forced displacement. Evidence for effective interventions in schools that promote an inclusive learning environment is scarce. This paper presents the results of an evaluation of the School Support Programme operating in schools in Victoria, Australia. The programme is provided to networks of schools in a region and facilitates partnerships between schools and agencies and provides a holistic model for a whole-school approach focused on the learning, social and emotional needs of refugee-background students. The evaluation concluded that the programme provides an appropriate and feasible model that supports the capacity of schools to provide an inclusive education for this group.
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    The Safe Pregnancy study - promoting safety behaviours in antenatal care among Norwegian, Pakistani and Somali pregnant women: a study protocol for a randomized controlled trial.
    Henriksen, L ; Flaathen, EM ; Angelshaug, J ; Garnweidner-Holme, L ; Småstuen, MC ; Noll, J ; Taft, A ; Schei, B ; Lukasse, M (Springer Science and Business Media LLC, 2019-06-10)
    BACKGROUND: Intimate partner violence (IPV) around the time of pregnancy is a recognized global health problem with damaging consequences. However, little is known about the effect of violence assessment and intervention during pregnancy. We hypothesise that routine enquiry about IPV during pregnancy, in combination with information about IPV and safety behaviours, has the potential to increase the use of these behaviours and prevent and reduce IPV. METHODS: The Safe Pregnancy study is a randomised controlled trial (RCT) to test the effectiveness of a tablet-based intervention to promote safety behaviours among pregnant women. Midwives include women who attend routine antenatal care. The intervention consists of a screening questionnaire for violence and information about violence and safety behaviours through a short video shown on a tablet. The materials are available in different languages to ensure participation of Norwegian, Urdu, Somali and English-speaking women. Eligible women answer baseline questions on the tablet including the Abuse Assessment Scale (AAS). Women who screen positive on the AAS will be randomized to an intervention video that contains information about violence and safety behaviours and women in the control group to a video with general information about a healthy and a safe pregnancy. All women receive information about referral resources. Follow up will be at three months post-partum, when the woman attends the maternal and child health centre (MCHC) for the baby's check-up. Outcome measures are: Use of safety behaviours and quality of life (primary outcomes), prevalence of violence, mental health measures and birth outcomes (secondary outcomes). Intention to treat analysis will be performed. DISCUSSION: The project will provide evidence on whether enquiry about violence and a short video intervention on a tablet is effective and feasible to prevent or reduce harm from IPV among women who attend antenatal care. TRIAL REGISTRATION: This study is registered in ClinicalTrials.gov. Identifier: NCT03397277 (Registered 11th January 2018).
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    Healthcare system responses to intimate partner violence in low and middle-income countries: evidence is growing and the challenges become clearer
    Taft, A ; Colombini, M (BIOMED CENTRAL LTD, 2017-07-12)
    The damage to health caused by intimate partner violence demands effective responses from healthcare providers and healthcare systems worldwide. To date, most evidence for the few existing, effective interventions in use comes from high-income countries. Gupta et al. provide rare evidence of a nurse-delivered intimate partner violence screening, supportive care and referral intervention from a large-scale randomised trial in Mexican public health clinics. No difference was found in the primary outcome of reduction in intimate partner violence. There were significant short-term benefits in safety planning and mental health (secondary outcomes) for women in the intervention arm, but these were not sustained.This important study highlights the challenges of primary outcome choices in such studies, and further challenges for the sustainability of healthcare systems and healthcare provider interventions. These challenges include the role of theory for sustainability and the risk that baseline measures of intimate partner violence can wash out intervention effects. We emphasise the importance of studying the processes of adaptation, integration and coordination in the context of the wider healthcare system.Please see related article: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0880-y.
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    Increasing the uptake of long-acting reversible contraception in general practice: the Australian Contraceptive ChOice pRoject (ACCORd) cluster randomised controlled trial protocol
    Mazza, D ; Black, K ; Taft, A ; Lucke, J ; McGeechan, K ; Haas, M ; McKay, H ; Peipert, JF (BMJ PUBLISHING GROUP, 2016-01-01)
    INTRODUCTION: The increased use of long-acting reversible contraceptives (LARCs), such as intrauterine devices and hormonal implants, has the potential to reduce unintended pregnancy and abortion rates. However, use of LARCs in Australia is very low, despite clinical practice guidance and statements by national and international peak bodies advocating their increased use. This protocol paper describes the Australian Contraceptive ChOice pRojet (ACCORd), a cluster randomised control trial that aims to test whether an educational intervention targeting general practitioners (GPs) and establishing a rapid referral service are a cost-effective means of increasing LARC uptake. METHODS AND ANALYSIS: The ACCORd intervention is adapted from the successful US Contraceptive CHOICE study and involves training GPs to provide 'LARC First' structured contraceptive counselling to women seeking contraception, and implementing rapid referral pathways for LARC insertion. Letters of invitation will be sent to 600 GPs in South-Eastern Melbourne. Using randomisation stratified by whether the GP inserts LARCs or not, a total of 54 groups will be allocated to the intervention (online 'LARC First' training and rapid referral pathways) or control arm (usual care). We aim to recruit 729 women from each arm. The primary outcome will be the number of LARCs inserted; secondary outcomes include the women's choice of contraceptive method and quality of life (Short Form Health Survey, SF-36). The costs and outcomes of the intervention and control will be compared in a cost-effectiveness analysis. ETHICS AND DISSEMINATION: The ACCORd study has been approved by the Monash University Human Research Ethics Committee: CF14/3990-2014002066 and CF16/188-2016000080. Any protocol modifications will be communicated to Ethics Committee and Trial Registration registry. The authors plan to disseminate trial outcomes through formal academic pathways comprising journal articles, nation and international conferences and reports, as well as using more 'popular' strategies including seminars, workshops and media engagements. TRIAL REGISTRATION NUMBER: ACTRN12615001346561.
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    Alcohol interventions, alcohol policy and intimate partner violence: a systematic review
    Wilson, IM ; Graham, K ; Taft, A (BMC, 2014-08-27)
    BACKGROUND: Intimate partner violence (IPV) is a significant global public health issue. The consistent evidence that alcohol use by one or both partners contributes to the risk and severity of IPV suggests that interventions that reduce alcohol consumption may also reduce IPV. This study sought to review the evidence for effects on IPV of alcohol interventions at the population, community, relationship and individual levels using the World Health Organization ecological framework for violence. METHODS: Eleven databases including Medline, PsycINFO, CINAHL and EMBASE were searched for English-language studies and grey literature published 1 January 1992 - 1 March 2013 investigating whether alcohol interventions/policies were associated with IPV reduction within adult (≥ 18) intimate relationships. Eleven studies meeting design criteria for attributing effects to the intervention and ten studies showing mediation of alcohol consumption were included in the review. The heterogeneity of study designs precluded quantitative meta analysis; therefore, a critical narrative approach was used. RESULTS: Population-level pricing and taxation studies found weak or no evidence for alcohol price changes influencing IPV. Studies of community-level policies or interventions (e.g., hours of sale, alcohol outlet density) showed weak evidence of an association with IPV. Couples-based and individual alcohol treatment studies found a relationship between reductions in alcohol consumption and reductions in IPV but their designs precluded attributing changes to treatment. Randomized controlled trials of combined alcohol and violence treatment programs found some positive effects of brief alcohol intervention as an adjunct to batterer treatment for hazardous drinking IPV perpetrators, and of brief interventions with non-dependent younger populations, but effects were often not sustained. CONCLUSIONS: Despite evidence associating problematic alcohol use with IPV, the potential for alcohol interventions to reduce IPV has not been adequately tested, possibly because studies have not focused on those most at risk of alcohol-related IPV. Research using rigorous designs should target young adult populations among whom IPV and drinking is highly prevalent. Combining alcohol and IPV intervention/policy approaches at the population, community, relationship and individual-level may provide the best opportunity for effective intervention.
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    Creatine and pregnancy outcomes, a prospective cohort study in low-risk pregnant women: study protocol.
    De Guingand, DL ; Ellery, SJ ; Davies-Tuck, ML ; Dickinson, H (BMJ, 2019-01-15)
    INTRODUCTION: The creatine kinase circuit is central to the regulation of high-energy phosphate metabolism and the maintenance of cellular energy turnover. This circuit is fuelled by creatine, an amino acid derivative that can be obtained from a diet containing animal products, and by synthesis in the body de novo. A recent retrospective study conducted in a cohort of 287 pregnant women determined that maternal excreted levels of creatine may be associated with fetal growth. This prospective study aims to overcome some of the limitations associated with the previous study and thoroughly characterise creatine homeostasis throughout gestation in a low-risk pregnant population. METHODS AND ANALYSIS: This study is recruiting women with a singleton low-risk pregnancy who are attending Monash Health, in Melbourne, Australia. Maternal blood and urine samples, along with dietary surveys, are collected at five time points during pregnancy and then at delivery. Cord blood and placenta (including membranes and cord) are collected at birth. A biobank of tissue samples for future research is being established. Primary outcome measures will include creatine, creatine kinase and associated metabolites in antenatal bloods and urine, cord bloods and placenta, along with molecular analysis of the creatine transporter (SLC6A8) and synthesising enzymes L - arginine:glycine amidinotransferase (AGAT) and guanidinoacetate methyltransferase (GAMT) in placental tissues. Secondary outcome measures include dietary protein intake over pregnancy and any associations with maternal creatine, pregnancy events and birth outcomes. ETHICS AND DISSEMINATION: Ethical approval was granted in August 2015 from Monash Health (Ref: 14140B) and Monash University (Ref: 7785). Study outcomes will be disseminated at international conferences and published in peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER: ACTRN12618001558213; Pre-results.
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    Improving Primary Care After Stroke (IPCAS) trial: protocol of a randomised controlled trial to evaluate a novel model of care for stroke survivors living in the community.
    Mullis, R ; Aquino, MRJR ; Dawson, SN ; Johnson, V ; Jowett, S ; Kreit, E ; Mant, J ; IPCAS investigator team, (BMJ, 2019-08-18)
    INTRODUCTION: Survival after stroke is improving, leading to increased demand on primary care and community services to meet the long-term care needs of people living with stroke. No formal primary care-based holistic model of care with clinical trial evidence exists to support stroke survivors living in the community, and stroke survivors report that many of their needs are not being met. We have developed a multifactorial primary care model to address these longer term needs. We aim to evaluate the clinical and cost-effectiveness of this new model of primary care for stroke survivors compared with standard care. METHODS AND ANALYSIS: Improving Primary Care After Stroke (IPCAS) is a two-arm cluster-randomised controlled trial with general practice as the unit of randomisation. People on the stroke registers of general practices will be invited to participate. One arm will receive the IPCAS model of care including a structured review using a checklist; a self-management programme; enhanced communication pathways between primary care and specialist services; and direct point of contact for patients. The other arm will receive usual care. We aim to recruit 920 people with stroke registered with 46 general practices. The primary endpoint is two subscales (emotion and handicap) of the Stroke Impact Scale (SIS) as coprimary outcomes at 12 months (adjusted for baseline). Secondary outcomes include: SIS Short Form, EuroQol EQ-5D-5L, ICEpop CAPability measure for Adults, Southampton Stroke Self-management Questionnaire, Health Literacy Questionnaire and medication use. Cost-effectiveness of the new model will be determined in a within-trial economic evaluation. ETHICS AND DISSEMINATION: Favourable ethical opinion was gained from Yorkshire and the Humber-Bradford Leeds NHS Research Ethics Committee. Approval to start was given by the Health Research Authority prior to recruitment of participants at any NHS site. Data will be presented at national and international conferences and published in peer-reviewed journals. Patient and public involvement helped develop the dissemination plan. TRIAL REGISTRATION NUMBER: NCT03353519.