Louise M. Stewart

Risk of death in prisoners after release from jail

Objective: To compare the risk of death in a cohort of Western Australian released prisoners with the risk experienced by the general population of Western Australia.

In vitro fertilization, endometriosis, nulliparity and ovarian cancer risk

OBJECTIVES To examine the risk of invasive epithelial ovarian cancer in a cohort of women seeking treatment for infertility. METHODS Using whole-population linked hospital and registry data, we conducted a cohort study of 21,646 women commencing hospital investigation and treatment for infertility in Western Australia in the years 1982-2002. We examined the effects of IVF treatment, endometriosis and parity on risk of ovarian cancer and explored potential confounding by tubal ligation, hysterectomy and unilateral oophorectomy/salpingo-oophorectomy (USO). RESULTS Parous women undergoing IVF had no observable increase in the rate of ovarian cancer (hazard ratio [HR] 1.01; 95% confidence interval [CI] 0.35-2.90); the HR in women who had IVF and remained nulliparous was 1.76 (95% CI 0.74-4.16). Women diagnosed with endometriosis who remained nulliparous had a three-fold increase in the rate of ovarian cancer (HR 3.11; 95% CI 1.13-8.57); the HR in parous women was 1.52 (95% CI 0.34-6.75). In separate analyses, women who had a USO without hysterectomy had a four-fold increase in the rate of ovarian cancer (HR 4.23; 95% CI 1.30-13.77). Hysterectomy with or without USO appeared protective. CONCLUSIONS There is no evidence of an increased risk of ovarian cancer following IVF in women who give birth. There is some uncertainty regarding the effect of IVF in women who remain nulliparous. Parous women diagnosed with endometriosis may have a slightly increased risk of ovarian cancer; nulliparous women have a marked increase in risk.

In vitro fertilization and breast cancer: Is there cause for concern?

OBJECTIVE To examine the incidence rate of breast cancer in a cohort of women undergoing treatment for infertility, comparing the rate in women who had in vitro fertilization (IVF) with those who did not. DESIGN Population-based cohort study using linked hospital and registry data. SETTING Hospital. PATIENT(S) All women aged 20-44 years seeking hospital investigation and treatment for infertility in Western Australia during the period 1983-2002 (n = 21,025). INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Hazard ratios (HRs) for breast cancer. RESULT(S) There was no overall increase in the rate of breast cancer in women who had IVF (HR 1.10, 95% confidence interval [CI] 0.88-1.36), but there was an increased rate in women who commenced IVF at a young age. Women who commenced hospital infertility treatment at 24 years and required IVF had an unadjusted HR of breast cancer of 1.59 (95% CI 1.05-2.42) compared with women of the same age who had infertility treatment but no IVF. When adjusted for late age at first delivery, which is associated with an increased rate of breast cancer, and delivery of twins and higher-order multiples, which is associated with a decreased rate of breast cancer, the HR remained elevated at 1.56 (95% CI 1.01-2.40). Hazard ratios were not elevated in women who commenced treatment at age 40 and required IVF (adjusted HR 0.87, 95% CI 0.62-1.22). CONCLUSION(S) Commencing IVF treatment at a young age is associated with an increased rate of breast cancer.

In vitro fertilization is associated with an increased risk of borderline ovarian tumours

OBJECTIVES To compare the risk of borderline ovarian tumours in women having in vitro fertilization (IVF) with women diagnosed with infertility but not having IVF. METHODS This was a whole-population cohort study of women aged 20-44 years seeking hospital infertility treatment or investigation in Western Australia in 1982-2002. Using Cox regression, we examined the effects of IVF treatment and potential confounders on the rate of borderline ovarian tumours. Potential confounders included parity, age, calendar year, socio-economic status, infertility diagnoses including pelvic inflammatory disorders and endometriosis and surgical procedures including hysterectomy and tubal ligation. RESULTS Women undergoing IVF had an increased rate of borderline ovarian tumours with a hazard ratio (HR) of 2.46 (95% confidence interval [CI] 1.20-5.04). Unlike invasive epithelial ovarian cancer, neither birth (HR 0.89; 95% CI 0.43-1.88) nor hysterectomy (1.02; 0.24-4.37) nor sterilization (1.48; 0.63-3.48) appeared protective and the rate was not increased in women with a diagnosis of endometriosis (HR 0.31; 95% CI 0.04-2.29). CONCLUSIONS Women undergoing IVF treatment are at increased risk of being diagnosed with borderline ovarian tumours. Risk factors for borderline ovarian tumours appear different from those for invasive ovarian cancer.

How effective is in vitro fertilization, and how can it be improved?

OBJECTIVE To measure IVF effectiveness, which is defined as the cumulative incidence of live delivery over real time in women after commencing IVF treatment. DESIGN Population-based retrospective cohort study. SETTING IVF clinics in Western Australia (WA). PATIENT(S) All women ages 20-44 years inclusive at start of treatment, commencing IVF in 1982-1992 and 1993-2002 at clinics in WA (n = 8,275). INTERVENTION(S) Data on IVF cycles were extracted from hospital records and a statutory reproductive technology register and linked to records of births. MAIN OUTCOME MEASURE(S) Cumulative incidence of an IVF-attributed live delivery and cumulative incidence of an IVF-attributed or IVF treatment-independent live delivery. RESULT(S) IVF effectiveness in the 1993-2002 cohort was 47% overall. It was highest in women ages 20-29 years at the start of treatment, measuring 58%; and 79% with the inclusion of IVF treatment-independent deliveries, and declined to 22% and 33%, respectively, in women ages 40-44 years. Couples underwent, on average, only three cycles, even though the cumulative probability of a live delivery increased with each successive cycle for at least the first five cycles. CONCLUSION(S) IVF effectiveness could be improved if women, particularly those over 35, underwent more cycles.

Hospitalisations for Pelvic Inflammatory Disease Temporally Related to a Diagnosis of Chlamydia or Gonorrhoea: A Retrospective Cohort Study

Objectives The presence and severity of pelvic inflammatory disease (PID) symptoms are thought to vary by microbiological etiology but there is limited empirical evidence. We sought to estimate and compare the rates of hospitalisation for PID temporally related to diagnoses of gonorrhoea and chlamydia. Methods All women, aged 15–45 years in the Australian state of New South Wales (NSW), with a diagnosis of chlamydia or gonorrhoea between 01/07/2000 and 31/12/2008 were followed by record linkage for up to one year after their chlamydia or gonorrhoea diagnosis for hospitalisations for PID. Standardised incidence ratios compared the incidence of PID hospitalisations to the age-equivalent NSW population. Results A total of 38,193 women had a chlamydia diagnosis, of which 483 were hospitalised for PID; incidence rate (IR) 13.9 per 1000 person-years of follow-up (PYFU) (95%CI 12.6–15.1). In contrast, 1015 had a gonorrhoea diagnosis, of which 45 were hospitalised for PID (IR 50.8 per 1000 PYFU, 95%CI 36.0–65.6). The annual incidence of PID hospitalisation temporally related to a chlamydia or gonorrhoea diagnosis was 27.0 (95%CI 24.4–29.8) and 96.6 (95%CI 64.7–138.8) times greater, respectively, than the age-equivalent NSW female population. Younger age, socio-economic disadvantage, having a diagnosis prior to 2005 and having a prior birth were also associated with being hospitalised for PID. Conclusions Chlamydia and gonorrhoea are both associated with large increases in the risk of PID hospitalisation. Our data suggest the risk of PID hospitalisation is much higher for gonorrhoea than chlamydia; however, further research is needed to confirm this finding.

Association between in-vitro fertilization, birth and melanoma.

A link between reproductive hormones and melanoma has long been suspected, and has been examined for numerous hormonal exposures, but the association between in-vitro fertilization (IVF) and melanoma has not been studied in depth. We used whole-population linked hospital and registry data to carry out a cohort study of women aged 20–44 years seeking hospital investigation and treatment for infertility in Western Australia from 1982 to 2002 with follow-up to 2010. The cohort comprised a total of 21 604 women followed for an average of 17.2 years. Of these, 7524 had IVF treatment, 14 870 gave birth and 149 women were diagnosed with an incident invasive melanoma. Using Cox regression analysis, we estimated hazard ratios (HRs) for melanoma associated with IVF and parity. Women who had IVF and gave birth had an increased rate of invasive melanoma compared with women who had IVF and remained nulliparous (HR 3.61; 95% confidence interval 1.79–7.26). There was little or no increase in the rate of invasive melanoma associated with giving birth in women who had non-IVF infertility treatment (HR 1.39; 95% confidence interval 0.88–2.20). These results suggest an association between reproductive factors and melanoma in the subgroup of women undergoing IVF treatment.

Growth in Western Australian emergency department demand during 2007–2013 is due to people with urgent and complex care needs

To determine the magnitude and characteristics of the increase in ED demand in Western Australia (WA) from 2007 to 2013.

Influence of offence type and prior imprisonment on risk of death following release from prison: A whole-population linked data study

PURPOSE The purpose of this paper is to examine the influence of offence type, prior imprisonment and various socio-demographic characteristics on mortality at 28 and 365 days following prison release. DESIGN/METHODOLOGY/APPROACH Using whole-population linked, routinely collected administrative state-based imprisonment and mortality data, the authors conducted a retrospective study of 12,677 offenders released from Western Australian prisons in the period 1994-2003. Cox proportional hazards regression was used to examine the association between mortality at 28 and 365 days post-release and offence type, prior imprisonment, and a range of socio-demographic characteristics (age, gender, social disadvantage and Indigenous status). FINDINGS Overall, 135 (1.1 per cent) died during the 365 days follow-up period, of these, 17.8 per cent (n=24) died within the first 28 days (four weeks) of their index release. Ex-prisoners who had committed drug-related offences had significantly higher risk of 28-day post-release mortality (HR=28.4; 95 per cent CI: 1.3-615.3, p=0.033), than those who had committed violent (non-sexual) offences. A significant association was also found between the number of previous incarcerations and post-release mortality at 28 days post-release, with three prior prison terms carrying the highest mortality risk (HR=73.8; 95 per cent CI: 1.8-3,092.5, p=0.024). No association between mortality and either offence type or prior imprisonment was seen at 365 days post-release. ORIGINALITY/VALUE Post-release mortality at 28 days was significantly associated with offence type (with drug-related offences carrying the greatest risk) and with prior imprisonment, but associations did not persist to 365 days after release. Targeting of short-term transitional programmes to reduce preventable deaths after return to the community could be tailored to these high-risk ex-prisoners.

Value of pathology review in a population-based series of ovarian tumors

Ovarian neoplasia comprises a heterogenous group of tumors with distinct clinicopathologic and molecular features and therefore assessment of potential risk factors should be tumor subtype specific. As part of ongoing epidemiological investigations of ovarian neoplasia in Western Australia, we performed an initial review of original pathology reports followed, in selected cases, by reassessment of histology material to optimize accurate diagnosis. Additional immunohistochemistry, often using antibodies unavailable at the time of initial assessment, was also performed as required. From an initial cohort of 1660 cases identified through the Western Australia Cancer Registry, benign, nonepithelial, nonovarian, miscellaneous, and indeterminate cases were excluded. Also excluded were 33 cases that were reclassified as ovarian metastases rather than primary ovarian tumors. Following exclusions there remained 1321 borderline and malignant epithelial neoplasms. The diagnosis was considered accurate in 1186 cases (89.8%) based upon information in the initial pathology reports and clinical follow-up data but uncertain in 135 cases (10.2%). Histologic review was possible in 92 of the latter tumors leading to an amended diagnosis in 63 cases (68.5%). The most common types of diagnostic amendment were the reclassification of high-grade carcinomas of undifferentiated, endometrioid, or transitional appearance as high-grade serous carcinoma, and the reclassification of most carcinomas of mixed epithelial type as “pure” carcinomas. This review illustrated specific pitfalls in the diagnosis of ovarian epithelial neoplasia and helped to maintain the accuracy of the Western Australia Cancer Registry. Accurate diagnosis will optimize further epidemiological studies assessing risk factors in specific subtypes of ovarian neoplasia.