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Effective off-loading is considered to be an important part of the successful clinical management of diabetic foot ulcers. The aim of this systematic review is to investigate the safety and effectiveness of different off-loading devices for the treatment of diabetic foot ulcers. The medical literature was extensively searched from January 1966 to May 2012. Systematic reviews and controlled studies that compared the use of different off-loading devices formed the evidence base. Studies were critically appraised to determine their risk of methodological bias, and data were extracted. Results were pooled using random effects meta-analysis and tested for heterogeneity. When compared with removable devices, non-removable off-loading devices were found, on average, to be more effective at promoting the healing of diabetic foot ulcers (RRp  = 1.43; 95% CI 1.11, 1.84; I(2)  = 66.9%; p = 0.001; k = 10). Analysis, stratified by type of removable device, did not detect a statistically significant difference between non-removable off-loading devices and removable cast walkers; however, on average non-removable off-loading devices performed better than therapeutic shoes at promoting the healing of diabetic foot ulcers (RRp  = 1.68; 95% CI 1.09, 2.58; I(2)  = 71.5%; p = 0.004; k = 6). The two types of non-removable off-loading devices i.e. total contact casts and instant total contact casts (removable cast walker rendered irremovable by securing with bandage or lace), were found to be equally effective (RRp  = 1.06; 95% CI 0.88, 1.27; I(2)  = 3.3%; p = 0.31; k = 2). In conclusion, non-removable off-loading devices regardless of type, are more likely to result in ulcer healing than removable off-loading devices, presumably because patient compliance with off-loading is facilitated.

ObjectivesSome early studies indicated lower survival with longer time from diagnosis to cancer treatment, but others showed the reverse. We investigated time to treatment of colorectal cancer and associations with survival.Setting and participantsClinical registry data for colorectal cancer cases diagnosed in 2000–2010 at four major public hospitals in South Australia and treated by surgery (n=1675), radiotherapy (n=616) and/or systemic therapy (n=1556).DesignA historic cohort design, with rank-order tests for ordinal clinical and sociodemographic predictors and multiple logistic regression for comparing time from diagnosis to treatment. Unadjusted Kaplan-Meier estimates and adjusted Cox proportional hazards regression were used to investigate disease-specific survival by time to treatment.Outcome measuresTime to treatment and survival from diagnosis to death from colorectal cancer.ResultsTreatment (any type) commenced for 87% of surgical cases <60 days of diagnosis, with 80% having surgery within this period. Of those receiving radiotherapy, 59% began this treatment <60 days, and of those receiving systemic therapy, the corresponding proportion was 56%. Adjusted analyses showed treatment delay >60 days was more likely for rectal cancers, 2006–2010 diagnoses, residents of northern than other metropolitan regions and for surgery, younger ages <50 years and unexpectedly, those residing closer to metropolitan services. Adjusting for clinical and sociodemographic factors, and diagnostic year, better survival occurred in <2 years from diagnosis for time to treatment >30 days. Survival in the 3–10 years postdiagnosis generally did not differ by time to treatment, except for lower survival for any treatment >90 days for surgical cases.ConclusionsThe lower survival <2 years from diagnosis for treatment <30 days of diagnosis is consistent with other studies attributed to preferencing more complicated cases for earlier care. Lower 3–10 years survival for surgical cases first treated >90 days from diagnosis is consistent with previously reported U-shaped relationships.

This study estimated the absolute risk of colorectal cancer (CRC) specific and other-cause mortality using data from the population-based South Australian Cancer Registry. The impact of competing risks on the absolute and relative risks of mortality in cases with and without comorbidity was also investigated. The study included 7115 staged, primary CRC cases diagnosed between 2003 and 2012 with at least one year of follow-up. Comorbidities were classified according to Charlson, Elixhauser and C3 comorbidity indices, using hospital inpatient diagnoses occurring five years before CRC diagnosis. To estimate the differences in measures of association, the subdistribution hazard ratios (sHR) for the effect of comorbidity on mortality from the Fine and Gray model were compared to the cause-specific hazards (HR) from Cox regression model. CRC was most commonly diagnosed in people aged ≧ 70 years. In cases without comorbidity, the 10-year cumulative probability of CRC and other cause mortality were 37.1% and 17.2% respectively. In cases with Charlson comorbidity scores ≥2, the 10-year cumulative probability of CRC-specific and other cause mortality was 45.5% and 32.2%, respectively. Comorbidity was associated with increased CRC-specific and other cause mortality and the effect differed only marginally based on comorbidity index used.

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BackgroundLittle is known about the impact of comorbidity on cervical cancer survival in Australian women, including whether Indigenous women’s higher prevalence of comorbidity contributes to their lower survival compared to non-Indigenous women.MethodsData for cervical cancers diagnosed in 2003–2012 were extracted from six Australian state-based cancer registries and linked to hospital inpatient records to identify comorbidity diagnoses. Five-year cause-specific and all-cause survival probabilities were estimated using the Kaplan-Meier method. Flexible parametric models were used to estimate excess cause-specific mortality by Charlson comorbidity index score (0,1,2+), for Indigenous women compared to non-Indigenous women.ResultsOf 4,467 women, Indigenous women (4.4%) compared to non-Indigenous women had more comorbidity at diagnosis (score ≥1: 24.2% vs. 10.0%) and lower five-year cause-specific survival (60.2% vs. 76.6%). Comorbidity was associated with increased cervical cancer mortality for non-Indigenous women, but there was no evidence of such a relationship for Indigenous women. There was an 18% reduction in the Indigenous: non-Indigenous hazard ratio (excess mortality) when comorbidity was included in the model, yet this reduction was not statistically significant. The excess mortality for Indigenous women was only evident among those without comorbidity (Indigenous: non-Indigenous HR 2.5, 95%CI 1.9–3.4), indicating that factors other than those measured in this study are contributing to the differential. In a subgroup of New South Wales women, comorbidity was associated with advanced-stage cancer, which in turn was associated with elevated cervical cancer mortality.ConclusionsSurvival was lowest for women with comorbidity. However, there wasn’t a clear comorbidity-survival gradient for Indigenous women. Further investigation of potential drivers of the cervical cancer survival differentials is warranted.ImpactThe results highlight the need for cancer care guidelines and multidisciplinary care that can meet the needs of complex patients. Also, primary and acute care services may need to pay more attention to Indigenous Australian women who may not obviously need it (i.e. those without comorbidity).

The incidence of cancer has increased over 25 years, and behavioral risks are responsible for a large proportion of cancer deaths. Scaling up of prevention (using strategies targeting cancer risk factors), early detection, and treatment of cancer is required to effectively address this growing health challenge.

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