Evaluation of the SUCCESS health literacy app for Australian adults with chronic kidney disease: Study protocol for a pragmatic randomised controlled trial (Preprint)

Background

We developed a smartphone app—the SUCCESS (Supporting Culturally and Linguistically Diverse CKD Patients to Engage in Shared Decision-Making Successfully) app—to support Australian adults with kidney failure undertaking dialysis to actively participate in self-management and decision-making. The content of the SUCCESS app was informed by a theoretical model of health literacy that recognizes the importance of reducing the complexity of health information as well as providing skills necessary to access, understand, and act on this information.

Objective

The purpose of this study is to investigate the efficacy of the SUCCESS app intervention.

Methods

We designed a multicenter pragmatic randomized controlled trial to compare the SUCCESS app plus usual care (intervention) to usual care alone (control). A total of 384 participants receiving in-center or home-based hemodialysis or peritoneal dialysis will be recruited from six local health districts in the Greater Sydney region, New South Wales, Australia. To avoid intervention contamination, a pragmatic randomization approach will be used for participants undergoing in-center dialysis, in which randomization will be based on the days they receive hemodialysis and by center (ie, Monday, Wednesday, and Friday or Tuesday, Thursday, and Saturday). Participants undergoing home-based dialysis will be individually randomized centrally using simple randomization and two stratification factors: language spoken at home and research site. Consenting participants will be invited to use the SUCCESS app for 12 months. The primary endpoints, which will be assessed after 3, 6, and 12 months of app usage, are health literacy skills, evaluated using the Health Literacy Questionnaire; decision self-efficacy, evaluated using the Decision Self-Efficacy Scale; and rates of unscheduled health encounters. Secondary outcomes include patient-reported outcomes (ie, quality of life, evaluated with the 5-level EQ-5D; knowledge; confidence; health behavior; and self-management) and clinical outcomes (ie, symptom burden, evaluated with the Palliative care Outcome Scale–Renal; nutritional status, evaluated with the Patient-Generated Subjective Global Assessment; and intradialytic weight gain). App engagement will be determined via app analytics. All analyses will be undertaken using an intention-to-treat approach comparing the intervention and usual care arms.

Results

The study has been approved by Nepean Blue Mountains Human Research Ethics Committee (2020/ETH00910) and recruitment has begun at nine sites. We expect to finalize data collection by 2023 and publish the manuscript by 2024.

Conclusions

Enhancing health literacy skills for patients undergoing hemodialysis is an important endeavor, given the association between poor health literacy and poor health outcomes, especially among culturally diverse groups. The findings from this trial will be published in peer-reviewed journals and disseminated at conferences, and updates will be shared with partners, including participating local health districts, Kidney Health Australia, and consumers. The SUCCESS app will continue to be available to all participants following trial completion.

Trial Registration

Australia New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621000235808; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380754&isReview=true

International Registered Report Identifier (IRRID)

DERR1-10.2196/39909

Pseudoangiomatous stromal hyperplasia causing massive unilateral breast enlargement-a case report

Background

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon mesenchymal benign breast neoplasm. PASH may present as a rapidly growing mass in pre-menopausal women. It is important to rule out other causes of a breast lump including fibroadenoma, hamartoma, phyllodes tumour and invasive adenocarcinoma. To our knowledge this is the largest case of PASH tumour in the English literature and the first to be managed with mastectomy and immediate breast implant reconstruction.

Case Description

A 45-year-old woman with a history of bilateral breast augmentation for cosmesis and no other co-morbidities, presented with gross asymmetry between her right and left breasts on 13th December 2020. She complained about pain and the noticeable difference in clothing. She underwent triple assessment (history and examination, imaging, and biopsy). Bilateral mammograms showed the right breast had a possible mass. On ultrasound imaging there was evidence of extensive ill-defined hypoechoic changes. Core biopsies and a vacuum assisted core biopsy were taken from the mass and came back as PASH/fibrocystic change on 12th January 2021. Surgical options were discussed, and after some consideration she decided on mastectomy and immediate implant reconstruction on 15th March 2021. She underwent the operation on 9th September 2021 and the specimen weight was 1.911 kg and measured 27 cm × 22.6 cm × 7.4 cm which is the largest reported PASH tumour. She made an uncomplicated recovery and was seen in clinic 4 weeks later and was happy with the cosmetic outcome. PASH can present as incidental microscopic foci in biopsies to diffuse enlargement of the breast. PASH has no specific radiological or diagnostic features, therefore is diagnosed based on histology. PASH is not associated with an increased risk of malignancy and the management is dependent on the presentation. When PASH is discovered incidentally or is asymptomatic it can be followed up with serial mammography to assess growth. If there are any suspicious features or discordance following triple assessment or symptoms such as discomfort surgical excision is indicated.

Conclusions

PASH should be considered as part of the differential diagnosis for rapid breast enlargement. Treatment options should be discussed early with the patient to prevent progression. For rapid breast enlargement mastectomy and immediate reconstruction should be considered and discussed with the patient.

Implementation of an organisational wide approach to improving policy documents using plain language: a case study

The impact of poorly written policies in healthcare is enormous, with the potential for significant economic and personal costs. Our local health district embarked on a major revision of policy document development that sought to reframe the process of policy development using health literacy principles. This included mandatory policy development changes that require policy to be written in plain language, at a readability level of grade 10-12. Staff training in plain language writing was undertaken. Consumer and staff feedback was incorporated in policy development. Four elements were critical to this process: effective leadership, effective instruction, practical support, and evidence-driven decisions. Staff responses to the revised processes were overwhelmingly positive and resulted in improved policy readability. The involvement of consumers in policy development has evolved. From this study, we have learned how to improve the governance of policy documents. It is possible for health literacy principles to be embedded in the development and revision of these documents.

Physical activity and exercise recommendations for people receiving dialysis: A scoping review

INTRODUCTION

Remaining physically active is important to patients undertaking dialysis, however, clinical recommendations regarding exercise type, timing, intensity, and safety precautions vary. The purpose of this scoping review was to analyse and summarise recommendations for physical activity and exercise for people undertaking dialysis and identify areas that require further research or clarification.

MATERIALS AND METHODS

A scoping review of literature from five bibliographic databases (Medline, Scopus, Web of Science, CINAHL, and SPORTDiscus) was conducted. Eligible articles included consensus guidelines, position statements, reviews, or clinical practice guidelines that included specific physical activity and exercise recommendations for people undertaking dialysis. Key search terms included "kidney disease" OR "kidney failure" OR "chronic kidney disease" OR "end stage kidney disease" AND guideline* OR consensus OR "position statement" OR prescription OR statement AND exercise OR "physical activity". Hand searching for relevant articles in all first twenty quartile 1 journals listed on SCImago under 'medicine-nephrology' and 'physical therapy, sports therapy and rehabilitation' using the terms 'exercise and dialysis' was undertaken. Finally, home pages of key societies and professional organisations in the field of sports medicine and nephrology were searched.

RESULTS

The systematic search strategy identified 19 articles met the inclusion criteria. Two were specific to pediatric dialysis and three to peritoneal dialysis. Whilst many publications provided recommendations on aerobic exercise, progressive resistance training and flexibility, few provided explicit guidance. Recommendations for the intensity, duration and frequency of aerobic and resistance training varied. Discrepancies or gaps in guidance about precautions, contraindications, termination criteria, progression, and access site precautions were also apparent.

CONCLUSION

Future guidelines should include specific guidance regarding physical activity, safety precautions, and timing and intensity of exercise for individuals who undertake dialysis. Collaborative multidisciplinary guideline development and appropriate exercise counselling may lead to increased participation in physical activity and exercise and facilitate better patient outcomes.

Diet in the management of non-dialysis dependent chronic kidney disease: perceptions and practices of health professionals

Background

Therapeutic strategies, including dietary intervention, to target non-dialysis dependent Chronic Kidney Disease (CKD) progression have been at the forefront of recent renal research. Nephrologists and other renal health professionals are key stakeholders in the dietary management of patients with non-dialysis dependent CKD and referrals to dietetic services. The aims of this study were to explore (i) health professional perceptions regarding the role of diet in managing non-dialysis dependent CKD, and (ii) health professional practices regarding the provision of dietary advice and referrals to dietetic services.

Methods

A 31-item online survey was emailed to members of professional renal networks and associations in Australia and New Zealand. Data was analysed descriptively. Categorical variables were assessed to determine associations between referral frequency, demographic variables, health professional role (non-dietetic versus dietetic) and perceptions of the role of diet.

Results

Overall, 189 health professionals completed the survey. Nephrologists (42%), renal nurses (29%) and renal dietitians (24%) were the most common respondents. Non-dietetic health professionals rated the importance of diet in the management of non-dialysis dependent CKD significantly lower than renal dietitians (73% versus 98% ranked as very-extremely important, p = 0.002). Fifty percent of non-dietetic health professionals referred patients to renal dietetic services never or 0–25% of the time. Reasons for not referring included perceptions there is a lack of evidence that diet reduces CKD progression, perceptions that patients will not adhere to dietary recommendations, and a desire to reduce visit burden for patients. Barriers to accessing dietetic services were perceived to be significant and include lengthy wait times and inadequate dietetic staffing.

Conclusion

Inconsistencies exist between non-dietetic health professionals and dietitians regarding the importance of diet in non-dialysis dependent CKD. Referral practices appear to be influenced by beliefs about the evidence base and perceptions regarding the ability of dietitians to meet referral demand. Raising awareness for non-dietetic health professionals working in nephrology regarding the evidence on diet and CKD progression is needed. An improved understanding of this evidence base may improve knowledge and referral patterns. Further, an increase in renal dietetic staffing is recommended to enhance patient access to services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02790-y.

Patient-Reported Outcome and Experience Measures Administered by Dietitians in the Outpatient Setting: Systematic Review

Understanding how patients perceive their health and the experience with the dietitian is fundamental to providing patient-centred care. The types of patient reported measures (PRMs) used by outpatient dietitians is unclear. Guidance about use of PRMs for dietitians is also lacking. The aim of this systematic review was to synthesise evidence regarding the use of PRMs by dietitians in the outpatient setting and evaluate the methodological quality of studies evaluating the psychometric properties of PRMs. Eight databases were searched systematically for studies of dietitians working in the outpatient setting and administering a PRM. Forty-four studies were evaluated and described 58 different PRMs. These included direct nutrition related (n = 12 studies), clinical (n = 21 studies), and health-related quality of life PRMs (n = 24 studies); 1 study documented use of a patient-reported experience measure. A large range of PRMs are used by outpatient dietitians. Of the most common PRMs, the majority are administered in similar populations to the original validation study. Dietitians should use a combination of 3 PRMs: a generic health-related quality of life tool, an experience measure, and at least 1 clinical or direct nutrition-related measure. This will enable dietitians to fully capture the impact of their care on patients.

Neurobiological effects of a probiotic-supplemented diet in chronically stressed male Long-Evans rats: Evidence of enhanced resilience

Probiotics that regulate the microbiome-gut-brain axis and provide mental health benefits to the host are referred to as psychobiotics. Preclinical studies have demonstrated psychobiotic effects on early life stress-induced anxiety- and depression-related behavior in rodents; however, the specific mechanisms remain ill-defined. In the current study, we investigated the effects of probiotic supplementation on neurobiological responses to chronic stress in adult male Long-Evans rats. Twenty-four rats were randomly assigned to probiotic (PB) or vehicle control (VEH) groups, then to either chronic unpredictable stress (CUS) or no-stress control (CON) conditions within each group (n = 6/subgroup). We hypothesized that PB supplementation would reduce markers of anxiety and enhance emotional resilience, especially in the CUS animals. In the cognitive uncertainty task, a nonsignificant trend was observed indicating that the PB-supplemented animals spent more time oriented toward the food reward than VEH animals. In the open-field task, CUS-PB animals spent more time in the center of the arena than CUS-VEH animals, an effect not observed between the two CON groups. In the swim task, the PB animals, regardless of stress assignment, exhibited increased floating, suggesting a conserved response in a challenging context. Focusing on the endocrine measures, higher dehydroepiandrosterone (DHEA)-to-corticosterone fecal metabolite ratios, a correlate of emotional resilience, were observed in PB animals. Further, PB animals exhibited reduced microglia immunoreactivity in the basolateral amygdala, possibly indicating a neuroprotective effect of PB supplements in this rodent model. These results provide evidence that PB supplementation interacts with stress exposure to influence adaptive responses associated with endocrine, neural, and behavioral indices of anxiety.

Physical activity and exercise in peritoneal dialysis: International Society for Peritoneal Dialysis and the Global Renal Exercise Network practice recommendations

Life participation requiring physical activity and physical function is a key patient-reported outcome for people receiving peritoneal dialysis (PD). Clinician guidance is required from multidisciplinary sources regarding exercise and activity advice to address the specific needs of this group. From August 2020 through to June 2021, the Global Renal Exercise Network and the International Society for Peritoneal Dialysis reviewed the published literature and international clinical experience to develop a set of clinical practice points. A set of questions relevant to physical activity and exercise were developed from the perspective of a person receiving PD and were the basis for the practice point development. The GRADE framework was used to evaluate the quality of evidence and to guide clinical practice points. The review of the literature found sparse quality evidence, and thus the clinical practice points are generally based on the expert consensus of people receiving PD, PD exercise expert clinicians and experienced PD exercise researchers. Clinical practice points address timing of exercise and activity (post-catheter insertion, peritoneal space empty or full), the uptake of specific activities (work, sex, swimming, core exercise), potential adverse outcomes related to activity and exercise (exit site care, perspiration, cardiovascular compromise, fatigue, intra-abdominal pressure), the effect of exercise and activity on conditions of interest (mental health, obesity, frailty, low fitness) and exercise nutrition.

Interventions to Improve Hydration in Older Adults: A Systematic Review and Meta-Analysis

Dehydration is common in the elderly, especially when hospitalised. This study investigated the impact of interventions to improve hydration in acutely unwell or institutionalised older adults for hydration and hydration linked events (constipation, falls, urinary tract infections) as well as patient satisfaction. Four databases were searched from inception to 13 May 2020 for studies of interventions to improve hydration. Nineteen studies (978 participants) were included and two studies (165 participants) were meta-analysed. Behavioural interventions were associated with a significant improvement in hydration. Environmental, multifaceted and nutritional interventions had mixed success. Meta-analysis indicated that groups receiving interventions to improve hydration consumed 300.93 mL more fluid per day than those in the usual care groups (95% CI: 289.27 mL, 312.59 mL; I² = 0%, p < 0.00001). Overall, there is limited evidence describing interventions to improve hydration in acutely unwell or institutionalised older adults. Behavioural interventions appear promising. High-quality studies using validated rather than subjective methods of assessing hydration are needed to determine effective interventions.

Elevated renal resistive index is independently predicted by older age, but not by the presence of chronic kidney disease: A retrospective cohort study

PURPOSE

Renal resistive index (RRI), which reflects intra-renal arterial impedance is routinely measured when undertaking renal Doppler ultrasonography (RDU). We investigated the relationship between elevated RRI and presence of chronic kidney disease (CKD), and examined whether elevated RRI at baseline is associated with decline in estimated glomerular filtration rate (eGFR) on follow-up.

METHODS

This retrospective observational study examined the association of elevated RRI (>0.7) with the presence of CKD (eGFR <60 mL/min for >3 months), demographic and clinical factors in multivariable models. We also examined the effect of elevated RRI on eGFR decline on follow-up using mixed models.

RESULTS

Of the 346 patients undergoing RDU (median age 69.7 years, 46.2% male), 180 had elevated RRI. There was a strong inverse association between RRI and eGFR at baseline, 1 and 2 years (rho = -0.53, -0.51, -0.53, all p < 001). Elevated RRI was independently predicted by older age (Odds Ratio 3.29, 95% CI: 2.25-4.8, p < 0.001) and diabetes (Odds Ratio 2.65, 95% CI: 1.21-5.80, p = 0.015) but not CKD using multivariate logistic regression. Decline of eGFR was not different between RRI categories on follow-up.

CONCLUSION

Elevated RRI was predicted by older age and diabetes, but not by the presence of CKD. Baseline RRI was not associated with eGFR decline. This article is protected by copyright. All rights reserved.

Systematic review with meta-analysis: dietary intake in adults with inflammatory bowel disease

BACKGROUND

Poor dietary intake is associated with the development of malnutrition, micronutrient deficiencies, anaemia and osteoporosis in individuals with inflammatory bowel disease. While trials are underway to manipulate the diet of people with IBD, there has been no comprehensive systematic review of the dietary intake of adults with IBD.

AIMS

To conduct a systematic evaluation and meta-analysis of the dietary intake of adults with IBD, including macronutrients, micronutrients and food group data.

METHODS

CINAHL, Embase, Medline and Scopus were searched from 1 January 2000 to 25 September 2020 for cohort, case-control or cross-sectional studies that reported usual dietary intake in adults. Data were pooled and reported as weighted mean intake for: all adults with IBD; Crohn's disease; ulcerative colitis; active disease; remission; males; females. A random-effects meta-analysis model compared intake with healthy individuals.

RESULTS

Forty studies were identified and 19 were included in the meta-analysis. All subgroups of adults with IBD consumed inadequate energy (mean intake in adults with IBD 1980 ± 130 kcal), fibre (14 ± 4 g), folate (246 ± 33 mg) and calcium (529 ± 114 mg) per day. Intake of breads and cereals, legumes, fruit, vegetables and dairy were inadequate. Compared to healthy individuals, adults with IBD consume significantly less dietary fibre (SMD -0.59; 95% CI: -0.73, -0.46).

CONCLUSIONS

This review provides improved clarity about the dietary intake of adults with IBD. Future attention is required to improve diet quality and increase understanding of factors influencing dietary intake in IBD.

Dietary Modelling to Explore the Impact of Potassium Chloride Replacement for Sodium in Bread for Adults with Chronic Kidney Disease

Food manufacturers are increasingly substituting potassium chloride (KCl) in food products so as to reduce the sodium chloride content. Bread and bread products are common staple foods in many Western households and are a target for recipe reformulation using KCl. Given that chronic kidney disease (CKD) is a medical condition of global importance that requires dietary potassium restriction in the later stages, we sought to evaluate the impact and safety of varying levels of KCl substitution in bread products. We undertook a secondary analysis of dietary data from the National Nutrition and Physical Activity Survey 2011–2012 for 12,152 participants (154 participants with CKD). The sodium chloride content in bread and bread-based products was substituted with 20%, 30%, and 40% of KCl. The contribution of these alterations in the dietary potassium intake to the total daily potassium intake were then examined. The replacement of sodium in bread with varying amounts of KCl (20%, 30%, and 40%) resulted in one third of people with CKD exceeding the safe limits for dietary potassium consumption (31.8%, 32.6%, and 33%, respectively). KCl substitution in staple foods such as bread and bread products have serious and potentially fatal consequences for people who need to restrict dietary potassium. Improved food labelling is required for consumers to avoid excessive consumption.

A Systematic Review of Handgrip Strength Measurement in Clinical and Epidemiological Studies of Kidney Disease: Toward a Standardized Approach

In chronic kidney disease (CKD), handgrip strength (HGS) is recommended as a surrogate measure of protein-energy status and functional status. However, it is not routinely used because of inconsistencies such as the optimal timing of the HGS measurement and unclear guidance regarding technique. We aimed to determine the extent of variation in the protocols and methods of HGS assessment. We aimed to identify clinical and epidemiological studies conducted on CKD that reported on the use of HGS as an outcome. A systematic literature search identified n = 129 studies with a total participant population of n = 35,192. We identified large variations in all aspects of the methodology including body and arm position, repetitions, rest time, timing, familiarization, and how scores were calculated. The heterogeneous methodologies used reinforce the need to standardize HGS measurement. After reviewing previously employed methodology in the literature, we propose a comprehensive HGS assessment protocol for use in CKD.

What are the information needs and concerns of individuals with Polycystic Kidney Disease? Results of an online survey using Facebook and social listening analysis

BACKGROUND

Polycystic Kidney Disease (PKD) is a hereditary disorder that has no cure and can result in end stage kidney failure. Searching for health information online and via social media is a common phenomenon in many medical conditions. However, no recent studies have documented the information needs, online behaviours, and concerns of people with PKD. The aim of this study was to explore the information needs of individuals with PKD and their carers by documenting (i) the information needs (ii) online information health seeking behaviours (iii) the perceived challenges of living with PKD and (iv) dietary concerns.

METHODS

A 17-item survey was constructed by undertaking a social listening analysis. This survey was then distributed via PKD related social media groups on Facebook. Seven groups distributed the survey with permission from the group owners. Open free text survey questions were analysed thematically using content analysis.

RESULTS

A total of 536 respondents completed the online survey (70.9 % female, 77 % aged 35-70, 70.2 % diagnosed more than 10 years ago). The major information need expressed by participants with PKD was for dietary information. Information regarding medications, medical management and symptom control were also desired. The overarching themes arising from the free text responses to the major challenge of living with PKD included 'learning to navigate dietary ambiguities'; 'managing social, psychological and emotional needs'; and 'accepting an uncertain future'. In addition to a strong desire for practical and specific dietary information, participants expressed a need for more online information pertaining to management of fatigue, pain, complications and how to manage mental health. Online peer support was also highly regarded and desired.

CONCLUSIONS

This study provides contemporary insights into the type of information desired by people with PKD. The results indicated that there was a strong desire for unambiguous information and guidance from health professionals to facilitate self-management, alleviate concerns, and address the complexities of living with Polycystic Kidney Disease. While diet is an important and frequently expressed need, there also remains a large demand for information on how to support psychological needs, and on medical management in order to support treatment decision making. Future work is required to develop specific, actionable and evidence-based resources for patients that are available online and through health professionals. Increased access to renal dietitians, peer support and additional training for health professionals could also improve patient-centered care and support self-management.

Incorporating digital platforms into nutritional care in chronic kidney disease

Digital health is increasingly recognized for its value to enhance patient care and clinical care processes. People with chronic kidney disease often find dietary self-management challenging. There is promising evidence that digital health interventions can support people with chronic kidney disease to self-manage their diet, by providing more frequent access to nutritional information and dietitians and by facilitating regular monitoring and feedback. There is some emerging evidence of the impact of digital interventions in chronic kidney disease; however, more research is needed to provide meaningful interpretation of how digital interventions can enhance current practice. Importantly, a number of factors need to be considered when designing, developing, implementing, and evaluating the impact of digital interventions. Consideration of the nutrition service and patients' needs, motivation and digital literacy, type of digital intervention, and the ability to embed the digital intervention into current care processes are critical. This paper overviews the current literature on digital health and self-management, factors to consider when embedding digital interventions and platforms into nutrition care and practical considerations for designing and implementing digital health interventions to enhance the nutritional care of people with chronic kidney disease.

Cytoarchitectural characteristics associated with cognitive flexibility in raccoons

With rates of psychiatric illnesses such as depression continuing to rise, additional preclinical models are needed to facilitate translational neuroscience research. In the current study, the raccoon (Procyon lotor) was investigated due to its similarities with primate brains, including comparable proportional neuronal densities, cortical magnification of the forepaw area, and cortical gyrification. Specifically, we report on the cytoarchitectural characteristics of raccoons profiled as high, intermediate, or low solvers in a multiaccess problem-solving task. Isotropic fractionation indicated that high-solvers had significantly more cells in the hippocampus (HC) than the other solving groups; further, a nonsignificant trend suggested that this increase in cell profile density was due to increased nonneuronal (e.g., glial) cells. Group differences were not observed in the cellular density of the somatosensory cortex. Thionin-based staining confirmed the presence of von Economo neurons (VENs) in the frontoinsular cortex, although no impact of solving ability on VEN cell profile density levels was observed. Elongated fusiform cells were quantified in the HC dentate gyrus where high-solvers were observed to have higher levels of this cell type than the other solving groups. In sum, the current findings suggest that varying cytoarchitectural phenotypes contribute to cognitive flexibility. Additional research is necessary to determine the translational value of cytoarchitectural distribution patterns on adaptive behavioral outcomes associated with cognitive performance and mental health.

NutriCoviD30 : étude nationale sur l’évaluation de l’état de santé et la prise en charge nutritionnelle à 1 mois d’une hospitalisation pour COVID-19

Introduction et but de l’étude

Matériel et méthodes

Résultats et analyse statistique

Conclusion

Australia IBD Microbiome (AIM) Study: protocol for a multicentre longitudinal prospective cohort study

INTRODUCTION

Crohn's disease and ulcerative colitis are common chronic idiopathic inflammatory bowel diseases (IBD), which cause considerable morbidity. Although the precise mechanisms of disease remain unclear, evidence implicates a strong multidirectional interplay between diet, environmental factors, genetic determinants/immune perturbations and the gut microbiota. IBD can be brought into remission using a number of medications, which act by suppressing the immune response. However, none of the available medications address any of the underlying potential mechanisms. As we understand more about how the microbiota drives inflammation, much interest has focused on identifying microbial signals/triggers in the search for effective therapeutic targets. We describe the establishment of the Australian IBD Microbiota (AIM) Study, Australia's first longitudinal IBD bioresource, which will identify and correlate longitudinal microbial and metagenomics signals to disease activity as evaluated by validated clinical instruments, patient-reported surveys, as well as biomarkers. The AIM Study will also gather extensive demographic, clinical, lifestyle and dietary data known to influence microbial composition in order to generate a more complete understanding of the interplay between patients with IBD and their microbiota.

METHODS

The AIM Study is an Australian multicentre longitudinal prospective cohort study, which will enrol 1000 participants; 500 patients with IBD and 500 healthy controls over a 5-year period. Assessment occurs at 3 monthly intervals over a 24-month period. At each assessment oral and faecal samples are self-collected along with patient-reported outcome measures, with clinical data also collected at baseline, 12 and 24 months. Intestinal tissue will be sampled whenever a colonoscopy is performed. Dietary intake, general health and psychological state will be assessed using validated self-report questionnaires. Samples will undergo metagenomic, transcriptomic, proteomic, metabolomic and culturomic analyses. Omics data will be integrated with clinical data to identify predictive biomarkers of response to therapy, disease behaviour and environmental factors in patients with IBD.

ETHICS AND DISSEMINATION

Ethical approval for this study has been obtained from the South Eastern Sydney Local Health District Research Ethics Committee (HREC 2019/ETH11443). Findings will be reported at national and international gastroenterology meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12619000911190.

Supporting patients to be involved in decisions about their health and care: Development of a best practice health literacy App for Australian adults living with Chronic Kidney Disease

ISSUE ADDRESSED

Inadequate health literacy is common in those with chronic kidney disease (CKD), especially among culturally and linguistically diverse groups. Patient information for people with CKD, including those with kidney failure requiring dialysis, is often written beyond their literacy level, and many CKD-related apps are not accurate or evidence based. These represent important barriers to health care decision-making and equity in access to health care.

METHODS

We developed a cross-platform application (the "SUCCESS app") to support Australian adults with kidney failure requiring dialysis to actively participate in self-management and decision-making. App content was informed by health literacy theory which recognises the importance of reducing the complexity of health information as well as equipping consumers with the skills necessary to access, understand and act on this information. The development team comprised members of diverse backgrounds and expertise, including nursing, allied health, psychology, epidemiology, nephrology and IT, as well as consumer representatives.

RESULTS

Content areas included diet, fluids, medicine, physical activity, emotional well-being and supportive care, chosen as they represent important decision points in the CKD trajectory. To support functional health literacy, a four-step process to simplify written content was used including calculating readability statistics, applying the Patient Education Materials Assessment Tool, supplementing written information with video and audio content, and incorporating micro-learning and interactive quizzes. To develop communicative and critical health literacy skills, question prompt lists and evidence-based volitional help sheets were included in each module to support question-asking and behaviour change. We also developed animated skills training related to communication, shared decision-making and critical appraisal of health information.

CONCLUSIONS

This is the first health literacy informed app developed to promote active patient participation in CKD management and decision-making. Ongoing evaluation of the SUCCESS app through analysis of quantitative and qualitative data will provide valuable insights into the feasibility of implementing the app with dialysis patients, and the impact of the intervention of psychosocial and clinical outcomes. SO WHAT?: Digital health solutions have been found to improve self-management for chronic conditions, and could optimise the use of health care services and patient outcomes.

Associations Among Plant-Based Diet Quality, Uremic Toxins, and Gut Microbiota Profile in Adults Undergoing Hemodialysis Therapy

OBJECTIVE

The objective of the study was to evaluate associations among diet quality, serum uremic toxin concentrations, and the gut microbiota profile in adults undergoing hemodialysis therapy.

DESIGN AND METHODS

This is a cross-sectional analysis of baseline data from a clinical trial involving adults receiving hemodialysis therapy. Usual dietary intake was determined using a diet history method administered by Accredited Practising Dietitians. Two approaches were used for diet quality assessment: (1) using three a priori defined plant-based diet indices-an overall plant-based diet index (PDI), a healthy PDI, and an unhealthy PDI and (2) classification of food group intake. Serum uremic toxins (p-cresyl sulfate and indoxyl sulfate (IS); free and total) were determined by ultra-performance liquid chromatography. Gut microbiota composition was established through sequencing the 16S rRNA gene in stool samples.

RESULTS

Twenty-two adults (median age 70.5 [interquartile range: 59-76], 64% male) were included in the final analysis. Higher adherence to the PDI was associated with lower total IS levels (P = .028), independent of dialysis adequacy, urinary output, and blood albumin levels. In contrast, higher adherence to the unhealthy PDI was associated with increases in both free and total IS. Several other direct and inverse associations between diet quality with uremic toxins, microbial relative abundances, and diversity metrics were also highlighted. Diet-associated taxa showed significantly different trends of association with serum uremic toxin concentrations (P < .05). Higher adherence to the PDI was negatively associated with relative abundances of Haemophilus and Haemophilus parainfluenzae that were related to elevated total IS levels. In contrast, increased intake of food items considered unhealthy, such as animal fats, sweets and desserts, were associated with bacteria linked to higher IS and p-cresyl sulfate (total and free) concentrations.

CONCLUSIONS

The quality of diet and food selections may influence uremic toxin production by the gut microbiota in adults receiving hemodialysis. Well-designed dietary intervention trials that adopt multi-omic technologies appropriate for the functional annotation of the gut microbiome are needed to validate our findings and establish causality.

Does a renal diet question prompt sheet increase the patient centeredness of renal dietitian outpatient consultations?

OBJECTIVE

Effective communication is fundamental to helping patients change behaviour. Few studies have operationalised how to quantify and improve the patient centeredness of communication during the dietitian outpatient consultation. We sought to evaluate the impact of a renal diet question prompt sheet (QPS) on patient centeredness (PC) in dietitian outpatient clinics and describe the impact of a renal diet QPS on the volume and pattern of communication between dietitians (n = 4) and patients/carers (n = 24, n = 11).

METHODS

The Roter Interaction Analysis System was used to compute a PC index, the volume communication (number of questions and utterances) and categorise dietitian communication.

RESULTS

The QPS was associated with significant improvements in the PC of communication (p = 0.004 and p = 0.001), without increasing the volume of communication. The QPS was also associated with an increase in the total number of questions asked (p < 0.0001) especially from patients (p = 0.0009); and an increase in the volume of communication devoted to education and counselling (p < 0.0001).

CONCLUSIONS

This study describes a promising intervention to increase the patient centeredness of dietetic consultations in an outpatient setting.

PRACTICE IMPLICATIONS

Whilst simple in design, the use of a QPS had a large effect on how patients and carers interact with the dietitian in the outpatient setting.

Factors associated with utilisation of health care interpreting services and the impact on length of stay and cost: A retrospective cohort analysis of audit data

ISSUE ADDRESSED

Utilisation of professional health care interpreting services improves the quality and safety of health care among patients with limited English proficiency. Health care interpreter service utilisation is inconsistent and suboptimal in Australia. Evidence of the impact of interpreter service use on patient outcomes and costs is limited. This study aimed to identify the proportion of hospitalised patients who received a health care interpreter during admission and describe the characteristics and outcomes for those requiring interpreter services.

METHODS

A retrospective cohort analysis of linked admitted patient data with internal interpreter audit data. This study included all inpatients in a health district-wide clinical audit of interpreter service use conducted between July 2016 and March 2018. The dataset comprised 74 patients (including 79 unique hospital stays and 90 episodes) from eight hospitals in one regional health district in New South Wales, Australia.

RESULTS

Interpreting services were utilised at least once for 54.4% (n = 43) of admissions. Females were more likely to receive an interpreter (65.1% vs 47.1%, P = .04). Age, preferred language, hospital, Diagnosis-Related Group partition and comorbidities were not associated with interpreter service utilisation. Differences in length of stay and cost associated with use of interpreter services were not statistically significant after casemix adjustment.

CONCLUSIONS

Approximately half of those who required an interpreter received one during their hospital stay. Further investigation is needed to establish whether regular clinical audits contributed to this rate of utilisation, which is higher than reported elsewhere in the literature. SO WHAT?: A detailed understanding of regional interpreting service use with evidence from the literature provides compelling and contextual evidence for change, at the level at which the service is delivered. This supports meaningful action to increase utilisation, and improve the quality and safety of health care delivered to patients with limited English proficiency.

The gut microbiota profile of adults with kidney disease and kidney stones: a systematic review of the literature

Background

There is mounting evidence that individuals with kidney disease and kidney stones have an abnormal gut microbiota composition. No studies to date have summarised the evidence to categorise how the gut microbiota profile of these individuals may differ from controls. Synthesis of this evidence is essential to inform future clinical trials. This systematic review aims to characterise differences of the gut microbial community in adults with kidney disease and kidney stones, as well as to describe the functional capacity of the gut microbiota and reporting of diet as a confounder in these studies.

Methods

Included studies were those that investigated the gut microbial community in adults with kidney disease or kidney stones and compared this to the profile of controls. Six scientific databases (CINHAL, Medline, PubMed, Scopus, Web of Science and Cochrane Library), as well as selected grey literature sources, were searched. Quality assessment was undertaken independently by three authors. The system of evidence level criteria was employed to quantitatively evaluate the alteration of microbiota by strictly considering the number, methodological quality and consistency of the findings. Additional findings relating to altered functions of the gut microbiota, dietary intakes and dietary methodologies used were qualitatively summarised.

Results

Twenty-five articles met the eligibility criteria and included data from a total of 892 adults with kidney disease or kidney stones and 1400 controls. Compared to controls, adults with kidney disease had increased abundances of several microbes including Enterobacteriaceae, Streptococcaceae, Streptococcus and decreased abundances of Prevotellaceae, Prevotella, Prevotella 9 and Roseburia among other taxa. Adults with kidney stones also had an altered microbial composition with variations to Bacteroides, Lachnospiraceae NK4A136 group, Ruminiclostridium 5 group, Dorea, Enterobacter, Christensenellaceae and its genus Christensenellaceae R7 group. Differences in the functional potential of the microbial community between controls and adults with kidney disease or kidney stones were also identified. Only three of the 25 articles presented dietary data, and of these studies, only two used a valid dietary assessment method.

Conclusions

The gut microbiota profile of adults with kidney disease and kidney stones differs from controls. Future study designs should include adequate reporting of important confounders such as dietary intake to assist with interpretation of findings.

Postpartum environmental challenges alter maternal responsiveness and offspring development

Because many threats exist in an animal's natural habitat, it is important to understand the impact of environmental challenges on maternal-offspring interactions and outcomes. In the current study, a rodent model incorporating the presence of restricted resources and an environmental threat (e.g. predator-related odors and sounds) was investigated. Specifically, pregnant females were assigned to one of four treatments: standard resources, without threat (SR; n = 7); standard resources plus threat (SR-T; n = 8); restricted resources, without threat (RR; n = 7); and restricted resources plus threat (RR-T; n = 6). Maternal rats were moved into the assigned conditions on postnatal day 2 and remained until pups were weaned. Following a standard pup retrieval task on postnatal days 2 and 6, maternal rats were exposed to a retrieval challenge task on postnatal day 8 in which each rat had to traverse a novel barrier to retrieve pups. For neurobiological measures of stress/resilience responsiveness, fecal samples were collected for detection of corticosterone and DHEA metabolites; additionally, immunohistochemistry was conducted on the maternal brains to indicate the presence of Neuropeptide Y (NPY) and Brain Derived Neurotrophic Factor (BDNF) immunoreactivity in the hippocampus, amygdala and hypothalamus. Pup development measures, including body weight and tail length, were also collected. Results suggest that maternal rats with restricted resources exhibited diminished maternal responsiveness that resulted in altered pup development measures; further, restricted resource rats exhibited endocrine markers of compromised emotional resilience (lower DHEA) and decreased neural markers of neuroplasticity (BDNF) and emotional resilience (NPY). Interestingly, predator threat affected various aspects of maternal-pup interactions but had no effect on neurobiological variables, suggesting that restricted resources had a more negative impact on maternal-related outcomes than the presence of predator threat.

P0561ACUTE KIDNEY INJURY AS A RISK FACTOR FOR KIDNEY STONES: A PROPENSITY MATCHED ANALYSIS

Background and Aims

Kidney stones affects 6-9% of the population, with an almost 30% risk of reoccurrence. Factors associated with kidney stone formation include male gender, ethnicity, family history and stone type. The underlying pathology of stone formation is complex and includes increased urine saturation, decreased urine stone inhibitors in addition to metabolic factors.

Acute kidney injury (AKI) refers to the abrupt decrease in kidney function, resulting in retention of urea and other waste products and the dysregulation of fluid and electrolyte balance. AKI affects 10-15% of the hospitalised population and is associated with long-term outcomes, such as chronic kidney disease, end-stage kidney disease (ESKD), cardiovascular disease, fractures and earlier mortality.

There is evidence that AKI may result in long-term renal damage and fibrosis. A potential effect is impairment in urine concentration which would limit kidney stone formation. However there has been no previous investigation about this potential association. We aim to investigate if there is an association between AKI and kidney stone formation.

Method

Retrospective clinical data available for all adult (≥18 years of age) hospital admissions to a local health district in Australia between January 2008 and December 2017 was used in the analysis. We excluded 1) non-residents, 2) stone diagnosis pre-AKI, 3) death within 1 month of an AKI episode, 4) dialysis dependent ESKD prior to an AKI episode and 5) incomplete patient information. AKI episode was diagnosed from ICD-10 coding and kidney stone from ICD-10 and SNOMED coding. Our outcome was a kidney stone episode. We examined the entire cohort in addition to propensity score matching (PSM) using 1:1 optimal matching, caliper 0.1 and without replacement based on covariates known to be associated with renal calculi and AKI. Balance before and after PSM was assessed between the groups to evaluate quality using standardised means. Baseline characteristics were compared with chi-square and Mann Whitney U. Multivariate analysis was compared using Logistic regression.

Results

For the cohort of 180,927 patients, after exclusions, 12,338 (6.8%) patients were diagnosed with an AKI and 4,495 (2.5%) patients with a kidney stone. Patients with an AKI (12,338), compared to patients with no AKI (168,523), were more likely to be older (75.0 vs 50.0 years, p&lt;0.001) with more comorbidities such as hypertension (31.8% vs 12.7%, p&lt;0.001), diabetes (21.5% vs 9.4%, p&lt;0.001), coronary artery disease (14.6% vs 7.0%, p&lt;0.001) and peripheral vascular disease (5.4% vs 1.8%, p&lt;0.001).

The risk of kidney stone formation for the entire cohort in patients with a history of AKI was lower when compared to the no AKI patients (1.1% vs 2.6%, Hazard ratio 0.42, 95% confidence interval 0.36- 0.52, p&lt;0.001). After PSM 12,336 patients with AKI were matched with 12,336 patients with no AKI with good balance of covariates. Patients with a history of AKI had a lower risk of kidney stone formation when compared to no AKI patients (Hazard ratio 0.57, 95% Confidence Interval 0.36- 0.51, p&lt;0.001)

Conclusion

Our findings suggest that patients with AKI appear to be at a significantly lower risk of developing subsequent kidney stone formation when compared to patients with no previous AKI episodes. Further analysis on a greater scale are required to confirm these findings and their implications.

How frequently are patients weighed in hospital ? Results from a five-year cross-sectional audit of clinical practice in nine hospitals

BACKGROUND AND AIMS

Knowledge of a person's weight is important for identifying malnutrition; occupational safety reasons; medication dosing and evaluating effectiveness of medical nutrition therapy. However, weighing of patients in hospitals is known to be problematic and suboptimal.

METHODS

Five annual cross-sectional audits of patients admitted to nine hospitals were conducted to determine the frequency that patients were weighed (i) on admission and (ii) during admission. Characteristics such as age, length of stay, the presence of cognitive impairment, culturally and linguistically diverse (CALD) background, mobility status and single room isolation were also recorded.

RESULTS

The frequency of weighing patients on admission was only 20.3%. Approximately 62.4% of patients had been weighed at least once during their admission. Individuals who were admitted to rehabilitation wards or those with independent mobility had significantly higher odds of being weighed during the admission, in addition to those with a longer length of stay (Odds Ratios 5.98 (95% CI: 2.51-10.3); 2.34 (95% CI: 1.60-3.4); and 1.05 (95% CI: 1.03-1.07) respectively, all p < 0.001). Differences between ward types were also evident with rehabilitation, paediatric, renal and mental health wards exhibiting a higher incidence of weighing patients during their admission.

CONCLUSIONS

The practice of weighing patients in this health district was suboptimal and places patients at high risk of a deterioration in their clinical condition. Strategies to ensure all patients are weighed including those who have a short hospital stay and those with poor mobility is required.

Barriers and enablers to detection and management of chronic kidney disease in primary healthcare: a systematic review

Background

Chronic kidney disease (CKD) is growing population health concern worldwide, and with early identification and effective management, kidney disease progression can be slowed or prevented. Most patients with risk factors for chronic kidney disease are treated within primary healthcare. Therefore, it is important to understand how best to support primary care providers (PC-P) to detect and manage chronic kidney disease. The aim of this systematic review was to evaluate barriers and enablers to the diagnosis and management of CKD in primary care.

Methods

A systematic review of qualitative research on the barriers and/or enablers to detection and/or management of CKD in adults within primary healthcare was conducted. The databases Medline (EBSCO), PubMed, Cochrane CENTRAL, CINAHL (EBSCO) and Joanna Briggs Institute Evidence Based Practice (Ovid) were searched until 27th August 2019. Barriers and/or enablers reported in each study were identified, classified into themes, and categorised according to the Theoretical Domains Framework.

Results

A total of 20 studies were included in this review. The most commonly reported barriers related to detection and management of CKD in primary care were categorised into the ‘Environmental context and resources’ domain (n = 16 studies). Overall, the most common barrier identified was a lack of time (n = 13 studies), followed by a fear of delivering a diagnosis of CKD, and dissatisfaction with CKD guidelines (both n = 10 studies). Overall, the most common enabler identified was the presence of supportive technology to identify and manage CKD (n = 7 studies), followed by the presence of a collaborative relationship between members of the healthcare team (n = 5 studies).

Conclusion

This systematic review identified a number of barriers and enablers which PC-P face when identifying and managing CKD. The findings of this review suggest a need for time-efficient strategies that promote collaboration between members of the healthcare team, and practice guidelines which consider the frequently co-morbid nature of CKD. Enhanced collaboration between PC-P and nephrology services may also support PC-Ps when diagnosing CKD in primary care, and facilitate improved patient self-management.

Peritoneal dialysis-related peritonitis as a risk factor for cardiovascular events

BACKGROUND

Cardiovascular disease is the leading cause of mortality in peritoneal dialysis (PD) patients. Infection is known to increase the risk of cardiovascular events (CVE); however, no studies have examined the association between PD peritonitis and CVE.

AIM

To examine peritonitis as a risk factor for CVE in PD patients.

METHODS

This retrospective cohort study included all adults undertaking PD for ≥3 months in one Australian health district from 2001 to 2015. Baseline characteristics and peritonitis event information was obtained from the Australian and New Zealand Dialysis and Transplant registry. The Centre for Health Research Illawarra Shoalhaven Population facilitated data linkage using ICD10 coding to capture CVE information.

RESULTS

A total of 211 patients was included, with median age of 66 years (interquartile range 54.49-74.45); 64% were male. Peritonitis occurred in 114 (54%) patients and 65 (30.8%) patients experienced a CVE. Identified risk factors for CVE included: cerebrovascular disease (hazard ratio (HR) 2.72, 95% confidence interval (CI) 1.36-5.47), diabetes (HR 2.41, 95% CI 1.47-3.96), coronary artery disease (HR 1.67, 95% CI 1.01-2.77) and age (HR 1.03, 95% CI 1.01-1.06). There was no significant increase in risk of CVE following peritonitis (HR 1.37, 95% CI 0.81-2.32, P = 0.24), even when accounting for age, cerebrovascular disease, diabetes and existing coronary artery disease (HR 1.32, 95% CI 0.78-2.23, P = 0.30).

CONCLUSIONS

We did not find an increase in the risk of CVE following a peritonitis episode in PD patients. This result may be due to small sample size or rapid peritonitis treatment mitigating cardiovascular risk.

Safety and Efficacy of Using Nuts to Improve Bowel Health in Hemodialysis Patients

OBJECTIVE

Constipation is common in patients with end-stage kidney disease. Nondrug strategies to manage constipation are challenging because of dietary potassium, phosphate, and fluid restrictions. Nuts are a high-fiber food but are excluded from the diet because of the high potassium and phosphate content. The aim of this study was to examine the safety and efficacy of using nuts to improve constipation in adults undertaking hemodialysis (HD).

DESIGN AND METHODS

Adult patients undertaking HD were recruited to this nonrandomized, 10-week repeated measures, within-subject, pragmatic clinical trial, conducted in two HD units. The intervention consisted of consumption of 40g of raw almonds daily for four weeks, followed by a two-week washout and four-week control period. The primary safety outcome measures were change in predialysis serum potassium and phosphate levels. The primary efficacy outcome was reduction in constipation, measured using the Bristol Stool Form Scale and Palliative Care Outcome Scale (POS-S) renal symptom score. Secondary outcomes included quality of life, selected uremic toxins, cognition, gut microbiota profile, and symptom burden.

RESULTS

Twenty patients completed the trial (median age: 67 [interquartile range: 57.5-77.8] years, 51% male). After controlling for dialysis adequacy, anuria, dietary intake, bicarbonate, and parathyroid hormone, there were no statistically significant changes in serum potassium (P = 0.21) or phosphate (P = 0.16) associated with daily consumption of almonds. However, statistically significant improvements in constipation were seen at weeks 2, 3, 4, and 10. There were statistically significant improvements in quality of life (P = 0.030), overall symptom burden (P = 0.002), vomiting (P = 0.020), itching (P = 0.006), and skin changes (P = 0.002).

CONCLUSION

Daily consumption of almonds for four weeks was safe, effective, and well tolerated. Improvements in quality of life and symptom burden warrant further research to elucidate potential mechanisms. The findings support the potential reinclusion of foods such as nuts into the diet of patients who underwent HD.

In search of optimal resilience ratios: Differential influences of neurobehavioral factors contributing to stress-resilience spectra

The ability to adapt to stressful circumstances, known as emotional resilience, is a key factor in the maintenance of mental health. Several individual biomarkers of the stress response (e.g., corticosterone) that influence an animal's position along the continuum that ranges from adaptive allostasis to maladaptive allostatic load have been identified. Extending beyond specific biomarkers of stress responses, however, it is also important to consider stress-related responses relative to other relevant responses for a thorough understanding of the underpinnings of adaptive allostasis. In this review, behavioral, neurobiological, developmental and genomic variables are considered in the context of emotional resilience [e.g., explore/exploit behavioral tendencies; DHEA/CORT ratios and relative proportions of protein-coding/nonprotein-coding (transposable) genomic elements]. As complex and multifaceted relationships between pertinent allostasis biomediators are identified, translational applications for optimal resilience are more likely to emerge as effective therapeutic strategies.

A practical guide for the use of very low calorie diets in adults with chronic kidney disease

Obesity is increasingly common in individuals with chronic kidney disease (CKD). Being overweight or obese is associated with both the development and progression of kidney disease. Lifestyle interventions such as the use of very low-calorie diets (VLCD) are being used increasingly for patients with CKD despite warnings from manufacturers that they should be avoided or used with caution. Whilst these diets are effective and can induce rapid weight loss and suppress appetite, their use in patients with chronic and end stage kidney disease is more complex than in the general population. VLCD use in adults with kidney disease requires a more nuanced approach to prescription and closer monitoring for unintended side effects. This review describes the indications and clinical management of patients with CKD undertaking a very low-calorie diet and provides practical guidance regarding how to manage a VLCD, particularly for the latter stages of CKD.

Nutritional Status According to the Mini Nutritional Assessment Predicts Speed and Degree of Functional Improvement and Discharge Outcomes in Rehabilitation Patients

This retrospective observational study evaluated the association between nutritional status, functional ability and discharge outcomes. Data from 1430 older rehabilitation patients (43% male, median age 79 years, interquartile range: 74-84) were analyzed. One fifth (20.6%, n = 294) of patients were malnourished on admission to rehabilitation. Three important findings were evident. Firstly, nutritional status on admission to rehabilitation was associated with reduced functional, motor, cognitive and feeding scores on admission and discharge (all P < 0.05). Secondly, malnutrition at admission was associated with significantly slower gains in rehabilitation. Finally, malnutrition at admission was associated with significantly higher odds of a decline in functional ability during admission (OR 3.95; 95% CI: 2.14-7.27), and almost three times greater odds of additional care requirements on discharge (OR: 2.9 ((95% CI: 1.02-8.3). The nutritional status of patients on admission to inpatient rehabilitation is a predictor of both the speed and degree of rehabilitation gains and discharge outcomes.

The association between dietetic consultation and time to dialysis for patients attending a pre-dialysis clinic: A retrospective cohort study

AIM

A multidisciplinary approach, including dietetics, is considered the optimal model of care for dialysis preparation. Dietetic consultation (DC) focuses on symptom management and dietary changes to delay time to dialysis. Evidence of the effectiveness of DC on time to dialysis is limited. This study aimed to investigate the impact of DC on time to dialysis for patients attending a pre-dialysis clinic.

METHODS

A retrospective cohort study was designed to include all patients attending outpatient pre-dialysis clinics at a large metropolitan renal service between January 2014 and March 2018. Time to dialysis (days) was compared between patients that received DC and those who did not. Cox proportional hazards analysis allowing for adjustment of differences and confounders was undertaken.

RESULTS

A cohort of 246 patients was identified. Median estimated glomerular filtration rate was 16mL/min per 1.73 m² (interquartile range = 13-20) at initial pre-dialysis clinic visit and 63% commenced dialysis during the study period. Only 41% of patients received dietetic consultation. Significantly fewer patients needed to commence dialysis in the DC group compared to the no-DC group (hazards ratio 0.63; 95% confidence interval (CI) 0.45-0.89; P = 0.008 Cox proportion hazard). The DC group commenced dialysis significantly later than the no-DC group; 933 days (95% CI 832-1034) versus 710 days (95% CI 630-790) respectively, after the initial pre-dialysis clinic visit; log-rank 0.005.

CONCLUSION

DC provided to patients attending a pre-dialysis clinic was associated with a delayed time to dialysis. Standardised referral pathways to improve patient access to renal dietetic services are recommended to optimise care.

Optimizing brain performance: Identifying mechanisms of adaptive neurobiological plasticity

Although neuroscience research has debunked the late 19^th century claims suggesting that large portions of the brain are typically unused, recent evidence indicates that an enhanced understanding of neural plasticity may lead to greater insights related to the functional capacity of brains. Continuous and real-time neural modifications in concert with dynamic environmental contexts provide opportunities for targeted interventions for maintaining healthy brain functions throughout the lifespan. Neural design, however, is far from simplistic, requiring close consideration of context-specific and other relevant variables from both species and individual perspectives to determine the functional gains from increased and decreased markers of neuroplasticity. Caution must be taken in the interpretation of any measurable change in neurobiological responses or behavioral outcomes, as definitions of optimal functions are extremely complex. Even so, current behavioral neuroscience approaches offer unique opportunities to evaluate adaptive functions of various neural responses in an attempt to enhance the functional capacity of neural systems.

Embedding health literacy into health systems: a case study of a regional health service

Objective The aim of the present study was to describe how one regional health service the Illawarra Shoalhaven Local Health District embedded health literacy principles into health systems over a 3-year period. Methods Using a case study approach, this article describes the development of key programs and the manner in which clinical incidents were used to create a health environment that allows consumers the right to equitably access quality health services and to participate in their own health care. Results The key outcomes demonstrating successful embedding of health literacy into health systems in this regional health service include the creation of a governance structure and web-based platform for developing and testing plain English consumer health information, a clearly defined process to engage with consumers, development of the health literacy ambassador training program and integrating health literacy into clinical quality improvement processes via a formal program with consumers to guide processes such as improvements to access and navigation around hospital sites. Conclusions The Illawarra Shoalhaven Local Health District has developed an evidence-based health literacy framework, guided by the core principles of universal precaution and organisational responsibility. Health literacy was also viewed as both an outcome and a process. The approach taken by the Illawarra Shoalhaven Local Health District to address poor health literacy in a coordinated way has been recognised by the Australian Commission on Safety and Quality in Health Care as an exemplar of a coordinated approach to embed health literacy into health systems. What is known about the topic? Poor health literacy is a significant national concern in Australia. The leadership, governance and consumer partnership culture of a health organisation can have considerable effects on an individual's ability to access, understand and apply the health-related information and services available to them. Currently, only 40% of consumers in Australia have the health literacy skills needed to understand everyday health information to effectively access and use health services. What does this paper add? Addressing health literacy in a coordinated way has the potential to increase safety and quality of care. This paper outlines the practical and sustainable actions the Illawarra Shoalhaven Local Health District took to partner with consumers to address health literacy and to improve the health experience and health outcomes of consumers. Embedding health literacy into public health services requires a coordinated whole-of-organisation approach; it requires the integration of leadership and governance, revision of consumer health information and revision of consumer and staff processes to effect change and support the delivery of health-literate healthcare services. What are the implications for practitioners? Embedding health literacy into health systems promotes equitable, safe and quality healthcare. Practitioners in a health-literate environment adopt consumer-centred communication and care strategies, provide information in a way that is easy to understand and follow and involve consumers and their families in decisions regarding and management of the consumer's care.

Here one year, gone the next? Investigating persistence of frequent emergency department attendance: a retrospective study in Australia

OBJECTIVES

Patients are presenting to emergency departments (EDs) with increasing complexity at rates beyond population growth and ageing. Intervention studies target patients with 12 months or less of frequent attendance. However, these interventions are not well targeted since most patients do not remain frequent attenders. This paper quantifies temporary and ongoing frequent attendance and contrasts risk factors for each group.

DESIGN

Retrospective population-based study using 10 years of longitudinal data.

SETTING

An Australian geographic region that includes metropolitan and rural EDs.

PARTICIPANTS

332 100 residents visited any ED during the study period.

MAIN OUTCOME MEASURE

Frequent attendance was defined as seven or more visits to any ED in the region within a 12-month period. Temporary frequent attendance was defined as meeting this threshold only once, and ongoing more than once. Risk factors for temporary and ongoing frequent attenders were identified using logistic regression models for adults and children.

RESULTS

Of 8577 frequent attenders, 80.1% were temporary and 19.9% ongoing (12.9% repeat, 7.1% persistent). Among adults, ongoing were more likely than temporary frequent attenders to be young to middle aged (aged 25-64 years), and less likely to be from a high socioeconomic area or be admitted. Ongoing frequent attenders had higher rates of non-injury presentations, in particular substance-related (OR=2.5, 99% CI 1.1 to 5.6) and psychiatric illness (OR=2.9, 99% CI 1.8 to 4.6). In comparison, children who were ongoing were more likely than temporary frequent attenders to be aged 5-15 years, and were not more likely to be admitted (OR=2.7, 99% CI 0.7 to 10.9).

CONCLUSIONS

Future intervention studies should distinguish between temporary and ongoing frequent attenders, develop specific interventions for each group and include rigorous evaluation.