Design and implementation of community consultation for research conducted under exception from informed consent regulations for the PreVent and the PreVent 2 trials: Changes over time and during the COVID-19 pandemic

INTRODUCTION

Emergency clinical research has played an important role in improving outcomes for acutely ill patients. This is due in part to regulatory measures that allow Exception From Informed Consent (EFIC) trials. The Food and Drug Administration (FDA) requires sponsor-investigators to engage in community consultation and public disclosure activities prior to initiating an Exception From Informed Consent trial. Various approaches to community consultation and public disclosure have been described and adapted to local contexts and Institutional Review Board (IRB) interpretations. The COVID-19 pandemic has precluded the ability to engage local communities through direct, in-person public venues, requiring research teams to find alternative ways to inform communities about emergency research.

METHODS

The PreVent and PreVent 2 studies were two Exception From Informed Consent trials of emergency endotracheal intubation, conducted in one geographic location for the PreVent Study and in two geographic locations for the PreVent 2 Study. During the period of the two studies, there was a substantial shift in the methodological approach spanning across the periods before and after the pandemic from telephone, to in-person, to virtual settings.

RESULTS

During the 10 years of implementation of Exception From Informed Consent activities for the two PreVent trials, there was overall favorable public support for the concept of Exception From Informed Consent trials and for the importance of emergency clinical research. Community concerns were few and also did not differ much by method of contact. Attendance was higher with the implementation of virtual technology to reach members of the community, and overall feedback was more positive compared with telephone contacts or in-person events. However, the proportion of survey responses received after completion of the remote, live event was substantially lower, with a greater proportion of respondents having higher education levels. This suggests less active engagement after completion of the synchronous activity and potentially higher selection bias among respondents. Importantly, we found that engagement with local community leaders was a key component to develop appropriate plans to connect with the public.

CONCLUSION

The PreVent experience illustrated operational advantages and disadvantages to community consultation conducted primarily by telephone, in-person events, or online activities. Approaches to enhance community acceptance included partnering with community leaders to optimize the communication strategies and trust building with the involvement of Institutional Review Board representatives during community meetings. Researchers might need to pivot from in-person planning to virtual techniques while maintaining the ability to engage with the public with two-way communication approaches. Due to less active engagement, and potential for selection bias in the responders, further research is needed to address the costs and benefits of virtual community consultation and public disclosure activities compared to in-person events.

homeRNA self-blood collection enables high-frequency temporal profiling of pre-symptomatic host immune kinetics to respiratory viral infection: a prospective cohort study

Background

Early host immunity to acute respiratory infections (ARIs) is heterogenous, dynamic, and critical to an individual's infection outcome. Due to limitations in sampling frequency/timepoints, kinetics of early immune dynamics in natural human infections remain poorly understood. In this nationwide prospective cohort study, we leveraged a self-blood collection tool (homeRNA) to profile detailed kinetics of the pre-symptomatic to convalescence host immunity to contemporaneous respiratory pathogens.

Methods

We enrolled non-symptomatic adults with recent exposure to ARIs who subsequently tested negative (exposed-uninfected) or positive for respiratory pathogens. Participants self-collected blood and nasal swabs daily for seven consecutive days followed by weekly blood collection for up to seven additional weeks. Symptom burden was assessed during each collection. Nasal swabs were tested for SARS-CoV-2 and common respiratory pathogens. 92 longitudinal blood samples spanning the pre-shedding to post-acute phase of eight SARS-CoV-2-infected participants and 40 interval-matched samples from four exposed-uninfected participants were subjected to high-frequency longitudinal profiling of 773 host immune genes.

Findings

Between June 2021 - April 2022, 68 participants across 26 U.S. states completed the study and self-collected a total of 691 and 466 longitudinal blood and nasal swab samples along with 688 symptom surveys. SARS-CoV-2 was detected in 17 out of 22 individuals with study-confirmed respiratory infection. With rapid dissemination of home self-collection kits, two and four COVID-19+ participants started collection prior to viral shedding and symptom onset, respectively, enabling us to profile detailed expression kinetics of the earliest blood transcriptional response to contemporaneous variants of concern. In pre-shedding samples, we observed transient but robust expression of T-cell response signatures, transcription factor complexes, prostaglandin biosynthesis genes, pyrogenic cytokines, and cytotoxic granule genes. This is followed by a rapid induction of many interferon-stimulated genes (ISGs), concurrent to onset of viral shedding and increase in nasal viral load. Finally, we observed increased expression of host defense peptides (HDPs) in exposed-uninfected individuals over the 4-week observational window.

Interpretation

We demonstrated that unsupervised self-collection and stabilization of capillary blood can be applied to natural infection studies to characterize detailed early host immune kinetics at a temporal resolution comparable to that of human challenge studies. The remote (decentralized) study framework enables conduct of large-scale population-wide longitudinal mechanistic studies. Expression of cytotoxic/T-cell signatures in pre-shedding samples preceding expansion of innate ISGs suggests a potential role for T-cell mediated pathogen control during early infection. Elevated expression of HDPs in exposed-uninfected individuals warrants further validation studies to assess their potential role in protective immunity during pathogen exposure.

Funding

This study was funded by R35GM128648 to ABT for in-lab developments of homeRNA, Packard Fellowship from the David and Lucile Packard Foundation to ABT, and R01AI153087 to AW.

Employee perceptions of race and racism in an Australian hospital

BACKGROUND

Racism contributes to health inequities faced by people of colour and marginalised groups. Despite widespread recognition of the impacts of racism, mitigating strategies and legislation have been largely unsuccessful. Research into racism in healthcare has mostly examined personal experiences of healthcare workers and patients, assuming that the definitions of racism and race are similarly understood by all. However, ethnicity and race are often conflated, and racism seen as primarily interpersonal and ahistorical.

PURPOSE

This paper explores hospital employee understandings of racism, its impacts and how to reduce it.

METHODS

Forty-nine staff within one Australian hospital participated in individual qualitative interviews regarding the definition, impact, and ways of reducing racism. Interviews were analysed with a reflexive thematic analytic approach using a Postcolonial framework.

RESULTS

Participants described racism as being experienced by marginalised groups of people in Australia. They identified that racism has detrimental effects on health and wellbeing. Not all were clear regarding what constituted racism: it was not described as an ideology created to justify colonial distribution of power and resources. Some thought that racism was individual prejudice while others noted it was also structural in nature. Participants commonly defined race as involving physical or cultural differences, suggesting that discredited historical and colonial concepts of race continue in Australian society. While many felt that education was the best way to reduce racism and its impacts, some participants noted that being educated did not necessarily change racist behaviour.

CONCLUSIONS

The lack of accurate understanding of the concept of race and racism likely contributes to the relatively poor effect of current strategies to combat racism. As an initial part of deeper systemic anti-racist reform, this research supports calls for anti-racist education to clarify the definition of racism as an ideology.

At-home saliva sampling in healthy adults using CandyCollect, a lollipop-inspired device

Respiratory infections are common in children, and there is a need for user-friendly collection methods. Here, we performed the first human subjects study using the CandyCollect device, a lollipop inspired saliva collection device. 1 We showed the CandyCollect device can be used to collect salivary bacteria from healthy adults using Streptococcus mutans and Staphylococcus aureus as proof-of-concept commensal bacteria. We enrolled healthy adults in a nationwide (USA) remote study in which participants were sent study packages containing CandyCollect devices and traditional commercially available oral swabs and spit tubes. Participants sampled themselves at home, completed usability and user preference surveys, and mailed the samples back to our laboratory for analysis by qPCR. Our results showed that for participants in which a given bacterium ( S. mutans or S. aureus ) was detected in one or both of the commercially available methods (oral swab and/or spit tubes), CandyCollect devices had a 100% concordance with the positive result (n=14 participants). Furthermore, the CandyCollect device was ranked the highest preference sampling method among the three sampling methods by 26 participants surveyed (combining survey results across two enrollment groups). We also showed that the CandyCollect device has a shelf life of up to 1 year at room temperature, a storage period that is convenient for clinics or patients to keep the CandyCollect device and use it any time. Taken together, we have demonstrated that the CandyCollect is a user-friendly saliva collection tool that has the potential to be incorporated into diagnostic assays in clinic visits and telemedicine.

For Table of Contents Only

A racial bias test with tertiary cancer centre employees: why anti-racist measures are required for First Nations Australians cancer care equity

Objective To examine implicit bias in employees at a cancer centre using an Australian race (Aboriginal-white) Implicit Association Test (IAT), in an attempt to understand a potential factor for inequitable outcomes of First Nations Australians cancer patients. Methods All employees at an Australian cancer centre were invited to take part in a web-based, cross-sectional study using an Australian race IAT. The results were analysed using Welch t-tests, linear regression and ANOVA. Results Overall, 538/2871 participants (19%) completed the IAT between January and June 2020. The mean IAT was 0.147 (s.d. 0.43, P < 0.001, 95% CI 0.11-0.18), and 60% had a preference for white over First Nations Australians. There was no significant mean difference in IAT scores between sub-groups of gender, age or clinical/non-clinical employees. 21% of employees (95% CI 17.65-24.53) had moderate to strong preference for white over First Nations Australians, compared to 7.1% with moderate to strong preference for First Nations over white Australians (95% CI 5.01-9.09). Conclusions Inequitable cancer survival for First Nations patients has been well established and cancer is now the leading cause of mortality. This paper documents the presence of racial bias in employees at one cancer centre. We argue that this cannot be understood outside the history of colonialism and its effects on First Nations Australians, healthcare workers and our society. Further research is required to evaluate measures of racism, its effect on health care, and how to eliminate it.

Correlation of placental pathology with the postoperative outcomes and white matter injury in preterm infants following necrotizing enterocolitis

BACKGROUND

To determine the association of placental pathologic lesions with postoperative outcomes, survival, and white matter injury (WMI) in preterm infants with NEC.

METHODS

A retrospective chart review of 107 neonates with NEC (Bell stage > IIa) from Jan 2013- June 2020 was completed. Demographic, clinical, and outcome data were compared between infants with or without placental pathologic lesions.

RESULTS

In this cohort, 59/107 (55%) infants had medical NEC, and 48 (45%) had surgical NEC. The infants had a mean gestational age of 28.1±3.7 weeks and a birth weight of 1103±647 g. Maternal vascular malperfusion (82/107, 76.6%) and acute histological chorioamnionitis (42, 39.3%) were the most common pathological placental lesions. Acute histologic chorioamnionitis with fetal inflammatory response was more common in infants with surgical NEC vs. medical NEC (35.4% vs. 15.3%; p = 0.02). The NEC Infants with WMI on brain MRI scans had a significantly higher incidence of acute histological chorioamnionitis (52% vs. 27.8%; P = 0.04). No significant differences in mortality, length of stay and postoperative outcomes in neonates with and without acute histologic chorioamnionitis with fetal inflammatory response were noted. On unadjusted logistic regression, acute histologic chorioamnionitis without fetal inflammatory response was also associated with higher odds of WMI (OR 2.81; 95% CI 1.05-7.54; p = 0.039).

CONCLUSION

Acute histological chorioamnionitis without fetal inflammatory response was associated with higher odds of WMI in infants with NEC, with no significant impact on mortality and other postoperative outcomes.

Development of a core descriptor set for Crohn's anal fistula

AIM

Crohn's anal fistula (CAF) is a complex condition, with no agreement on which patient characteristics should be routinely reported in studies. The aim of this study was to develop a core descriptor set of key patient characteristics for reporting in all CAF research.

METHOD

Candidate descriptors were generated from published literature and stakeholder suggestions. Colorectal surgeons, gastroenterologists and specialist nurses in inflammatory bowel disease took part in three rounds of an international modified Delphi process using nine-point Likert scales to rank the importance of descriptors. Feedback was provided between rounds to allow refinement of the next ratings. Patterns in descriptor voting were assessed using principal component analysis (PCA). Resulting PCA groups were used to organize items in rounds two and three. Consensus descriptors were submitted to a patient panel for feedback. Items meeting predetermined thresholds were included in the final set and ratified at the consensus meeting.

RESULTS

One hundred and thirty three respondents from 22 countries completed round one, of whom 67.0% completed round three. Ninety seven descriptors were rated across three rounds in 11 PCA-based groups. Forty descriptors were shortlisted. The consensus meeting ratified a core descriptor set of 37 descriptors within six domains: fistula anatomy, current disease activity and phenotype, risk factors, medical interventions for CAF, surgical interventions for CAF, and patient symptoms and impact on quality of life.

CONCLUSION

The core descriptor set proposed for all future CAF research reflects characteristics important to gastroenterologists and surgeons. This might aid transparent reporting in future studies.

'Maybe what I do know is wrong…': Reframing educator roles and professional development for teaching Indigenous health

Settler colonisation continues to cause much damage across the globe. It has particularly impacted negatively on Indigenous peoples' health and wellbeing causing great inequity. Health professional education is a critical vehicle to assist in addressing this; however, non-Indigenous educators often feel unprepared and lack skill in this regard. In this qualitative study, 20 non-Indigenous nursing, physiotherapy and occupational therapy educators in Australia were interviewed about their experiences and perspectives of teaching Indigenous health. Findings from the inductive thematic analysis suggest educators require skill development to: identify their discomfort in teaching cultural safety; contextualise the sources of this discomfort and; reflect on how this understanding can improve their teaching. Additionally, educators require professional training to become practitioners of cultural humility and to be facilitators and colearners (rather than experts) of the Aboriginal-led curriculum. Of relevance to this is educator training in how to decentre non-Indigenous needs and perspectives. Educators can also renew their teaching practices by understanding what a dominant settler paradigm is, identifying if this is problematically present in their teaching and knowing how to remedy this. Crucial to improved cultural safety teaching is institutional support, which includes Indigenous leadership, institutional commitment, relevant policies, and well-designed professional development.

Much being Written about Us, not much being Written with Us: Examining how alcohol and other drug use by indigenous Australians is portrayed in Australian Government policies and strategies: A discourse analysis

BACKGROUND

Using critical discourse analysis, this study examined the portrayal of Aboriginal and Torres Strait Islander people in Australian Government policies regarding alcohol and other drug (AOD) use.

METHODS

We used critical discourse analysis, informed by an Indigenous Research Paradigm, to analyse texts and contexts of six key Australian Government AOD drug policies; two Aboriginal AOD data documents, two reporting documents and two AOD strategy documents.

RESULTS

The social practice analysis found issues of power imbalance relating to the socio-political situation the documents were created in. Textual analysis identified: culture being performative or functional in documents; cultural unsafety in construction of targets and outcomes, and; the decentring of Aboriginal peoples in the framing of the documents. The discourse analysis identified that the documents often wrote about Aboriginal peoples rather than writing documents with or by Aboriginal peoples. This typically: absented complexities of consultation occurring within a complex power imbalanced cultural interface; did not support an Aboriginal paradigm; centred Gubba people in power and; promoted a paternalistic view of 'helping' Aboriginal people.

CONCLUSIONS

There is an urgent need to move from policy relating to Aboriginal affairs that relies on a deficit discourse, to more effective AOD policy that improves power balance in policy development, is written with or by Aboriginal people, is inclusive of Aboriginal epistemologies and ontologies, and represents a paradigm-shift to a strength-based approach.

The Effects of Leadership Curricula With and Without Implicit Bias Training on Graduate Medical Education: A Multicenter Randomized Trial

PURPOSE

To determine whether a brief leadership curriculum including high-fidelity simulation can improve leadership skills among resident physicians.

METHOD

This was a double-blind, randomized controlled trial among obstetrics-gynecology and emergency medicine (EM) residents across 5 academic medical centers from different geographic areas of the United States, 2015-2017. Participants were assigned to 1 of 3 study arms: the Leadership Education Advanced During Simulation (LEADS) curriculum, a shortened Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) curriculum, or as active controls (no leadership curriculum). Active controls were recruited from a separate site and not randomized to limit any unintentional introduction of materials from leadership curricula. The LEADS curriculum was developed in partnership with the Council on Resident Education in Obstetrics and Gynecology and Council of Residency Directors in Emergency Medicine as a novel way to provide a leadership toolkit. Both LEADS and the abbreviated TeamSTEPPS were designed as six 10-minute interactive web-based modules.The primary outcome of interest was the leadership performance score from the validated Clinical Teamwork Scale instrument measured during standardized high-fidelity simulation scenarios. Secondary outcomes were 9 key components of leadership from the detailed leadership evaluation measured on 5-point Likert scales. Both outcomes were rated by a blinded clinical video reviewer.

RESULTS

One hundred ten obstetrics-gynecology and EM residents participated in this 2-year trial. Participants in both LEADS and TeamSTEPPS had statistically significant improvement in leadership scores from "average" to "good" ranges both immediately and at the 6-month follow-up, while controls remained unchanged in the "average" category throughout the study. There were no differences between LEADS and TeamSTEPPS curricula with respect to the primary outcome.

CONCLUSIONS

Residents who participated in a brief structured leadership training intervention had improved leadership skills that were maintained at 6-month follow-up.

Translation to practice of cultural safety education in nursing and midwifery: A realist review

OBJECTIVES

Health inequities exist for racial groups as a result of political, societal, historical and economic injustices, such as colonisation and racism. To address this, health professions have applied various health education pedagogies to equip learners to contribute better to cultural safety. The aim of this realist review was to provide an overview of cultural safety programs that evaluate transition of learning to practice to generate program theory as to what strategies best translate cultural safety theory to practice for nurses and midwives.

DESIGN

A systematic review following realist review publication standards.

DATA SOURCES

Nine papers were selected from six databases, from inception to January 2020. Any article that evaluated nurses and midwives practice change following participation in cultural safety education programs was included.

REVIEW METHODS

A realist review was undertaken to refine cultural safety education program theory. This involved an initial broad search of literature, research team consultation, systematic literature search with refinement of the inclusion criteria. For each included article the context, mechanism and outcomes were extracted and analysed.

RESULTS

Three program theories resulted. Firstly, system and structural leadership to drive the change process, including adoption of policy and accreditation standards and involvement of the community impacted by health inequity. Second critical pedagogy to reveal institutional and individual racist behaviours and third, nurse and midwife commitment to cultural safety.

CONCLUSION

Change in practice to achieve cultural safety is complex, requiring a multi-system approach. Cultural safety education programs adopting critical pedagogy is necessary for critical consciousness building by nurses and midwives to have impact. However, this is only one part of this interdependent change process. Involvement of those communities experiencing culturally unsafe practice is also necessary for program effectiveness. Further research is required to examine the effectiveness of coordinated multi-system approaches, alongside, nurse and midwife commitment for cultural safety.

When I say … Situation

In this latest contribution to the 'When I say … ' series, Vass and Adams explore the pervasive impact of colonisation as an under-recognised and poorly addressed context of medical education.

HAND HYGIENE COMPLIANCE IN THE PREVENTION OF HOSPITAL ACQUIRED INFECTIONS: A SYSTEMATIC REVIEW

BACKGROUND

Healthcare worker's (HCW) hands are known to be a primary source of transmission of hospital-acquired infections (HAIs). Thus, practicing hand hygiene (HH) and adhering to HH guidelines are both expected to decrease the risk of transmission but there is no consensus on the optimal hand hygiene compliance (HHC) rate that HCWs should aim for.

AIM

The objective of this study was to systematically review the published literature to determine an optimal threshold of HCW HHC rate associated with the lowest incidence rate of HAIs.

METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. We searched online databases using a comprehensive search criterion for randomized controlled trials and non-randomized controlled studies, investigating the impact of HCW's HHC rate on HAI rates in patients of all ages, within healthcare facilities in high income countries.

FINDINGS

Of the 8,093 articles citations and abstracts screened, 35 articles were included in the review. Most studies reported overall HAIs per 1000 patient-days and device-associated HAIs per 1000 device-days. Most studies reported HHC rates between 60%-70%. Lower incidence HAI rates seemed to be achieved with HHC rates of approximately 60%. Studies included were not originally designed to assess the impact of HHC on HAI rates but risk of bias was assessed as per our predetermined exposure and outcome criterion. 11 (31%) of studies were deemed at low risk of bias.

CONCLUSIONS

Although HHC is part of HCW's code of conduct, very high HHC rates were difficult to reach. In observational studies, HHC and HAI followed a negative relationship up to about 60%. Due to flaws in study design, causality could not be inferred; only general trends could be discussed. Given the limitations, there is a need for high-quality evidence to support the implementation of specified targets of HHC rates.

"Connection to Culture Is Like a Massive Lifeline": Yarning With Aboriginal Young People About Culture and Social and Emotional Wellbeing

Culture is an important social and emotional wellbeing factor for Aboriginal peoples in Australia, particularly regarding recovery from colonization. However, little is understood about how culture and wellbeing interact for young urban Aboriginal people. This study used Yarning methods to explore experiences and perceptions of culture and wellbeing for young urban Aboriginal people in Narrm, Australia. Findings indicate that culture is experienced as connection, and that perceived connection or disconnection has an essential influence on the wellbeing of young people. Through sharing young people stories, a range of factors, including colonization, relationships, cultural knowledge, community support, and agency, were identified as affecting perceptions of connectedness, and therefore on wellbeing. Youth were able to develop strategies to increase connection and provided illuminating advice and suggestions for improving connection for future generations. This study thus contributes to efforts to improved understanding of Aboriginal perspectives about social and emotional wellbeing and culture.

Roadmap to recovery: Reporting on a research taskforce supporting Indigenous responses to COVID-19 in Australia

In April 2020 a Group of Eight Taskforce was convened, consisting of over 100 researchers, to provide independent, research-based recommendations to the Commonwealth Government on a "Roadmap to Recovery" from COVID-19. The report covered issues ranging from pandemic control and relaxation of social distancing measures, to well-being and special considerations for vulnerable populations. Our work focused on the critical needs of Aboriginal and Torres Strait Islander communities; this paper presents an overview of our recommendations to the Roadmap report. In addressing the global challenges posed by pandemics for citizens around the world, Indigenous people are recognised as highly vulnerable. At the time of writing Australia's First Nations Peoples have been largely spared from COVID-19 in comparison to other Indigenous populations globally. Our recommendations emphasise self-determination and equitable needs-based funding to support Indigenous communities to recover from COVID-19, addressing persistent overcrowded housing, and a focus on workforce, especially for regional and remote communities. These latter two issues have been highlighted as major issues of risk for Indigenous communities in Australia It remains to be seen how governments across Australia take up these recommendations to support Indigenous peoples' health and healing journey through yet another, potentially catastrophic, health crisis.

Educator perceptions on teaching Indigenous health: Racism, privilege and self-reflexivity

INTRODUCTION

General practitioners (GPs) and family medicine clinicians should respond to Indigenous peoples' health needs. However, medical graduates feel underprepared for this work. The foundational elements of racism, white privilege and cultural self-reflexivity remain conspicuously absent from medical education in general practice programmes, despite inclusion in curriculum frameworks. This study explored the perception and experiences of Australian GP educators in teaching this content.

METHODS

We undertook a qualitative study that gathered data through semi-structured interviews with GP educators (n = 12) at a medical school in Victoria, Australia. We utilised the Reflection learning domain of the Aboriginal and Torres Strait Islander Health Curriculum Framework to shape interview questions on racism, white privilege and cultural self-reflexivity. Data were analysed from constructivist and Critical Indigenous Theory paradigms to formulate key themes.

RESULTS

General practitioner educators were challenged by Reflection content, struggled to articulate a refined pedagogy for provision of anti-racist, self-reflexive learning and felt poorly qualified to teach Indigenous health, articulating preference for delegation of teaching to Indigenous peoples. They simultaneously stated the importance of inclusion of Reflection teaching in general practice, alongside expressing beliefs that appeared to devalue its perceived relevance. Students were perceived as being either disinterested or incapable of Reflection learning, or conversely, more engaged than previous generations with these topics.

DISCUSSION

The results call into question how skilled are GP educators to teach elements of Indigenous health education such as racism, white privilege and cultural self-reflexivity. Unskilled educators can reinforce colonialism in curricula, including through minimisation of content. Stronger anti-racist pedagogy is urgently required in medical education. Vital to this is active research on educator preparedness, evidence-based teaching models and accountable curriculum accreditation.

Frontal sinus as an identity and sex indicator

The present study explores the variability of frontal sinuses volume in modern Greeks and their potential use in the forensic identification process.

METHODS

The sample consisted of 102 CT scan images from a modern Greek population. 50 (49%) were male and 52 (51%) were female. Ages ranged from 19 to 101 (mean age 70.6 for males and 69.6 for females). 3D models of the skull were constructed, and volume calculations of the frontal sinus were done with the software Amira 5.4. 10 CT scans were used to extract 2D frontal and lateral images that were used as proxies of antemortem X-rays which were matched to the CT scans using manual craniofacial superimposition.

RESULTS

The average of frontal sinus volume of male was 9,220 mm³ (±SD) and female was 5,880 mm³ (±SD). Mann-Witney test confirmed that mean values were significantly different (P<0.05) between them. Pearson's correlation coefficient showed no evident correlation between the volumes and ages of the skulls in both groups. Using the lateral and anterior oriented radiographs for matching the sinuses, the method produced 60% sensitivity / 99.32% specificity and 80% sensitivity / 99.97% specificity, respectively.

CONCLUSIONS

Even though there are statistically significant differences in the shape and volume between sexes, these are not sufficient to be used as an indicator of sex in worldwide populations. The results indicate that using the anterior view of the frontal sinuses is more consistent in human identification, and that the method proves to be reliable, as long as the sinus is adequately observed on the radiograph.

Primary Conjunctival Kaposi Sarcoma; A Rare And Unheard Entity

Introduction/Objective

Kaposi’s sarcoma (KS) is the most common malignant vascular tumor in human immunodeficiency virus (HIV) patients caused by human herpesvirus 8. It can affect the vascular endothelium of any part of the body however ocular KS as an initial manifestation has been reported only in 3 cases so far. It affects the vascular endothelium of the lacrimal gland, eyelids, orbit, palpebral and bulbar conjunctiva. It presents as a violaceous fleshy nodular mass.

Methods

A 23-year-old male with a past medical history of HIV presented with bilateral eye erythema and significant upper and lower lid edema. The patient was initially admitted for facial swelling which led to a conjunctival biopsy and a diagnosis of KS was made and doxorubicin along with chemotherapy was started. Four months later after the initiation of chemotherapy, the patient experienced worsening of facial swelling, and an area on the left side of his face got very firm. His physical examination was positive for a fever, drooling, facial swelling with trouble swallowing, and change of voice along with shortness of breath.

Results

CT of the orbit revealed symmetric enhancement swelling of the preseptal periorbital soft tissues which was thought to be nonspecific and a differential diagnosis included lymphedema, acute sinusitis, and orbital cellulitis was considered. A chest x-ray revealed bilateral pleural effusions and CT head revealed diffuse scalp and facial cutaneous and subcutaneous edema. Lab findings were significant for a low CD4: CD8 ratio. Cytological examination of the pleural fluid revealed predominantly blood, reactive mesothelial cells, macrophages, neutrophils, and lymphocytes, and appropriately controlled immunostain was positive for ERG and HHV8 with a possibility that Kaposi’s sarcoma cannot be completely excluded. Unfortunately, the patient passed away during the same time of pleural fluid analysis.

Autopsy findings revealed multiple metastatic foci in the mediastinal soft tissue, within the right land left lung, scalp soft tissue, retroperitoneal soft tissue, and hilar lymph node which were positive for CD34, CD31, and HHV8 and consistent with metastatic KS.

Conclusion

Thus, it is important to keep in mind that isolated conjunctival KP with later on systemic metastasis is rare with conjunctiva being an unusual site for the initial presentation, and a possibility of primary conjunctival KS should be considered in HIV positive patients.

Action research to implement an Indigenous health curriculum framework

In recent decades Indigenous health curriculum frameworks have been developed, however, few studies about their implementation exist. This study aimed to employ critical theory and action research to understand how an Indigenous health curriculum framework could be applied and associated learning and teaching iteratively improved. Three action research cycles where conducted from 2017 to 2019. Student reaction (satisfaction and engagement) was collected via survey 2017-2019. Student learning was collated 2018-2019 via self-perception survey (knowledge, attitude, confidence, commitment); multi-choice questions (knowledge) and; content analysis of apply and analyse activities (skill). The teaching team met annually to reflect on findings and plan enhancements to learning and teaching. Over 2017-2019 there was a pattern of improved student reaction and learning. Connecting this research to Faculty level committees led to widening success and improved sustainability of the practice. The online unit and workshop delivery were scalable, overcame a barrier of educator skill and confidence to teach this area, allowed for quality content control and provided data for analysis. Interestingly, learning gained from this unit matched that described as occurring from student placements in health settings with high numbers of Indigenous people. Student learning occurred across the Framework three levels (novice, intermediate and entry to practice) suggesting that the taxonomy of the Framework does not necessarily align with the reality of learning and teaching. Vertical implementation of the five learning domains would benefit from alignment with training evaluation models and validated assessment to understand learning that has occurred rather than the teaching that has been taught. In this study health profession accreditation bodies had driven the imperative for an Indigenous health program and curriculum. Research on Indigenous health learning and teaching relating to behaviour and results in workplaces is needed.

Not just a policy; this is for real. An affirmative action policy to encourage Aboriginal and Torres Strait Islander peoples to seek employment in the health workforce

Delivery of culturally safe healthcare is critical to ensuring access to high-quality care for indigenous people. A key component of this is for Aboriginal and Torres Strait Islander people to be participants in the health workforce. The proportion of indigenous people in the health workforce should at least equate to the proportion in the population served. We describe the development and implementation of a successful affirmative action employment policy at Monash Health, one of Australia's largest Academic Health Centres, and provide perspective on its adoption.

Outcomes of emergency laparotomy in patients on extracorporeal membrane oxygenation for severe respiratory failure: A retrospective, observational cohort study

PURPOSE

There is a paucity of literature to support undertaking emergency laparotomy when indicated in patients supported on ECMO. Our study aims to identify the prevalence, outcomes and complications of this high risk surgery at a large ECMO centre.

MATERIALS AND METHODS

A single centre, retrospective, observational cohort study of 355 patients admitted to a university teaching hospital Severe Respiratory Failure service between December 2011 and January 2017.

RESULTS

The prevalence of emergency laparotomy in patients on ECMO was 3.7%. These patients had significantly higher SOFA and APACHE II scores compared to similar patients not requiring laparotomy. There was no difference in the duration of ECMO or intensive care unit (ICU) stay post decannulation between the two groups. 31% of laparotomy patients survived to hospital discharge. Major haemorrhage was uncommon, however emergency change of ECMO oxygenator was commonly required.

CONCLUSION

Survival to hospital discharge is possible following emergency laparotomy on ECMO, however the mortality is higher than for those patients not requiring laparotomy, this likely reflects the severity of underlying organ failure rather than the surgery itself. Our service's collocation with a general surgical service has made this development in care possible. ECMO service planning should consider general surgical provision.

Indigenous Health Curriculum and Health Professional Learners: A Systematic Review

Background: Globally, an estimated 370 million Indigenous peoples reside in more than 70 countries with these people commonly experiencing health care access inequity. Purpose: This systematic review aimed to examine the impact of Indigenous health care curriculum on entry-level health professional learners in preparation to deliver equitable health care. Methods: Seventeen articles were identified and analyzed for: context; study design; study measures, teaching and learning delivery mode, content and duration; positive and negative learner reactions; learning gained and article quality was assessed using the Medical Education Research Study Quality Instrument. Results: Most included studies described face-to-face delivery along with blended learning combining a placement in an Indigenous setting, stand-alone placements and digital learning. Descriptions of learning gained covered five domains: remembering, understanding, self-knowledge, perspective and application relating mostly to cultural awareness. Factors contributing to positive learner reactions included attitude, environment, educator skill, pedagogy and opportunities. Factors contributing to negative learner reactions included attitude and environment. Conclusions: There is a need to further explore how health professional graduates are prepared to work in Indigenous health and the appropriate measures to do this. There is opportunity to learn more about Indigenous health teaching and learning across learning domains, in mainstream clinical placements and in digital learning.

Functional anatomy of the equine temporomandibular joint: Histological characteristics of the articular surfaces and underlining tissues

It has been assumed that dental conditions cause disorders of the equine temporomandibular joint (TMJ), due to biomechanical overload or aberrant loading. However, the incidence of published TMJ disorders in horses is low and this leads to the question whether the equine TMJ is adapted well to its biomechanical requirements or is able to remodel its articular surfaces in response to modified loading conditions. The aim of this study was to determine the histological characteristics of healthy equine TMJs. The tissue components of the articular surfaces of 10 TMJs obtained from horses without any clinical history of dental or TMJ disorders were analysed. Apart from the mandibular fossa of the temporal bone, the osseous aspects of the TMJ exhibited a uniform zoning pattern. The articular surfaces were composed of three tissue layers: (1) a superficial cell-rich dense connective tissue layer; (2) a middle fibrocartilage layer; and (3) a deep hyaline-like cartilage layer. The articular disc was composed of an inner core of fibrocartilage and hyaline-like cartilage meshwork covered with both cell-rich dense connective tissue and fibrocartilage at its dorsal and ventral aspects. In contrast, the mandibular fossa was only covered by a dense connective tissue, frequently supplemented by a synovial membrane, suggesting low biomechanical stress. Glycosaminoglycans, which are indicative of compressive loads, were predominantly present within the rostral part of the articular tubercle and the retroarticular process, the dorsal part of articular disc and the entire mandibular head, but were absent within the mandibular fossa. The results of this study suggest the presence of different biomechanical demands in the dorsal and ventral compartment of the equine TMJ.

Transformative effects of Aboriginal health placements for medical, nursing, and allied health students: A systematic review

The aim of the present systematic review was to investigate whether placements in Aboriginal health affect the self-perceived skill in working in Aboriginal health settings and career aspirations of health students, and in particular, aspects of the placement that had the greatest impact. The Embase, Cinahl, ProQuest, Scopus, Informit, Ovid MEDLINE, PsychINFO, and PubMed databases were searched in April/May 2016. Placements of at least 1 week duration in an Aboriginal health setting involving Australian students of medical, nursing, dentistry, or allied health disciplines, with outcomes relating to changes in students' knowledge, attitudes, and/or career aspirations, were included. The search retrieved 1351 papers. Fourteen studies were eligible for inclusion in this review. Narrative synthesis found that work placements in Aboriginal health increased understanding and awareness of Aboriginal culture, promoted deeper understanding of Aboriginal health determinant complexity, increased awareness of everyday racism toward Aboriginal Australians, and enhanced desire to work in Aboriginal health. There is a need for improved teaching and learning scholarship to understand whether placements improve students' skill working with Aboriginal people in health care or increase the likelihood of future employment in these settings.

Continued Tumor Reduction of Metastatic Pheochromocytoma/Paraganglioma Harboring Succinate Dehydrogenase Subunit B Mutations with Cyclical Chemotherapy

Patients harboring germline mutations in the succinate dehydrogenase complex subunit B (SDHB) gene present with pheochromocytomas and paragangliomas (PPGL) that are more likely malignant and clinically aggressive. The combination chemotherapy cyclophosphamide, vincristine, and dacarbazine (CVD) was retrospectively evaluated in patients with SDHB-associated metastatic PPGL.Query Twelve metastatic PPGL patients harboring SDHB mutations/polymorphisms with undetectable SDHB immunostaining were treated with CVD. CVD therapy consisted of 750 mg/m² cyclophosphamide with 1.4 mg/m² vincristine on day 1 and 600 mg/m² dacarbazine on days 1 and 2, every 21-28 days. Treatment outcome was determined by RECIST criteria as well as determination of response duration and progression-free and overall survivals. A median of 20.5 cycles (range 4-41) was administered. All patients had tumor reduction (12-100% by RECIST). Complete response was seen in two patients, while partial response was observed in 8. The median number of cycles to response was 5.5. Median duration of response was 478 days, with progression-free and overall survivals of 930 and 1190 days, respectively. Serial [¹⁸F]-fluorodeoxyglucose positron emission tomography and computed tomography imaging demonstrated continued incremental reduction in maximal standardized uptake values (SUV_max) values in 26/30 lesions. During treatment administration, the median SUV decreased from > 25 to < 6, indicating the efficacy of chemotherapy over a prolonged period of time. Prolonged therapy results in continued incremental tumor reduction, and is consistent with persistent drug sensitivity. CVD chemotherapy is recommended to be considered part of the initial management in patients with metastatic SDHB-related PPGL.

Food and nutrition programs for Aboriginal and Torres Strait Islander Australians: an overview of systematic reviews

Objective To provide an overview of previous reviews of programs that aimed to improve nutritional status or diet-related health outcomes for Aboriginal and Torres Strait Islander peoples, in order to determine what programs are effective and why. Methods A systematic search of databases and relevant websites was undertaken to identify reviews of nutrition interventions for Aboriginal and Torres Strait Islander Australians. Pairs of reviewers undertook study selection and data extraction and performed quality assessment using a validated tool. Results Twelve papers reporting 11 reviews were identified. Two reviews were rated high quality, three were rated medium and six were rated low quality. The reviews demonstrated that a positive effect on nutrition and chronic disease indicators can be a result of: 1) incorporating nutrition and breastfeeding advice into maternal and child health care services; and 2) multifaceted community nutrition programs. The evidence suggests that the most important factor determining the success of Aboriginal and Torres Strait Islander food and nutrition programs is community involvement in (and, ideally, control of) program development and implementation. Conclusions Community-directed food and nutrition programs, especially those with multiple components that address the underlying causes of nutrition issues, can be effective in improving nutrition-related outcomes. What is known about the topic? More effective action is urgently required in order to reduce the unacceptable health inequalities between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians. Food insecurity and nutrition-related chronic conditions are responsible for a large proportion of the ill health experienced by Australia’s First Peoples. What does this paper add? This narrative overview of 11 reviews published between 2005 and 2015 provides a synthesis of the current evidence for improving Aboriginal and Torres Strait Islander nutrition across the lifespan. The findings suggest that community-based and community-controlled programs, especially those with multiple components that address the underlying causes of nutrition issues, have the greatest potential to improve nutrition-related health outcomes. What are the implications for practitioners? Food and nutrition programs that are initiated and designed by local Aboriginal and Torres Strait Islander people are most likely to be effective. Nutrition and breastfeeding education and advice should be consistently incorporated into maternal and child healthcare services. Nutrition issues should be addressed through multifaceted approaches that address improving individual knowledge and skills, as well as strategies that increase access to nutritious food and provide a healthy food environment.

Use of the Harmonic scalpel for Delorme's procedure

AIM

There are many surgical techniques that deal with external rectal prolapse but perineal procedures have the advantage of reduced invasiveness. Therefore, despite concerns regarding high recurrence rates, the technique is still used by many surgeons.

METHOD

This manuscript and video describe our early clinical experience using the Harmonic scalpel in 11 consecutive patients who underwent a Delorme's procedure for external rectal prolapse.

RESULTS

The median age of patients was 76 (range: 30-94) years. There were no intra-operative complications, and the median operative time was 78 min. Intra-operative blood loss was minimal (mean 45 ml; range 20-70 ml). Median length of stay was 2 (range: 0-8) days. Overall morbidity and recurrence were both 18%, with a median follow-up of 15 (range: 1-23) months. Nine patients were operated on by a senior trainee with consultant supervision.

CONCLUSION

The advantages of this device are mainly those of ease of mucosal dissection, minimal blood loss and shorter operative time in comparison with published series.

How's Your Sugar? Evaluation of a Website for Aboriginal People With Diabetes

Background

Australia’s Aboriginal and Torres Strait Islander peoples (hereafter referred to as “Aboriginal people”) have the longest continuing culture in the world, living sustainably for at least 65,000 years on the Australian continent. In relatively recent times, colonization processes have resulted in Aboriginal people experiencing unacceptable health inequalities compared with other Australians. One disease introduced due to colonization is diabetes, the second leading cause of death for Aboriginal peoples.

Objectives

The objective of this study was to describe the construction and utilization of the website “How’s Your Sugar, ” a website for Aboriginal people with type 2 diabetes (herein after referred to as diabetes). The questions for the evaluation were as follows: how was the website constructed; did target groups utilize the website; and did engagement with the website improve diabetes management.

Methods

A mixed-method study design was employed. A content analysis of project documents provided information about the website construction. Data from Google analytics provided information about website utilization. To describe patterns of website sessions, percentages and numbers were calculated. A voluntary survey provided more information on website utilization and diabetes self-management. Percentage, numbers, and 95% CIs were calculated for each variable. A chi-square test was performed for Aboriginal status, age, gender, and Aboriginal diabetic status using Australian population estimates and Aboriginal diabetes rates.

Results

The website development drew on Aboriginal health, social marketing, interactive health promotion frameworks, as well as evidence for diabetes self-management. The website build involved a multidisciplinary team and participation of Aboriginal diabetics, Aboriginal diabetic family members, and Aboriginal health workers. This participation allowed for inclusion of Aboriginal ways of knowing and being. The highest number of website sessions came from Australia, 98.15% (47,717/48,617) and within Australia, Victoria 50.97% (24,323/47,717). There were 129 survey respondents, and the distribution had more female, 82.9% (107/129, 95% CI 76-88), Aboriginal, 21.7% (28/129, 95% CI 16-30), and Aboriginal diabetic, 48% (13/27, 95% CI 31-66) respondents than expected with P<.001 for these three groups. Most common reasons for visits were university assignment research, 40.6% (41/101), and health workers looking for information, 20.8% (21/101). The sample size was too small to calculate diabetes self-management change.

Conclusions

Inclusion of Aboriginal ways of knowing and being alongside other theoretical and evidence models in Web design is possible. Aboriginal people do utilize Web-based health promotion, and further understanding about reaching to this population would be of use. Provision of an education resource would likely have enhanced educational engagement. Web-based technologies are rapidly evolving, and these can potentially measure behavior change in engaging ways that also have benefits for the participant. A challenge for designers is inclusivity of cultural diversity for self-determination.

Treating Psoriasis and Psoriatic Arthritis: Position Paper on Applying the Treat-to-target Concept to Canadian Daily Practice

Objective.

To develop preliminary treat-to-target (T2T) recommendations for psoriasis and psoriatic arthritis (PsA) for Canadian daily practice.

Methods.

A task force composed of expert Canadian dermatologists and rheumatologists performed a needs assessment among Canadian clinicians treating these diseases as well as an extensive literature search on the outcome measures used in clinical trials and practice.

Results.

Based on results from the needs assessment and literature search, the task force established 5 overarching principles and developed 8 preliminary T2T recommendations.

Conclusion.

The proposed recommendations should improve management of psoriasis and PsA in Canadian daily practice. However, these recommendations must be further validated in a real-world observational study to ensure that their use leads to better longterm outcomes.

Genetic structure of Pseudococcus microcirculus (Hemiptera: Pseudococcidae) populations on epiphytic orchids in south Florida

In 2012, the orchid mealy bug Pseudococcus microcirculus was first detected in situ in North America's more diverse orchid region, the Big Cypress Basin (Collier Co FL). A follow-up survey showed that the mealy bug is more widespread and found on epiphytic orchids in two locations, in both the Fakahatchee Strand State Preserve (sites B and F) and the Florida Panther National Wildlife Refuge (sites M and C). There, we collected mealy bugs (n = 54) from 35 orchid individuals and screened allelic variation at seven microsatellite loci. We estimated genetic diversity and differentiation among all sites and compared the variation among individuals collected on the same plant. Genetic differentiation between sites M and C (F_ST = 0.03, P < 0.01) and,Mand B (F_ST = 0.04, P < 0.01) was detected.We also detected significantly lower mean pairwise relatedness among individuals from site B compared to all the other locations, and this population had the lowest inbreeding coefficient. Genetic diversity and mean pairwise relatedness were highly variable among plants with multiple individuals; however, plants from sites F and M tend to have collections of individuals with higher mean pairwise relatedness compared to sites B and C. Our results indicate that there is genetic diversity and differentiation among mealy bugs in these locations, and that collections of individuals on the same plant are genetically diverse. As such, the mealy bugs throughout these areas are likely to be genetically diverse and exist in multiple distinct populations.

Renal Squamous Cell Carcinoma of a Native Kidney After Renal Transplant: A Case Report

BACKGROUND

Renal squamous cell carcinoma is a rare primary tumor of the kidney that rapidly invades local structures and has a poor prognosis. Presentation is usually nonspecific and is associated with renal stone disease and chronic infection. Immunosuppressed renal transplant recipients are more likely to develop a malignancy than the general population. Squamous cell carcinoma of the kidney in the context of a renal transplant and long-term immunosuppression has not previously been described in the literature.

CASE REPORT

A 46-year-old white man with previous renal stones and recurrent urinary infections underwent a right nephrectomy and subsequent renal transplantation owing to failure of the remaining kidney. Five years posttransplant, an abdominal ultrasound scan was performed owing to recurrent urinary infections and ongoing pyuria. This was reported as normal, but he later developed a discharging sinus in his left flank. A computed tomography (CT) scan revealed a tracking perinephric abscess with an associated cystic lesion of the left kidney. A left nephrectomy was performed and histologic examination suggested an invasive squamous cell carcinoma of the renal pelvis. The patient later required major surgery for chronic infection, and further imaging revealed metastatic disease, resulting in the decision to manage palliatively.

CONCLUSION

Given the nonspecific nature of the symptoms and the poor prognosis, health care professionals should have a lower threshold for diagnostic imaging in these patients. Abdominal ultrasonography was unhelpful and only a later CT scan revealed the underlying malignancy. This should be expedited if there is a persistent abnormality on urinalysis. Once diagnosed, a change in immunosuppressant regime to include sirolimus should be considered.