Health systems model for chronic disease secondary prevention in rural and remote areas - Chronic disease: Road to health

ObjectivesCardiac rehabilitation (CR) provides evidence-based secondary prevention for people with heart disease (HD) (clients). Despite HD being the leading cause of mortality and morbidity, CR is under-utilised in Australia. This research investigated healthcare systems required to improve access to CR in rural and remote areas of North Queensland (NQ).MethodsA qualitatively dominant case study series to review management systems for CR in rural and remote areas of NQ was undertaken. Data collection was via semi-structured interviews in four tertiary hospitals and four rural or remote communities. An audit of discharge planning and CR referral, plus a review of community-based health services, was completed. An iterative and co-design process including consultation with healthcare staff and community members culminated in a systems-based model for improving access to CR in rural and remote areas.ResultsPoorly organised CR systems, poor client/staff understanding of discharge planning and low referral rates for secondary prevention, resulted in the majority of clients not accessing secondary prevention, despite resources being available. Revised health systems and management processes were recommended for the proposed Heart: Road to health model, and given common chronic diseases risk factors it was recommended to be broadened into Chronic disease: Road to health.ConclusionA Chronic disease: Road to health model could provide effective and efficient secondary prevention for people with chronic diseases in rural and remote areas. It is proposed that this approach could reduce gaps and duplication in current healthcare services and provide flexible, client-centred, holistic, culturally responsive services, and improve client outcomes.

COVID-19 Stroke Apical Lung Examination Study 2: a national prospective CTA biomarker study of the lung apices, in patients presenting with suspected acute stroke (COVID SALES 2)

BACKGROUND

Apical ground-glass opacification (GGO) identified on CT angiography (CTA) performed for suspected acute stroke was developed in 2020 as a coronavirus-disease-2019 (COVID-19) diagnostic and prognostic biomarker in a retrospective study during the first wave of COVID-19.

OBJECTIVE

To prospectively validate whether GGO on CTA performed for suspected acute stroke is a reliable COVID-19 diagnostic and prognostic biomarker and whether it is reliable for COVID-19 vaccinated patients.

METHODS

In this prospective, pragmatic, national, multi-center validation study performed at 13 sites, we captured study data consecutively in patients undergoing CTA for suspected acute stroke from January-March 2021. Demographic and clinical features associated with stroke and COVID-19 were incorporated. The primary outcome was the likelihood of reverse-transcriptase-polymerase-chain-reaction swab-test-confirmed COVID-19 using the GGO biomarker. Secondary outcomes investigated were functional status at discharge and survival analyses at 30 and 90 days. Univariate and multivariable statistical analyses were employed.

RESULTS

CTAs from 1,111 patients were analyzed, with apical GGO identified in 8.5 % during a period of high COVID-19 prevalence. GGO showed good inter-rater reliability (Fleiss κ = 0.77); and high COVID-19 specificity (93.7 %, 91.8-95.2) and negative predictive value (NPV; 97.8 %, 96.5-98.6). In subgroup analysis of vaccinated patients, GGO remained a good diagnostic biomarker (specificity 93.1 %, 89.8-95.5; NPV 99.7 %, 98.3-100.0). Patients with COVID-19 were more likely to have higher stroke score (NIHSS (mean +/- SD) 6.9 +/- 6.9, COVID-19 negative, 9.7 +/- 9.0, COVID-19 positive; p = 0.01), carotid occlusions (6.2 % negative, 14.9 % positive; p = 0.02), and larger infarcts on presentation CT (ASPECTS 9.4 +/- 1.5, COVID-19 negative, 8.6 +/- 2.4, COVID-19 positive; p = 0.00). After multivariable logistic regression, GGO (odds ratio 15.7, 6.2-40.1), myalgia (8.9, 2.1-38.2) and higher core body temperature (1.9, 1.1-3.2) were independent COVID-19 predictors. GGO was associated with worse functional outcome on discharge and worse survival after univariate analysis. However, after adjustment for factors including stroke severity, GGO was not independently predictive of functional outcome or mortality.

CONCLUSION

Apical GGO on CTA performed for patients with suspected acute stroke is a reliable diagnostic biomarker for COVID-19, which in combination with clinical features may be useful in COVID-19 triage.

Evaluating Allied Health Clinical Placement Performance: Protocol for a Modified Delphi Study

BACKGROUND

University-affiliated student-led health care services have emerged in response to the challenges faced by universities in securing quality clinical placements for health care students. Evidence of the health care benefits and challenges of student-led health care services is growing, while evidence of clinical placement performance remains variable and not generalizable. Though there have been previous attempts to develop a framework for evaluation of clinical placement performance, concerns have been raised about the applicability of these frameworks across the various placement settings. Additionally, the perspectives of all key stakeholders on the critical areas of clinical placement performance have yet to be considered.

OBJECTIVE

This study's objective is to gather information on areas of measurement related to student learning outcomes, experience of placement, and costs of placement and then develop consensus on which of those areas need to be included in a framework for evaluation of clinical placement performance within the context of student-led health care services. The aim of this paper is to outline a protocol for a modified Delphi study designed to gain consensus on what is important to measure when evaluating an allied health clinical placement.

METHODS

We will recruit up to 30 experts to a heterogeneous expert panel in a modified Delphi study. Experts will consist of those with firsthand experience either coordinating, supervising, or undertaking clinical placement. Purposive sampling will be used to ensure maximum variation in expert panel member characteristics. Experts' opinions will be sought on measuring student learning outcomes, student experience, and cost of clinical placement, and other areas of clinical placement performance that are considered important. Three rounds will be conducted to establish consensus on what is important to measure when evaluating clinical placement. Each round is anticipated to yield both quantitative data (eg, percentage of agreement) and qualitative data (eg, free-text responses). In each round, quantitative data will be analyzed descriptively and used to determine consensus, which will be defined as ≥70% agreement. Qualitative responses will be analyzed thematically and used to inform the subsequent round. Findings of each round will be presented, both consensus data and qualitative responses in each subsequent round, to inform expert panel members and to elicit further rankings on areas of measurement yet to achieve consensus.

RESULTS

Data analysis is currently underway, with a planned publication in 2024.

CONCLUSIONS

The modified Delphi approach, supported by existing research and its ability to gain consensus through multiround expert engagement, provides an appropriate methodology to inform the development of a framework for the evaluation of clinical placement performance in allied health service.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44020.

A role for androgen receptor variant 7 in sensitivity to therapy: Involvement of IGFBP-2 and FOXA1

Prostate cancer (PCa) is one of the leading causes of cancer-related deaths in men. Localised PCa can be treated effectively, but most patients relapse/progress to more aggressive disease. One possible mechanism underlying this progression is alternative splicing of the androgen receptor, with AR variant 7(ARV7) considered to play a major role. Using viability assays, we confirmed that ARV7-positive PCa cells were less sensitive to treatment with cabazitaxel and an anti-androgen-enzalutamide. Also, using live-holographic imaging, we showed that PCa cells with ARV7 exhibited an increased rate of cell division, proliferation, and motility, which could potentially contribute to a more aggressive phenotype. Furthermore, protein analysis demonstrated that ARV7 knock-down was associated with a decrease in insulin-like growth factor-2 (IGFBP-2) and forkhead box protein A1(FOXA1). This correlation was confirmed in-vivo using PCa tissue samples. Spearman rank correlation analysis showed significant positive associations between ARV7 and IGFBP-2 or FOXA1 in tissue from patients with PCa. This association was not present with the AR. These data suggest an interplay of FOXA1 and IGFBP-2 with ARV7-mediated acquisition of an aggressive prostate cancer phenotype.

A good life for people living with disability: the story from Far North Queensland

PURPOSE

People with disability in regional, rural and remote Australia have poorer service access compared to people from metropolitan areas. There is urgent need for reform. This study's aim was to explore the needs and aspirations of people with lived experience of disability in Far North Queensland (FNQ) to inform a new service framework.

MATERIALS AND METHODS

Twenty-five individuals with diverse experience of disability were engaged in semi-structured interviews. Participants were recruited from four sites that differed geographically, culturally, and socioeconomically. Using an inductive then deductive thematic approach to data analysis, statements of needs and aspirations were compiled and aligned with three pre-determined vision statements.

RESULTS

Needs and aspirations aligned well with the vision statements which were to: feel "included, connected, safe and supported"; have "opportunities to choose one's own life and follow one's hopes and dreams"; and have "access to culturally safe services close to home." To realise this vision in FNQ, support to navigate and coordinate services across sectors is essential.

CONCLUSION

People of FNQ of all abilities, need and aspire to experience "a good life" like their fellow Australians. Any new service model must focus on providing service navigation and co-ordination amid the complexities of service delivery in FNQ.Implications for RehabilitationThe perspective of people with lived experience of disability needs to be heard and respected when designing services to support them.Service navigation and co-ordination are required to manage the complexity of service delivery for people living in regional, rural and remote Australia.Engaging with the whole the community is prudent when designing community disability, rehabilitation, and lifestyle services in regional, rural, and remote Australia.

Democratising data to address health system inequities in Australia

Understanding the health status of a population or community is crucial to equitable service planning. Among other uses, data on health status can help local and national planners and policy makers understand patterns and trends in current or emerging health and well-being, especially how disparities relating to geography, ethnicity, language and living with disability influence access to services. In this practice paper we draw attention to the nature of Australia's health data challenges and call for greater 'democratisation' of health data to address health system inequities. Democratisation implies the need for greater quality and representativeness of health data as well as improved access and usability that enable health planners and researchers to respond to health and health service disparities efficiently and cost-effectively. We draw on learnings from two practice examples, marred by inaccessibility, reduced interoperability and limited representativeness. We call for renewed and urgent attention to, and investment in, improved data quality and usability for all levels of health, disability and related service delivery in Australia.

Commentary: Improving access to cardiac rehabilitation (Heart: Road for health) for Aboriginal and Torres Strait Islander peoples in rural and remote areas of North Queensland

AIMS

To focus on the needs, challenges and opportunities to improve access to cardiac rehabilitation (CR) (Heart: Road to health [HRH]) for Aboriginal and Torres Strait Islander peoples in rural and remote (R&R) areas of North Queensland.

CONTEXT

It is known that there is insufficient access to HRH for Aboriginal and Torres Strait Islander peoples in R&R areas of NQ, who have the highest rates of heart disease and socioeconomic disadvantage mainly due to poor social determinants of health. However, at least in part due to the impact of colonialism and predominantly western medicalised approach to health care, few gains have been made.

APPROACH

This commentary draws on recent research and literature and reflects on cultural issues that impact on improving access to an HRH for Aboriginal and Torres Strait Islander peoples in R&R areas. The underutilisation of the skills of Aboriginal and Torres Strait Islander Health Workers (ATSIHW) and a lack of a defined process to ensure access to culturally responsive HRH are discussed. Finally, a way forward is proposed that includes the development of policies, pathways and guidelines to ensure that appropriate support is available in the client's home community.

CONCLUSION

It is proposed that culturally responsive, accessible and effective HRH is achievable through the reorientation of current health systems that include a continuous client-centred pathway from hospital to home. In this model, ATSIHW will take a lead or partnership role in which their clinical, cultural brokerage and health promotion skills are fully utilised.

Suicide crises among women and mothers during and around the time of pregnancy: Prevalence and timing of initial contact with first responders and health services

OBJECTIVES

Suicide is a leading cause of maternal mortality. Suicidality during and around the time of pregnancy can have detrimental impacts on a child's development and outcomes. This paper examines prevalence, demographic characteristics, and timing of initial contact with first responders and health services for a cohort of women who experienced suicidality during and around the time of pregnancy.

METHODS

Findings are drawn from the Partners in Prevention (PiP) study, a population-wide linked data set of suicide-related attendances by police or paramedics in Queensland, Australia. A sub-cohort of women was identified, who were between 6 months preconception and 2 years postpartum at the time of a suicide-related contact with police or paramedics (PiP-Maternal). Findings are compared to other girls and women who had a suicide-related contact with police or paramedics (PiP-Female). Prevalence, demographic characteristics, timing of contact with first responders and health services, re-presentations, and mortality are reported.

RESULTS

The PiP-Maternal cohort comprised 3020 individuals and 3400 births. Women in the PiP-Maternal cohort were younger, more likely to be of Aboriginal and/or Torres Strait Islander descent and live outside of a major city than the PiP-Female cohort. There were high rates of out-of-hours calls to police and ambulance, and similar perceived seriousness of the call between women in the PiP-Maternal and PiP-Female cohorts. Women in the PiP-Maternal cohort were less likely to be admitted to an emergency department within 24 hours, even after matching on covariates. Prevalence of suicidality for women who were pregnant and up to 2 years postpartum was 1.32% (95% CI = [1.27, 1.37]).

CONCLUSION

Vulnerabilities and high rates of contact with police or paramedics, coupled with lower levels of follow-up, highlight the critical need to improve service responses for women with mental health needs during these phases of life.

A Public Health Review into Two Decades of Domestic Trampoline Injuries in Children within Queensland, Australia

Trampolining as an activity brings enjoyment and many health benefits, but at the same time it carries an injury risk. Most domestic trampoline users are children who are developing in skill, cognition, risk perception, physical strength and resilience to injury. Several common patterns of child trampoline injuries have been identified and countermeasures outlined in standards have been taken to reduce higher risk injury mechanisms, such as entrapment and falls from the trampoline through design, product and point of sale labelling. In Australia, the first national trampoline standard was published in 2003 which introduced improvements in trampoline design and requirements for labelling and padding. This work investigated the potential impact of these and subsequent changes based on almost two decades of emergency department trampoline injury data collected in Queensland, Australia. These data describe the changing representative proportion and pattern of trampoline injuries in Queensland over time by age, mechanism, gender, severity and nature of injury of injured persons up to the age of 14 years. The interrelationships between different injury characteristics were also analysed to propose the main factors influencing injury occurrence and severity. These findings seem to indicate that safety evolution in the form of enclosure nets, frame impact attenuation and entrapment protection have likely improved domestic trampoline safety. Other factors, such as adult supervision, minimum age and avoidance of multiple users, could further reduce injury but are harder to influence in the domestic setting.

The feasibility of a flexible exercise participation programme (FEPP) for individuals with multiple sclerosis

BACKGROUND AND PURPOSE

Individuals with multiple sclerosis (MS) want health advice regarding participation in their choice of exercise. To address this need, a flexible exercise participation programme (FEPP) was developed, underpinned by the MS aerobic exercise guidelines and supported by a physiotherapist using behaviour change techniques. The aim of this study was to investigate the feasibility of the FEPP for individuals with minimal disability from MS.

METHODS

A feasibility study utilising a single group pre/post-intervention design was conducted. The 12-week FEPP was completed by 10 individuals with MS (EDSS 0-3.5). Exercise progression in duration, intensity or frequency of exercise (in line with MS exercise guidelines) was guided by a self-perceived weekly energy level score, and weekly telephone coaching sessions using behavioural change techniques. Trial feasibility was assessed via measures of process (recruitment and retention), resources/management (communication time; data entry) and scientific feasibility (safety; compliance). Secondary FEPP feasibility outcomes included the Goal Attainment Scale (GAS) T-score, exercise participation (weekly exercise diary), high-level mobility (HiMAT), vitality (Subjective Vitality Scale), biomarkers for inflammation (cytokines levels [IL2, IL4, IL6, IL10, TNF and IFNγ]), and acceptability (participant survey).

RESULTS

Process: In total, 11 (85%) of 13 eligible participants enroled at baseline with 10 (91%) completing the study. Resources/management: Coaching sessions included a baseline interview-mean 39 min (SD: 6.6) and telephone coaching-mean 10 min (SD: 3.8) per week. Outcome measure data collection time-mean 44 min (SD: 2.1). Scientific feasibility: Two participants experienced a fall during their exercise participation. Self-reported compliance was high (99%). GAS T-scores increased significantly, indicating achievement of exercise participation goals. Secondary outcomes showed trends towards improvement.

DISCUSSION

The FEPP was feasible, safe and highly acceptable for use with individuals with MS and warrants a larger trial to explore effectiveness.

Designing augmentative and alternative communication systems with Aboriginal Australians: vocabulary representation, layout, and access

Yolŋu (Aboriginal Australians of northeast Arnhem Land) are interested in developing augmentative and alternative communication (AAC) systems in their own languages to support communication opportunities and participation for their family members living with Machado-Joseph disease. Designing AAC systems in Aboriginal languages requires consideration of unique linguistic and cultural elements. Participatory action research in strength-based communication contexts was carried out by Yolŋu and Balanda (the Yolŋu word for non-Aboriginal people) researchers working together through a collaborative intercultural process. Culturally responsive literacy, language, and AAC activities were used to develop four prototype Yolŋu AAC sytems for Yolŋu with varied literacy skills. Data were coded using gerunds to identify and focus on action in the data. Reflective and analytical collaborative, oral group discussions were used to identify key considerations and, ultimately, a Yolŋu metaphor for the research. Yolŋu language, culture and worldview impacted all aspects of prototype design and decision making. Salient considerations related to representation, organization, layout, and access, are presented. Clinical implications and future research considerations are outlined.

Augmentative and alternative communication for Aboriginal Australians: Developing core vocabulary for Yolŋu speakers

Yolŋu, Aboriginal people from Arnhem Land, Australia are at risk of Machado-Joseph disease, with progressive loss of speech. Yolŋu are interested in developing augmentative and alternative communication (AAC) systems in their own languages. This research aimed to develop a culturally responsive process to explore and create a core vocabulary word list for Yolŋu adults living with the disease for inclusion in AAC system prototypes. A list of 243 Yolŋu words and morphemes was created. In this highly collaborative, mixed methods, participatory action research, Balanda (the Yolŋu word for non-Aboriginal people) and Yolŋu researchers conducted cycles of transcription and analysis of a language sample, with oral group discussions to identify which words to include, omit, or add, based on Yolŋu perceptions of the structure and use of their languages. A Yolŋu metaphor, Gulaka-buma ("Harvesting yams"), was identified by Yolŋu researchers to represent and share the research process and findings. Three key themes were identified that summarize the main cultural and linguistic considerations related to changes made to the core vocabulary. Study findings emphasized the role of language as an expression of culture and identity for Indigenous peoples and the importance of considering cultural and linguistic factors in selecting vocabulary for AAC systems.

Developing Augmentative and Alternative Communication Systems in Languages Other Than English: A Scoping Review

INTRODUCTION

Access to augmentative and alternative communication (AAC) systems in languages other than English and multilingual AAC systems remains limited for many people with complex communication needs, despite a growing interest in this field, and an acknowledged need for culturally responsive AAC practice.

PURPOSE

The purpose of this scoping review was to identify published research that has reported on the development of components or whole AAC systems in languages other than English, and the linguistic and cultural factors that influenced research methods and AAC system development.

METHOD

Nine databases were systematically searched for published research that presented development of components or whole AAC systems in languages other than English. The Mixed Methods Appraisal Tool was used to assess the quality of studies. Charted data from studies included journal and publication date, research team, language of AAC system, aims of the study, study methodologies, study participants, and type of AAC systems developed. An analytical framework was developed to identify the cultural and linguistic factors that influenced research methods and or AAC system outcomes.

RESULTS

A total of 22 studies were included (13 qualitative, one quantitative nonrandomized, six quantitative descriptive, and two mixed-methods studies). Overall quality of studies was high. Some qualitative studies were of lower quality due to limited analysis or interpretation of results. Linguistic factors were extensively reported in the existing literature, whereas cultural factors were rarely explicitly reported.

CONCLUSION

Factors contributing to lack of reporting of cultural considerations are posited with suggestions for future research.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21482607.

Co‐creation of a student‐implemented allied health service in a First Nations remote community of East Arnhem Land, Australia

OBJECTIVES

To co-create a culturally responsive student-implemented allied health service in a First Nations remote community and to determine the feasibility and acceptability of the service.

DESIGN

Co-creation involved a pragmatic iterative process, based on participatory action research approaches. Feasibility and acceptability were determined using a mixed-method pre/postdesign.

SETTING

The service was in Nhulunbuy, Yirrkala and surrounding remote First Nations communities of East Arnhem Land, Northern Territory, Australia.

PARTICIPANTS

Co-creation of the service was facilitated by the Northern Australia Research Network, guided by Indigenous Allied Health Australia leadership, with East Arnhem local community organisations and community members. Co-creation of the day-to-day service model involved local cultural consultants, service users and their families, staff of community organisations, students, supervisors, placement coordinators and a site administrator.

FINDINGS

A reciprocal learning service model was co-created in which culturally responsive practice was embedded. The service was feasible and acceptable: it was delivered as intended; resources were adequate; the service management system was workable; and the service was acceptable. Health outcome measures, however, were not appropriate to demonstrate impact, particularly through the lens of the people of East Arnhem. Recommendations for the service included: continuing the reciprocal learning service model in the long term; expanding to include all age groups; and connecting with visiting and community-based services.

CONCLUSION

The co-created service was feasible and acceptable. To demonstrate the impact of the service, measures of health service impact that are important to First Nations people living in remote communities of northern Australia are required.

UK Doctors Delivering Physical Activity Advice: What Are the Challenges and Possible Solutions? A Qualitative Study

Despite strategies to enable Health Care Professionals (HCPs) to give physical activity (PA) advice to patients, this appears to be rarely done in consultations. The aims of the present study were to gain an understanding of doctors' awareness of current PA guidelines and to explore their opinions on barriers and solutions. A qualitative approach using semi-structured interviews was adopted. This study included 15 doctors currently working in the UK's National Health Service (NHS). A thematic analysis approach was used to analyse the transcripts. Four themes and twelve sub-themes were deciphered. Intrinsic factors limiting the delivery of PA advice included a lack of knowledge of PA guidelines and PA being an afterthought. Barriers to delivering PA guidance included a lack of PA education, time pressures, and patient engagement. Solutions included staff training, incorporating PA into undergraduate training, and encouraging staff to be physically active. Methods to optimise PA guidance included individualised PA advice, local exercise services and schemes, utilising online and visual resources, and motivational interviewing. This study provides an updated insight into doctors' opinions on barriers and solutions to discussing PA with patients. It is clear that further work is needed to ensure greater awareness of PA guidelines amongst clinicians.

An unusual case of comedones

We present the case of a 71-year-old woman with widespread comedones since adolescence. Histological examination revealed branching hyperpigmented rete ridges and cystically dilated follicular infundibulum containing laminated keratinous debris. We explore the differential diagnosis in the context of other reticulate hyperpigmentation disorders.

Sleep disorders among Aboriginal Australians with Machado-Joseph Disease: Quantitative results from a multiple methods study to assess the experience of people living with the disease and their caregivers

Background

Machado-Joseph Disease (MJD), or Spinocerebellar Ataxia Type 3 (SCA3), is a genetic disorder that causes progressive muscle weakness, loss of motor control, ataxia and permanent physical disability. Sleep disturbances are associated with MJD but remain poorly understood.

Objective

To investigate frequency and characteristics of sleep disorders and their association with health-related quality of life and psychosocial wellbeing for Aboriginal Australians living with MJD.

Methods

A convenience sample of MJD participants n = 24 participated in a semi-attended, ambulatory diagnostic sleep study to capture polysomnography, actigraphy and sleep diary data. Self-report measures collected were the Pittsburgh Sleep Quality Index (PSQI), STOP-BANG Questionnaire for Obstructive Sleep Apnoea (OSA), International Restless Legs Syndrome Study Group rating scale (IRLS), Kessler-5 (K5) and EuroQoL-5 Dimension (EQ5D). Caregivers (n = 22) reported EQ-5D, K5 and bed partners’ sleep behaviour (Mayo Sleep Questionnaire-Informant). Environmental factors were measured.

Results

We observed Nocturia, Sleep Related Leg Cramps, OSA, REM Behaviour Disorder, and RLS, respectively in 100%, 71%, 47%, 43%, and 33% of participants with a significant positive correlation between Body mass index (BMI) and Apnoea hypopnea index (AHI). The majority of sleep was spent in non-rapid eye movement sleep (NREM)-N2 stage (77.8% (67.7, 81.6)). Overcrowding (92%) and overnight care needs (42%) interrupted sleep. MJD participants and caregivers reported high psychological distress (K5 median 12.5 IQR 7, 16.5 & 8 IQR 6, 12 respectively).

Conclusion

Poor sleep quality and sleep disturbances are prevalent among this cohort. Disease manifestations and environmental factors are driving factors. Larger sample sizes are required to predict risk factors and confirm observed associations.

•

Aboriginal People living with MJD in Australia experience numerous sleep disorders.

•

Majority of sleep was spent in non-rapid eye movement sleep.

•

Overcrowding and overnight care needs interrupt sleep.

•

MJD participants and caregivers reported high psychological distress.

Management of oesophageal impaction of button batteries in Queensland

BACKGROUND

Oesophageal button battery impaction (OBBI) is a medical emergency requiring timely removal due to rapid oesophageal tissue injury. The aim of this study was to characterize circumstances of OBBI and identify potential barriers to timely removal of button batteries (BB) in the paediatric population.

METHODS

This is a retrospective review of OBBI cases between January 2018 to June 2019. Medical records were used to obtain patient demographics, battery size and type, battery source, location of initial presentation and outcomes. Time to obtaining x-ray, transfer to tertiary centre and to removal of button battery were recorded.

RESULTS

Eight cases of OBBI were recorded during the 18 months study timeframe. Six patients were male and two were female, aged 0.97 to 2.8 years. Six were from an English-speaking background and two were from families of non-English speaking background. Battery removal occurred at Queensland Children's Hospital (QCH) in seven of eight cases. Time from ingestion to initial presentation to hospital ranged from 39 min to 123 h with a mean time of 2 h and 13 min. Overall, the total time from ingestion of BB to removal ranged from 2 h 54 min to 126 h 51 min.

CONCLUSION

Despite being recognized as a time critical emergency, diagnostic, geographic and logistic challenges in Queensland make optimal care a challenge. Primary prevention strategies coupled with an expanded network for safe battery removal, and novel management strategies such as honey and acetic acid could improve care and reduce morbidity.

Cardiac rehabilitation in rural and remote areas of North Queensland: How well are we doing?

OBJECTIVE

To address access to cardiac rehabilitation (CR) for people in R&R areas, this research aimed to investigate: (1) post discharge systems and support for people returning home from hospital following treatment for heart disease (HD). (2) propose changes to improve access to CR in R&R areas of NQ.

SETTING

Four focus communities in R&R areas of NQ.

PARTICIPANTS

Focus communities' health staff (resident/visiting) (57), community leaders (10) and community residents (44), discharged from hospital in past 5 years following treatment for heart disease (purposeful sampling).

DESIGN

A qualitative descriptive case study, with data collection via semi-structured interviews. Inductive/deductive thematic analysis was used to identify primary and secondary themes. Health service audit of selected communities.

RESULTS

Health services in the focus communities included multipurpose health services, and primary health care centres staffed by resident and visiting staff that included nurses, Aboriginal and Torres Strait Islander Health Workers, medical officers, and allied health professionals. Post-discharge health care for people with HD was predominantly clinical. Barriers to CR included low referrals to community-based health professions by discharging hospitals; poorly defined referral pathways; lack of guidelines; inadequate understanding of holistic, multidisciplinary CR by health staff, community participants and leaders; limited centre-based CR services; lack of awareness, or acceptance of telephone support services.

CONCLUSION

To address barriers identified for CR in R&R areas, health care systems' revision, including development of referral pathways to local health professionals, CR guidelines and in-service education, is required to developing a model of care that focuses on self-management and education: Heart: Road to Health.

Importance of cardiac rehabilitation in rural and remote areas of Australia

OBJECTIVE

To assess implementation of in-patient cardiac rehabilitation (Phase-1-cardiac rehabilitation), impact on people in rural and remote areas of Australia and potential methods for addressing identified weaknesses.

DESIGN

Exploratory case study methodology using qualitative and quantitative methods. Qualitative data collection via semi-structured interviews, using thematic analysis, augmented by quantitative data collection via a medical record audit.

SETTING

Four regional hospitals (2 Queensland Health and 2 private) providing tertiary health care.

PARTICIPANTS

(a) Hospital in-patients with heart disease ≥18 years. (b) Staff responsible for their care.

OUTCOME MEASURES

Implementation of Phase-1-cardiac rehabilitation in tertiary hosptials in North Queensland and the impact on in-patients discharge planning and post discharge care. Recommentations and implications for practice are proposed to address deficits.

RESULTS

Phase-1-cardiac rehabilitation implementation rates, in-patient understanding and multidisciplinary team involvement were low. The highest rates of Phase-1-cardiac rehabilitation were for in-patients with a length of stay three days or more  in cardiac units with cardiac educators. Rates were lower in cardiac units with no cardiac educators, and lowest for in-patients in all areas of all hospitals with length of stay of two days or less days. Low Phase-1-cardiac rehabilitation implementation rates resulted in poor in-patient understanding about their disease, treatment and post-discharge care. Further, medical discharge summaries rarely mentioned cardiac rehabilitation/secondary prevention or risk factor management resulting in a lack of information for health care providers on cardiac rehabilitation and holistic health care.

CONCLUSION

Implementation of Phase-1-cardiac rehabilitation in regional hospitals in this study fell short of recommended best practice, resulting in patients' poor preparation for discharge, and insufficient information on holistic care for health care providers in rural and remote areas. These factors potentially impact on holistic care for people returning home following treatment for heart disease.

Marŋgithirri guŋga'yunarawu ga guŋga'yunyarawu marŋgithinyarawu Learning to connect and connecting to learn: Preparing the rural and remote allied health workforce through a co-created student-implemented service in East Arnhem, Australia

OBJECTIVES

To explore the process of learning for allied health students providing a student-implemented service for older Yolŋu in remote East Arnhem, Northern Territory, Australia.

DESIGN

An exploratory qualitative study following an 8-week student-implemented service.

SETTING

Nhulunbuy and Yirrkala and surrounding remote Aboriginal communities of the East Arnhem Region of the Northern Territory.

PARTICIPANTS

Data were collected from: 4 students who implemented the service; 4 professional supervisors, 3 placement coordinators, a Yolŋu cultural consultant and a care manager from a local community organisation, all of whom supported implementation of the service; and 7 older Yolŋu and their families who were recipients of the service.

INTERVENTIONS

A student-implemented service for older Yolŋu delivered by allied health students from James Cook University. Clinical, cultural and pastoral supervision and support was provided by Flinders University, James Cook University, Indigenous Allied Health Australia and 2 Yolŋu cultural consultants and 2 local community organisations.

MAIN OUTCOME MEASURES

Semi-structured interviews with those who implemented, supported and received the service. Data were analysed thematically using an inductive approach.

RESULTS

'Learning to connect and connecting to learn' described how allied health students were learning to provide a service for older Yolŋu. Four interrelated processes connected their learning: 'preparing and supporting', 'bonding and responding', 'growing and enriching' and 'working and weaving'.

CONCLUSION

The co-created student-implemented service provided a unique learning opportunity for allied health students on how to provide a culturally safe service in a remote Aboriginal community in northern Australia.

Improving access to cardiac rehabilitation in rural and remote areas: a protocol for a community-based qualitative case study

Background/Aims

Heart disease is the largest single cause of death and contributes to poor quality of life and high healthcare costs in Australia. There are higher rates of heart disease in rural and remote areas, with the highest rates in Aboriginal and Torres Strait Islander people. Cardiac rehabilitation is known to improve health outcomes for people with heart disease but referral rates remain low (30.2% overall and 46% following acute coronary syndrome) in Australia. Further, access to cardiac rehabilitation in rural and remote areas is affected by there being few centre-based services, and poor use of home-based services. The aim of this protocol is to investigate: (i) understanding of cardiac rehabilitation by health staff, community leaders and community participants discharged from hospital following treatment for heart disease; (ii) access and support for cardiac rehabilitation in rural and remote areas via health service availability in each community.

Methods

A qualitative case study methodology, using an interpretive descriptive framework, will be used together with content analysis that will encompass identification of themes through a deductive/inductive process.

Conclusions

To improve access to services and health outcomes in rural and remote areas, a strong evidence base is essential. To achieve this, as well as having appropriate methodology, it is necessary to build relationships and trust with local communities and healthcare providers. This research protocol describes a qualitative community-based case study, together with processes to build sound relationships required for effective data collection through semi-structured interviews or focus groups. Each step of the pre-research planning data collection and analysis is described in detail for the guidance of future researchers.

Consumer experience of a flexible exercise participation program (FEPP) for individuals with multiple sclerosis: A mixed-methods study

BACKGROUND AND PURPOSE

The flexible exercise participation program (FEPP) is a novel intervention developed to enable individuals with multiple sclerosis (MS) participate and progress in an exercise or sport of their choice. The FEPP is underpinned by guidelines on aerobic exercise for individuals with MS and is supported by a physiotherapist using behaviour change techniques. As part of a FEPP feasibility trial, the aim of this nested study was to explore the experience of participation in the FEPP from the perspective of individuals with MS. The objectives were to (i) determine the acceptability of the FEPP and (ii) identify recommendations for improvement.

METHODS

A mixed methods study using a sequential explanatory design was conducted. Part I consisted of a quantitative participant survey. Survey data were analysed descriptively using SPSS and informed the protocol for part II - qualitative interviews. Interview data were analysed thematically using NVivo. Part III consisted of integration of quantitative and qualitative data to allow greater explanation of survey responses. Individuals with MS who had participated in the FEPP feasibility trial were invited to take part in the study.

RESULTS

The FEPP was highly acceptability to the 10 participants. Five themes emerged to describe the experience of participating in the FEPP: (i) exploring exercise boundaries, (ii) measuring energy, (iii) acknowledging accountability, (iv) adjusting to exercising in a pandemic and (v) sustaining participation. Recommendations for improving the FEPP included changes to energy level monitoring and incorporation of peer support mechanisms.

DISCUSSION

Participants found the FEPP highly acceptable and valued the flexibility to choose their own activity and the health professional support. Based on participant recommendations, future versions of the FEPP will include daily rather than weekly monitoring of exercise and peer support to further enable individuals with MS to find the right balance with exercise and sport.

A systematic review of disability, rehabilitation and lifestyle services in rural and remote Australia through the lens of the people-centred health care

PURPOSE

The aim of this systematic review was to identify models of community disability, rehabilitation and lifestyle service delivery in non-metropolitan areas of Australia, and to describe these models through an Integrated People-Centred Health Services (IPCHS) lens.

MATERIALS AND METHODS

We identified peer-reviewed studies published between 2000 and June 2021 that met the following criteria: described or evaluated a community service delivery model, intervention or program in regional, rural or remote Australia; provided for people with a disability or a potentially disabling health condition. A scoring rubric was developed covering the five IPCHS strategies.

RESULTS

Nineteen studies were included in the review. We identified a range of service delivery models providing support to people with a range of disabilities or conditions. We report evidence of the use of the IPCHS strategies in ways relevant to the local context.

DISCUSSION

Several strengths emerged, with many services tailored to individual need, and significant community engagement. Innovative rural service delivery approaches were also identified. Key areas requiring action included improved coordination or integration within and across professions and sectors. There was limited evidence of co-production of solutions or participatory governance. While people-centred approaches show promise to improve community-based services, large-scale fundamental change is required.IMPLICATIONS FOR REHABILITATIONCommunity-based disability and rehabilitation services in rural and remote Australia performed well at delivering tailored care and engaging in community consultation.These services must urgently implement strategies to enhance community ownership of solutions and participatory governance.Services must place a greater focus on explicit strategies to integrate and coordinate across services and professions, and to create an enabling environment, to deliver people-centred care.The World Health Organisation Integrated People-Centred Health Services framework provides an important roadmap to improving service delivery in rural and remote Australian communities.

Evaluation of the Allied Health Rural Generalist Program 2017-2019

OBJECTIVE

To evaluate the development and implementation of the Allied Health Rural Generalist Program, a two-level online post-graduate education program, which includes Level 1, an entry-level non-award pathway program, and Level 2, a Graduate Diploma in Rural Generalist Practice.

DESIGN

A convergent mixed methodology evaluation in two overlapping stages: a process evaluation on quality and reach, together with a mixed method case study evaluation on benefits, of the program.

SETTING

Rural and remote Australia across ten sites and seven allied health professions: dietetics; occupational therapy; pharmacy; physiotherapy; podiatry; radiography; speech pathology.

PARTICIPANTS

Process evaluation included 91 participants enrolled in all or part of the Rural Generalist Program. Case study evaluation included 50 managers, supervisors and Rural Generalist Program participants from the ten study sites.

INTERVENTIONS

The Allied Health Rural Generalist Program.

MAIN OUTCOME MEASURES

Process evaluation data were derived from enrolment data and education evaluation online surveys. Case study data were gathered via online surveys and semi-structured interviews. Quantitative and qualitative data were collected concurrently, analysed separately and then integrated to identify consistency, expansion or discordance across the data.

RESULTS

The Rural Generalist Program was viewed as an effective education program that provided benefits for Rural Generalist Program participants, employing organisations and consumers. Key improvements recommended included increasing profession-specific and context-specific content, ensuring Rural Generalist Program alignment with clinical and project requirements, strengthening support mechanisms within employing organisations and ensuring benefits can be sustained in the long term.

CONCLUSION

The Rural Generalist Program offers a promising strategy for building a fit-for-purpose rural and remote allied health workforce.

Bronchiectasis is associated with delayed diagnosis and adverse outcomes in the New Zealand Common Variable Immunodeficiency Disorders cohort study

Common variable immunodeficiency disorders (CVID) are multi-system disorders where target organ damage is mediated by infective, autoimmune and inflammatory processes. Bronchiectasis is probably the most common disabling complication of CVID. The risk factors for bronchiectasis in CVID patients are incompletely understood. The New Zealand CVID study (NZCS) is a nationwide longitudinal observational study of adults, which commenced in 2006. In this analysis, the prevalence and risk factors for bronchiectasis were examined in the NZCS. After informed consent, clinical and demographic data were obtained with an interviewer-assisted questionnaire. Linked electronic clinical records and laboratory results were also reviewed. Statistical methods were applied to determine if variables such as early-onset disease, delay in diagnosis and increased numbers of infections were associated with greater risk of bronchiectasis. One hundred and seven adult patients with a diagnosis of CVID are currently enrolled in the NZCS, comprising approximately 70% of patients known to have CVID in New Zealand. Fifty patients (46·7%) had radiologically proven bronchiectasis. This study has shown that patients with compared to those without bronchiectasis have an increased mortality at a younger age. CVID patients with bronchiectasis had a greater number of severe infections consequent to early-onset disease and delayed diagnosis. Indigenous Māori have a high prevalence of CVID and a much greater burden of bronchiectasis compared to New Zealand Europeans. Diagnostic latency has not improved during the study period. Exposure to large numbers of infections because of early-onset disease and delayed diagnosis was associated with an increased risk of bronchiectasis. Earlier diagnosis and treatment of CVID may reduce the risk of bronchiectasis and premature death in some patients.

Developing a community rehabilitation and lifestyle service for a remote indigenous community

PURPOSE

Community rehabilitation is an essential health service that is often not available to remote Australians. This paper describes the first cycle of a collaborative project, between local community members, allied health professionals and a university, to co-design a community rehabilitation and lifestyle service to support adults and older people to stay strong and age well in place.

METHODS

An action research framework was used to develop the service for adults in two remote communities, one being a discrete Aboriginal community. The first cycle involved planning for, and trialling of a service, with observations, reflections and feedback from clients, community members, university students and health service providers, to inform the subsequent service.

RESULTS

Over two years, stakeholders worked collaboratively to plan, trial, reflect and replan an allied health student-assisted community rehabilitation service. The trial identified the need for dedicated clinical and cultural supervision. During replanning, three key elements for culturally responsive care were embedded into the service: reciprocity and yarning; holistic community-wide service; and Aboriginal and Torres Strait Islander mentorship.

CONCLUSIONS

An action-research approach to co-design has led to the establishment of a unique community rehabilitation service to address disability and rehabilitation needs in two remote Australian communities.Implications for rehabilitationCo-design of community rehabilitation services between Aboriginal and Torres Strait Islander community members and the local allied health professionals can lead to development of an innovative service model for remote Aboriginal communities.Culturally responsive community rehabilitation services in Aboriginal and Torres Strait Islander communities requires holistic and community-wide perspectives of wellbeing.Incorporating Aboriginal and Torres Strait Islander ways of engaging and communicating, and leadership and mentorship for non-Indigenous allied health professionals and students are essential components for students-assisted culturally responsive services.

Yolŋu with Machado-Joseph disease: Exploring communication strengths and needs

Purpose: Yolŋu are Aboriginal Australians from northeast Arnhem Land in the Northern Territory (NT). Machado-Joseph disease (MJD) prevalence in the NT Aboriginal population is the highest in the world. Yolŋu living with progressive dysarthria associated with MJD could benefit from augmentative and alternative communication (AAC). However, there are no aided AAC systems in Yolŋu languages. This research aimed to explore the views of Yolŋu with MJD about communication, speech-language pathology (SLP) services and AAC.Method: A collaborative, culturally responsive research design was informed by Indigenist Research methodology and Constructivist Grounded Theory. Yolŋu with MJD (n = 10) and their interested family members (n = 4) participated in interviews and created visual representations of their social networks. Data were analysed through an oral interpretive process with Yolŋu researchers.Result: A Yolŋu metaphor, Goŋdhu "Building understanding by hand", emerged as a culturally meaningful way to represent the core understandings required for speech-language pathologists (SLPs) to work effectively with Yolŋu with MJD. Elements of this metaphor include seeking to understand the complex lived experiences of Yolŋu with MJD, and working with families to explore the potential benefits of SLP services and AAC.Conclusion: Yolŋu with MJD and their families want to work collaboratively with SLPs to develop bilingual AAC systems and culturally responsive SLP services that build on strengths of Yolŋu culture and kinship to improve communication opportunities and participation.

Finding the right balance with participation in exercise and sport for individuals with multiple sclerosis: protocol for a pre and post intervention feasibility study

INTRODUCTION

Individuals with minimal disability from multiple sclerosis (MS) requested advice on finding the right balance, between too much and too little exercise, when participating in their choice of sport or exercise. To optimise exercise participation during the early stages of the disease, a flexible exercise participation programme (FEPP) has been developed. The FEPP is novel because it provides guidance and support for individuals with MS to participate and progress in their preferred sport or exercise. The primary objective was to assess the feasibility of the FEPP. The secondary objective was to assess the feasibility of a larger trial to demonstrate the efficacy of the FEPP.

METHODS AND ANALYSIS

A stage I feasibility study of the FEPP, using a single group preintervention/post-intervention design, will be conducted with 16 participants with minimal disability from MS (Expanded Disability Status Scale level of 0-3.5). The 12-week FEPP will guide participants to independently participate in their preferred sport or exercise at a location of their choice. Exercise progression will be guided by individual energy levels and a weekly telephone coaching session with a physiotherapist. Participation in exercise or sport will be recorded in parallel with assessment of disease biomarkers (plasma cytokines interleukin (IL)-2, IL-4, IL-6, IL-10, interferon (IFN)-γ and tumour necrosis factor (TNF)), subjective vitality and high-level mobility. Acceptability of the FEPP will be assessed using a sequential explanatory mixed methods design where the findings of a participant survey will inform the interview guide for a series of focus groups.Feasibility of a larger trial will be assessed via process, resources, management and scientific metrics. Progression to a larger trial will depend on the achievement of specified minimum success criteria.

ETHICS AND DISSEMINATION

Ethical approval has been obtained for this study from the James Cook University Human Research Ethics Committee (H7956). Dissemination of findings is planned via peer-reviewed journals, conference presentations and media releases. The protocol date was 21 December 2019, V.1.

TRIAL REGISTRATION NUMBER

The trial is registered with Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12620000076976.

Heart disease, hospitalisation and referral: Coaching to Achieving Cardiovascular Health through cardiac rehabilitation in Queensland

OBJECTIVES

To describe rates of hospitalisation and Coaching on Achieving Cardiovascular Health referral, for Queensland's adults with heart and related disease, and comparisons between Aboriginal and Torres Strait Islander and non-Indigenous peoples in northern Queensland.

DESIGN

Descriptive retrospective epidemiological study of Queensland Health Patient Admission Data Collection for adults with heart and related disease, and Coaching on Achieving Cardiovascular Health referral data. Relative risk and age standardisation were calculated for Aboriginal and Torres Strait Islander and non-Indigenous peoples.

PARTICIPANTS

Queensland's adults ≥20 years, hospitalised with heart and related disease (1 January 2012-31 December 2016).

SETTING

Queensland, Australia.

MAIN OUTCOME MEASURES

Queensland Health Hospital and Health Services' hospitalisation and Coaching on Achieving Cardiovascular Health referral rates for heart and related disease.

RESULTS

Queensland's Aboriginal and Torres Strait Islander peoples have a higher hospitalisation rate for heart and related disease, with higher rates for northern Queensland. Queensland's overall Coaching on Achieving Cardiovascular Health referral rates were low, but higher for Aboriginal and Torres Strait Islander peoples. Deficiencies in documentation of Aboriginal and Torres Strait Islander people's status affected results in some areas.

CONCLUSION

Queensland's Aboriginal and Torres Strait Islander peoples were more likely to be admitted to hospital for heart and related disease and referred to Coaching on Achieving Cardiovascular Health than non-Indigenous peoples. However, hospitalisation and Coaching on Achieving Cardiovascular Health referral rates are unlikely to reflect the needs of Aboriginal and Torres Strait Islander peoples especially in rural and very remote areas given their higher mortality and morbidity rates and fewer services.

Patterns and features of methamphetamine-related presentations to emergency departments in QLD from 2005 to 2017

This study explores the patterns and features of methamphetamine-related presentations to emergency departments (EDs) in Queensland. Despite an overall decrease in the use of methamphetamine in Australian, an increase in the use of the crystalized form of methamphetamine has been noted over recent years. A descriptive observational study was utilized to analyse emergency department (ED) injury surveillance data sourced from Queensland Injury Surveillance Unit (QISU) from 2005 to 2017. Data were analysed for presentations related to stimulants (n = 564) with methamphetamine (n = 250) included as a subcategory. Descriptive statistics were used to identify patterns and features of presentations related to methamphetamines. The relationship between demographic variables, service type variables, and drug type was assessed using chi-square and z-tests. Results included the following: 84.4% of methamphetamine-related presentations were allocated a triage score of 1, 2, or 3; 14.8% of all methamphetamine-related presentations required police involvement; 18% were brought in by ambulance; and 15.6% exhibited behaviour that was either, agitated, aggressive, or violent in nature. Methamphetamine-related presentations more frequently required police or ambulance services and more often included aggression or agitation. Methamphetamine-related presentations to ED have a high acuity and often require other emergency resources (police and ambulance). There is a need to develop policy for managing aggressive and agitated people presenting to EDs as a result of methamphetamine use and to further explore the experience of personnel (police and ambulance) managing persons under the influence of methamphetamine.

Home versus outpatient pulmonary rehabilitation in COPD: a propensity-matched cohort study

Home-based exercise has been proposed as an equivalent treatment strategy to supervised outpatient pulmonary rehabilitation (PR), but it is not known whether its implementation into clinical practice produces similar benefits to those observed in trials. We compared the real-world responses of 154 patients with COPD undergoing home-based exercise with a matched group attending supervised PR. We observed smaller improvements in exercise capacity with home-based exercise compared with PR, but similar improvements in quality of life. We propose that supervised PR remains the standard of care, with home-based exercise a less effective alternative for those unable to attend PR.

The effect of exercise on high-level mobility in individuals with neurodegenerative disease: a systematic literature review

OBJECTIVE

To investigate the effect of exercise on high-level mobility (i.e. mobility more advanced than independent level walking) in individuals with neurodegenerative disease.

DATA SOURCES

A systematic literature search was conducted in Medline, CINAHL, Scopus, SportDiscus and PEDro.

STUDY SELECTION

Randomised controlled trials of exercise interventions for individuals with neurodegenerative disease, with an outcome measure that contained high-level mobility items were included. High-level mobility items included running, jumping, bounding, stair climbing and backward walking. Outcome measures with high-level mobility items include the High Level Mobility Assessment Tool (HiMAT); Dynamic Gait Index; Rivermead Mobility Index (RMI) or modified RMI; Functional Gait Assessment and the Functional Ambulation Category.

STUDY APPRAISAL

Quality was evaluated with the Cochrane Risk of Bias Tool.

RESULTS

Twenty-four studies with predominantly moderate to low risk of bias met the review criteria. High-level mobility items were included within primary outcome measures for only two studies and secondary outcome measures for 22 studies. Eight types of exercise interventions were investigated within which high-level mobility tasks were not commonly included. In the absence of outcome measures or interventions focused on high-level mobility, findings suggest some benefit from treadmill training for individuals with multiple sclerosis or Parkinson's disease. Progressive resistance training for individuals with multiple sclerosis may also be beneficial. With few studies on other neurodegenerative diseases, further inferences cannot be made.

CONCLUSION

Future studies need to specifically target high-level mobility in the early stages of neurodegenerative disease and determine the impact of high-level mobility interventions on community participation and maintenance of an active lifestyle. Systematic review registration number PROSPERO register for systematic reviews (registration number: CRD42016050362).

Penetrating head injuries in children presenting to the emergency department in Australia and New Zealand: A PREDICT prospective study

AIM

Penetrating head injuries (pHIs) are associated with high morbidity and mortality. Data on pHIs in children outside North America are limited. We describe the mechanism of injuries, neuroimaging findings, neurosurgery and mortality for pHIs in Australia and New Zealand.

METHODS

This was a planned secondary analysis of a prospective observational study of children <18 years who presented with a head injury of any severity at any of 10 predominantly paediatric Australian/New Zealand emergency departments (EDs) between 2011 and 2014. We reviewed all cases where clinicians had clinically suspected pHI as well as all cases of clinically important traumatic brain injuries (death, neurosurgery, intubation >24 h, admission >2 days and abnormal computed tomography).

RESULTS

Of 20 137 evaluable patients with a head injury, 21 (0.1%) were identified to have sustained a pHI. All injuries were of non-intentional nature, and there were no gunshot wounds. The mechanisms of injuries varied from falls, animal attack, motor vehicle crashes and impact with objects. Mean Glasgow Coma Scale on ED arrival was 10; 10 (48%) had a history of loss of consciousness, and 7 (33%) children were intubated pre-hospital or in the ED. Fourteen (67%) children underwent neurosurgery, two (10%) craniofacial surgery, and five (24%) were treated conservatively; four (19%) patients died.

CONCLUSIONS

Paediatric pHIs are very rare in EDs in Australia and New Zealand but are associated with high morbidity and mortality. The absence of firearm-related injuries compared to North America is striking and may reflect Australian and New Zealand firearm regulations.

Helmet use in preventing acute concussive symptoms in recreational vehicle related head trauma

OBJECTIVES

Helmets use has proved effective in reducing head trauma (HT) severity in children riding non-motorised recreational vehicles. Scant data are available on their role in reducing concussive symptoms in children with HT while riding non-motorised recreational vehicles such as bicycles, push scooters and skateboards (BSS). We aimed to investigate whether helmet use is associated with a reduction in acute concussive symptoms in children with BSS-related-HT.

METHODS

Prospective study of children <18 years who presented with a BSS related-HT between April 2011 and January 2014 at a tertiary Paediatric Emergency Department (ED).

RESULTS

We included 190 patients. Median age 9.4 years (IQR 4.8-13.8). 66% were riding a bicycle, 23% a push scooter, and 11% a skateboard. 62% were wearing a helmet and 62% had at least one concussive symptom. Multivariate logistic regression analysis adjusting for age, gender, and type of vehicle showed that patients without a helmet presented more likely with headache (adjusted odds-ratio (aOR) 2.54, 95% CI 1.27-5.06), vomiting (aOR 2.16, 95% CI 1.00-4.66), abnormal behaviour (aOR 2.34, 95% CI 1.08-5.06), or the presence of at least one concussive symptom (aOR 2.39, 95% CI 1.20-4.80).

CONCLUSIONS

In children presenting to the ED following a wheeled BSS-related HT helmet use was associated with less acute concussive symptoms.

ABBREVIATIONS

aOR, adjusted odds ratio; APHIRST, Australasian Paediatric Head Injury Rules Study; BSS, bicycles, push scooters and skateboards; CI, confidence interval; CT, computed tomography; ED, emergency department; HT, head trauma; IQR, interquartile range; OR, odds ratio; RCH, Royal Children's Hospital; RV, recreational vehicle.

Adjuncts for sputum clearance in COPD: clinical consensus versus actual use

Introduction

Oscillatory positive pressure devices (OPEP) can be used as adjuncts to improve sputum clearance in chronic obstructive pulmonary disease (COPD), though the evidence base is incomplete. The attitudes of physiotherapists towards these devices in the care of patients with COPD is unknown. In addition, actual use compared with the prescription of medications has not been studied.

Methods

We analysed English prescribing data, obtained from OpenPrescribing.net, for a 3-year period from 2013. In addition, we conducted an online survey of members of the Association of Chartered Physiotherapists in Respiratory Care regarding awareness of devices, thresholds for treatment and device preference.

Results

Out of a potential 3.2 million COPD patient-years of treatment between 2013 and 2015, 422 744 patient-years of treatment with carbocisteine, at a cost of £73 million, were prescribed, as well as 1.1 million years treatment with tiotropium. In the same period, only 4989 OPEP devices were prescribed. There were 116 responses to the survey (12% response rate), 72% in hospital practice, 28% based in the community. There were variations in respondents’ threshold for treatment with sputum adjuncts in COPD, and when asked to select either the Acapella, Flutter or positive expiratory pressure mask, preferences were 69%, 24% or 6%, respectively.

Conclusions

There is a 100-fold difference between use of carbocisteine and OPEP devices in COPD, with far fewer devices prescribed than are included in the phenotypes clinicians believe them to be effective in. Variation in physiotherapist attitudes to treatment thresholds highlights the need for research into the effectiveness of OPEP devices in specific patient phenotypes.

Introduction of the Community Rehabilitation Northern Queensland Service

Objective: To analyse trends in length of hospital stay before and after the implementation of the Community Rehabilitation Northern Queensland Service (CRNQ) in Townsville, Australia. Design: Retrospective analysis of collected administrative data provided by the data custodian Townsville Hospital Health Service District. Setting: All patients discharged from the Townsville hospital between 1 July 2008 and 30 June 2013 for whom the Australian Refined Diagnosis Related Groups were stroke (B70), degenerative nervous system disorders (B67) or rehabilitation (Z60). Main outcome measures: Average length of stay and total number of inpatient episodes coded stroke, degenerative nervous system disorders or rehabilitation. Results: Length of stay for the selected diagnosis related groups was consistently ranging from 23 days to 25 days for the period 2008-2012. In the first year of full operational capacity of CRNQ (2012-13), there was an average reduction of six days in length of stay. The major reductions in length of stay occurred in patients admitted for rehabilitation care. Conclusions: This study adds additional evidence that earlier discharge can be facilitated for patients with neurological conditions living outside metropolitan areas when appropriate rehabilitation services are available in the community. Abbreviations: AR-DRG – Australian Refined Diagnosis Related Groups; CRNQ – Community Rehabilitation Northern Queensland Service.

Understanding disability and the 'social determinants of health': how does disability affect peoples' social determinants of health?

PURPOSE

The purpose of this study was to investigate how an individual's social determinants of health are affected by the acquisition of physical disability in adulthood. The secondary aim was to report the described facilitators and barriers to living with a disability.

METHOD

This qualitative study used an exploratory, descriptive approach. Nine individuals with a neurologically derived disability were purposively recruited from a rehabilitation center in northern Queensland. Participation in the study involved semi-structured interviews. QSR NVivo was used for the data analysis process.

RESULTS

Changes to social determinants of health resulting from the acquisition of disability had substantial flow-on consequences in all aspects of life for the individual and those close to them. Income had the greatest influence over the other social determinant of health. Following the acquisition of disability, the reduced inflow and increased outflow of finances had subsequent negative effects on housing, transport and social interactions, and also personal relationships.

CONCLUSIONS

When considering changes to the social determinants of health resulting from disability acquisition, it is impractical to view these changes and those affected in isolation. Consideration of this multidimensional effect on life associated with the acquisition of disability will be useful in disability research, advocacy and support services. Implications for Rehabilitation Social determinants of health are known to have a direct influence on health status. As social determinants of health decrease, morbidity and mortality rates increase. Following the acquisition of disability, there is a decline in social determinants of health. This decline affects quality of life for individuals' with a disability, and those closest to them. The effects of declining social determinants of health may inhibit the rehabilitation process. Thus, it is important to acknowledge the multifaceted impact the acquisition of disability has on peoples' lives, and the consequences this may have for their rehabilitation.

An assessment of implications of adaptive licensing for pharmaceutical intellectual property and regulatory exclusivity rights in the European Union

One of the key advantages of adaptive licensing (AL) is to align the licensing of new medicines more closely with patient needs for earlier access to beneficial treatments. From an innovators perspective, "earlier" market access may seem an obvious incentive to gain earlier revenue generation. However, this is offset with an "earlier" start to patent and regulatory protection periods, which, depending on the technology, disease, population, and timing of subsequent asset protection periods, can present a conflict.