A psychometric investigation of health-related quality of life measures for paediatric neurodevelopment assessment: Reliability and concurrent validity of the PEDS-QL, CHU-9D, and the EQ-5D-Y

There is a need for tools that can provide a brief assessment of functioning for children with neurodevelopmental conditions, including health-related quality of life (HR-QoL). This study evaluated the psychometric properties of three commonly used and well known HR-QoL measures in a cohort of children presenting to clinical developmental assessment services. The most common diagnoses received in these assessment services were autism spectrum disorders. Findings showed good internal consistency for the PedsQL and the CHU-9D, but not the EQ-5D-Y. This research also found that the CHU-9D, EQ-5D-Y, and PedsQL correlated with relevant functioning domains assessed by the VABS-III. Overall, the measures showed that children with neurodevelopmental conditions experienced poor HR-QoL. The majority of children (>86%) met cut-off criteria for significant health concerns on the PedsQL. On the EQ-5D-Y and CHU-9D, they showed reduced HR-QoL particularly on domains relating to school and homework, being able to join in activities, looking after self, and doing usual activities. This study supports the use of the CHU-9D and PedsQL in this population to assess and potentially track HR-QoL in a broad neurodevelopment paediatric population.

Development of the What Matters 2 Adults (WM2A) wellbeing measure for Aboriginal and Torres Strait Islander adults

PURPOSE

As wellbeing is culturally bound, wellbeing measures for Aboriginal and Torres Strait Islander peoples must be culturally relevant and grounded in Aboriginal and Torres Strait Islander values and preferences. We describe the development of a nationally-relevant and culturally grounded wellbeing measure for Aboriginal and Torres Strait Islander adults: the What Matters to Adults (WM2A) measure.

METHODS

We used a mixed methods approach to measure development, combining Indigenist methodologies and psychometric methods. Candidate items were derived through a large national qualitative study. Think-aloud interviews (n = 17) were conducted to assess comprehension, acceptability, and wording of candidate items. Two national surveys collected data on the item pool (n = 312, n = 354). Items were analysed using exploratory factor analysis (EFA), and item response theory (IRT) to test dimensionality, local dependence and item fit. A Collaborative Yarning approach ensured Aboriginal and Torres Strait Islander voices were privileged throughout.

RESULTS

Fifty candidate items were developed, refined, and tested. Using EFA, an eight factor model was developed. All items met pre-specified thresholds for maximum endorsement frequencies, and floor and ceiling effects; no item redundancy was identified. Ten items did not meet thresholds for aggregate adjacent endorsement frequencies. During Collaborative Yarning, six items were removed based on low factor loadings (<0.4) and twelve due to conceptual overlap, high correlations with other items, endorsement frequencies, and/or low IRT item level information. Several items were retained for content validity. The final measure includes 32 items across 10 domains (Balance & control; Hope & resilience; Caring for others; Culture & Country; Spirit & identity; Feeling valued; Connection with others; Access; Racism & worries; Pride & strength).

CONCLUSIONS

The unique combination of Indigenist and psychometric methodologies to develop WM2A ensures a culturally and psychometrically robust measure, relevant across a range of settings and applications.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

CELPI: trial protocol for a randomised controlled trial of a Carer End of Life Planning Intervention in people dying with dementia

Background

Dementia is a leading cause of death in developed nations. Despite an often distressing and symptom laden end of life, there are systematic barriers to accessing palliative care in older people dying of dementia. Evidence exists that 70% of people living with severe dementia attend an emergency department (ED) in their last year of life. The aim of this trial is to test whether a Carer End of Life Planning Intervention (CELPI), co-designed by consumers, clinicians and content specialists, improves access to end of life care for older people with severe dementia, using an ED visit as a catalyst for recognising unmet needs and specialist palliative care referral where indicated.

Methods

A randomised controlled trial (RCT) enrolling at six EDs across three states in Australia will be conducted, enrolling four hundred and forty dyads comprising a person with severe dementia aged ≥ 65 years, and their primary carer.

Participants will be randomly allocated to CELPI or the control group. CELPI incorporates a structured carer needs assessment and referral to specialist palliative care services where indicated by patient symptom burden and needs assessment. The primary outcome measure is death of the person with dementia in the carer-nominated preferred location. Secondary outcomes include carer reported quality of life of the person dying of dementia, hospital bed day occupancy in the last 12 months of life, and carer stress. An economic evaluation from the perspective of a health funder will be conducted.

Discussion

CELPI seeks to support carers and provide optimal end of life care for the person dying of dementia. This trial will provide high level evidence as to the clinical and cost effectiveness of this intervention.

Trial registration

ACTRN12622000611729 registered 22/04/2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03534-1.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Acceptability of the Cognition Test Battery in Astronaut and Astronaut-Surrogate Populations

BACKGROUND

Sustained high levels of astronaut cognitive performance are a prerequisite for mission success. A neuropsychological battery of 10 brief cognitive tests (Cognition) covering a range of cognitive domains was specifically developed for high performing astronauts to objectively assess cognitive performance. Extended mission durations require repeated cognitive testing and thus high acceptability of the Cognition software to the astronaut population. The aim of this qualitative study was to evaluate acceptability of Cognition to astronauts and astronaut surrogate populations.

METHODS

Cognition was administered repeatedly to N=87 subjects (mean age ±SD 35.1 ±8.7 years, 52.8% male) on a laptop or iPad across five individual studies on the International Space Station or in space analog environments on Earth. Following completion of each study, participants were interviewed regarding their experience using Cognition in a semi-structured debrief. Participant comments were analyzed using a qualitative conventional content analysis approach.

RESULTS

The majority of participants' comments (86.1%) were coded as positive or neutral in valence, with most positive comments relating to software usability, engagement, and overall design. Among the 10 Cognition tests, subjects liked the Visual Object Learning Test most (28 likes, 32.2% of participants), while the Emotion Recognition Test was liked least (44 dislikes, 50.6% of participants). Some subjects (36.8%) were frustrated with the level of difficulty of some of the 10 Cognition tests, especially during early administrations, which was by design to avoid ceiling effects in repeated administrations of high-performers. Technical difficulties were rare (20.7% of participants), and most often observed in environments with restricted internet access. Most participants (82.3% of those who commented) liked the feedback provided by Cognition after each test, which includes a graph showing performance history.

CONCLUSION

Cognition was found to be acceptable to astronaut and astronaut-surrogate populations across a variety of settings and mission durations. Participant feedback provided was used to further improve Cognition and increase its acceptability during sustained space missions.

An exploration of the sociodemographic and health conditions associated with self-rated wellbeing for Aboriginal and Torres Strait Islander adults

Objective

To identify sociodemographic factors and health conditions associated with self-rated wellbeing for Aboriginal and Torres Strait Islander adults. Participants were recruited via investigator networks and an online panel provider with an established nationwide panel of Aboriginal and Torres Strait Islander adults. Those interested were invited to complete a survey that included an assessment of wellbeing using a visual analogue scale. Data was collected from October–November 2019 and August–September 2020. Exploratory analyses were conducted to ascertain factors associated with self-rated wellbeing for Aboriginal and Torres Strait Islander adults.

Results

Having more than enough money to last until next pay day, full-time employment, completion of grade 12, having a partner, and living with others were significantly associated with higher wellbeing among Aboriginal and Torres Strait Islander adults. A self-reported history of depression, anxiety, other mental health conditions, heart disease, or disability were associated with lower self-rated wellbeing scores. Our findings indicate a need for further investigation among these socioeconomic and patient groups to identify how to improve and support the wellbeing of Aboriginal and Torres Strait Islander adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05794-3.

0187 The Effects of Nocturnal Aircraft Noise on Self-Reported Sleep

Introduction

Nocturnal traffic noise can fragment sleep through cortical arousals and induce self-reported sleep disturbance. Here we present data gathered around Atlanta International Airport in a pilot field study on the effects of aircraft noise on sleep.

Methods

N=34 subjects participated in a five night in-home study. Every night, subjects recorded noise inside their bedroom, and completed questionnaires the following morning containing items on sleep latency; number of awakenings; sleepiness (Stanford Sleepiness Scale); 11-point scales on sleep quality, tiredness, ease of falling asleep and calmness or restlessness of sleep; and a 5-point scale on sleep disturbance by noise. We analyzed the effect of both the average (LAEq,sleep) and maximum (LAS,max,sleep) aircraft noise level during a subject’s sleep period for each questionnaire outcome in repeated measures multiple regression adjusted for the number of aircraft noise events during sleep, sex, age, and if the window was open or closed.

Results

A total of 165 sleep questionnaires (97.1% of expected) were completed. Self-reported awakenings increased by n=0.051 per decibel (dB) LAS,max,sleep (p&lt;0.001). An increase in LAS,max,sleep was associated with a significant increase in tiredness (0.118/dB, p=0.005). There was a significant effect of sex on tiredness in the LAEq,sleep model, whereby men were less tired than women. There were no significant effects of LAEq,sleep on any questionnaire outcomes.

Conclusion

There was some evidence for adverse effects of aircraft noise on self-reported sleep outcomes. Effects were predominantly found for maximum rather than average noise exposure during the sleep period, stressing the importance of individual noise events for sleep. A larger-scale, adequately powered National Sleep Study will be conducted to better understand the observed effects.

Support

This research was funded by the U.S. Federal Aviation Administration Office of Environment and Energy through ASCENT, the FAA Center of Excellence for Alternative Jet Fuels and the Environment, project 017 through FAA Award Number 13-C-AJE-UPENN-011 under the supervision of Natalia Sizov. Any opinions, findings, conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the FAA.

Comparing the effect of STan (cardiotocographic electronic fetal monitoring (CTG) plus analysis of the ST segment of the fetal electrocardiogram) with CTG alone on emergency caesarean section rates: study protocol for the STan Australian Randomised controlled Trial (START)

BACKGROUND

Cardiotocography is almost ubiquitous in its use in intrapartum care. Although it has been demonstrated that there is some benefit from continuous intrapartum fetal monitoring using cardiotocography, there is also an increased risk of caesarean section which is accompanied by short-term and long-term risks to the mother and child. There is considerable potential to reduce unnecessary operative delivery with up to a 60% false positive diagnosis of fetal distress using cardiotocography alone. ST analysis of the fetal electrocardiogram is a promising adjunct to cardiotocography alone, and permits detection of metabolic acidosis of the fetus, potentially reducing false positive diagnosis of fetal distress.

METHODS

This study will be a single-centre, parallel-group, randomised controlled trial, conducted over 3 years. The primary hypothesis will be that the proportion of women with an emergency caesarean section on ST analysis will not equal that for women on cardiotocography monitoring alone. Participants will be recruited at the Women's and Children's Hospital, a high-risk specialty facility with approximately 5000 deliveries per annum. A total of 1818 women will be randomised to the treatment or conventional arm with an allocation ratio of 1:1, stratified by parity. The primary outcome is emergency caesarean section (yes/no). Statistical analysis will follow standard methods for randomised trials and will be performed on an intention-to-treat basis. Secondary maternal and neonatal outcomes will also be analysed. Additional study outcomes include psychosocial outcomes, patient preferences and cost-effectiveness.

DISCUSSION

Approximately 20% of Australian babies are delivered by emergency caesarean section. This will be the first Australian trial to examine ST analysis of the fetal electrocardiogram as an adjunct to cardiotocography as a potential method for reducing this proportion. The trial will be among the first to comprehensively examine ST analysis, taking into account the impact on psychosocial well-being as well as cost-effectiveness. This research will provide Australian evidence for clinical practice and guideline development as well as for policy-makers and consumers to make informed, evidence-based choices about care in labour.

TRIAL REGISTRATION

ANZCTR, ACTRN1261800006268 . Registered on 19 January 2018.

Cost of dialysis therapies in rural and remote Australia - a micro-costing analysis

BACKGROUND

Maintenance dialysis is a costly and resource intense activity. In Australia, inadequate health infrastructure and poor access to technically skilled staff can limit service provision in remote areas where many Aboriginal dialysis patients live. With most studies based on urban service provision, there is little evidence to guide service development. However permanent relocation to an urban area for treatment can have significant social and financial impacts that are poorly quantified. This study is part of a broader project to quantify the costs and benefits of dialysis service models in urban and remote locations in Australia's Northern Territory (NT).

METHODS

We undertook a micro-costing analysis of dialysis service delivery costs in urban, rural and remote areas in the NT from the payer perspective. Recurrent maintenance costs (salaries, consumables, facility management and transportation) as well as capital costs were included. Missing and centralised costs were standardised; results were inflated to 2017 values and reported in Australian dollars.

RESULTS

There was little difference between the average annual cost for urban and rural services with respective median costs of $85,919 versus $84,629. However remote service costs were higher ($120,172 - $124,492), driven by higher staff costs. The inclusion of capital costs did not add substantially to annual costs. Annual home haemodialysis costs ($42,927) were similar to other jurisdictions despite the significant differences in program delivery and payment of expenses not traditionally borne by governments. Annual peritoneal dialysis costs ($58,489) were both higher than home and in-centre haemodialysis by recent national dialysis cost studies.

CONCLUSION

The cost drivers for staffed services were staffing models and patient attendance rates. Staff salaries and transport costs were significantly higher in remote models of care. Opportunities to reduce expenditure exist by encouraging community supported services and employing local staff. Despite the delivery challenges of home haemodialysis including high patient attrition, the program still provides a cost benefit compared to urban staffed services. The next component of this study will examine patient health service utilisation and costs by model of care to provide a more comprehensive analysis of the overall cost of providing services in each location.

Conservation implications of turtle declines in Australia's Murray River system

Conservation requires rapid action to be effective, which is often difficult because of funding limitations, political constraints, and limited data. Turtles are among the world’s most endangered vertebrate taxa, with almost half of 356 species threatened with extinction. In Australia’s Murray River, nest predation by invasive foxes (Vulpes vulpes) was predicted to drive turtle declines in the 1980s. We assessed populations of the broad-shelled turtle (Chelodina expansa), eastern long-necked turtle (C. longicollis), and Murray River turtle (Emydura macquarii) in the Murray River and some of its associated waterways. Our results suggest that the predicted decline is occurring. All three species are rare in the lower Murray River region, and were undetected in many locations in South Australia. Moreover, E. macquarii had considerable population aging almost everywhere, possibly due to comprehensive nest destruction by foxes. Chelodina longicollis also had population aging at some sites. Sustained low recruitment has potential to lead to collapses as turtles age, which is particularly worrying because it was predicted over 30 years ago and may have already occurred in South Australia. Our results show that turtle declines were not mitigated since that prediction. If the crash continues, a vertebrate guild responsible for considerable nutrient cycling in the aquatic ecosystem will disappear. Our results highlight a worst-case outcome when species declines are predicted, but insufficiently mitigated.

Changes in psychosocial health during a 7-week paediatric weight management program

Youth with obesity are at increased risk of psychosocial symptoms; however, little is known regarding the impact of paediatric weight management (PWM) on psychosocial health. The aim of the study was to investigate changes in psychosocial health among children who completed a 7-week PWM program. Participants aged 5 to 16 years with a BMI ≥85th percentile completed a 7-week, family-centred PWM program focused on health behaviour education, exercise and mentored goal setting. The Paediatric Symptom Checklist (PSC) was assessed via parent report to evaluate psychosocial symptoms before and after the program, and subscales were calculated for internalizing (PSC-IS), externalizing (PSC-ES) and attention symptoms (PSC-AS). At baseline, positive screen rates for psychosocial symptoms among the 317 patients included 16.1% for PSC, 14.1% for PSC-ES, 18.6% for PSC-IS and 12.3% for PSC-AS. Among program completers, total PSC scores improved in those with normal (p = 0.010) and elevated p < .001 psychosocial symptoms at baseline. Youth with positive screens for elevated PSC subscales improved their subscale scores, on average, and the majority reduced scores to below elevated levels for PSC (54.2%), PSC-ES (64.7%), PSC-IS (78.3%) and PSC-AS (64.7%). Improvements in PSC remained significant after adjusting for BMI changes during treatment, but BMI differed across PSC-change groups, including BMI increases among participants with PSC deterioration (0.33 ± 0.64 kg m^-2 ) (P = 0.035) and BMI decreases among patients with no reliable PSC change (-0.26 ± 1.04 kg m^-2 ) (P = 0.038) or reliable PSC improvement (-0.22 ± 0.74 kg m^-2 ) (P = 0.025). Youth with positive screens for psychosocial symptoms can improve emotional and behavioural functioning during short-term PWM. Future research is needed to elucidate mechanisms and long-term outcome durability.

Smallest worthwhile effect of exercise programs to prevent falls among older people: estimates from benefit-harm trade-off and discrete choice methods

BACKGROUND

the smallest worthwhile effect (SWE) of an intervention is the smallest treatment effect that justifies the costs, risks and inconveniences associated with that health intervention.

OBJECTIVE

to estimate the SWE of exercise programs designed to prevent falls among older people and to compare estimates derived by two methodological approaches.

STUDY DESIGN AND SETTING

discrete choice experiment (n = 220) and benefit-harm trade-off (subsample n = 66) methods were used.

PARTICIPANTS

community-dwelling older people who reported a past fall or a mobility limitation answered online or face-to-face questionnaires.

RESULTS

a substantial proportion of participants (82% in the discrete choice experiment and 50% in the benefit-harm trade-off study) did not consider that participation in the proposed exercise programs would be worthwhile, even if it reduced their risk of falling to 0%. Among remaining participants, the average SWE of participation in an exercise program was an absolute reduction in the risk of falling of 35% (standard deviation [SD] = 13) in the discrete choice experiment and 16% (SD = 11) in the benefit-harm trade-off study.

CONCLUSIONS

many participants did not consider the hypothetical falls' risk reduction of the proposed exercise programs to be worth the associated costs and inconveniences. Greater community awareness of the fall prevention effects of exercise for older people is required.

Health and social support services in older adults recently discharged from hospital: service utilisation and costs and exploration of the impact of a home-exercise intervention

BACKGROUND

Admission to hospital can lead to persistent deterioration in physical functioning, particularly for the more vulnerable older population. As a result of this physical deterioration, older people who have been recently discharged from hospital may be particularly high users of health and social support services. Quantify usage and costs of services in older adults after hospitalisation and explore the impact of a home-exercise intervention on service usage.

METHOD

The present study was a secondary analysis of data from a randomised controlled trial (ACTRN12607000563460). The trial involved 340 participants aged 60 years and over with recent hospitalisation. Service use and costs were compared between intervention (12 months of home-exercise prescribed in 10 visits from a physiotherapist) and control groups.

RESULTS

33 % of participants were re-admitted to hospital, 100 % consulted a General Medical Practitioner and 63 % used social services. 56 % of costs were associated with hospital admission and 22 % with social services. There was reduction in General Medical Practitioner services provided in the home in the intervention group (IRR 0.23, CI 0.1 to 0.545, p < 0.01) but no significant between-group difference in service use or in costs for other service categories.

CONCLUSION

There appears to be substantial hospital and social service use and costs in this population of older people. No significant impact of a home-based exercise program was evident on service use or costs.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registry ACTRN12607000563460 >TrialSearch.

Preliminary evidence suggests freshwater turtles respond positively to an environmental water delivery during drought

Environmental flows (e-flows) are a common management tool to improve the health of flow-regulated river systems and their biota. The effect of e-flows on fish, waterbirds and vegetation has been assessed in Australia, but their influence on turtles remains largely unstudied. We opportunistically examined the effect of e-flows on the eastern long-necked turtle (Chelodina longicollis), a species that occupies ephemeral aquatic habitats, by measuring an index of abundance (catch per unit effort) and body condition before and after an environmental watering event that replenished a severely contracted creek in the mid-Murray region. We found that average body condition increased after watering. Abundance decreased markedly after watering, but the change was not statistically significant. While the causal inference of our study was limited by the opportunistic nature of our before-after experimental design, this study provides preliminary evidence that environmental flows may improve the health of turtles occupying ephemeral floodplain habitats. We encourage further research into the effect of e-flows on turtles to confirm the hypothesis that the increase in average body condition recorded in the current study was a function of e-flows.

Evaluating the effectiveness of a home-based exercise programme delivered through a tablet computer for preventing falls in older community-dwelling people over 2 years: study protocol for the Standing Tall randomised controlled trial

INTRODUCTION

In order to prevent falls, older people should exercise for at least 2 h per week for 6 months, with a strong focus on balance exercises. This article describes the design of a randomised controlled trial to evaluate the effectiveness of a home-based exercise programme delivered through a tablet computer to prevent falls in older people.

METHODS AND ANALYSIS

Participants aged 70 years or older, living in the community in Sydney will be recruited and randomly allocated to an intervention or control group. The intervention consists of a tailored, home-based balance training delivered through a tablet computer. Intervention participants will be asked to complete 2 h of exercises per week for 2 years. Both groups will receive an education programme focused on health-related information relevant to older adults, delivered through the tablet computer via weekly fact sheets. Primary outcome measures include number of fallers and falls rate recorded in weekly fall diaries at 12 months. A sample size of 500 will be necessary to see an effect on falls rate. Secondary outcome measures include concern about falling, depressive symptoms, health-related quality of life and physical activity levels (in all 500 participants); and physiological fall risk, balance, functional mobility, gait, stepping and cognitive performance (in a subsample of 200 participants). Adherence, acceptability, usability and enjoyment will be recorded in intervention group participants over 2 years. Data will be analysed using the intention-to-treat principle. Secondary analyses are planned in people with greater adherence. Economic analyses will be assessed from a health and community care provider perspective.

ETHICS AND DISSEMINATION

Ethical approval was obtained from UNSW Ethics Committee in December 2014 (ref number HC#14/266). Outcomes will be disseminated through publication in peer-reviewed journals and presentations at international conferences.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN)12615000138583.

Family perspectives on deceased organ donation: thematic synthesis of qualitative studies

A major barrier to meeting the needs for organ transplantation is family refusal to give consent. This study aimed to describe the perspectives of donor families on deceased donation. We conducted a systematic review and thematic synthesis of qualitative studies. Electronic databases were searched to September 2012. From 34 studies involving 1035 participants, we identified seven themes: comprehension of sudden death (accepting finality of life, ambiguity of brain death); finding meaning in donation (altruism, letting the donor live on, fulfilling a moral obligation, easing grief); fear and suspicion (financial motivations, unwanted responsibility for death, medical mistrust); decisional conflict (pressured decision making, family consensus, internal dissonance, religious beliefs); vulnerability (valuing sensitivity and rapport, overwhelmed and disempowered); respecting the donor (honoring the donor's wishes, preserving body integrity) and needing closure (acknowledgment, regret over refusal, unresolved decisional uncertainty, feeling dismissed). Bereaved families report uncertainty about death and the donation process, emotional and cognitive burden and decisional dissonance, but can derive emotional benefit from the "lifesaving" act of donation. Strategies are needed to help families understand death in the context of donation, address anxieties about organ procurement, foster trust in the donation process, resolve insecurities in decision making and gain a sense of closure.

5 DISRUPTION OF THE HIGH MOBILITY GROUP AT-HOOK 2 (HMGA2) GENE IN SWINE REDUCES POSTNATAL GROWTH

The high mobility group AT-hook 2 (HMGA2) protein has been shown to be a crucial gene for cell growth, proliferation, and apoptosis; HMGA2 is also a strong biological candidate for growth, because mutations in this gene alter body size in mice and humans. Compared with wild-type controls, adult mice lacking HMGA2 are 60% smaller, and adult heterozygous mutants are 20% smaller. In humans, HMGA2 has been associated with adult and childhood height without any other deleterious effect. Additionally, a microdeletion in the HMGA2 gene in a human patient resulted in short stature, with no dysmorphologies and normal puberty. In order to determine the effect of HMGA2 on fetal and adult growth in pigs, a transgenic pig line deficient in HMGA2 expression was generated by gene targeting in fetal fibroblasts (FF). Using a targeting vector carrying a reporter gene, and homology arms specific to HMGA2, heterozygous mutant cell lines were generated. The cell lines were then used to generate 6 heterozygous females by somatic cell nuclear transfer (SCNT). Bodyweights and lengths from snout to base of tail were measured every 2 weeks for a year for mutant (n = 6) and wild-type farm gilts (n = 6). Data were analysed by one-way ANOVA. As in mice, disruption of one allele of the HMGA2 gene resulted in 25% reduction in weight (P < 0.0001) and 14% reduction in length (P < 0.0001). Early in postnatal growth (2 months), weights of mutants were not different than wild-type. However, mutants were 20 to 35% lighter (P < 0.05) during mid stages (6 months) and 25 to 30% (P < 0.0001) in late stages (3 months). The same insertional mutation generated 8 heterozygous male clones by SCNT. In addition, 7 nontransgenic males from the same FF line were generated as SCNT controls. Bodyweights and lengths were measured every 2 weeks for 30 weeks for HMGA2 heterozygous mutants (n = 8), control SCNT (n = 7) and wild-type farm boars (n = 5). The weight curve of boars showed similar pattern as for mutant gilts. At 30-week postnatal stage, mutants were 17% (P < 0.05) and 16% (P < 0.05) lighter in weight compared with littermate and wild-type animals, respectively. We are presently developing homozygous HMGA2 mutant lines. Currently, 3 of 6 heterozygous gilts have been bred with heterozygous boars, with 1 confirmed pregnancy. The expectation is that the homozygous animals will, like mice, be 60% smaller than the wild-type animals. The approach described here will result not only in a valuable large-animal model of dwarfism, but also in a tool to reduce the size of existing transgenic and nontransgenic swine lines. This, in turn, will increase the receptivity of valuable transgenic lines by the biomedical community. Funding for this work was provided by NIH grant R21-OD010553 to JP.

Effectiveness and cost-effectiveness of sentinel lymph node biopsy compared with axillary node dissection in patients with early-stage breast cancer: a decision model analysis

Background:

Sentinel lymph node biopsy (SLNB) is less invasive than axillary lymph node dissection (ALND) for staging early breast cancer, and has a lower risk of arm lymphoedema and similar rates of locoregional recurrence up to 8 years. This study estimates the longer-term effectiveness and cost-effectiveness of SLNB.

Methods:

A Markov decision model was developed to estimate the incremental quality-adjusted life years (QALYs) and costs of an SLNB-based staging and management strategy compared with ALND over 20 years’ follow-up. The probability and quality-of-life weighting (utility) of outcomes were estimated from published data and population statistics. Costs were estimated from the perspective of the Australian health care system. The model was used to identify key factors affecting treatment decisions.

Results:

The SLNB was more effective and less costly than the ALND over 20 years, with 8 QALYs gained and $883 000 saved per 1000 patients. The SLNB was less effective when: SLNB false negative (FN) rate >13% 5-year incidence of axillary recurrence after an SLNB FN>19% risk of an SLNB-positive result >48% lymphoedema prevalence after ALND <14% or lymphoedema utility decrement <0.012.

Conclusion:

The long-term advantage of SLNB over ALND was modest and sensitive to variations in key assumptions, indicating a need for reliable information on lymphoedema incidence and disutility following SLNB. In addition to awaiting longer-term trial data, risk models to better identify patients at high risk of axillary metastasis will be valuable to inform decision-making.

A comparative case study of bowel cancer screening in the UK and Australia: evidence lost in translation?

OBJECTIVES

(i) To document the current state of the English, Scottish, Welsh, Northern Irish and Australian bowel cancer screening programmes, according to seven key characteristics, and (ii) to explore the policy trade-offs resulting from inadequate funding.

SETTING

United Kingdom and Australia.

METHODS

A comparative case study design using document and key informant interview analysis. Data were collated for each national jurisdiction on seven key programme characteristics: screening frequency, population coverage, quality of test, programme model, quality of follow-up, quality of colonoscopy and quality of data collection. A list of optimal features for each of the seven characteristics was compiled, based on the FOBT screening literature and our detailed examination of each programme.

RESULTS

Each country made different implementation choices or trade-offs intended to conserve costs and/or manage limited and expensive resources. The overall outcome of these trade-offs was probable lower programme effectiveness as a result of compromises such as reduced screening frequency, restricted target age range, the use of less accurate tests, the deliberate setting of low programme positivity rates or increased inconvenience to participants from re-testing.

CONCLUSIONS

Insufficient funding has forced programme administrators to make trade-offs that may undermine the potential net population benefits achieved in randomized controlled trials. Such policy compromise contravenes the principle of evidence-based practice which is dependent on adequate funding being made available.

Monoclonal antibodies to B and T lymphocyte attenuator (BTLA) have no effect on in vitro B cell proliferation and act to inhibit in vitro T cell proliferation when presented in a cis, but not trans, format relative to the activating stimulus

B and T lymphocyte attenuator (BTLA) is an immunoglobulin superfamily member surface protein expressed on B and T cells. Its ligand, herpesvirus entry mediator (HVEM), is believed to act as a monomeric agonist that signals via the CRD1 of HVEM to inhibit lymphocyte activation: HVEM is also the receptor for lymphotoxin-α and LIGHT, which both bind in the CRD2 and CRD3 domains of the HVEM molecule, and for CD160 which competes with BTLA. We have shown that recombinant HVEM and a panel of different monoclonal antibodies specifically bind murine BTLA on both B and T cells and that some antibodies inhibit anti-CD3ε-induced T cell proliferation in vitro, but only when constrained appropriately with a putatively cross-linking reagent. The antibodies had no significant effect on in vitro T cell proliferation in a mixed lymphocyte reaction (MLR) assay nor on in vitro DO11.10 antigen-induced T cell proliferation. None of these antibodies, nor HVEM-Fc, had any significant effect on in vitro B cell proliferation induced by anti-immunoglobulin M antibodies (±anti-CD40) or lipopolysaccharide. We further elucidated the requirements for inhibition of in vitro T cell proliferation using a beads-based system to demonstrate that the antibodies that inhibited T cell proliferation in vitro were required to be presented to the T cell in a cis, and not trans, format relative to the anti-CD3ε stimulus. We also found that antibodies that inhibited T cell proliferation in vitro had no significant effect on the antibody captured interleukin-2 associated with the in vivo activation of DO11.10 T cells transferred to syngeneic recipient BALB/c mice. These data suggest that there may be specific structural requirements for the BTLA molecule to exert its effect on lymphocyte activation and proliferation.

Transfer from residential aged care to emergency departments: an analysis of patient outcomes

BACKGROUND

In order to design optimal systems to meet the acute healthcare needs of the frail elderly living in residential care, good clinical information is essential. The aims of this study were to analyse the casemix and outcomes of patients transferred from residential aged care facilities to public hospital emergency departments in New South Wales.

METHODS

Individual patient data from six hospital emergency departments and inpatient wards were obtained from merged databases and analysed using descriptive and comparative statistics.

RESULTS

Outcomes in 4680 patient transfers over a 12-month period in 2006-2007 were analysed. Transfers occur mostly in high-acuity patients, with approximately three of every four transfers admitted; one in every 12 dying; and admitted patients undergoing an average of 2.4 interventions or procedures during each hospital stay. Several variables are associated with prolonged length of emergency department stay including triage urgency, type of hospital and transfers occurring in winter or out of hours.

CONCLUSIONS

Patients transferred from aged care facilities to emergency departments are predominantly high-acuity patients with a substantial likelihood of hospitalisation, intervention and death. Nevertheless, scope exists for some episodes of acute care, in both discharged and admitted patients, to be provided outside a hospital setting.

The views of patients and carers in treatment decision making for chronic kidney disease: systematic review and thematic synthesis of qualitative studies

OBJECTIVE

To synthesise the views of patients and carers in decision making regarding treatment for chronic kidney disease, and to determine which factors influence those decisions.

DESIGN

Systematic review of qualitative studies of decision making and choice for dialysis, transplantation, or palliative care, and thematic synthesis of qualitative studies.

DATA SOURCES

Medline, PsycINFO, CINAHL, Embase, social work abstracts, and digital theses (database inception to week 3 October 2008) to identify literature using qualitative methods (focus groups, interviews, or case studies). Review methods Thematic synthesis involved line by line coding of the findings of the primary studies and development of descriptive and analytical themes.

RESULTS

18 studies that reported the experiences of 375 patients and 87 carers were included. 14 studies focused on preferences for dialysis modality, three on transplantation, and one on palliative management. Four major themes were identified as being central to treatment choices: confronting mortality (choosing life or death, being a burden, living in limbo), lack of choice (medical decision, lack of information, constraints on resources), gaining knowledge of options (peer influence, timing of information), and weighing alternatives (maintaining lifestyle, family influences, maintaining the status quo).

CONCLUSIONS

The experiences of other patients greatly influenced the decision making of patients and carers. The problematic timing of information about treatment options and synchronous creation of vascular access seemed to predetermine haemodialysis and inhibit choice of other treatments, including palliative care. A preference to maintain the status quo may explain why patients often remain on their initial therapy.

A prospective randomised trial of absorbable versus non-absorbable sutures for wound closure after fasciectomy for Dupuytren's contracture

After fasciectomy for Dupuytren's contracture the wound has traditionally been closed with non-absorbable sutures. A prospective randomised study of 59 patients was undertaken to compare wound closure after fasciectomy with irradiated polyglactin 910 absorbable sutures and non-absorbable sutures. The outcomes studied were: time spent attending to the wound at the first postoperative visit; the patient's pain score at that visit; and any complications. Wound care required significantly more time when non-absorbable sutures were used. There was no significant difference in pain scores or in complications between the two groups. We recommend the use of irradiated polyglactin 910 absorbable sutures for wound closure after fasciectomy as it saves time and resources without compromising wound healing.

Measuring heroin use in methadone maintenance programmes

This study compares a number of self-reported measures of drug use with the results of urine testing in a group of patients receiving methadone maintenance treatment. One hundred and twenty-nine subjects were interviewed and 4-5 months later, a second interview was obtained from 87 of these. At each interview subjects were asked about drug use on each of the preceding 7 days and also about the number of days of drug use in the previous month. It was found that most patients were continuing to use heroin, usually fairly infrequently. Direct comparisons of urine test results and self-reported drug use indicate substantial positive correlations. However, there was a tendency for self-report to underestimate drug use in this patient sample. It appears that urine testing is the single most useful measure of drug use. This supports the notion that it is a valid tool in evaluation research. However, the combination of self-report and urine tests provides more information about drug use than any single measure.

The cost-effectiveness of sentinel node biopsy in patients with intermediate thickness primary cutaneous melanoma

BACKGROUND

The aim of this study was to determine the cost-effectiveness of wide excision (WEX) + sentinel node biopsy (SNB) compared with WEX only in patients with primary melanomas >/=1 mm in thickness.

METHODS

A Markov model was populated with probabilities of disease progression and survival from the published literature. Costs were obtained from diagnostic-related group weightings and health outcomes were measured in quality-adjusted life years (QALYs).

RESULTS

Base case analyses suggested that, over a 20-year timeframe, the mean total cost per patient receiving WEX only was AU $23,182 with 10.45 life years (LY) and 9.90 QALYs. The mean cost per patient for WEX + SNB was AU $24,045 with 10.77 LY and 10.34 QALYs. The incremental cost effectiveness ratio for WEX + SNB was AU $2,770 per LY and AU $1,983 per QALY.

CONCLUSION

WEX + SNB appears to offer an improvement in health outcomes (in both LYs and QALYs) with only a slight increase in cost.

Home bowel cancer tests and informed choice-is current information sufficient?

OBJECTIVES

To evaluate the type of information that is available to purchasers of home-based bowel cancer test kits.

METHODS

Manufacturers, pharmacies and independent testing programs were contacted to obtain faecal occult blood test (FOBT) kits. State cancer organisations were contacted for information on bowel cancer screening. Information on bowel cancer, the FOBT kit, the testing process and potential benefits and harms of the screening process were assessed using guidelines provided by the UK General Medical Council (GMC).

RESULTS

FOBT kits and cancer organisation information provided adequate information on the purpose of screening, the screening process itself and potential benefits, but provided no information concerning uncertainties of screening or potential harms.

CONCLUSIONS

On the basis of both the UK GMC criteria and patient desires for information, the information available at present falls short of being considered adequate for an informed decision to purchase a home-based FOBT.

IMPLICATIONS

We must ensure adequate and balanced information is available to redress the present information asymmetry to facilitate informed participation in a potentially valuable public health initiative.

A proposed rural healthcare ethics agenda

The unique context of the rural setting provides special challenges to furnishing ethical healthcare to its approximately 62 million inhabitants. Although rural communities are widely diverse, most have the following common features: limited economic resources, shared values, reduced health status, limited availability of and accessibility to healthcare services, overlapping professional-patient relationships and care giver stress. These rural features shape common healthcare ethical issues, including threats to confidentiality, boundary issues, professional-patient relationship and allocation of resources. To date, there exists a limited focus on rural healthcare ethics shown by the scarcity of rural healthcare ethics literature, rural ethics committees, rural focused ethics training and research on rural ethics issues. An interdisciplinary group of rural healthcare ethicists with backgrounds in medicine, nursing and philosophy was convened to explore the need for a rural healthcare ethics agenda. At the meeting, the Coalition for Rural Health Care Ethics agreed to a definition of rural healthcare ethics and a broad-ranging rural ethics agenda with the ultimate goal of enhancing the quality of patient care in rural America. The proposed agenda calls for increasing awareness and understanding of rural healthcare ethics through the development of evidence--informed, rural-attuned research, scholarship and education in collaboration with rural healthcare professionals, healthcare institutions and the diverse rural population.

Novel selective medium for isolation of Burkholderia pseudomallei

Isolation of Burkholderia pseudomallei currently relies on the use of Ashdown's selective agar (ASA). We designed a new selective agar (Burkholderia pseudomallei selective agar [BPSA]) to improve recovery of the more easily inhibited strains of B. pseudomallei. B. pseudomallei, Burkholderia cepacia, and Pseudomonas aeruginosa were used to determine the selectivity and sensitivity of BPSA. BPSA was more inhibitory to P. aeruginosa and B. cepacia and should make recognition of Burkholderia species easier due to distinctive colony morphology. BPSA also inhibited Enterococcus, Escherichia, Staphylococcus, and Streptococcus: These results indicate that BPSA is a potential replacement for ASA.

Resistance of Acanthamoeba castellanii cysts to physical, chemical, and radiological conditions

Resistance of Acanthamoeba castellanii cysts to disinfection agents, antimicrobial agents, heat, freeze-thawing, ultraviolet radiation (UV), gamma irradiation, and cellulase were evaluated in vitro. Following exposure to different agents, the cysts were removed and cultured for A. castellanii trophozoites for 3-14 days. Solutions containing 20% isopropyl alcohol or 10% formalin effectively killed A. castellanii cysts. Hydrogen peroxide (3%, AOSept Disinfectant) effectively killed A. castellanii cysts after 4 hr of exposure. Polyhexamethylene biguanide (0.02%), clotrimazole (0.1%), or propamidine isethionate (Brolene) were effective in killing A. castellanii cysts in vitro. Acanthamoeba castellanii cysts were resistant to both 250 K rads of gamma irradiation and 800 mJ/cm2 of UV irradiation. Excystment of trophozoites was accelerated after exposure to 10, 100, and, 1,000 units of cellulase. These results suggest that A. castellanii cysts benefit by enhanced survival because of their resistance to very harsh environmental conditions.

Effect of steroids on Acanthamoeba cysts and trophozoites

PURPOSE

Topical steroids are frequently used to control corneal inflammation and uveitis or is administered after surgery, to prevent corneal graft rejection. This study was undertaken to determine whether steroids could affect the pathogenicity of Acanthamoeba castellanii.

METHODS

The effect of dexamethasone phosphate on excystment, proliferation, and encystment of trophozoites and cysts of A. castellanii was examined in vitro. Cytolysis capacity of steroid-treated Acanthamoeba was quantified by a spectrophotometric assay, and plasminogen activators were measured by a fibrinolysis assay. The influence of steroid treatment on corneal infection in a Chinese hamster model of Acanthamoeba keratitis was examined in vivo.

RESULTS

Treatment of Acanthamoeba cysts with dexamethasone induced 4- to 10-fold increases in the number of trophozoites compared with untreated control cultures. Acceleration of trophozoite proliferation was observed when trophozoites were treated with dexamethasone. However, dexamethasone treatment did not affect encystment of Acanthamoeba trophozoites. Dexamethasone-treated trophozoites or cysts induced a significant cytopathic effect on corneal epithelial cells compared with untreated organisms. Supernatants collected from either dexamethasone-treated or untreated organisms failed to lyse corneal epithelial cells. Treatment of organisms with dexamethasone had no effect on production of plasminogen activators by Acanthamoeba trophozoites. Intramuscular injection of dexamethasone had a profound effect on the incidence, severity, and chronicity of keratitis. Keratitis in dexamethasone-treated hamsters was significantly more severe at all time points than in untreated animals (P < 0.05).

CONCLUSIONS

These findings indicate that exposure of Acanthamoeba trophozoites and cysts to dexamethasone increases the pathogenicity of the organisms. The results emphasize the importance of maintaining adequate amebicidal therapy if a topical steroid is used in the management of Acanthamoeba keratitis.

Vaccination of boars with a GnRH vaccine (Improvac) eliminates boar taint and increases growth performance

Peri- and postpubertal boars accumulate substances (e.g., androstenone and skatole) in their fatty tissue that are responsible for boar taint in pork. The objective of this study was to assess the efficacy of a GnRH vaccine, Improvac, in eliminating boar taint. Three hundred male (200 intact boars, 100 barrows) crossbred (Large White x Landrace) pigs were used in a 2 x 3 factorially arranged experiment. The respective factors were sex group (barrows, boars treated with placebo, or boars treated with Improvac) and slaughter age (23 or 26 wk). Vaccines were administered 8 and 4 wk before slaughter. All Improvac-treated pigs exhibited anti-GnRH titers. Testes and bulbo-urethral gland weights in treated pigs were reduced by approximately 50% (P < 0.001) and serum testosterone levels were below 2 ng/mL in the majority of treated boars (94 and 92% across both age groups at 2 and 4 wk, respectively). Boar taint, as assessed by the concentration of androstenone and skatole in s.c. fat, was suppressed to low or undetectable levels in 100% of Improvac-treated boars. No Improvac-treated pigs had significant concentrations of either androstenone (> 1.0 microg/g) or skatole (> 0.20 microg/g). In contrast, 49.5% of placebo-treated controls had significant androstenone and 10.8% had significant skatole levels, resulting in 10% of the control boars with high concentrations of both compounds. The mean concentrations of taint compounds in the Improvac-treated pigs were not significantly different from those in barrows. Improvac-treated boars grew more rapidly (P = 0.051 and < 0.001 for pigs slaughtered at 23 and 26 wk of age, respectively) than control boars over the 4 wk after the secondary vaccination, possibly because of reduced sexual and aggressive activities. Compared with barrows, Improvac-treated boars were leaner and had superior feed conversion efficiency. The vaccine was well tolerated by the pigs, and no observable site reactions could be detected at the time of slaughter. Vaccination of boars with Improvac allows production of heavy boars with improved meat quality through prevention and control of boar taint.