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The purpose of this essay is to describe how to prepare a qualitative research paper. The essay discusses the crucial components for preparing a qualitative paper. The topics that are addressed are: sample size, sampling procedure, data collection procedure, reliability and trustworthiness, data quality, and integrity of qualitative findings. [ABSTRACT FROM AUTHOR]

Background: While implementation studies in aphasia management have shown promising improvements to clinical practice, it is currently unknown if aphasia implementation outcomes are sustained and what factors may influence clinical sustainability. Aims: To evaluate the sustainment (i.e., sustained improvement of aphasia management practices and domains influencing clinicians' practice) and sustainability (i.e., factors influencing sustainability) outcomes of the Acute Aphasia IMplementation Study (AAIMS). Methods & Procedures: A convergent interactive mixed‐methods sustainability evaluation was conducted on two previously delivered implementation interventions (AAIMS). The AAIMS interventions were targeted at improving either written aphasia‐friendly information provision (Intervention A) or collaborative goal‐setting (Intervention B). Outcomes were collected 2 and 3 years post‐implementation, addressing the research questions of sustainment (e.g., medical record audits and behavioural constructs questionnaires) and sustainability (e.g., post‐study focus groups and organizational readiness surveys). Quantitative sustainability data were compared with post‐implementation data, allowing for sustainment to be determined. Clinicians' perspectives on sustainability outcomes and challenges were analysed using framework analysis and integrated with the quantitative findings. Outcomes & Results: A total of 35 speech–language therapists (SLTs) from four hospitals participated. The medical records of 79 patients were audited in the sustainability period compared with the 107 medical records audited during AAIMS. Overall, there was variable sustainment of the target behaviours; implementation for Intervention A was not sustained at either sustainability time point (2018 = 47.8% decrease; 2019 = 22.78% decrease), but implementation for Intervention B was sustained at both time points (2018 = 7.78% increase; 2019 = 18.1% increase). There was a pattern of sustained change in the behaviour change domains targeted by the implementation interventions, where scores of the targeted domains increased over time (0.13, 95% confidence interval (CI) = −0.05 to 0.30) and scores of the non‐targeted domains declined (−0.03, 95% CI = −0.11 to 0.04). Factors influencing sustainability were mainly related to 'processes', 'the inner context' and 'SLT characteristics', and these interacted dynamically to account for variation between teams. Conclusions & Implications: Implementation outcomes (i.e., practice changes) were not sustained to the same level for three of the four participating SLT teams, with variable or partial sustainment most common. While the factors influencing sustainability differed depending on the context and individuals involved, the most important factor influencing outcomes seemed to be the level to which behaviour‐change processes and strategies were embedded within the SLT department. Future implementation studies should incorporate sustainability measures from the onset and include follow‐ups and monitoring systems to help support sustained change in the long term. What this paper adds: What is already known on the subject: In post‐stroke aphasia management, there are few examples of long‐term sustainability of implementation outcomes. It is therefore unknown what factors are potentially important to sustain implementation of best‐practice recommendations in aphasia services. What this paper adds to existing knowledge: There is potential for implementation outcomes to be sustained long term, but sustainment is impacted by a range of factors. Ongoing facilitation or follow‐up after initial implementation may to useful to promote sustainment, but is not essential if processes are sufficiently embedded. Gradual implementation into practice may lead to better sustainment than rapid change that is quickly forgotten. What are the potential or actual clinical implications of this work?: Future implementation efforts should incorporate sustainability measures from the onset. Applying a sustainability framework was useful to guide evaluations and explore factors influencing the sustainment outcomes and is recommended for those interested in sustainability. Results from our evaluation can be used to guide refinement and support future development of sustainable implementation interventions. [ABSTRACT FROM AUTHOR]

Dysphagia (impaired swallowing) is known to contribute to decreased quality of life, and increased length of hospital stay and mortality post‐stroke. Despite the advancements in stroke treatment with the introduction of thrombolysis and endovascular clot retrieval (ECR), patients continue to present with high rates of dysphagia. Speech and language therapists and stroke teams should consider the presence of haemorrhagic transformation, success of reperfusion and presence of communication deficits as risk factors for dysphagia post‐ECR and/or thrombolysis. Purpose: To establish incidence rates and patterns of dysphagia following the administration of reperfusion therapies in acute ischaemic stroke management. Method: A retrospective review of 193 patients admitted with acute ischaemic stroke to a quaternary stroke unit in Australia over a three year period was completed. Clinical information extracted included demographics, type (thrombolysis and/or endovascular clot retrieval) and success of reperfusion therapy, and the progression of dysphagia and related factors. Results: Over half of all patients treated with reperfusion therapies presented with dysphagia on initial assessment by speech‐language pathology (SLP). The type of reperfusion therapy administered was not significantly correlated with the presence of dysphagia. Dysphagia on initial assessment was significantly correlated with the presence of aphasia on initial assessment, the presence of haemorrhagic transformation, and the success of reperfusion. Increased rates of enteral feeding were also found in this study compared to figures reported in literature. Conclusion: This study identified ongoing high rates of dysphagia amongst this patient population regardless of treatment type, demonstrating the need for ongoing SLP management post stroke. Further research is required in this area to develop an evidence‐base for SLPs and the wider medical team and to inform clinical practice guidelines. What this paper adds: What is already known on the subject: Stroke is one of the leading causes of disability and death internationally. Dysphagia (impaired swallowing), a common sequalae of stroke, is known to contribute to decreased quality of life, increased length of hospital stay and mortality. With advancements in technology, treatments for acute ischaemic stroke (endovascular clot retrieval and thrombolysis) are increasing in popularity. However, limited research exists exploring the impact of these therapies on dysphagia. What this paper adds: Despite the advancements in stroke treatment, patients continue to present with high rates of dysphagia. Dysphagia following thrombolysis and/or ECR was found to be significantly correlated to the presence of aphasia, haemorrhagic transformation, and the success of reperfusion (regardless of treatment type). Additionally, increased rates of enteral feeding were found amongst this patient population compared to figures reported in the literature for patients following traditional stroke management. Clinical implications of this study: Speech‐language pathologists and the wider medical team should consider dysphagia as an ongoing consequence of stroke following reperfusion therapies, with consideration for success of reperfusion and adverse outcomes i.e., haemorrhagic transformation. Further research is required to provide an evidence‐base and specific guidelines for the management of dysphagia post reperfusion therapies, including use of enteral feeding. [ABSTRACT FROM AUTHOR]

Context: Gender bias has been observed in the authorship and editorship of academic literature in varied medical specialties. This is important as peer‐reviewed publications, and participation on editorial boards, are closely related to academic productivity and advancement. The aim of this paper was to examine whether gender‐based disparities in authorship and editorship exist in leading medical education journals. Methods: A retrospective bibliometric review was conducted of articles published at eight different time‐points across a 49‐year time period (specifically: 1970, 1980, 1990, 2000, 2005, 2010, 2015 and 2019) in four leading medical education journals (Academic Medicine, BMC Medical Education, Medical Education and Medical Teacher). First and last (as a proxy for senior) author gender was determined for each article, along with the gender of the 2019 editorial board members of each journal. Chi‐square tests for trend were conducted to examine variations in author gender distributions over time, and binomial tests of proportions were conducted to examine gender distributions in authorship and editorship in 2019. Logistic regression analyses were carried out to determine factors that predicted the odds of authorship by women. Results: A total of 5749 articles were included. A significant trend of increased women as first and last authors was observed across all journals. The percentage of women first authors increased from 6.6% in 1970 to 53.7% in 2019 (P <.001), and women last authors increased from 9.5% in 1970 to 46% in 2019 (P <.001). Overall, the distributions of women first authors, last authors and editorial board members in 2019 indicated greater gender parity than many other fields of medicine. Conclusions: Positive progress towards gender parity has been made in medical education scholarship. However, future research and efforts are needed to ensure the continued participation, and highlighting, of women in medical education scholarship and to address other factors which may hinder academic advancement for women in this field. [ABSTRACT FROM AUTHOR]

Background: Although previous research studies have defined several prognostic factors that affect cognitive‐communication performance in patients with all traumatic brain injury (TBI) severity, little is known about what variables are associated with cognitive‐communication impairment in complicated mild TBI (mTBI) specifically. Aims: To determine which demographic and trauma‐related factors are associated with cognitive‐communication performance in the early recovery phase of acute care following a complicated mTBI. Methods & Procedures: Demographic and accident‐related data as well as the scores on cognitive‐communication skill measures in the areas of auditory comprehension (complex ideational material subtest of the Boston Diagnostic Aphasia Examination), verbal reasoning (verbal absurdities subtest of the Detroit Test of Learning Aptitude), confrontation naming (short form of the Boston Naming Test), verbal fluency (semantic category and letter category naming), and conversational discourse (conversational checklist of the Protocole Montréal d'évaluation de la communication) were retrospectively collected from the medical records of 128 patients with complicated mTBI admitted to a tertiary care trauma hospital. Multiple linear regressions analyses were carried out on the variables sex, age, education level, Glasgow Coma Scale (GCS) score, lesion site and bilingualism. Outcomes & Results: Females performed better than males on letter‐category naming, while those more advanced in age performed worse on most cognitive‐communication measures. Patients with higher education achieved better confrontation and letter‐category naming, whereas reading comprehension results were worse with a lower GCS score. Bilingual individuals presented more difficulty in conversational discourse skills than those who spoke only one language. In terms of site of lesion, the presence of a right frontal injury was associated with worse auditory and reading comprehension and an occipital lesion was related to worse confrontation naming. Conclusions & Implications: Cognitive‐communication skills should be evaluated early in all patients with complicated mTBI, but especially in those who are advanced in age, those with fewer years of education and those who present with lower GCS scores, in order to determine rehabilitation needs. The findings of this study will allow acute care clinicians to better understand how various demographic and injury‐related factors affect cognitive‐communication skills after complicated mTBI and to better nuance the interpretation of their evaluation results in order to improve clinical care. Further study is required regarding the influence of lesion location, sex and bilingualism following complicated mTBI. What this paper addsWhat is already known on the subjectIn early acute recovery studies including all severity of TBI, cognitive‐communication performance was poorer in individuals with more advanced age, those with fewer years of education and with more severe TBI. It is not yet known which demographic and injury‐related variables predict cognitive‐communication performance after a complicated mTBI specifically.What this paper adds to existing knowledgeWe confirmed that age, level of education and TBI severity, as measured with the GCS score, were associated with some areas of cognitive‐communication performance for a group of patients in the acute stage of recovery from a complicated mTBI. We also identified that sex, bilingualism and site of lesion were new variables that show an influence on aspects of cognitive‐communication skills in this group of patients.What are the potential or actual clinical implications of this work?The findings of this study on prognostic factors in the case of complicated mTBI will help acute care clinicians to better understand evaluation results knowing the variables that can influence cognitive‐communication performance and to nuance the interpretation of these results with the goal of determining rehabilitation needs and enhancing clinical care. [ABSTRACT FROM AUTHOR]

Objective: Neuropathic orofacial pain disorders are frequently managed with topical or systemic medications that carry a risk of dangerous side effects such as drowsiness, disorientation, and/or physical addiction. The aim of this paper is to report the use of neurosensory oral appliances as a safe means of providing symptomatic relief for neuropathic orofacial pain. Study design: This is a retrospective chart review of patients with diagnoses of persistent idiopathic facial pain (PIFP), painful post‐traumatic trigeminal neuropathy (PTTN), or an oral dysesthesia, who utilized neurosensory appliances with or without the use of topical anesthetic gel. Results: Eleven patients were identified. Eight patients (62.5%) found benefit with the neurosensory appliance alone, and three patients (37.5%) found relief with the addition of lidocaine 2% gel. All patients reported >50% resolution of their symptoms, with three (37.5%) reporting complete resolution. Seven patients maintained follow‐up ≥3 months, with efficacy lasting for a range of at least 3–8 months. Conclusion: Oral neurosensory appliances, whether used alone as a physical barrier or as a vehicle to deliver topical anesthetic, represent a safe and effective modality for the management of neuropathic orofacial pain disorders. Additional studies are needed to assess long‐term efficacy. [ABSTRACT FROM AUTHOR]

Rationale, aim and objective: The physiotherapy profession did not escape the effects of racially based segregatory practises. While numerous strategies and initiatives have been employed to redress the inequities of the past, the extent of demographic transformation within the physiotherapy profession in South Africa remains uncertain. Transformation is defined in this article as an intentional change aimed at addressing inequalities and the ultimate goal is for population group and gender profiles of higher education graduates to be representative of the national epidemiological profile. This paper describes the demographic patterns of Health Professions Council of South Africa (HPCSA) registered physiotherapists from 1938 to 2018. Method: A retrospective record review of the HPCSA database from 1938 until 2018 was performed. De‐identified data were extracted, coded and analyzed for descriptive purposes. Z‐tests were used for analysis of proportion differences, along with P‐values and 95% confidence intervals for interpretation. Results: In 2018, 7663 physiotherapists (6350 women and 1313 men) were registered with the HPCSA. Most registered physiotherapists (55.6%) were classified as white, followed by black (17.3%), coloured (10.3%) and Indian (9.8%). A progressive increase was found in the number of new registrations over time (1949‐2018) by black (0.00%‐24.38% of total new registrations), coloured (0.00%‐15.47%) and Indian individuals (0.00%‐10.03%), with a statistically significant increase in newly registered black therapists in the decade prior to 2018 (P =.005). Gender transformation appears to be occurring at a slower pace as the profession remains female‐dominated (82.9% of registered physiotherapists in 2018). Conclusion: There has been a steady transformation of the South African physiotherapy graduates composition regarding population categories and gender. However, it is clear that much more than selection criteria is needed to transform the profession in a way that is nationally representative, remain actively accountable for transformation and apt for local context. [ABSTRACT FROM AUTHOR]

Objective: To investigate differences in presenting patient characteristics, investigation, management and related outcomes between culturally and linguistically diverse (CALD) and non‐CALD chest pain (CP) patients presenting to the ED. Methods: A cohort study of 258 patients was enrolled on presentation to Liverpool Hospital ED with a complaint of CP over a 2‐week period. Main outcomes included frequency and timeliness of diagnostic and radiological investigations, medication administered and ED length of stay. Administrative and clinical data were extracted and linked from Cerner EMR FirstNet®, PowerChart® and paper records. Results: There were 155 (60%) CALD and 103 (40%) non‐CALD patients. CALD patients were older by 10 years (95% CI 4, 15; P < 0.0001). There were no significant differences in the number of pathology and imaging investigations carried out in each group, and similarly there were no significant differences in the number of patients administered analgesia or cardiac‐specific medications. Neither group differed in their ED length of stay (median 280 vs 259.5 min; P = 0.79) or hospital admission rate (median 56% vs 55%, P = 0.8). Conclusion: Both CALD and non‐CALD ED CP patients had similar test ordering, medication administration and clinical outcomes, but this was in the context of CALD patients being 10 years older together with a small study sample size. A larger cohort, matched for age, would provide further insights into potentially important differences. [ABSTRACT FROM AUTHOR]

The COVID‐19 global health crisis compelled behavior analysts to consider alternatives to face‐to‐face services to treat children with feeding disorders. Research suggests telehealth is one method behavior analysts could use to initiate or continue assessment of and treatment for feeding disorders. In the current paper, we conducted pilot studies in which we analyzed chart records of patients with Avoidant/Restrictive Food Intake Disorder; who graduated from an intensive, day‐treatment program; and transitioned to an outpatient follow‐up program. In Experiment 1, we analyzed the data of participants who received follow‐up both in‐clinic and via telehealth. In Experiment 2, we analyzed goal attainment for participants who received outpatient follow‐up either in‐clinic exclusively or via telehealth exclusively. Results of both studies showed that outcomes were equivalent along most dimensions for in‐clinic and telehealth services. We provide recommendations for telehealth feeding services and discuss other considerations relevant to telehealth service delivery. [ABSTRACT FROM AUTHOR]

Objective: This paper will discuss the process of mapping opioid use disorder (OUD) treatment resources for pregnant women and discuss the intersection between treatment resources and rates of neonatal abstinence syndrome (NAS). Design: A resource manual was developed through a systematic process with stakeholders across Illinois. Resources were mapped by county and overlaid with county rates of NAS, using hospital discharge data. Results: Across Illinois, 89 treatment resources were identified for pregnant women insured by Medicaid. Resources were concentrated in 36% of Illinois' counties. Counties with limited treatment resources generally had high rates of NAS. Sixty‐six percent of NAS cases among rural Illinois residents had no OUD treatment resources in their county. Rural counties had less access to medication‐assisted treatment (MAT), the standard of care for treatment of OUD, compared with other counties across the state. Conclusions: Efforts to increase OUD treatment options for pregnant women insured by Medicaid should concentrate on geographic areas with limited access and high need. [ABSTRACT FROM AUTHOR]

Objectives: Gay, bisexual, and other men who have sex with men (gbMSM) are 131 times more likely to acquire HIV compared with other Canadian men. Pre‐Exposure Prophylaxis (PrEP) for HIV has the potential to reduce or eliminate disparities in HIV acquisition among key affected populations. This paper aims to discuss the feasibility and utility of a nurse‐led PrEP program administered by the Cool Aid Community Health Centre (CACHC) in Victoria, British Columbia as a public health PrEP program was initiated. Design, Sample and Measurements: A retrospective chart review of 124 gbMSM patients accessing PrEP at CACHC in 2018 collected information on patient demographics, STI testing results, and PrEP prescription pick‐ups at 3 time points. Results: Ninety‐nine (79.8%) patients have continued on PrEP, as defined as having picked up their second 90‐day PrEP prescription. Both older age and having an Sexually Transmitted Infection after PrEP enrolment were significantly associated with staying on PrEP; decreased risk perceptions contributed most to clinic‐level discontinuance. Very few patients who stayed on PrEP have transitioned to their own General Practitioner. Conclusions: Patients appear to recognize their risk and are continuing on PrEP to reduce their risk of HIV. As evidenced by ability to recruit and maintain patients, we conclude that nurse‐led PrEP at community health centres supports access and uptake of essential health services to optimize individual and population health. [ABSTRACT FROM AUTHOR]

Introduction: Employment of occupational therapists in generic roles in public mental health services (PMHSs) constrains capacity to undertake discipline‐specific activity meaning consumers may be unable to access valuable occupational therapy assessments and interventions that could promote recovery. Establishing a dedicated occupational therapy clinic has been identified as one way of improving care provided and outcomes for organisations, therapists, and consumers. To inform such developments, this paper reports evaluation of feasibility, acceptability, and sustainability of a pilot clinic established within a PMHS. Methods: An observational evaluation was used combining quantitative and qualitative data collected from service documents, clinic records, and in semi‐structured interviews with 42 stakeholders. Quantitative data were used to describe referrals and flow through the clinic. Framework analysis of qualitative data examined the process and outcomes of referrals and enabled understanding of acceptability, perceived impact and areas for improvement. Results: Substantial ground work, particularly stakeholder engagement, and redistribution of resources enabled establishment and successful operation of an assessment clinic for 12 months. Assessments were completed for 68% of the 100 accepted referrals, with the remainder in process or unable to be completed. Stakeholders agreed that the clinic enabled clinicians' timely access to specialist assessment, improving care for consumers. Occupational therapists valued the opportunity to deploy and develop discipline‐specific skills and when there was some impact on work flow of occupational therapists' 'home teams', team managers judged the investment worthwhile. Strong leadership by the discipline lead and support from team managers who enabled allocation of occupational therapists to the clinic were critical to success. Conclusion: An occupational therapy assessment clinic can be established and operate successfully within a public mental health setting. Redistribution of resources supported increased efficiency and consumer access to specialist interventions that support their recovery. [ABSTRACT FROM AUTHOR]

Objective: We explore factors that may have contributed to differences in treatment‐emergent adverse events in the phase 2 and phase 3 lasmiditan clinical trials. Background: Phase 2 and phase 3 trials showed that the centrally penetrant 5‐HT1F agonist, lasmiditan, was effective; higher frequency and severity of adverse events (AEs) were seen in phase 2. Methods: This work represents a hybrid of a review of primary documents and study reports with additional post hoc analyses. Protocols, informed consents, data collection forms, and methodologies were reviewed. This information was supplemented by results from the clinical study reports and post hoc analyses of individual patient data from each trial. Results: For lasmiditan 100 and 200 mg, in phase 2, the incidence of ≥1 AE was 72‐86% (26% severe), while in phase 3 was 36‐43% (2% severe). The most common AEs in all studies were CNS‐related. The phase 2 consent form was more descriptive of AEs than phase 3. In phase 2, patients recorded AEs and severity in a paper diary that warned about drowsiness and dizziness. In phase 3, patients recorded in electronic diaries whether they experienced unusual feelings after dosing with lasmiditan that they had not felt with a migraine before, and were contacted to determine if an AE had occurred. In phase 2, the AE Schwindel was variably translated from German as "vertigo" or "dizziness," while phase 3 vertigo cases were queried to ensure there was a sensation of rotation or movement. History of recurrent dizziness and/or vertigo was exclusionary in phase 3. Conclusions: This work illustrates how informed consent wording, AE collection methods, translation, exclusion criteria, and other factors may be important determinants for reporting of the frequency and severity of AEs in clinical trials. [ABSTRACT FROM AUTHOR]

This study set out to answer the research question: 'What are the similarities and differences in the nature of abuse, patterns of disclosure and characteristics of the perpetrator between boys and girls attending a sexual assault referral centre (SARC) for a forensic medical examination?' Retrospective data collection was undertaken from paper case files of 986 service users (142 boys, 844 girls) who attended Saint Mary's SARC for a forensic medical examination (April 2012–March 2015). Demographic data as well as information on the context of the abuse were coded into a standardised digital format. Cross‐tabulation and Pearson's chi‐squared tests were performed to compare the abuse experienced and how abuse was disclosed by children of different genders and ages. Older children accounted for 20 per cent of the boys and 56 per cent of the girls. A higher proportion of girls attended the SARC after a single abusive episode; the abuse of boys was more frequently reported by a parental figure; and boys' abuse was reported later. Younger children were more likely to be abused in the family environment. Younger girls were more likely to experience abuse by a single perpetrator, whereas all boys reported multiple perpetrators. These findings suggest that the relationship between child sexual abuse (CSA) and gender is a complicated and nuanced one. 'What are the similarities and differences in the nature of abuse, patterns of disclosure and characteristics of the perpetrator between boys and girls attending a sexual assault referral centre (SARC) for a forensic medical examination?' Key Practitioner Messages: Some gender differences in CSA may be due to professionals' perceptions. It is important to remain mindful that boys may present differently to girls.Care should be taken when interpreting these results. The majority of CSA is not disclosed nor identified. Where it is, few children receive a forensic medical examination. Practitioners need to be alert to this to safeguard children adequately.Future research can pursue how identified differences affect boys and girls, thereby enabling better support or protection for children. [ABSTRACT FROM AUTHOR]

Background: Robust quality indicators (QIs) are essential for monitoring and improving the quality of care and learning from good practice. We aimed to identify and assess QIs for the care of older people and people with dementia who are nearing the end of life and recommend QIs for use with routinely collected electronic data across care settings. Methods: A systematic review was conducted, including five databases and reference chaining. Studies describing the development of QIs for care of older people and those with dementia nearing the end of life were included. QIs were categorized as relating to processes or outcomes, and mapped against six care domains. The psychometric properties (acceptability, evidence base, definition, feasibility, reliability, and validity) of each QI were assessed; QIs were categorized as robust, moderate, or poor. Results: From 12,980 titles and abstracts screened, 37 papers and 976 QIs were included. Process and outcome QIs accounted for 780 (79.7%) and 196 (20.3%) of all QIs, respectively. Many of the QIs concerned physical aspects of care (n = 492, 50.4%), and very few concerned spiritual and cultural aspects of care (n = 19, 1.9%). Three hundred and fifteen (32.3%) QIs were robust and of those 220 were measurable using routinely collected electronic data. The final shortlist of 71 QIs came from seven studies. Conclusions: Of the numerous QIs developed for care of older adults and those with dementia nearing the end of life, most had poor or moderate psychometric properties or were not designed for use with routinely collected electronic datasets. Infrastructure for data availability, combined with use of robust QIs, is important for enhancing understanding of care provided to this population, identifying unmet needs, and improving service provision. [ABSTRACT FROM AUTHOR]

Background: An electronic prescribing and administration (ePA) system has been progressively rolled out to Canterbury District Health Board (CDHB, Christchurch, New Zealand) public hospitals since 2014, and is currently used for around 1300 tertiary beds. ePA data can be used to monitor user behaviour, and to evaluate and inform the local customisation of clinical decision support (CDS) tools within the ePA system. Aims: To describe retrospectively illustrative vignettes of CDHB ePA analyses that have been used for CDS. Methods: Alerts were developed according to a set of common principles agreed upon by the CDHB CDS Working Group. Alerts were informed and evaluated by extracting and parsing data for various time periods during 2016 to 2018 from the CDHB ePA database. Results: There was a median of 74 000 prescriptions a month. After examining 525 spironolactone prescriptions, the high dose alert threshold was set at 100 mg with an expected alert burden of 3%. The presence of a ceftriaxone shortage prescribing alert for 1 week was associated with a prescribing rate that was lower than 95% of the preceding 52 weeks. Following review of 367 fentanyl patch alerts, revision of the alert led to false positives falling from 43% to 3% (P < 0.0001). At the point of firing, 6% of antithrombotic drug interactions alerts led to immediate changes in prescriptions (94% overridden), and a further 22% were changed within 30 min after the alert. Conclusions: Local data extracts from ePA systems can inform iterative configuration of the software and monitor user behaviour. [ABSTRACT FROM AUTHOR]

The article focuses on nonspecific complaints like fatigue, and dizziness are relatively common among elderly patients presenting to the emergency department. Topics include the appropriate workup of such complaints is not always evident, the significant number of elderly patients presenting with nonspecific symptoms are ultimately diagnosed with serious conditions, and the patients diagnosed with acute coronary syndrome being more likely than younger patients to present without chest pain.

Objective: The purpose of this case–control study was to compare the pharmacological anamnesis collected from a group of 150 burning mouth syndrome (BMS) patients with that of a control group of 150 patients matched for age and sex. Materials and Methods: The patients' medical histories were reviewed, and data on drug therapy were collected. Drugs were classified on the basis of pharmacological effects; the classes were antihypertensives (i.e., ACE inhibitors/ARBs, calcium antagonists, diuretics and beta‐blockers), antiaggregants, anticoagulants, antidiabetics, vitamin D integrators, bisphosphonates, psychotropics (i.e., anxiolytics and antidepressants), gastroprotectors, statins, thyroid hormone substitutes, corticosteroids and immunosuppressants. Results: The BMS patients and the controls were matched for age (mean age: 69 years) and sex (128 females and 22 males). Antihypertensives, especially ACE inhibitors/ARBs (OR = 0.37, CI: 0.22–0.63, p = 0.0002) and beta‐blockers (OR = 0.36, CI: 0.19–0.68 p = 002), revealed an inverse association with the presence of BMS, whereas anxiolytics (OR = 3.78, CI: 2.12–6.75 p < 0.0001), but neither antidepressants nor antipsychotics, were significantly associated with BMS. There were no correlations with other drug classes. Conclusion: Our study highlighted that ACE inhibitors, ARBs and beta‐blockers were in inverse relation to BMS and found that anxiolytics, but neither antidepressants nor antipsychotics, were linked to the presence of the syndrome. [ABSTRACT FROM AUTHOR]

Objectives: To investigate associations between alcohol use, psychological treatment attendance, and clinical outcomes. Methods: We analysed electronic health records for N = 7,986 patients accessing psychological treatment for common mental disorders. Data were collected for pre‐treatment alcohol use (average units per week) and severity of dependence (SDS), number of therapy contacts attended, pre‐ and post‐treatment anxiety (GAD‐7), and depression (PHQ‐9) symptom severity. Hierarchical regression was used to examine associations between alcohol use/dependence and post‐treatment symptom severity controlling for intake severity and relevant confounders. Results: After controlling for confounders, alcohol use had significant nonlinear associations with pre‐treatment depression severity (R2 =.54, p <.01, cubic trend), and post‐treatment anxiety (R2 =.23, p <.01, quadratic trend). Alcohol use was not significantly associated with intake anxiety, post‐treatment depression or treatment duration. SDS was not significantly associated with depression severity, alcohol severity, or total contacts after controlling for confounders. Conclusion: Alcohol users are just as likely to engage in and benefit from evidence‐based psychological treatments for depression in primary care. A nonlinear association between alcohol use and anxiety treatment outcomes indicates that light‐to‐moderate drinkers have some shared characteristic that favours treatment response. Practitioner points: Depression and anxiety problems often co‐occur with alcohol use and dependence.Conventional wisdom in the field suggests that heavy alcohol users may not engage well or benefit from psychological therapies for depression and anxiety.We found no empirical support for the above assumptions in a large clinical sample.Alcohol consumption was not significantly associated with treatment attendance or depression treatment outcomes.A nonlinear association between alcohol use and anxiety outcomes suggests that moderate drinkers may have some shared characteristic that favours treatment response. [ABSTRACT FROM AUTHOR]

Objective: To explore rural motor vehicle collision (MVC) fatalities by trends over time, mode of transport, age, state, sex, and Aboriginal and Torres Strait Islander status. Design: A retrospective total population‐based time series was conducted using the Australian Bureau of Statistics (ABS) death registration data. Setting: All statistical local area (SLA) within Australia from 2006 to 2017. Participants: Australian residents whose deaths were registered with the ABS between 01 January 2006 and 31 December 2017 where the underlying cause of death was related to unintentional transport accidents. Main outcome measures: Fatality rates were determined using population data collected from the 2006, 2011 and 2016 census. Trends over time by rurality were analysed by financial year. Rates of transport deaths by vehicle type were determined by rurality. Risk ratios were calculated to compare demographic groups based on sex, Aboriginal and Torres Strait Islander status and age. A 3‐year scorecard was organised by state and rurality using 99.7% confidence intervals. Results: Motor vehicle collision fatalities increase with increasing remoteness. Females, children from 0 to 14 years, pedestrians, and Aboriginal and Torres Strait Islander peoples are at a significantly higher risk of fatal MVCs than their respective metropolitan counterparts. The 3‐year scorecard indicates that road fatality rates in the NT, WA, and all rural and remote areas required immediate attention and targeted action. Conclusions: There is a need for investment in MVC fatality prevention in rural Australia from inner regional to remote areas in order to meet the road safety targets established by the National Road Safety Strategy. [ABSTRACT FROM AUTHOR]

Background: Interstitial lung abnormality (ILA) is closely related to lung cancer. This study aimed to assess whether the presence of ILA is associated with the clinicoradiological features of elderly patients (≥70 years) with early‐stage non‐small cell lung cancer (NSCLC). Methods: Elderly patients who underwent surgical resection for stage I or II NSCLC with preserved lung function between 2012 and 2019 were retrospectively identified. ILA was evaluated using a three‐point scale. Univariate analyses were performed for clinicoradiological features based on the presence of ILA. Logistic and linear regression analyses were performed for cancer staging and tumor size, respectively. Results: A total of 254 patients were evaluated. The presence of ILA (score = 2) was significantly associated with male sex, current or former smoker status, higher pack‐years of smoking, low forced expiratory volume in one second/forced vital capacity ratios and diffusing capacity of the lung for carbon monoxide, and presence of emphysema (≥5%). Tumor characteristics, such as lower lobe and outer one‐third location, squamous cell carcinoma, and higher cancer stage (stage II) were significantly associated with ILA. The presence of ILA independently predicted a higher cancer stage (adjusted odds ratio, 1.81; 95% confidence interval, 1.10–2.96; p = 0.02) and a larger tumor size in linear regression analysis (p = 0.04). Conclusions: Patients with ILA showed clinicoradiological features similar to those of idiopathic pulmonary fibrosis in elderly patients with early‐stage NSCLC. Identifying the clinical implications of ILA in early‐stage lung cancer will guide clinicians in providing appropriate management for these patients. [ABSTRACT FROM AUTHOR]

Objective: Predictors for post‐operative reverse remodeling in patients with severe aortic regurgitation (AR) and reduced left ventricular ejection fraction (LVEF) are unknown. We performed low‐dose dobutamine stress echocardiography (DSE) in patients with severe AR and reduced LVEF to evaluate the relationship between contractile reserve (CR) and reverse remodeling after surgery. Methods: In 31 patients with chronic severe AR and reduced LVEF (LVEF < 50%), we performed pre‐operative DSE, assessed CR, and examined whether changes in preoperative DSE were associated with improvement of post‐operative LVEF after aortic valve surgery. Results: The pre‐operative echocardiographic findings were as follows: left ventricular (LV) end‐diastolic dimension: 67 ± 10 mm, LV end‐systolic dimension: 52 ± 13 mm, and LVEF: 42 ± 8%. All patients underwent aortic valve surgery. Patients with pre‐operative LVEF of ≥45% exhibited a significant increase in LVEF; however, patients with pre‐operative LVEF of <45% showed no significant change. When we examined the results of DSE performed in patients with pre‐operative LVEF of <45%, ΔLVEF of ≥6% (with CR) during DSE was related to an improvement in post‐operative LVEF; ΔLVEF of ≥6% during DSE predicted an improvement in post‐operative LVEF, with sensitivity 100%; specificity 78%; and area under curve (AUC).92. Conclusions: DSE might be a helpful tool for predicting post‐operative reverse remodeling in patients with severe AR and moderately reduced LVEF. [ABSTRACT FROM AUTHOR]

Introduction: The myelodysplastic syndromes (MDSs) are heterogeneous myeloid malignancies, conventionally diagnosed by cytomorphology and cytogenetics, with an emerging role for flow cytometry. This study compared the performance of a 4‐parameter flow cytometry scoring system, the Ogata Score, with other modalities in the diagnosis of MDS. Methods: Bone marrow aspirate and trephine biopsies from 238 patients performed to assess for possible MDS were analysed, and the flow cytometry score was retrospectively applied. The sensitivity and specificity of the flow cytometry score, the aspirate microscopy, the trephine microscopy with immunohistochemistry, and cytogenetic and molecular results were determined relative to the final diagnosis. Results: The medical records of the 238 patients were reviewed to determine the final clinical diagnosis made at the time of the bone marrow examination. This final diagnosis of MDS, possible MDS or not MDS, was based on clinical features and laboratory tests, including all parameters of the bone marrow investigation, except for the flow cytometry score, which was only determined for this study. The flow cytometry score was 67.4% sensitive and 93.8% specific. Aspirate microscopy had higher sensitivity (83.7%) and similar specificity (92.0%), whereas trephine microscopy had similar sensitivity (66.3%) and specificity (89.4%) to flow cytometry. Although the flow cytometry score had a lower sensitivity than aspirate microscopy, in 18 patients (7.6% of the total) the flow cytometry score was positive for MDS, whereas aspirate microscopy was negative or inconclusive. Conclusion: The flow cytometry score and trephine microscopy exhibited reasonable sensitivity and high specificity, and complement aspirate microscopy in the assessment of MDS. [ABSTRACT FROM AUTHOR]

Aim: To investigate whether placental abruption without fetal distress could be assessed by apparent diffusion coefficient (ADC) values in magnetic resonance imaging (MRI). Methods: We conducted a retrospective case–control study at a single center. ADC values at the lesions of placental abruption in the abruption group (n = 8) were compared to those in the control group (n = 32). In the abruption group, ADC values at the sites of abruption were also compared to those at the nonabruption sites within the same placenta. Results: The ADC values in the placental area above the abruption site in the abruption group showed lower values than those in the control group when the slice containing the umbilical cord insertion site was set as the reference, and those values were compared in each corresponding slice. Compared with average ADC values, those above the abruption site in the abruption group were also significantly lower than those in the control group (p < 0.001). Furthermore, ADC values at the area above abruption were lower than those at the nonabruption area of all planes in the abruption group. Conclusions: ADC values at the lesions above the placental abruption site were reduced compared to those in the normal placenta and those in the nonabruption area. Thus, it would be helpful to understand the pathophysiology of placental abruption in expectant management, although further investigations would be needed. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: The primary purpose of this study was to test both classic and novel FM pain and non‐pain symptoms to determine their practical efficacy in aiding clinicians to distinguish FM pain from other chronic pain disorders. Methods: 158 pain patients from two primary care clinics were evaluated with history, physical exam, chart review, and a questionnaire containing 26 exploratory symptoms (10 from the Symptom Impact Questionnaire (SIQR) and 16 from the FM literature)). The symptoms were rated on a 0‐10 VAS for severity by those patients reporting pain over the past week. Somers' D and mean severity differences between FM and chronic pain patients without FM were used to rank the discriminatory and diagnostic contributions of symptoms. Results: Fifty patients (14.2%) carried a chart diagnosis of FM, 108 (30.7%) had pain but not FM, and 192 (54.5%) who had neither pain nor FM. Comparing means between the two pain groups, the 5 best differentiating symptoms (all, P <.0001) were: a persistent deep aching over most of my body, poor balance (7.4 vs 3.1), environmental sensitivity (6.8 vs 3.0), tenderness to touch (6.8 vs 3.6) and pain after exercise (8.1 vs 4.1). Notably, VAS pain though significantly higher for FM was least discriminatory (6.5 vs 5.1, P <.001). The five best symptoms generated a ROC = 0.85 and Somers' D = 0.69, an accuracy of 81%, and an odd's ratio of 14.4. Conclusions: Our results herein suggest that clinicians may be well‐served to consider symptoms in addition to those contained in current diagnostic criteria when recognizing FM in their chronic pain patients. [ABSTRACT FROM AUTHOR]

Rational and objective: Requests for magnetic resonance imaging (MRI) exams have notably increased in Canada. However, many of these exams may not always be indicated. The Joint Department of Medical Imaging and the eReferral Program have worked collaboratively to embed an integrated clinical decision support (DS) tool within the eReferral process for diagnostic imaging requests. This retrospective chart review aimed to assess the necessity of MRI exams for knee pain patients at the point of referral in relation to the referral method (no DS tools within fax‐ vs. DS tools within eReferral). Methods: Seven hundred and seventeen medical charts of routine MRI referral requests to an Ontario Hospital for patients with knee complaints were reviewed during the study period. The necessity of the MRI exams was evaluated using the supporting algorithm and knee pathway appropriateness guidelines. MRI exams were considered necessary if requested for symptoms or signs that align with best‐practice standards, complemented with sound clinical assessment or history of a radiography scan before ordering an MRI. Results: In general, MRI requests made through eReferral were 13.289 times more likely to be necessary orders than those made through fax. The likelihood of referring patients for a necessary MRI exam was higher for eReferral than fax for the year 2018/2019 (53.0% vs. 26.8%, P < 0.001) and for the year 2019/2020 (58.5% vs. 16.3%, P < 0.001). In addition, the rate of ordering X‐ray as the proper initial imaging scan for patients presenting with knee pain has steadily increased by 10% over the year for users of the eReferral platform compared to a decrease of 7% for those using fax. Conclusion: Our findings highlight the positive impact of integrating DS tools at the point of referral in supporting the ordering of necessary MRI scans, suggesting that service re‐design and implementation of automated assistive technology services would impact patient care. [ABSTRACT FROM AUTHOR]

Deep surgical site infection (DSSI) is a serious complication affecting the surgical outcome of displaced intra‐articular calcaneal fracture, and a risk prediction model based on the identifiable risk factors will provide great clinical value in prevention and prompt interventions. This study retrospectively identified patients operated for calcaneal fracture between January 2014 and December 2019, with a follow‐up ≥1 year. The data were extracted from electronic medical records, with regard to demographics, comorbidities, injury, surgery and laboratory biomarkers at admission. Univariate and multivariate logistics regression analyses were used to identify the independent factors for DSSI, thereby the risk prediction model was developed. Among 900 patients included, 2.7% developed a DSSI. The multivariate analyses identified five factors independently associated with DSSI, including current smoking (OR, 2.8; 95% confidence interval [CI], 1.3‐6.4; P =.021), BMI ≥ 26.4 kg/m2 (OR, 3.1; 95% CI, 1.6‐8.4; P =.003), ASA ≥II (OR, 1.3; 95% CI, 1.0‐5.1; P =.043), incision level of II (OR, 3.8; 95% CI, 1.3‐12.6; P =.018) and NLR ≥6.4 (OR, 3.2; 95% CI, 1.3‐7.5; P =.008). A score of 14 as the optimal cut‐off value was corresponding to sensitivity of 0.542 and specificity of 0.872 (area, 0.766; P <.001); ≥14 was associated with 8.1‐times increased risk of DSSI; a score of 7 was corresponding sensitivity of 100% and 10 corresponding to sensitivity of 0.875. The risk prediction model exhibited excellent performance in distinguishing the risk of DSSI and could be considered in practice for improvement of wound management, but its validity requires to be verified by better‐design studies. [ABSTRACT FROM AUTHOR]

Background: Aging may affect ascending colon (AC) differently from descending colon (DC) and increase the risk of fecal loading (FL) in AC. Methods: Patients aged ≥65 years admitted to a community hospital were analyzed by abdominal x‐ray for fecal loads and stool retention patterns. FL was scored between 0 and 5 (severe) on each segment of colon with a possible total score 20. Mean segment scores ≥3.5 were designated as high scores for both AC and DC. Logistic regression was performed between groups to identify factors associated with FL patterns. Results: Groups identified were high FL in both AC and DC (N = 21, 17.2%), FL predominantly in AC (N = 38, 31.1%), low FL in both AC and DC (N=60, 49.2%), and FL low in AC and high in DC (N = 3, 2.5%). Among 71 patients with total FL scores ≥13 (indicating significant stool retention), 37 (52.1%) had the FL predominantly in AC. Patients prescribed antibiotic(s) prior to hospitalization had lower odds of FL predominantly in AC (adjusted odds ratio = 0.18, 95% confidence interval = 0.04–0.84) compared to the group of low FL in both AC and DC with the adjustment of confounders. Conclusion: This study found that 52.1% of those with significant stool retention on x‐ray had the FL predominantly in AC. Antibiotic use was associated with lower odds of having FL predominately in AC. This study provided insights of FL distribution in colon and AC could be an area for significant stool burden in older adults with stool retention. [ABSTRACT FROM AUTHOR]

Background: Alcohol use disorder (AUD) is underdiagnosed and undertreated in medical settings, in part due to a lack of AUD assessment instruments that are reliable and practical for use in routine care. This study evaluates the test‐retest reliability of a patient‐report Alcohol Symptom Checklist questionnaire when it is used in routine care, including primary care and mental health specialty settings. Methods: We performed a pragmatic test‐retest reliability study using electronic health record (EHR) data from Kaiser Permanente Washington, an integrated health system in Washington state. The sample included 454 patients who reported high‐risk drinking on a behavioral health screen and completed two Alcohol Symptom Checklists 1 to 21 days apart. Subgroups of these patients who completed both checklists in primary care (n = 271) or mental health settings (n = 79) were also examined. The primary measure was an Alcohol Symptom Checklist on which patients self‐reported whether they experienced each of the 11 AUD criteria within the past year, as defined by the Diagnostic and Statistical Manual of Mental Disorders‐5th edition (DSM‐5). Results: Alcohol Symptom Checklists completed in routine care and documented in EHRs had excellent test‐retest reliability for measuring AUD criterion counts (ICC = 0.79, 95% CI: 0.76 to 0.82). Test‐retest reliability estimates were also high and not significantly different for the subsamples of patients who completed both checklists in primary care (ICC = 0.82, 95% CI: 0.77 to 0.85) or mental health settings (ICC = 0.74, 95% CI: 0.62 to 0.83). Test‐retest reliability was not moderated by having a past two‐year AUD diagnosis, nor by the age or sex of the patient completing it. Conclusions: Alcohol Symptom Checklists can reliably and pragmatically assess AUD criteria in routine care among patients who screen positive for high‐risk drinking. The Alcohol Symptom Checklist may be a valuable tool in supporting AUD‐related care and monitoring AUD criteria longitudinally in routine primary care and mental health settings. [ABSTRACT FROM AUTHOR]

Objectives: By 2030 the majority of the people living with HIV in the United Kingdom will be over the age of 50. HIV services globally must adapt to manage people living with HIV as they age. Currently these services are often designed based on data from the wider population or from the experiences of HIV clinicians. This article aims to help clinicians designing inclusive HIV services by presenting the most common needs identified during the first year of a specialist clinic for older people living with HIV at the Ian Charleson Day Centre, Royal Free Hospital in London, United Kingdom. Methods: The records of all thirty‐five patients attending the inaugural nine sessions were reviewed. Results: The median age of attendees was 69 (53–93) with 77% being male, 63% being White, 49% being heterosexual and 97% being virally suppressed respectively. The majority (83%) met the criteria for frailty using the Fried frailty phenotype. Eighteen issues linked to ageing were identified with the most common being affective symptoms (51%), memory loss (37%) and falls (29%). Conclusions: Whilst older people living with HIV are a heterogeneous group frailty is common and appears to present earlier. HIV services either need to adapt to meet these additional needs or must support users in transitioning to existing services. We feel that our multidisciplinary model is successful in identifying problems associated with ageing in people living with HIV and could be successfully replicated elsewhere. [ABSTRACT FROM AUTHOR]

Background: Change on the Numeric Rating Scale (NRS) is based on subjective pain experience, hampering the establishment of clinically important improvement. An anchor‐based method, the Patients' Global Impression of Change (PGIC), is often added to determine whether a patient has improved. A two‐point change on the NRS has been shown to be equivalent to a moderate clinically important improvement in randomized controlled trials (RCT's) on medication effects. We contemplated whether these findings could be reproduced in cohort and data and in non‐drug interventional RCT's. Methods: The NRS change was quantified by subtracting the NRS of baseline from the NRS at 6‐month follow‐up. Categorization of success/nonsuccess was applied on the PGIC, and their average NRS raw changes were calculated. The Spearman correlation coefficient quantified the overall relationship, while the discriminative ability was explored through the receiver operating characteristic curve. Data were stratified on design, sex, and pain intensity at baseline. Besides, the cohort evaluated treatment status at follow‐up. Results: The records of 1661 patients were examined. Overall, the observed NRS change needed for moderate clinically important improvement was larger than the average two points. Yet, the changes in the cohort were smaller compared with the RCT's. Moreover, it modified with pain intensity at baseline and treatment statuses indicated differences in mean clinical importance of −4.15 (2.70) when finalized at 6 months and −2.16 (2.48) when treatment was ongoing. Conclusion: The moderate clinically important improvement varied substantially, representing heterogeneity in pain relief and its relation to treatment success in chronic pain patients. [ABSTRACT FROM AUTHOR]

Background: Due to altered nutrition regimens and complex medical needs, pediatric intestinal failure (IF) may have a powerful impact on health‐related quality of life (HRQOL). Studies have shown that children with IF experience lower HRQOL. Data on the HRQOL of families of children with IF are lacking. Methods: We performed a prospective analysis of the HRQOL of families of children with IF in a regional intestinal rehabilitation program from 2011 to 2018. The Pediatric Quality of Life Family Impact Module (FIM) was administered annually to parents. FIM scores were regressed on risk factors using linear mixed‐effect models that accounted for repeated surveys within families. Results: A total of 117 families completed 272 surveys. FIM scores increased with patient age across nearly all survey dimensions. Total FIM scores were lower when compared to families of healthy children (median differences = –5, P =.01) and similar to families of chronically ill children. While IF families reported major deficits in the Communication (–11, P <.001) and Worry (–17, P <.001) dimensions, they also reported higher Family Relationship scores (+7, P <.01). On multivariable regression, presence of a major comorbidity and four or more hospital admissions in the prior year were associated with lower family HRQOL (P <.05). Parenteral nutrition dependence was independently associated with lower scores in the Communication (–7, P =.03) and Daily Activities (–10, P =.02) dimensions. Conclusion: Families of children with IF experience a decreased HRQOL that may improve with patient age. Intestinal rehabilitation programs should address the HRQOL of families in addition to patients. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 (COVID‐19) has caused an increase in patients requiring enteral feeding access while undergoing proning for severe acute respiratory distress syndrome (ARDS). We investigated the safety and feasibility of fluoroscopy‐guided nasojejunal (NJ) feeding tube placement in the prone position. Methods: This is a retrospective cohort study of all patients who underwent fluoroscopic placement of NJ feeding tubes at a single institution between March 2020 and December 2020. Primary end points were success rate and number of attempts. Chi‐squared and Fischer exact tests were used to compare prone and supine groups. Results: A total of 210 patients were included in the study: 53 patients received NJ feeding tubes while prone and 157 while supine. All but one patient in the prone group had ARDS secondary to COVID‐19, whereas 47 (30.3%) had COVID‐19 in the supine group. The rate of successful placement was 94.3% in the prone group and 100% in the supine group. Mean number of attempts was 1.1 (SD, ±0.4) in the prone and 1.0 (SD, ±0.1) in the supine group (P =.14). Prone patients had a longer median fluoroscopy time (69 s, interquartile range [IQR] = 92; vs 48 s, IQR = 43; P <.001) and received a higher radiation dose during the procedure (47 mGy, IQR = 50; vs 25 mGy, IQR = 33; P =.004). No procedural complications were reported. Conclusion: Fluoroscopy‐guided NJ feeding tube placement in prone patients is feasible and safe. Patient positioning should not delay obtaining postpyloric feeding access. [ABSTRACT FROM AUTHOR]

Background: The stillbirth rate for Australian Aboriginal and Torres Strait Islander infants remains higher than non‐Indigenous rates. Risks for stillbirth include maternal factors such as ethnicity, age, geographic location, and physical health. Fetal risk factors include gestational age, birthweight and congenital anomalies. The total stillbirth rate for all babies born at the Townsville University Hospital during the study period was 11 per 1000 births. Aims: To identify Aboriginal and Torres Strait Islander stillbirth rates, risk factors and causes in North Queensland. Materials and Methods: A retrospective chart audit was conducted to identify Indigenous women who had experienced stillbirth in the Townsville University Hospital between January 2005 and December 2014. Results: Thirty‐two charts were available for audit. The stillbirth rate for non‐Indigenous infants was 10.3 per 1000 births. The stillbirth rate for Indigenous infants was 11.7 per 1000 births. Almost half of the women lived in rural, remote or very remote areas. Maternal risk factors included poorer physical health, such as obesity, diabetes, hypertension, and smoking, fertility issues and lack of antenatal care. Fetal risk factors included congenital anomalies, including cardiac and skeletal abnormalities, placental disorders, and preterm birth. Conclusions: Stillbirth risk remains higher for Aboriginal and Torres Strait Islander women and their babies. Supporting women to enhance their health is paramount, particularly during pregnancy. Further, increasing awareness of stillbirth risk factors through education for both women and healthcare professionals will support culturally responsive care for women and their families to mitigate stillbirth risk and enhance pregnancy outcomes in non‐urban Queensland. [ABSTRACT FROM AUTHOR]

Background: Emergency general surgical patients are inherently at high risk of malnutrition. Early decision‐making with implementation is fundamental to patient recovery. For many patients, parenteral nutrition (PN) is the only feeding option available. The present study assessed the timing and outcomes of this decision‐making process. Methods: A sample of at least 10 consecutive adult patients admitted as a general surgical emergency to eight UK hospitals over 1 year who had received PN was identified. Patient demographics, basic descriptors and nutritional data were captured. Process measures regarding dates decisions were made or activities completed were extracted from records, as were outcome measures including PN complications. Six time frames examining the process of PN delivery were analysed. Associations between categorical and binary variables were investigated with a chi‐squared test with significance determined as p < 0.05. Results: In total, 125 patients were included. Intestinal obstruction was the most common diagnosis with 59% of all patients deemed high risk on nutritional assessment at admission. Median time to decision for PN was 5 days following admission (n = 122, interquartile range = 7). Patients received PN for a mean of 11 days. Eighty‐five percent of patients developed a complication, with a phosphate abnormality being the most commonly reported (54%). Only altered blood glucose levels appeared to correlate with a delay in starting PN (p < 0.01). Conclusions: The present study shows there are delays in the decision to use PN in the acutely ill surgical patient. Once initiated, the pathway is relatively short. There are high rates of electrolyte abnormalities in this population. [ABSTRACT FROM AUTHOR]

Background: This study investigated trends in computed tomography (CT) utilization across different triage categories of injury presentations to tertiary emergency departments (EDs) and associations with diagnostic yield measured by injury severity, hospitalization and length of stay (LOS), and mortality. Methods: A total of 411,155 injury‐related ED presentations extracted from linked records from Western Australia from 2004 to 2015 were included in the retrospective study. The use of CT scanning and diagnostic yield measured by rate of diagnosis with severe injury, hospitalizations and LOS, and mortality were captured annually for injury‐related ED presentations. Multivariable regression models were used to calculate the annual adjusted rate of CT scanning for injury presentations and hospitalizations across triage categories, diagnosis with severe injury, LOS, and mortality. The significance of changes observed was compared among patients with CT imaging relative to those without CT. Results: While the number of ED presentations with injury increased by 65% from 2004 to 2015, the use of CT scanning in these presentations increased by 176%. The largest increase in CT use was among ED presentations triaged as semi‐/nonurgent (+256%). Injury presentations with CT, compared to those without, had a higher rate of diagnosis with moderate/severe injury and hospitalization but no difference in LOS and mortality. The probability/rate observed in the outcomes of interest had a greater decrease over time in those with CT scanning compared with those without CT scanning across triage categories. Conclusions: The reduction in diagnostic yield in terms of injury severity and hospitalization found in our study might indicate a shift toward overtesting using CT in ED for injury or a higher use of CT to assist in the management of injuries. This helps health care policymakers consider whether the current increase in CT use meets the desired levels of quality and efficient care. [ABSTRACT FROM AUTHOR]

Objective: To determine sex differences in refeeding (i.e., short‐term nutritional rehabilitation) outcomes among hospitalized adolescents and young adults with eating disorders. Methods: We retrospectively reviewed electronic medical records of 601 patients aged 9–25 years admitted to the University of California, San Francisco Eating Disorders Program for medical and nutritional management between May 2012 and August 2020. Descriptive statistics, crude, and adjusted linear regression models were used to assess the association between sex and nutritional outcomes and predictors of length of stay. Results: A total of 588 adolescents and young adults met eligibility criteria (16% male, mean [SD] age 15.96 [2.75], 71.6% anorexia nervosa, admission percent median body mass index [%mBMI] 87.1 ± 14.1). In unadjusted comparisons, there were no significant sex differences in prescribed kilocalories (kcal) per day at admission (2013 vs. 1980, p =.188); however, males had higher estimated energy requirements (EER, kcal) (3,694 vs. 2,925, p <.001). In linear regression models adjusting for potential confounders, male sex was associated with higher prescribed kcals at discharge (B = 835 kcal, p <.001), greater weight change (B = 0.47 kg, p =.021), and longer length of stay (B = 1.94 days, p =.001) than females. Older age, lower admission weight, lower prescribed kcal at admission, higher EER, and lower heart rate at admission were factors associated with longer length of stay in a linear regression model. Discussion: These findings support the development of individualized approaches for males with eating disorders to improve quality of care and health care efficiency among an underserved population. [ABSTRACT FROM AUTHOR]

Objective: Anecdotal reports indicate an increase in mental health presentations and acuity to EDs during the COVID‐19 pandemic and associated stay at home restrictions. Paediatric and adolescent data to confirm this are unavailable in the Australian setting. Methods: Retrospective electronic medical record review of all ED patients with mental health discharge codes at a large tertiary children's hospital in Australia during the period of stay at home restrictions from 1 April to 30 September 2020 compared with the same dates in 2019. Results: We found a 40% decrease in ED presentations (18 935–11 235) with a concurrent 47% increase in mental health presentations (809–1190) to ED during the study periods between 2019 and 2020. This resulted in an increase of 100 mental health admissions from ED. Diagnoses with greatest percentage increases were eating disorders, social issues and suicidality. We found suicidality presentation numbers were highest in June to September 2020 compared with 2019. Patients with a diagnosis of suicidality had a higher rate of re‐presentation in 2020 (1.83 presentations per patient) compared to 2019 (1.38 presentations per patient). Conclusions: Despite an overall decrease in ED presentations, the absolute increase in mental health presentations for children and adolescents during the stay at home restriction period was pronounced. It is unclear how sustained this change and the impact on mental health resource use will be post‐pandemic. [ABSTRACT FROM AUTHOR]

Objective: Continuous cardiac monitoring has been recommended for ED patients being evaluated for possible acute coronary syndrome (ACS) due to concern for arrhythmia, although evidence suggests this risk is low. Indiscriminate use of monitored beds restricts access for other critically unwell patients and contributes to overcrowding. The objective of the present study was to determine if a low/intermediate‐risk HEART score identified patients at very low risk for a clinically important arrhythmia who could be removed from cardiac monitoring. Methods: This was a single centre, retrospective, cohort study of consecutive ED patients in a tertiary referral hospital evaluated for possible ACS from July to August 2017. Patients with ST‐elevation myocardial infarction or an arrhythmia at presentation which would mandate monitoring were excluded. Data was obtained by medical chart review. The primary outcome was the occurrence of an arrhythmia requiring treatment while in ED. Results: Inter‐rater reliability for data extraction demonstrated very strong agreement (kappa 0.87, 95% confidence interval 0.83–0.91). There were 653 participants included with 83 (12.7%) having a final diagnosis of ACS. Three (0.5%) clinically important arrhythmias occurred. There were no cases of ventricular tachycardia, ventricular fibrillation or cardiac arrest. Five hundred and forty (82.7%) participants were low/intermediate‐risk HEART score and one (0.2%) clinically important arrhythmia occurred (this was supraventricular tachycardia treated by a valsalva manoeuvre). Conclusion: Among ED patients presenting with a possible ACS, a low/intermediate‐risk HEART score identified those at very low risk for having a clinically important arrhythmia while in ED. Continuous cardiac monitoring has been recommended for ED patients being evaluated for possible acute coronary syndrome (ACS) due to concern for arrhythmia. Indiscriminate use of monitored beds restricts access for other critically unwell patients and contributes to overcrowding. In this single centre, retrospective study of consecutive ED patients evaluated for possible ACS, a low/intermediate‐risk HEART score identified those at very low risk for having a clinically important arrhythmia while in ED. [ABSTRACT FROM AUTHOR]

The Pfizer/BioNtech BNT162b2 is a major vaccine used in the Australian COVID‐19 immunisation programme. We report on BNT162b2 safety in the observation period in a dedicated vaccination clinic linked to a quaternary teaching hospital. We performed a retrospective review of medical records for 57 842 vaccinations, and describe the model of care and adverse event rate at the clinic during its first 2 months of operation. A total of 243 adverse events following immunisation (0.42% of total vaccine doses) were recorded in the immediate observation period post‐vaccination, which were predominantly immunisation stress‐related responses. Of the 110 patients who experienced an adverse event with their first dose of the vaccine, 90% returned for their second dose of the vaccine, with 87% not reporting any further adverse reaction with the subsequent dose. Nineteen (0.03% of total doses) people were reviewed for an allergic reaction, of which 10 (53%) reported a history of prior allergies. A female predominance was present in both total adverse reactions (70%) and allergic vaccine reactions (79%). Only two patients experienced anaphylaxis (0.003% of total doses), in keeping with low rates of adverse reactions to the BNT162b2 vaccine in the current literature. Overall, the present study reinforces the safety of BNT162b2 in the Australian population, describes vaccination completion rates after adverse events and identifies predisposing factors for rare allergic reactions to the vaccine. [ABSTRACT FROM AUTHOR]

Background: Functional gut disorders (FGD) are common. Diagnosis is symptom based, although symptoms may be indistinguishable from inflammatory bowel disease. As a result of this, investigations are common, diagnostic yield is low. A streamlined novel model of care may reduce costly investigations. Aim: To compare a new model of care for patients with low‐risk gastrointestinal symptoms to a matched historical cohort. Methods: Data were prospectively collected over 12 months. General practitioner referrals for low‐risk abdominal symptoms were triaged to a new multidisciplinary clinic structure utilising intestinal ultrasound. Outcomes were compared to the historical model in the preceding 12 months. Duration of care (time from referral to discharge), number of contact episodes and investigations ordered were reviewed. Results: Thirty‐seven patients meeting strict inclusion criteria completed their care. Compared with the historical cohort, colonoscopies reduced from 0.7 to 0.05 per patient (P < 0.0001). Gastroenterology consults reduced from 1.5 to 1.2 (P = 0.303) and dietitian review increased from 0.8 to 1.5 (P < 0.0001). Total contact episodes reduced from 3.2 to 1.8 (P < 0.0001). Duration of care reduced from a median of 252 days to 130 days (interquartile ranges (IQR) 287 and 69, respectively; P < 0.0001). Time from first consultation to discharge reduced from 125 to 42 days (IQR 188 and 63; P < 0.0001). Conclusion: This multidisciplinary approach to care of low‐risk abdominal symptoms significantly reduced contact episodes, time in care and invasive investigations. It decreased costly gastroenterology consultation and increased allied health exposure. It demonstrates improved health service outcomes. [ABSTRACT FROM AUTHOR]

Australia has the second highest rate of non‐traumatic lower extremity amputation (LEA) globally. Australia's large geographical size is one of the biggest challenges facing limb preservation services and may be contributing to LEA. The aim of this study was to determine what factors contribute to the likelihood of LEA in people with active foot ulceration in regional Australia. This retrospective cohort study audited patients with active foot ulceration in a multidisciplinary high risk foot service (HRFS) in regional Australia. Neurological, vascular and wound characteristics were systematically extracted, along with demographic information. Participants were followed for at least 12 months until healing or LEA occurred. Correlations between LEA and clinical and demographic characteristics were assessed using the Pearson's product moment correlation coefficient and chi squared test for independence. Significant variables (p < 0.05) were included in the model. Direct logistic regression assessed the independent contribution of significantly correlated variables on the likelihood of LEA. Of note, 1876 records were hand screened with 476 participants (25%) meeting the inclusion criteria. Geographical distance from the HRFS, toe systolic pressure (TSP), diabetes and infection were all significantly correlated with LEA and included in the logistic regression model. TSP decrease of 1 mmHg (OR 1.02, 95% CI 1.01–1.03), increased geographical distance (1 km) from HRFS (OR 1.006, 95% CI 1.001–1.01) infection (OR 2.08, 95% CI 1.06–4.07) and presence of diabetes (OR 3.77, 95% CI 1.12–12.65) were all significantly associated with increased likelihood of LEA. HRFS should account for the disparity in outcomes between patients living in close proximity to their service, compared to those in rural areas. Optimal management of diabetes, vascular perfusion and control of infection may also contribute to preventing LEA in people with active foot ulceration. [ABSTRACT FROM AUTHOR]

Objective: To describe the real‐world treatment persistence (defined as the continuation of medication for the prescribed treatment duration), demographics and clinical characteristics, and treatment patterns for patients prescribed erenumab for migraine prevention in Canada. Background: The effectiveness of prophylactic migraine treatments is often undermined by poor treatment persistence. In clinical trials, erenumab has demonstrated efficacy and tolerability as a preventive treatment, but less is known about the longer term treatment persistence with erenumab. Methods: This is a real‐world retrospective cohort study where a descriptive analysis of secondary patient data was conducted. Enrollment and prescription data were extracted from a patient support program for a cohort of patients prescribed erenumab in Canada between September 2018 and December 2019 and analyzed for persistence, baseline demographics, clinical characteristics, and treatment patterns. Descriptive analyses and unadjusted Kaplan–Meier (KM) curves were used to summarize the persistence and dose escalation/de‐escalation at different timepoints. Results: Data were analyzed for 14,282 patients. Median patient age was 47 years, 11,852 (83.0%) of patients were female, and 9443 (66.1%) had chronic migraine at treatment initiation. Based on KM methods, 71.0% of patients overall were persistent to erenumab 360 days after treatment initiation. Within 360 days of treatment initiation, it is estimated that 59.3% (KM‐derived) of patients who initiated erenumab at 70 mg escalated to 140 mg, and 4.4% (KM‐derived) of patients who initiated at 140 mg de‐escalated to 70 mg. Conclusions: The majority of patients prescribed erenumab remained persistent for at least a year after treatment initiation, and most patients initiated or escalated to a 140 mg dose. These results suggest that erenumab is well tolerated, and its uptake as a new class of prophylactic treatment for migraine in real‐world clinical practice is not likely to be undermined by poor persistence when coverage for erenumab is easily available. [ABSTRACT FROM AUTHOR]

Background: Delayed diagnosis of cerebrovascular disease (CVD) among patients can result in substantial harm. If diagnostic process failures can be identified at emergency department (ED) visits that precede CVD hospitalization, interventions to improve diagnostic accuracy can be developed. Methods: We conducted a nested case–control study using a cohort of adult ED patients discharged from a single medical center with a benign headache diagnosis from October 1, 2015 to March 31, 2018. Hospitalizations for CVD within 1 year of index ED visit were identified using a regional health information exchange. Patients with subsequent CVD hospitalization (cases) were individually matched to patients without subsequent hospitalization (controls) using patient age and visit date. Demographic, clinical, and ED process characteristics were assessed via detailed chart review. McNemar's test for categorical and paired t‐test for continuous variables were used with statistical significance set at ≤0.05. Results: Of the 9157 patients with ED headache visits, 57 (0.6%, 95% confidence interval [CI] = 0.5–0.8) had a subsequent CVD hospitalization. Median time from ED visit to hospitalization was 107 days. In 25 patients (43.9%, 25/57) the CVD hospitalization and the index ED visit were at different hospitals. Fifty‐three cases and 53 matched controls were included in the final study analysis. Cases and controls had similar baseline demographic and headache characteristics. Cases more often had a history of stroke (32.1% vs. 13.2%, p = 0.02) and neurosurgery (13.2% vs. 1.9%, p = 0.03) prior to the index ED visit. Cases more often had less than two components of the neurologic examination documented (30.2% vs. 11.3%, p = 0.03). Conclusion: We found that 0.6% of patients with an ED headache visit had subsequent CVD hospitalization, often at another medical center. ED visits for headache complaints among patients with prior stroke or neurosurgical procedures may be important opportunities for CVD prevention. Documented neurologic examinations were poorer among cases, which may represent an opportunity for ED process improvement. [ABSTRACT FROM AUTHOR]

Purpose: To describe the nursing interventions provided to patients with COVID‐19 using the Nursing Interventions Classification. Method: This is a retrospective study involving the review of 1,344 patient records of adults admitted to a specialty hospital for COVID‐19 in Tabriz, Iran. The nursing intervention was used to classify documented nursing care and interventions provided to COVID‐19–positive patients from February 20 to August 20, 2020. Data were analyzed descriptively using SPSS16. Findings: The 10 most frequently documented nursing interventions across in‐patient (ward) and intensive care unit (ICU) contexts included Admission Care (7310), Environmental Management (6486), Health Education (5510), Infection Protection (6550), Medication Administration (2300), Positioning (0840), Respiratory Monitoring (3350), Vital Signs Monitoring (6680), Nausea Management (1450), and Diarrhea Management (0460). No records of distraction, relaxation techniques, or massage for anxiety reduction were documented. Conclusion: This study used a common language to describe nursing interventions for patients with COVID‐19 admitted to a tertiary hospital. Implications for nursing practice: The most commonly identified nursing interventions for COVID‐19 identified in this study provide evidence‐based insight into nurses' scope of practice in the COVID‐19 in‐patient context. [ABSTRACT FROM AUTHOR]

Our aim was to analyze the outcomes in children with short‐bowel syndrome (SBS), parenteral nutrition dependence (PND), and intestinal failure–associated liver disease (IFALD) treated in our Intestinal Rehabilitation Program (IRP) during 2007–2018. We retrospectively reviewed charts of 135 patients with SBS‐PND at the time of enrollment in IRP; of these, 89 (66%) had IFALD, defined as conjugated bilirubin (CB) of ≥2 mg/dl at enrollment and/or abnormal liver biopsy showing stage 2–4 fibrosis. Outcomes included resolution of CB, enteral autonomy, laboratory parameters (platelets, aspartate aminotransferase to platelet ratio index), growth trends, transplant rates, and mortality. Of the 89 patients, 74 had elevated CB at enrollment; the other 15 had normalized CB but had fibrosis on liver biopsy. Thirty‐eight patients had liver biopsies: 36 (95%) had fibrosis, including 21/36 with bridging fibrosis/cirrhosis. The median proportion of residual small bowel was 23% (interquartile range, 13%–38%) of the expected length for age and median, daily energy requirement by PN was 100%. Two received a transplant, three died (one posttransplant), and the remaining 85 survived; 69 (81%) achieved enteral autonomy. Seventy‐three (99%) of the 74 patients with hyperbilirubinemia normalized their CB with medical treatment. In a subset of eight of 89 patients with initial platelet count of <100,000/μl(median 50,500/μl) and median CB of 21 mg/dl, seven achieved CB normalization and had improved platelet count. Overall survival was 97% (censored 96.3%). We demonstrate high transplant‐free survival and enteral autonomy rates among children with SBS‐IFALD relying on low‐dose soybean lipid emulsion. [ABSTRACT FROM AUTHOR]

Objective: This study reviewed the audit outcomes of the documented end‐of‐life care in a private hospital against the Australian Commission on Safety and Quality in Health Care's five recommended processes of care (Essential Elements (EE) 1‐5). Methods: A retrospective database review of deaths over a three‐year period was undertaken. This was followed by a sequential medical record audit (n = 100) to evaluate the end‐of‐life care documented in the three days preceding death. Results: There were 997 deaths from 2015 to 2017. The audit found communication to family the patient was dying (91%) and to the patient (36%) (EE1); evidence of specialist referral (68%) (EE2); assessment of the ability to eat/drink in the last 72 hours (86%) (EE3); advance care directives (13%) and hospital resuscitation plans (92%) (EE4); and response to patient or family concerns (100%) (EE5). Conclusions: Components of the processes of care of the Essential Elements need to be addressed to improve patient‐centred communication and shared decision‐making. [ABSTRACT FROM AUTHOR]

Introduction: Hemophagocytic lymphohistiocytosis (HLH) is an immune deregulation disorder with varied clinical presentation which clinically overlaps with widespread tropical infections. Methods: We conducted a retrospective chart review of children diagnosed with HLH at our center from February‐2017 to October‐2020. Results: Out of the nine diagnosed patients, genetic predisposition was present in three children; two had identified infectious triggers. The mean age of presentation was 30 months with male predominance. The most common clinical findings were fever, organomegaly, and pancytopenia. The median value of fibrinogen was‐156 mg/dL, ferritin‐12 957 ng/mL and for triglycerides‐349 mg/dL, respectively. In children with identified genetic predisposition, serum ferritin levels were usually more than 10 000 ng/mL. The majority of our patients had evidence of hemophagocytosis on bone marrow examination. In our experience, although nonspecific, very high ferritin and serum triglycerides with low fibrinogen in a patient with bi‐cytopenia, pancytopenia was the most suggestive evidence of HLH. Genetic evaluation in our series identified three children, one with primary HLH genetic mutation and two with underlying immune deficiency syndrome. The presence of HLH in the accelerated phase of Chediak‐Higashi and AD Hyper IgE syndrome with HLH is extremely rare. Leishmaniasis (in nonendemic area) and Ebstein‐Barr virus (EBV) was identified as an infectious trigger in two cases. Most of our cases received treatment as per HLH 2004 protocol. Three children died during the initial diagnosis and treatment. HLH with subcutaneous panniculitis‐like T‐cell lymphoma recovered well. Conclusion: HLH remains a life‐threatening disorder associated with a variety of underlying illnesses as highlighted by our case series. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study was to evaluate the effects of nurse-led health coaching on adherence to health regimens and lifestyle factors among frequent attenders in primary health care. Methods: One hundred and ten patients were enrolled in the quasi-experimental study. The experimental group (n = 52) received nurse-led health coaching and the control group (n = 58) received conventional care at primary healthcare centres between 2015 and 2016. Data were collected before the intervention and 12 months afterwards using a questionnaire on adherence to health regimens and lifestyle factors. The intervention consisted of individual health coaching provided by a nurse, healthcoaching sessions, and a written action plan. [ABSTRACT FROM AUTHOR]

Rationale and objective: The discharge summary (DS) is one of the most important instruments to transmit information to the treating general physician (GP). The objective of this study was to analyse important components of DS, structural characteristics as well as medical and general abbreviations. Method: One hundred randomly selected DS from five different clinics were evaluated by five independent reviewers regarding content, structure, abbreviations and conformity to the Austrian Electronic Health Records (ELGA) using a structured case report form. Abbreviations of all 100 DS were extracted. All items were scored on a 4‐point Likert‐type scale ranging from "strongly agree" to "strongly disagree" (or "not relevant"). Subsequently, the results were discussed among reviewers to achieve a consensus decision. Results: The mandatory fields, reason for admission and diagnosis at discharge were present in 80% and 98% of DS. The last medication was fully scored in 48% and the recommended medication in 94% of 100 DS. There were significant overall differences among clinics for nine mandatory items. In total, 750 unexplained abbreviations were found in 100 DS. Conclusions: In conclusion, DS are often lacking important items. Particularly important are a detailed medication history and recommendations for further medication that should always be listed in each DS. It is thus necessary to design and implement changes that improve the completeness of DS. An important quality improvement can be achieved by avoiding the use of ambiguous abbreviations. [ABSTRACT FROM AUTHOR]