Search

Background Hospital-based contact tracing aims to limit spread of COVID-19 within healthcare facilities. In large outbreaks, this can stretch resources and workforce due to quarantine of uninfected staff. We analysed the performance of a manual contact tracing system for healthcare workers (HCW) at a multi-site healthcare facility in Melbourne, Australia, from June–September 2020, during an epidemic of COVID-19. Methods All HCW close contacts were quarantined for 14 days, and tested around day 11, if not already diagnosed with COVID-19. We examined the prevalence and timing of symptoms in cases detected during quarantine, described this group as proportions of all close contacts and of all cases, and used logistic regression to assess factors associated with infection. Results COVID-19 was diagnosed during quarantine in 52 furloughed HCWs, from 483 quarantine episodes (11%), accounting for 19% (52/270) of total HCW cases. In 361 exposures to a clear index case, odds of infection were higher after contact with an infectious patient compared to an infectious HCW (aOR: 4.69, 95% CI: 1.98–12.14). Contact with cases outside the workplace increased odds of infection compared to workplace contact only (aOR: 7.70, 95% CI: 2.63–23.05). We estimated 30%, 78% and 95% of symptomatic cases would develop symptoms by days 3, 7, and 11 of quarantine, respectively. Conclusion In our setting, hospital-based contact tracing detected and contained a significant proportion of HCW cases, without excessive quarantine of uninfected staff. Effectiveness of contact tracing is determined by a range of dynamic factors, so system performance should be monitored in real-time.

STUDY OBJECTIVES: This study examined whether sleep disturbances were associated with neurobehavioral outcome following a traumatic brain injury (TBI) in a well characterized group of service members and veterans. METHODS: Six hundred and six participants were enrolled into the Defense and Veterans Brain Injury Center, 15-Year Longitudinal TBI study. All participants completed a battery of tests measuring self-reported sleep disturbances, neurobehavioral symptoms, and posttraumatic stress disorder symptoms. Data were analyzed using analysis of variance with post hoc comparisons. Four groups were analyzed separately: uncomplicated mild TBI; complicated mild, moderate, severe, or penetrating combined TBI; injured controls (ie, orthopedic or soft-tissue injury without TBI); and noninjured controls. RESULTS: A higher proportion of the mild TBI group reported moderate-severe sleep disturbances (66.5%) compared to the injured control group (54.9%), combined TBI (47.5%), and noninjured control groups (34.3%). Participants classified as having Poor Sleep had significantly worse scores on the majority of TBI-Quality of Life scales compared to those classified as having Good Sleep, regardless of TBI severity or the presence of TBI. There was a significant interaction between sleep disturbances and posttraumatic stress disorder. While sleep disturbances and posttraumatic stress disorder by themselves were significant factors associated with worse outcome, both factors combined resulted in worse outcome than either singularly. CONCLUSIONS: Regardless of group (injured or noninjured control), sleep disturbances were common and were associated with significantly worse neurobehavioral functioning. When experienced concurrently with posttraumatic stress disorder, sleep disturbances pose significant burden to service members and veterans. CITATION: Pattinson CL, Brickell TA, Bailie J, et al. Sleep disturbances following traumatic brain injury are associated with poor neurobehavioral outcomes in US military service members and veterans. J Clin Sleep Med. 2021;17(12):2425–2438.

OBJECTIVE To evaluate the potential impact of timing between the current and the most recent previous concussions on symptom severity among acutely concussed active duty military Service members (SMs). SETTING Three military installations. PARTICIPANTS Eighty-four SMs aged 18 to 44 years who sustained a concussion within 72 hours of enrollment. No previous concussion within 1 year preenrollment. DESIGN Longitudinal study with enrollment within 72 hours of injury, and follow-up at 1 week and 1 month postinjury. MAIN MEASURES Lifetime concussion history (yes/no) and recency of the latest concussion (no history, relatively more recent [1 to

Primary care providers can play a crucial role in the clinical management of concussion. However, many providers lack up-to-date information about best practices for rest and return to activity after these injuries. Most research on this topic has been conducted in athletes, and so less is known about how to assist patients with returning to activity in other settings and populations. This article provides a review of best practices for management of progressive return to activity after concussion, with an emphasis on "lessons learned" from the Defense and Veterans Brain Injury Center (DVBIC) Progressive Return to Activity (PRA) study, a multi-site longitudinal research project conducted to evaluate concussion management practices and the effectiveness of provider training on DVBIC clinical recommendations (CRs). Provider clinical practices and patient outcomes were examined at three U.S. military treatment facilities before and after providers completed a standardized training on DVBIC PRA CRs. In summary, research findings provide additional support that concussion recovery can be influenced by patients' activity levels after injury. Patients with concussion may experience poorer outcomes if they return to pre-injury levels of activity too rapidly, but they may also be at risk for prolonged symptoms if they fail to increase activity levels over time after an initial period of rest. Additionally, training primary care providers in return to activity guidelines can result in more effective patient education and better clinical outcomes. This knowledge can be used to inform best practices for progressive return to activity in both civilian and military settings.

BACKGROUND: Rehabilitation following shoulder surgery involves the use of resistive exercise but dosing of these ­exercises historically employs multiple sets of pre-determined repetitions and few reports document the perceived effort encountered by patients during these exercises for both elastic resistance and free-weights. The OMNI-Resistance Exercise Scale (OMNI-RES) has been tested and applied as a measure of perceived exertion (RPE) for resistive exercise but has not gained widespread acceptance as an optimal method for physical therapists to document RPE during rehabilitation of shoulder surgery. PURPOSE: To generate descriptive values of RPE encountered during common shoulder exercises of varying resistance in patients following shoulder surgery as well as provide a comparative analysis between perceived exertion ratings of similar exercise movement patterns using elastic and traditional isotonic resistance. STUDY DESIGN: Descriptive Cross-sectional Cohort METHODS: Sixty-six subjects (mean age 53.3 + 12.8 years) were included in this study following shoulder surgery (RC repair n=22, labral repair n=10, SA n=34). Perceived exertion using the OMNI-RES was recorded during performance of seven rotator cuff and scapular rehabilitation exercises at 6- and 12-weeks following surgery. RESULTS: Mean RPE using OMNI-RES in combined surgical groups ranged between 3.6 and 5.7 (mean = 4.50 + 2.1) across all seven exercises (scale 0 = very easy to 10 = extremely hard). From the external rotation (ER) exercise pair, paired t-tests revealed standing ER w/ Thera-band® (ERB) had a significantly higher OMNI-RES score versus sidelying ER w/ cuff weight (SLERW) (mean: 5.13 vs 4.41, p = 0.001) while the extension exercise pair consisting of standing shoulder extension w/ band (EXTB) and prone extension w/ cuff weight (PEXTW) showed no significant difference in OMNI-RES score (mean: 3.54, 3.67, p = 0.626). CONCLUSION: Commonly prescribed resistance exercise in the rehabilitation following shoulder surgery show light-moderate ratings of perceived exertion at both 6 & 12 week post-operative timepoints across three surgical procedures. LEVEL OF EVIDENCE: 3b

Objectives To evaluate relationships between beliefs about the impact of rest and the level of activities and symptoms over time among active duty Service members sustaining concussion, and whether these relationships vary by provision of concussion education. Design Longitudinal study using multilevel modeling to assess the relationship between beliefs about rest within 72 hours of concussion and change in activity and symptom level over time, as well as interaction by concussion education at the initial clinic visit. Setting Three military treatment facilities. Participants Study participants included active duty Service members diagnosed with a concussion (N=111; median age, 24 y). Individuals with previous history of concussion within 12 months of study enrollment were excluded. Intervention Not applicable. Main Outcome Measures Activity questionnaire and the Neurobehavioral Symptom Inventory assessed within 72 hours of concussion; at 1 week; and at 1, 3, and 6 month(s) postinjury. Results Receipt of concussion education from providers was significantly associated with greater belief that rest influences concussion recovery. Greater belief that rest influences symptom recovery at the acute stage of concussion was associated with a greater increase in activities over time, but only among those who received education from their provider. Additionally, greater belief about the influence of rest was related to a more rapid decrease in symptoms over time. Conclusions Concussed Service members who underestimate the influence of rest during acute recovery may be at risk for poorer recovery. Treatment of Service members with postconcussive symptoms should consider patient knowledge and/or beliefs about rest and recovery, which may influence prognosis. Our results support the provider’s use of concussion education to correct potential misconceptions that may negatively impact symptom recovery.

To examine factors related to resilience in military caregivers across caregiver health-related quality of life (HRQOL), caregiver sociodemographic variables, and service member/veteran (SMV) injury and health status. Caregivers (N = 346, Female = 96.2%; Spouse = 91.0%; Age: M = 40.6 years, SD = 9.3) of SMVs following a mild, moderate, severe, or penetrating TBI were recruited from U.S. military treatment facilities and via community outreach. Caregivers completed select TBI-CareQOL and NIH Toolbox scales, the Caregiver Appraisal Scale, Caregiver Questionnaire, and Mayo-Portland Adaptability Inventory-4. Caregivers were divided into three groups using the TBI-QOL Resilience scale: (1) Low-Moderate Resilience (n = 125), (2) Moderate Resilience (n = 122), and (3) Moderate-High Resilience (n = 99). Factors related to low caregiver resilience were strain on employment, financial burden from out-of-pocket expenses, caring for children, less personal time, caring for both verbal and physical irritability, anger, and aggression, and lower SMV functional ability (all p’s

Concurrent posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) is common in military populations. The purpose of this study was to examine long-term neurobehavioral outcomes in service members and veterans (SMVs) with versus without PTSD symptoms following TBI of all severities. Participants were 536 SMVs prospectively enrolled from three military medical treatment facilities who were recruited into three experimental groups: TBI, injured controls (IC), and noninjured controls (NIC). Participants completed the PTSD Checklist, Neurobehavioral Symptom Inventory, and the TBI-Quality of Life (TBI-QOL) and were divided into six subgroups based on the three experimental categories, two PTSD categories (i.e., present vs. absent), and two broad TBI severity categories (unMTBI, which included uncomplicated mild TBI; and smcTBI, which included severe TBI, moderate TBI, and complicated mild TBI): (a) NIC/PTSD-absent, (b) IC/PTSD-absent, (c) unMTBI/PTSD-absent, (d) unMTBI/PTSD-present, (e) smcTBI/PTSD-absent, and (f) smcTBI/PTSD-present. There were significant main effects across the six groups for all TBI-QOL measures, ps < .001. Select pairwise comparisons revealed significantly lower scores, p < .001, on all TBI-QOL measures in the PTSD-present groups when compared to the PTSD-absent groups within the same TBI severity classification, ds = 0.90-2.11. In contrast, when controlling for PTSD, there were no significant differences among the TBI severity groups for any TBI-QOL measures. These results provide support for the strong influence of PTSD but not TBI severity on neurobehavioral outcomes following TBI. Concurrent PTSD and TBI of all severities should be considered a risk factor for poor long-term neurobehavioral outcomes that require ongoing monitoring.

Background Flooding is an increasingly prevalent natural hazard worldwide and can have a profound impact on the mental health of those directly and indirectly affected. Little is known about the impact on business owners, who may be particularly vulnerable to the mental health complications of flooding given the additional economic stressors. Methods A large cross-sectional survey was conducted six months after severe flooding in the rural Northern Rivers region of New South Wales, Australia in 2017. The survey assessed demographics, probable depression (using the Patient Health Questionnaire-2), flood exposure, flood-related financial factors, prior flood exposure and support from various organisations. Logistic regression was used to identify predictors of probable depression in 653 of the 745 participants who identified as business owners. Results The prevalence of probable depression in our sample was 17.0%. A quarter (25.1%) of business owners whose business was flooded suffered from probable depression, compared to 12.4% of non-flooded business owners. The multivariable model for probable depression demonstrated elevated adjusted odds ratios (AOR) for business owners who had to evacuate their business (AOR = 2.11, 95% Confidence Interval (CI) 1.25–3.57) compared to those who did not evacuate. Insurance disputes/rejections were a strong predictor for probable depression (AOR = 3.76, CI 1.86–7.60). Those whose income was reduced due to the flood and had not returned to normal six months post-flood demonstrated an increased AOR for probable depression (AOR 2.53, CI 1.26–5.07) compared to those whose income had returned to normal. The univariable analysis found elevated crude odds ratios (OR) for the cumulative effect of multiple flood exposures and unmet support needs by the state government (OR = 2.74, CI 1.12–6.68). The majority of business owners felt their needs were not met by most organisations providing flood-related support. Conclusion The impact of flood exposure and flood-related financial factors on probable depression was highly significant for the business owner population. Furthermore, business owners felt under-supported by flood-related services. These findings highlight the vulnerability of exposed business owners and the need for increased support. Disaster planning programs in conjunction with system level changes such as infrastructure and education are vital for disaster preparedness.

The purpose of this study was to examine individual postconcussion symptom [PCSx] trajectories following mild traumatic brain injury (MTBI), and to examine risk factors for persistent PCSx reporting.Participants were 138 U.S. military service members and veterans (SMVs) prospectively enrolled in the Defense and Veterans Brain Injury Center, 15-Year Longitudinal TBI study. Participants were classified into three groups: uncomplicated MTBI (n = 54), injured controls (IC, n = 26), and non-injured controls (NIC, n = 58). Participants completed the Neurobehavioral Symptom Inventory, PTSD Checklist, and Traumatic Brain Injury Quality of Life at baseline (8 months post-injury) and at follow-up (2-4 years post-injury).The prevalence of those who met DSM-IV-TR symptom criteria for Postconcussional Disorder (PCD) was high in all three groups (e.g., 44.8-63.0%) and did not significantly change from baseline to follow-up (all ps.05). However, there was substantial variability in individual symptom trajectories over time. The majority of participants had symptom trajectories classified as either 'persistent' (∼32-55%) or 'asymptomatic' (∼30-36%), with a substantial minority classified as 'improved' (∼7-12%) or 'developed' (∼7-19%). Factors associated with 'persistent' PCD trajectories included cognitive complaints, PTSD, depression, anxiety, pain, and headaches at baseline; but not the presence/absence of MTBI. Factors associated with 'developed' PCD trajectories included PTSD and the number of lifetime exposures to blast.

OBJECTIVE To evaluate the impact on symptom resolution of activity acutely following a concussion and the role of acute-phase symptoms on this relationship among active duty service members (SMs). SETTING Three military installations. PARTICIPANTS Sixty-two SMs aged 18 to 44 years who sustained a concussion within 72 hours of enrollment. DESIGN Longitudinal design with data collected within 72 hours of injury (baseline, n = 62) and at 1 week (n = 57), 1 month (n = 50), 3 months (n = 41), and 6 months (n = 40) postinjury. MAIN MEASURES Baseline activity level using a 60-item Activity Questionnaire. Symptom level at baseline and during follow-up using Neurobehavioral Symptoms Inventory. RESULTS Significant interaction (Pi < .05) was found, with significant main effects (P < .05) limited to SMs with elevated baseline symptomatology. Among these participants, greater baseline total activity was significantly related to greater vestibular symptoms at 1, 3, and 6 months (β = .61, .63, and .59, respectively). Significant associations were also found for particular types of baseline activity (eg, physical; vestibular/balance; military-specific) and symptoms at 1, 3, and/or 6 months postinjury. CONCLUSION These results provide support for clinical guidance that symptomatic SMs, particularly those with high levels of acute symptoms, may need to avoid excessive activity acutely following concussion.

"Return to duty" (RTD) is often used as an outcome metric in military concussion research, but is inconsistently defined across studies and presents several key problems to researchers. Using results from the Defense and Veterans Brain Injury Center's (DVBIC) Progressive Return to Activity (PRA) study, we highlight problems with RTD, and suggest solutions to inform future efforts.116 service members (SMs) were enrolled in one of two groups (pre-implementation and post-implementation of the PRA Clinical Recommendation [CR]). Data, including the Neurobehavioral Symptom Inventory (NSI-22), was collected within 72-hours of injury (baseline), and at 1-week, 1-month, 3-months, and 6-months post-injury. Our analyses focused on three time points: baseline, approximate RTD date, and post-RTD follow-up, with RTD data captured via self-report and electronic medical record (EMR). Secondary analyses included comparisons across PRA-CR implementation groups.Of those SMs (50% of the sample) with both self-reported and EMR RTD dates, dates largely did not match (range 1 to 36 days). RTD (either date) also did not indicate symptom recovery, with50% of SMs reporting "abnormally high" symptom levels (i.e., NSI-22 total ≥75Our data demonstrate challenges encountered with a RTD outcome metric. Military concussion researchers should strive to use a well-defined RTD outcome metric. We propose defining RTD as a

ObjectivesThough multidisciplinary research networks support the practice and effectiveness of continuous quality improvement (CQI) programmes, their characteristics and development are poorly understood. In this study, we examine publication outputs from a research network in Australian Indigenous primary healthcare (PHC) to assess to what extent the research network changed over time.SettingAustralian CQI research network in Indigenous PHC from 2002 to 2019.ParticipantsAuthors from peer-reviewed journal articles and books published by the network.DesignCoauthor networks across four phases of the network (2002–2004; 2005–2009; 2010–2014; 2015–2019) were constructed based on author affiliations and examined using social network analysis methods. Descriptive characteristics included organisation types, Indigenous representation, gender, student authorship and thematic research trends.ResultsWe identified 128 publications written by 308 individual authors from 79 different organisations. Publications increased in number and diversity over each funding phase. During the final phase, publication outputs accelerated for organisations, students, project officers, Indigenous and female authors. Over time there was also a shift in research themes to encompass new clinical areas and social, environmental or behavioural determinants of health. Average degree (8.1), clustering (0.81) and diameter (3) indicated a well-connected network, with a core-periphery structure in each phase (p≤0.03) rather than a single central organisation (degree centralisation=0.55–0.65). Academic organisations dominated the core structure in all funding phases.ConclusionCollaboration in publications increased with network consolidation and expansion. Increased productivity was associated with increased authorship diversity and a decentralised network, suggesting these may be important factors in enhancing research impact and advancing the knowledge and practice of CQI in PHC. Publication diversity and growth occurred mainly in the fourth phase, suggesting long-term relationship building among diverse partners is required to facilitate participatory research in CQI. Despite improvements, further work is needed to address inequities in female authorship and Indigenous authorship.

To identify points for improvements within the health system where Aboriginal and Torres Strait Islander cancer patients may experience a lack of continuity in their cancer care. The optimal care pathway for Aboriginal and Torres Strait Islander people with cancer (OCP) framework was utilised as a tool in this work.Semi-structured interviews were conducted with health professionals at the primary health care (PHC) and hospital setting. Data were categorised into six steps using the OCP framework.This study identified multiple time-points in the cancer pathways that could be strengthened to increase the continuity of cancer care for these patients. In addition, the provision of person-centred care and adequate education tailored to patients' and health professionals' needs can help minimise the likelihood of patients experiencing a lack of continuity in their cancer care. Participants were recruited from an urban hospital (n = 9) and from six Aboriginal Community Controlled Health Services (n = 17) across geographical locations in Queensland. The provision of culturally competent care, effective communication, coordination and collaboration between services along the cancer pathway from prevention and early diagnosis through to end-of-life care were highlighted as important to enhance care continuity for Indigenous Australians.The implementation of recommendations outlined in the OCP framework may help with improving cancer care continuity for Indigenous patients with cancer.Aboriginal and Torres Strait Islander people can sometimes find cancer care pathways complex and difficult to navigate. This study identified points in the cancer pathways that could be strengthened to increase the continuity of cancer care for these patients which could potentially lead to improved outcomes.

BackgroundDuring the pandemic there were significant changes to our Emergency Department (ED). For example there was the creation of ‘Red’ (Patients requiring aerosol generating procedures or suspected COVID-19 patients) and ‘Green’ (low risk of COVID-19 patients) resuscitation and majors areas and complete relocation of the Paediatric ED to the Adult Clinical Decisions Unit. There were also significant changes to paediatric emergency protocols.We established an on-going programme of simulation within the multidisciplinary teams managing children in the ED to enable the dissemination of these changes.ObjectivesOur aims wereto create a face to face Paediatric Emergency Medicine Simulation package that could be delivered during a pandemicdisseminate changes in protocols and geography within the Paediatric ED and wider EDcollect feedback from simulation participantsuse this feedback to improve our programmeMethodsIn-situ simulations involving the acute on-call teams with real arrest calls were planned weekly. 6 participants could sign up to simulation teaching, but all other participants were ‘unaware’ of the simulation taking place.Departmental leads were informed of training dates to minimise clinical disruption. Additional Personal Protective Equipment was sourced and debriefs were run in large spaces following social distancing rules. Advanced Life Support Group recommendations regarding the running of courses during a pandemic were followed.We collected feedback from participants using electronic questionnaires.Results4 in-situ simulation mornings were held during July and August 2020. Participants included paediatricians, ED nurses and doctors, the trauma team, PICU and anaesthetics.All participants found the simulation a positive learning experience with 81% of participants rating the sessions ‘excellent’ 36% rating the sessions ‘very good’ and 9% ‘good’.93% of respondents felt more prepared to manage children in ED during the COVID pandemic.ConclusionsWe have shown that face-to-face simulation training is still possible during the pandemic, by ensuring social distancing rules are followed and sourcing PPE. Our simulation sessions allowed sharing of geographical & protocol changes and provides a model for shared learning within the paediatric ED. We have shown the majority of participants have found it a useful learning experience.We have continued to run these simulations throughout the Pandemic from October 2020 into March 2021, focussing on new trainees rotating into our hospital and departments. We would hope in the future to ensure that this programme is sustainable and would like to include a larger teaching faculty, particularly including more nurses and resus officers.

Study question Does high-dose testosterone therapy affect the stage distribution, morphological health and DNA damage repair capacity of human ovarian follicles and their survival in vitro? Summary answer Testosterone exposure is associated with reduced follicle growth activation, reduced follicle health and increased DNA damage: these further deteriorate after six days of culture. What is known already Androgens have diverse actions within the ovary, however, there is a lack of information regarding the long-term effects of high-dose testosterone on ovarian function and reproductive potential. Cumulus-oocyte complexes recovered from transgender men have been successfully matured in-vitro but little is known regarding the impact of this gender affirming endocrine therapy on the primordial follicle pool Study design, size, duration Whole ovaries were obtained from four transgender men aged 25-36 years with informed consent at oophorectomy. All patients had received 1000mg testosterone undecanoate intramuscularly at 12-16 week intervals for a minimum of 4 years pre-operatively. Cortical tissues were dissected into small pieces (≈1x1x0.5mm) and either immediately fixed for histological analysis or cultured for 6 days. Testosterone-treated ovaries were compared to cortical biopsies from age-matched healthy women obtained at caesarean section (n = 4, age 26-36). Participants/materials, setting, methods Follicle number, classification of developmental stage and morphology were evaluated by histological analysis of ovarian cortical tissue from day 0 and 6 days post culture. Immunohistochemical analysis included γH2AX as a marker of DNA damage, and meiotic recombination 11 (MRE11), ataxia telangiectasia mutated (ATM) and Rad51 as DNA repair proteins. A total of 3802 follicles from testosterone exposed and 878 from control ovaries were analysed. Main results and the role of chance At day 0 (D0), transgender tissue had a higher proportion of non-growing follicles (92.7±1.7%) compared to control (85.4±6.2%, p DNA damage was assessed by expression of γH2AX. At D0, the proportion of oocytes showing DNA damage was significantly higher in transgender non-growing follicles (48.1±12.5%, vs 12.3±0.25%, p At D0, there was no difference in expression of DNA repair enzymes ATM and RAD51 between transgender and control oocytes, and increased expression of MRE11 in control non-growing follicles (p Limitations, reasons for caution A large number of follicles have been analysed, but only from a small number of ovaries. DNA damage at D0 and after 6 days of culture may not reflect DNA damage and repair capacity at later stages of follicle growth. The effect of duration of testosterone treatment was not investigated. Wider implications of the findings These data indicate that high circulating concentrations of testosterone have previously unrecognised effects on the primordial and small-growing follicles of the ovary. These results may have implications for transgender men receiving gender-affirming therapy prior to considering pregnancy or fertility preservation measures. Trial registration number n/a

OBJECTIVES: In 2014–2015, over 400 social housing units were constructed in selected communities in Nunavik and Nunavut, two Inuit regions in northern Canada where housing shortages and poor quality housing are endemic and undermine population health. This paper presents results from a before-and-after study examining the effects of rehousing, i.e., relocating to a newly constructed or pre-existing social housing unit, on psychosocial health and asthma-related symptoms for Inuit adults. METHODS: Baseline data were collected 1–6 months before, and follow-up data 15–18 months after rehousing. Of the 289 participants at baseline, 186 were rehoused. Of the 169 participants eligible at follow-up, 102 completed the study. Self-reported health measures included psychological distress, perceived stress in daily life, perceived control over one’s life, and asthma-related symptoms. Data are analyzed using multilevel models for longitudinal data. RESULTS: After adjusting for age, sex, and region of residence, participants reported significantly lower levels of psychological distress and perceived stress in daily life, and improved sense of control over their lives 15 to 18 months after rehousing. Participants were also significantly less likely to report asthma-related symptoms at follow-up. CONCLUSION: Significant positive health impacts are observed for adults who relocated to newly constructed or pre-existing social housing units. Increasing investments to redress the housing situation across Inuit Nunangat is required, not only to improve living conditions but also to improve the health and well-being of the population.

Background: Clinical recommendations for concussion management encourage reduced cognitive and physical activities immediately after injury, with graded increases in activity as symptoms resolve. Empirical support for the effectiveness of such recommendations is needed. Purpose: To examine whether training medical providers on the Defense and Veterans Brain Injury Center’s Progressive Return to Activity Clinical Recommendation (PRA-CR) for acute concussion improves patient outcomes. Study Design: Cohort study; Level of evidence, 2. Methods: This study was conducted from 2016 to 2018 and compared patient outcomes before and after medical providers received an educational intervention (ie, provider training). Patients, recruited either before or after intervention, were assessed at ≤72 hours, 1 week, 1 month, 3 months, and 6 months after a concussion. The participant population included 38 military medical providers and 106 military servicemembers with a diagnosed concussion and treated by one of the military medical providers: 58 patient participants received care before the intervention (ie, provider training) and 48 received care after intervention. The primary outcome measure was the Neurobehavioral Symptom Inventory. Results: The patients seen before and after the intervention were predominantly male (89.7% and 93.8%, respectively) of military age (mean ± SD, 26.62 ± 6.29 years and 25.08 ± 6.85 years, respectively) and a mean ± SD of 1.92 ± 0.88 days from injury. Compared with patients receiving care before intervention, patients receiving care after intervention had smaller increases in physical activities (difference in mean change; 95% CI, 0.39 to 6.79) and vestibular/balance activities (95% CI, 0.79 to 7.5) during the first week of recovery. Although groups did not differ in symptoms at ≤72 hours of injury ( d = 0.22; 95% CI, –2.21 to 8.07), the postintervention group reported fewer symptoms at 1 week ( d = 0.61; 95% CI, 0.52 to 10.92). Postintervention patients who completed the 6-month study had improved recovery both at 1 month ( d = 1.55; 95% CI, 5.33 to 15.39) and 3 months after injury ( d = 1.10; 95% CI, 2.36 to 11.55), but not at 6 months ( d = 0.35; 95% CI, 5.34 to 7.59). Conclusion: Training medical providers on the PRA-CR for management of concussion resulted in expedited recovery of patients.

Background Climate change is associated with greater frequency, duration, intensity and unpredictability of certain weather-related events, including floods. Floods harm mental health. There is limited understanding of the mental health and well-being effects from river flooding, particularly over the longer term and in rural contexts. This paper describes the rationale, aims, objectives, study design and socio-demographic characteristics of the sample for a study measuring associations between flood experience and mental health and wellbeing of residents (particularly those most likely to be negatively impacted and hard to reach) in rural NSW Australia 6 months following a devastating flood in 2017. To our knowledge, the study is the first of its kind within Australia in a rural community and is an important initiative given the likelihood of an increasing frequency of severe flooding in Australia given climate change. Methods A conceptual framework (The Flood Impact Framework) drawing on social ecological approaches was developed by the research team. It was based on the literature and feedback from the community. The Framework describes putative relationships between flood exposure and mental health and wellbeing outcomes. Within a community-academic partnership approach, a cross-sectional survey was then undertaken to quantify and further explore these relationships. Results The cross-sectional survey was conducted online (including on mobile phone) and on paper between September and November 2017 and recruited 2530 respondents. Of those, 2180 provided complete demographic data, among whom 69% were women, 91% were aged 25–74, 4% identified as Aboriginal and/or Torres Strait Islander, 9% were farmers and 33% were business owners. Conclusions The study recruited a wide range of respondents and the partnership facilitated the community’s engagement with the design and implementation of the study. The study will provide a basis for a follow-up study, that will aim to improve the understanding of mental health and wellbeing effects over the longer term. It will provide an important and original contribution to understanding river flooding and mental health in rural Australia, a topic that will grow in importance in the context of human-induced climate change, and identify critical opportunities to strengthen services, emergency planning and resilience to future flooding.

Background Anemia rates are over 60% in disadvantaged children yet there is little information about the quality of anemia care for disadvantaged children. Methods Our primary objective was to assess the burden and quality of anemia care for disadvantaged children and to determine how this varied by age and geographic location. We implemented a cross-sectional study using clinical audit data from 2287 Indigenous children aged 6–59 months attending 109 primary health care centers between 2012 and 2014. Data were analysed using multivariable regression models. Results Children aged 6–11 months (164, 41.9%) were less likely to receive anemia care than children aged 12–59 months (963, 56.5%) (adjusted odds ratio [aOR] 0.48, CI 0.35, 0.65). Proportion of children receiving anemia care ranged from 10.2% (92) (advice about ‘food security’) to 72.8% (728) (nutrition advice). 70.2% of children had a hemoglobin measurement in the last 12 months. Non-remote area families (115, 38.2) were less likely to receive anemia care compared to remote families (1012, 56.4%) (aOR 0.34, CI 0.15, 0.74). 57% (111) aged 6–11 months were diagnosed with anemia compared to 42.8% (163) aged 12–23 months and 22.4% (201) aged 24–59 months. 49% (48.5%, 219) of children with anemia received follow up. Conclusions The burden of anemia and quality of care for disadvantaged Indigenous children was concerning across all remote and urban locations assessed in this study. Improved services are needed for children aged 6–11 months, who are particularly at risk.

The role of general practitioners in cancer care has expanded in recent years. However, little is known about utilization of primary health care (PHC) services by patients with cancer, particularly among socio-economically disadvantaged groups. We describe utilization of PHC services by patients with cancer, and the nature of the care provided. The study focuses on a disadvantaged group in Australia, namely Indigenous Australians. A retrospective audit of clinical records in ten PHC services in Queensland, Australia. Demographic and clinical data of Indigenous Australians diagnosed with cancer during 2010–2016 were abstracted from patient’s medical records at the PHC services. The rates of cancer-related visits were calculated using person years at risk as a denominator. A total of 138 patients’ records were audited. During 12 months following the cancer diagnosis, patients visited the PHC service on average 5.95 times per year. Frequency of visits were relatively high in remote areas and among socioeconomic disadvantaged patients (IRR = 1.87, 95%CI 1.61–2.17; IRR = 1.79, 95%CI 1.45–2.21, respectively). Over 80% of visits were for seeking attention for symptoms, wound care, and emotional or social support. Patients who did not undergo surgery, had greater comorbidity, received chemotherapy and/or radiotherapy, and male gender had significantly greater rate of visits than their counterparts. The frequency of utilization of PHC services, especially by patients with comorbidities, and the range of reasons for attendance highlights the important role of PHC services in providing cancer care. The reliance on PHC services, particularly by patients in remote and disadvantaged communities, has important implications for appropriate resourcing and support for services in these locations.

Through a phenotypic high throughput screen (HTS) using a serum response element luciferase (SRE.L) promoter, we identified a novel 5-aryl-1,3,4-oxadiazol-2-ylthiopropionic acid lead inhibitor of Rho/MRTF/SRF-mediated gene transcription with good potency (IC(50) = 180 nM). We were able to rapidly improve the cellular potency by 5 orders of magnitude guided by sharply defined and synergistic SAR. The remarkable potency and depth of the SAR, as well as the relatively low molecular weight of the series, suggests, but does not prove, that binding to the unknown molecular target may be occurring through a covalent mechanism. The series nevertheless has no observable cytotoxicity up to 100 μM. Ensuing pharmacokinetic optimization resulted in the development of two potent and orally bioavailable anti-fibrotic agents that were capable of dose-dependently reducing connective tissue growth factor (CTGF) gene expression in vitro as well as significantly reducing the development of bleomycin-induced dermal fibrosis in mice in vivo.

People in close contact with tuberculosis should have screening and appropriate management, as an opportunity for active case detection and prevention. However, implementation of tuberculosis contact screening and management is limited in high-burden settings. Behaviour change is needed across three levels of the healthcare system—policymakers, healthcare providers, and patients. To bridge the wide policy-practice gap, this study draws on the Consolidated Framework for Implementation Research, the Behaviour Change Wheel, and the RE-AIM model (Reach, Effectiveness, Adoption, Implementation, Maintenance) to respectively understand barriers, implement change, and evaluate process and outcome. This methods paper describes a mixed-methods intervention study in Eastern Indonesia. Quantitative data will be collected during baseline, intervention, and sustainability periods and analyzed using time series analysis. The primary outcome is the number of individuals completing tuberculosis preventive therapy by the end of the two-year intervention phase. Of an estimated 10,000 contacts during this period, we anticipate that a minimum of 416 will be found to have active TB or will complete preventive therapy. Qualitative data (semi-structured interviews, focus group discussions, and observations) will be collected from consenting healthcare providers, patients, and contacts. Activities to promote policy implementation include healthcare provider training, quarterly continuous quality improvement workshops, a social media discussion forum, and promotional materials. The Consolidated Framework for Implementation Research will be used to identify reasons for limited policy implementation at baseline. The Behaviour Change Wheel will be used to ensure that a suitable range of activities are implemented to facilitate change. The RE-AIM model will be used as the evaluation framework. Use of theoretical frameworks in combination can ensure a comprehensive understanding of, and robust response to, health policy underimplementation. The selected frameworks are highly applicable to this pragmatic intervention study, in a setting where End TB Strategy targets will not be met without substantial behavior change within health systems. Continuous quality improvement cycles will provide a way to engage staff and stakeholders in understanding local data to motivate behavior change. If successful, up to 500 people could be prevented from developing complications of tuberculosis through early case-finding or receiving preventive therapy over a two-year period. Australian New Zealand Clinical Trials Register 375803 .

Background Humidified high-flow nasal cannula (HHFNC) has become an increasingly common treatment modality, used to provide respiratory support for bronchiolitis patients. In our UK paediatric unit, we have seen the proportion of bronchiolitis patients receiving HHFNC increase from 3% in 2016/17 to 13% in 2017/18 to 21% in 2019/20. However, at the time of initiating this project, guidelines on how HHFNC weaning should be performed were not provided at a local or national level. This is of particular importance in the current SARS CoV-2 pandemic as HHFNC is categorised as an aerosol generating procedure, so it is advantageous to minimise the length of time patients spend on HHFNC through efficient weaning. Objectives We investigated how efficiently patients were weaned from HHFNC, and whether providing a specific weaning plan was associated with more efficient weaning. Methods The medical records of all patients presenting to our centre under 1 year of age diagnosed with bronchiolitis between 01/10/2019 and the 11/02/2020 were reviewed (n=70). Of these, 14 patients (20%) were placed on HHFNC for longer than 3 hours. For these patients, we calculated the total length of time on HHFNC and time taken to wean from HHFNC. We then assessed whether a specific weaning plan was documented for each patient, judging a specific weaning plan to be one in which there were instructions as to how the flow rate or fraction of inspired oxygen (FiO2) should be reduced with respect to time. Results The median time spent on HHFNC was 2.1 days. A median of 1.0 day was spent weaning from HHFNC, however there was a large range in weaning time, from 3.5 hours to 4.0 days. We found specific weaning plans were documented for 4 patients. Patients who had a specific weaning plan documented were weaned from HHFNC more quickly (mean = 14.75 hours) than those who did not (mean = 34.6 hours); Welch’s t-test, t(11.93) = 2.26, p = 0.043. Conclusions This project showed a high proportion of time spent on HHFNC, in our unit, was spent weaning. It provided evidence that weaning can be more efficient when specific guidance is provided. Therefore, we created new Trust guidelines for standardised HHFNC weaning in bronchiolitis patients. These guidelines are in-line with the RCPCH guidance published on the 18/09/2020, in light of concerns about HHFNC and its classification as an aerosol generating procedure. It is planned to repeat the data collection for the 2020/21 bronchiolitis season to assess whether this new guidance both improves the efficiency of HHFNC weaning whilst remaining safe. However, this may be challenging with the unusually low rates of bronchiolitis we are seeing so far this season!

Pediatric oncology patients with an external central venous catheter (CVC) in situ can be discharged from the hospital. Caregivers are expected to learn how to care for the CVC prior to discharge while also dealing with their child's new cancer diagnosis. This study aimed to evaluate the perceptions of a CVC education program received by caregivers to identify opportunities for improvement. A qualitative study was conducted in 3 stages, using an evidence-based co-design approach, involving caregivers and one adolescent patient discharged from the British Columbia Children's Hospital Oncology/Hematology/BMT inpatient unit. Stage I involved semi-structured interviews to gain feedback on the existing CVC education program. In Stage II, educational resources were updated or developed and implemented. For Stage III, the revised CVC education program was evaluated through a focus group and semi-structured interviews. Interview transcripts were analyzed using QSR NVivo®. The original CVC education program was overall well received. Repeated instruction and support provided by nurses was reported to have increased confidence with performing CVC skills. Participants appreciated the multimodal approach to meet learning needs and expressed interest in additional visual aids. Inconsistencies in nurses’ practice and offers of “tips and tricks” were identified to be challenging for caregivers while learning a new skill. Videos depicting CVC care were developed to provide an additional visual tool, decreased inconsistencies in care, and support to caregivers at home. Caring for a CVC at home is challenging and overwhelming for caregivers. A standardized multimodal education program is required to support caregivers at home.

ObjectivesTo (1) apply the Framework to Assess the Impact from Translational health research (FAIT) to Lessons from the Best to Better the Rest (LFTB), (2) report on impacts from LFTB and (3) assess the feasibility and outcomes from a retrospective application of FAIT.SettingThree Indigenous primary healthcare (PHC) centres in the Northern Territory, Australia; project coordinating centre distributed between Townsville, Darwin and Cairns and the broader LFTB learning community across Australia.ParticipantsLFTB research team and one representative from each PHC centre.Primary and secondary outcome measuresImpact reported as (1) quantitative metrics within domains of benefit using a modified Payback Framework, (2) a cost-consequence analysis given a return on investment was not appropriate and (3) a narrative incorporating qualitative evidence of impact. Data were gathered through in-depth stakeholder interviews and a review of project documentation, outputs and relevant websites.ResultsLFTB contributed to knowledge advancement in Indigenous PHC service delivery; enhanced existing capacity of health centre staff, researchers and health service users; enhanced supportive networks for quality improvement; and used a strengths-based approach highly valued by health centres. LFTB also leveraged between $A1.4 and $A1.6 million for the subsequent Leveraging Effective Ambulatory Practice (LEAP) Project to apply LFTB learnings to resource development and creation of a learning community to empower striving PHC centres.ConclusionRetrospective application of FAIT to LFTB, although not ideal, was feasible. Prospective application would have allowed Indigenous community perspectives to be included. Greater appreciation of the full benefit of LFTB including a measure of return on investment will be possible when LEAP is complete. Future assessments of impact need to account for the limitations of fully capturing impact when intermediate/final impacts have not yet been realised and captured.

Background The suspicion of PE is a common reason for both hospital admission and hospital stays. Being able to prevent admission in low risk PE patients has previously shown to be safe and cost effective with an established ambulatory service running in our hospital since 2010. In this study we describe the findings from an 8 year retrospective analysis of this service, building on a previous 2 year study. Method An 8 year retrospective analysis from June 2010 to January 2018 was carried out using the PE database. Patients with suspected PE referred to the service using acceptance criteria (appendix a). PE risk was then stratified using the PE severity index (PESI) (3). D-dimers were performed in the low and intermediate probability groups. Those with negative d-dimers were discharged, those with high risk or positive d-dimer underwent imaging in the form of CT pulmonary angiography (CTPA) or ventilation-perfusion (VQ) scanning. This was generally a same day service. For a subset of 418 patients (admitted April-December 2017) 30-day mortality was determined. Results 3767 patients were referred to the service. Out of these patients 2651 (70%) were female and 1116 (30%) were male. 1474 (40%) referrals came from general practice, 898 (24%) from bed bureau, 621 (17%) came from the clinical decisions unit and 562 (15%) came from the emergency department. 106 (3%) of referrals came from other sources. 269 (7%) had a confirmed PE out of which 265 (99%) were managed as outpatients. 1438 CTPAs were performed, 226 (18%) were positive. 416 VQ scans were performed, 27 (6%) were positive. 30-day mortality was zero. Conclusions The analysis shows ambulatory PE care to be effective with 99% of those with confirmed PE being managed without admission. This is an improvement of 27% from the previous study. The service is safe with zero 30-day mortality in a recent subgroup. Summarizing, this is the largest ambulatory PE study which demonstrates the effectiveness and safety of an outpatient ambulatory pulmonary embolism (PE) pathway. Similar services such as this should be implemented in other centres. Reference https://www.ncbi.nlm.nih.gov/pubmed/16020800

Much of our current understanding about novel coronavirus disease 2019 (COVID-19) comes from hospitalised patients. However, the spectrum of mild and subclinical disease has implications for population-level screening and control. Forty-nine participants were recruited from a group of 99 adults repatriated from a cruise ship with a high incidence of COVID-19. Respiratory and rectal swabs were tested by polymerase chain reaction (PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Sera were tested for anti-SARS-CoV-2 antibodies by enzyme-linked immunosorbent assay (ELISA) and microneutralisation assay. Symptoms, viral shedding and antibody response were examined. Forty-five participants (92%) were considered cases based on either positive PCR or positive ELISA for immunoglobulin G. Forty-two percent of cases were asymptomatic. Only 15% of symptomatic cases reported fever. Serial respiratory and rectal swabs were positive for 10% and 5% of participants respectively about 3 weeks after median symptom onset. Cycle threshold values were high (range 31–45). Attempts to isolate live virus were unsuccessful. The presence of symptoms was not associated with demographics, comorbidities or antibody response. In closed settings, incidence of COVID-19 could be almost double that suggested by symptom-based screening. Serology may be useful in diagnosis of mild disease and in aiding public health investigations.

Aim: To explore health professionals’ perspectives on communication, continuity and between-service coordination for improving cancer care for Indigenous people in Queensland.Methods: Semi-structured interviews were conducted in a purposive sample of primary health care (PHC) services in Queensland with Indigenous and non-Indigenous health professionals who had experience caring for Indigenous cancer patients in the PHC and hospital setting. The World Health Organisation integrated people-centred health services framework was used to analyse the interview data.Results: Seventeen health staff from six Aboriginal Community Controlled Services and nine health professionals from one tertiary hospital participated in this study. PHC sites were in urban, regional and rural settings and the hospital was in a major city. Analysis of the data suggests that timely communication and information exchange, collaborative approaches, streamlined processes, flexible care delivery, and patient-centred care and support were crucial in improving the continuity and coordination of care between the PHC service and the treating hospital.Conclusion: Communication, collaboration and care coordination are integral in the provision of quality cancer care for Indigenous Australians. It is recommended that health policy and funding be designed to incorporate these aspects across services and settings as a strategy to improve cancer outcomes for Indigenous people in Queensland. Publisher's Note: A corrigendum relating to this article has been published at http://doi.org/10.5334/ijic.5641.

Within the military, cognitive readiness is essential to ensure the warfighter can return to highly demanding combat training and deployment operations. The warfighter must be able to make split second decisions and adapt to new tools and environments. After a traumatic brain injury, clinicians helping the warfighter must have techniques that address warfighter cognitive readiness. Current rehabilitation for cognitive complaints used in military medicine are modeled after civilian therapies which focus on remediating moderate to severe impairment through building compensatory strategies. This traditional approach to cognitive rehabilitation does not translate well to mild traumatic brain injury (mTBI) where impairments are subtle, nor does it meet the needs of our warfighters in deployed and combat training environments. Challenging our current methods is critical in adapting to the needs of this highly valued population to ensure that our warfighters are able to carry out mission critical decision making. Here we present a review of our best current practices for cognitive rehabilitation, describe the limitations our traditional approaches impose for mTBI in military personnel, and present an alternative treatment called Strategic Memory Advanced Reasoning Training (SMART) that can be adopted through a randomized clinical trial design. We propose directly comparing traditional treatment approaches with a novel cognitive rehabilitation strategy which has been well validated outside of the military setting. Procedures were developed to execute this clinical trial in a way that is most relevant to the study population by establishing ecologically valid outcome metrics.

Objective: To describe patterns of uptake of Indigenous-specific health assessments and associated follow-up items, and examine the barriers and enablers to delivery and billing of follow-up over the first 3 years of implementation of the Indigenous Chronic Disease Package (ICDP). Design, setting and participants: We used a socioecological approach to analyse data derived from the Sentinel Sites Evaluation of the ICDP - with data from 24 sites across Australia. Administrative data (1 May 2009 to 30 May 2012) and program data (1 March 2010 to 30 May 2012) were provided by the Department of Health. Data on barriers and enablers to follow-up of health assessments were obtained from community focus groups, in-depth interviews and discussions with key informants (1 November 2010 to 30 December 2012). Main outcome measures: Monthly number of Medicare Benefits Schedule items claimed for Indigenous-specific health services and follow-up; qualitative data on enablers and barriers categorised according to patient, patient-health service relationship, health service or organisation, community and policy environment levels or influence. Results: There was an increase in the uptake of health assessments, but relatively limited delivery of follow-up care and billing for Indigenous-specific follow-up items. Follow-up was constrained by factors that operated at various levels: patient, interpersonal, health service, community and policy. Constraints included practitioners' lack of awareness of item numbers, staffing, poor state of clinical information systems, billing against non-Indigenous-specific items or more general follow-up items, emphasis on health assessments with less attention to requirements for follow-up, limited capacity to arrange and facilitate follow-up, and communication and transport challenges for patients. Conclusions: Work is required across various levels of the system to address barriers to follow-up care. Enhancing follow-up care is vital to achieving health benefits from the large financial and human resource investment in health assessments. Refereed/Peer-reviewed