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Ventilator-associated pneumonia (VAP) is a common complication of mechanical ventilation in the intensive care unit. The incidence, patient characteristics, and outcomes have not been described in a regional Australian setting.Τhe primary objective was to establish the incidence of VAP in a regional intensive care unit using predetermined diagnostic criteria. The secondary objective was to compare the agreement between criteria-based and physician-based diagnostic processes. The tertiary objectives were to compare patient characteristics and clinical outcomes of cases with and without VAP.A retrospective clinical audit was performed of adult patients admitted to Rockhampton Intensive Care Unit, Australia, between 2013 and 2016. We included all patients ventilated for ≥72 h and not diagnosed with a pneumonia before or during the first 72 h of ventilation.A total of 170 cases met the inclusion criteria. The incidence of VAP as per the criteria-based diagnosis was 27.3 cases per 1000 ventilator days (95% confidence interval [CI]: 18.4-36.2) and as per the physician-based diagnosis was 25.8 cases per 1000 ventilator days (95% CI: 17.1-34.4). There was a moderate chance-corrected agreement between the criteria- and physician-based diagnosis. Very obese cases (body mass index [BMI] ≥40) were nearly four times more likely to develop VAP than cases with normal BMI (BMI30) (odds ratio: 3.664; 95% CI: 1.394-9.634; p = 0.008). After controlling for sex, BMI category, comorbidities, and Acute Physiology and Chronic Health Evaluation II scores, there was a trend (p = 0.283) for higher adjusted mortality rate for cases with VAP (10.1%, 95% CI: 4.8-21.5) than for those without VAP (6.1%, 95% CI: 3.0-12.4). Cases with VAP had a higher total hospital cost ($123,223 AUD vs $66,425 AUD, p 0.001), than cases without VAP.This is the first study reporting incidence of VAP in an Australian regional intensive care unit setting. An increased length of stay and significantly higher hospital costs warrant research investigating reliable and valid clinical prediction rules to forecast those at risk of VAP.

Background/Aim: An alarming increase in vitamin D deficiency even in sunny regions highlights the need for a better understanding of the genetic background of the vitamin D endocrine system and the molecular mechanisms of gene polymorphisms of the vitamin D receptor (VDR). In this study, the serum levels of 25(OH)D3 were correlated with common VDR polymorphisms (ApaI, BsmI, FokI, and TaqI) in 98 subjects of a Greek homogeneous rural population. Methods: 25(OH)D3 concentration was measured by ultra-HPLC, and the VDR gene polymorphisms were identified by quantitative real-time PCR followed by amplicon high-resolution melting analysis. Results: Subjects carrying either the B BsmI (OR: 0.52, 95% CI: 0.27–0.99) or t TaqI (OR: 2.06, 95%: 1.06–3.99) allele presented twice the risk for developing vitamin D deficiency compared to the reference allele. Moreover, subjects carrying 1, 2, or all 3 of these genotypes (BB/Bb, Tt/tt, and FF) demonstrated 2-fold (OR: 2.04, 95% CI: 0.42–9.92), 3.6-fold (OR: 3.62, 95% CI: 1.07–12.2), and 7-fold (OR: 6.92, 95% CI: 1.68–28.5) increased risk for low 25(OH)D3 levels, respectively. Conclusions: Our findings reveal a cumulative effect of specific VDR gene polymorphisms that may regulate vitamin D concentrations explaining, in part, the paradox of vitamin D deficiency in sunny regions, with important implications for precision medicine.

Background This report describes and objectivizes reported problems among a cohort of previously hospitalized COVID-19 patients by clinical examination and determination of the required level of rehabilitation sevices. Methods This report forms part of the Linkoping COVID-19 Study (LinCoS) that induded 745 individuals from one of 21 Swedish healthcare regions, Region Ostergotland (RO), admitted to hospital for COVID-19 during March 1st-May 31st, 2020. In this descriptive ambidirectional cohort study, all 185 individuals who had reported concerning persisting symptoms were invited to a multi-professional dinical assessment of somatic, functional, affective, neuropsychological status and rehabilitation needs. Rehabilitation needs were assessed using three sub-scales of the Rehabilitation Complexity Scale-Extended. Findings Among the 158 (85.4%) cases consenting and included in the analysis, we found a broad array of symptoms and signs attributable to COVID-19 involving respiratory, visual, auditory, motor, sensory and cognitive functions that could be confirmed clinically at five months post-discharge. This translated into 16% [95% CI 13-20] of survivors (70/433) of the total regional cohort of hospitalised patients requiring further rehabilitative interventions at follow-up. Weakness in extremities was reported in 28.5% [21.6, 36.2] (45/158). On examination, clinically overt muscle weakness could be corroborated in 15 individuals (10.5%) [6.1, 16.4]. 48% [40, 56] (76/158) reported cognitive symptoms, while the physician noted overt cognitive impairments in only 3% [1.1, 7.5]. In neuropsychological testing, 37% [28-46] (45/122) performed 1.5 SD below the norm, indicating neurocognitive deficits. Fifty-five individuals (34.8%) [27.4, 42.8] reported new or aggravated pain. In three fourths of them, it exerted a moderate or worse detrimental effect on their ability to work. Interpretation Our study underscores the importance of providing extensive examination of cases with persisting problems after COVID-19, especially since symptoms such as fatigue and breathlessness are highly nonspecific, but may represent significant underlying functional impairments. Robust neurocognitive testing should be performed, as cognitive problems may easily be overlooked during routine medical consultation. In the Swedish context, most rehabilitative interventions could be provided in a primary care setting. A substantial minority of patients should be triaged to specialized rehabilitation services. Funding Agencies: ALF grant and RÖ

BackgroundThis first report of the Linköping Covid-19 Study (LinCoS) aimed at determination of Covid-19-associated mortality, impairments, activity and participation limitations denoting rehabilitation needs four months after discharge from hospital.MethodsAn ambidirectional population-based cohort study including all confirmed Covid-19 cases admitted to hospital during 1/03-31/05 and those living in home healthcare settings identified through a regional registry and evaluated through medical records, including WHO Clinical Progression Scale (CPS). All patients discharged from hospital were followed-up by structured telephone interview at 4 months post-discharge. Respondents indicated any new or aggravated persisting problems in any of 25 body functions and 12 activity/participation items and rated them for impact on daily life.FindingsOut of 734 hospitalised patients, 149 were excluded, 125 died, and 460 were alive at 4-month follow-up of whom 433 (94.1%) were interviewed. In total, 40% reported impairments and activity/participation limitations affecting daily life and warranted further multi-professional rehabilitation assessment, predominantly those with severe disease and a considerable proportion of those with moderate disease. Cognitive and affective impairments were equally common in all groups and were reported by 20-40% of cases. Limb weakness was reported by 31%, with CPS 7-9 being four times more likely to report this problem as compared to CPS 4-5. 26% of those working or studying reported difficulties returning to these activities, this being 3.5 times more likely in CPS 7-9 as compared to CPS 4-5. 25% reported problems walking >1 km, with CPS 7-9 over three times more likely to report this as compared to the other two sub-groups. 90-day mortality rate of Covid-19 associated deaths was 15.1%.InterpretationMost rehabilitation needs after Covid-19 involved higher cerebral dysfunction both in patients with moderate and severe disease. This should be considered when designing services aiming at minimizing long-term disability.FundingALF grant and Region Östergötland.

To evaluate whether attending a face-to-face pre-operative joint replacement education in a regional setting reduces overall hospital costs and length of stay (LOS) following total knee replacement (TKR) or total hip replacement (THR). A retrospective clinical audit reviewed the medical records of all patients who underwent an elective THR or TKR at Rockhampton Hospital in regional Queensland, Australia, between 03/2015 and 12/2016 (22 months). The pre-operative joint replacement education class was provided by a multidisciplinary team that included a physiotherapist, an occupational therapist, a dietician, a pharmacist and a social worker. In addition to demographic data, we extracted and analysed data related to total acute care and total healthcare cost, prevalence of post-operative complications, discharge destination and comorbidities (using the Functional Comorbidity Index). Out of 326 cases that were included in the analysis, 115 cases with TKR and 51 cases with THR attended a pre-operative education class. Demographic characteristics between those attending and not attending the class were largely similar, except from more females attending in the THR group. There was no difference in hospital costs or LOS between those who attended the class compared to those who did not for both the TKR and THR groups. Outcomes related to total acute stay costs, total cost including travel and education and score for Functional Comorbidities Index were similar between those who attended the class and those who did not. Pre-operative education does not reduce hospital costs (surgery and hospital stay) in Central Queensland.

ObjectivesTo report findings on brain MRI and neurocognitive function, as well as persisting fatigue at long-term follow-up after COVID-19 hospitalisation in patients identified as high risk for affection of the central nervous system.DesignAmbidirectional observational cohort study.SettingAll 734 patients from a regional population in Sweden with a laboratory-confirmed COVID-19 diagnosis admitted to hospital during the period 1 March to 31 May 2020.ParticipantsA subgroup (n=185) with persisting symptoms still interfering with daily life at a telephone follow-up 4 months after discharge were invited for a medical and neuropsychological evaluation. Thirty-five of those who were assessed with a neurocognitive test battery at the clinical visit, and presented a clinical picture concerning for COVID-19-related brain pathology, were further investigated by brain MRI.Main outcome measuresFindings on brain MRI, neurocognitive test results and reported fatigue.ResultsTwenty-five patients (71%) had abnormalities on MRI; multiple white matter lesions were the most common finding. Sixteen patients (46%) demonstrated impaired neurocognitive function, of which 10 (29%) had severe impairment. Twenty-six patients (74%) reported clinically significant fatigue. Patients with abnormalities on MRI had a lower Visuospatial Index (p=0.031) compared with the group with normal MRI findings.ConclusionsIn this group of patients selected to undergo MRI after a clinical evaluation, a majority of patients had abnormal MRI and/or neurocognitive test results. Abnormal findings were not restricted to patients with severe disease.

Prospective cohort study with a repeated measures analysis. To measure the effects of the Active Rehabilitation (AR) training programme for community-dwelling individuals with spinal cord injury (SCI) in Botswana on physical independence, wheelchair mobility, self-efficacy, life satisfaction, level of physical activity and community participation. The inaugural AR training programme in Botswana, a community peer-based programme for people with SCI. The 10-day residential programme in Botswana was led by an international team of peer mentors and health professionals. Participants with SCI (on average 4 years after injury) completed a survey comprising a battery of standardised outcome measures at three timepoints: at the start, on completion and at 5 months after the programme (n = 14). Participants also completed a practical wheelchair skills test at start and completion of the programme (n = 17). Participants improved in the mobility subscale of the Spinal Cord Independence Measure Self Report on completion (p = 0.011, d = 0.85) and at 5-month follow-up (p = 0.005, d = 0.93) as compared to baseline. They also achieved moderate improvement in self-efficacy to manage their condition (physical function domain of Moorong Self-Efficacy Scale) and large improvements in wheelchair mobility as assessed through the Queensland Evaluation of Wheelchair Skills test and the Wheelchair Skills Test Questionnaire. All positive results were retained at 5-month follow-up. Findings indicate that the peer-based programme AR can play an important role in promoting physical independence, wheelchair mobility and injury-management self-efficacy in community-dwelling individuals with SCI in Botswana.

Systematic review and meta-synthesis of qualitative findings. To establish the perceived effectiveness and mechanisms of community peer-based programmes based on narratives of consumers with spinal cord injury (SCI). Scopus, Academic Search Complete, CINAHL, Health Source, Medline, PsycARTICLES, PsychINFO, SPORTSDiscus and ProQuest were searched for articles published in English between January 1990 and December 2015. Qualitative studies referring to community peer-based interventions were included if most cases had a SCI. The results section of included studies was extracted and entered in NVivo. Data were inductively coded and analysed according to the three phases of Thematic Synthesis. The search yielded 1402 unique records, out of which 126 were scrutinised in full. Four studies were appraised based on eight criteria and were finally included in the analysis. Three analytical themes emerged: (1) a unique learning environment created by the right mixture of learning resources, learning processes and a can-do attitude; (2) peer mentors—a unique learning resource with high level of relatedness that eases and empowers participants; and (3) an intervention that responds to important unmet needs and unrealised potential. Community peer-based programmes for people with SCI provide individualised training in important life areas, using a variety of learning resources and a plethora of learning processes. The high level of perceived effectiveness suggests that this type of intervention is an important tool of health systems post discharge from initial rehabilitation. Community organisations should be supported with evaluating their programmes through quality research.

Publisher's version (útgefin grein), Objective: To explore self-reported health problems and functional goals in community-dwelling individuals with spinal cord injury in Sweden. Design: Cross-sectional descriptive study that used a survey designed by an experienced peer mentor with spinal cord injury. Subjects: Community-dwelling individuals with spinal cord injury from Sweden. Methods: The survey was distributed online by the community peer-based organization RG Active Rehabilitation. Results: A total of 203 individuals (55% males, 90% acquired spinal cord injury) from all regions in Sweden completed the survey. Of these, 33% reported living with > 2 unbearable physical or psychological problems. While some problems (e.g. problems related to bladder and balance) were consistently ranked to be common across all years since injury and type of spinal cord injury, distribution of some other unbearable problems (e.g. type of pain, excessive weight) varied between subgroups. Years since injury, level of acquired spinal cord injury and sex, but not age-group or type of spinal cord injury, explained some of the variation in the goals. Conclusion: The high proportion of reported “unbearable” problems point to the stronger need for systematic, comprehensive, life-long, multi-disciplinary follow-up for people with spinal cord injury. The high rate of goals related to improving strength and fitness across all participants independently of their characteristics highlight the important role of community organizations that offer such lifetime services.

An increasing number of universities offer educational programmes across multiple campuses, as a way of facilitating access to tertiary education and filling the shortage of health professionals in rural and regional settings. Offering an equitable learning experience across all sites has been considered an important aspect in any learning and teaching approach. This qualitative study analysed data from 10 focus group discussions and 11 unit evaluations, to explore student perceptions of synchronous dual-campus delivery of a physiotherapy programme in Central Queensland, Australia. An inductive approach to thematic analysis was used. Three themes emerged: (a) Student location influences learning; (b) Videoconferencing impacts learning and teaching; and (c) Dual-campus delivery determines teaching structures and shapes teaching processes. Difficulties related to cross-campus communication, logistics, and opportunities for interaction and engagement were seen as detrimental to synchronous dual-campus delivery. Skill-based demonstrations added another level of complexity. However, students identified a potential benefit from accessing expertise from both campuses. With careful planning and consideration of the potential barriers and facilitators, synchronous dual-campus learning environments can be an effective delivery option for higher education institutions. This study builds on existing literature and suggests a number of strategies that are specific to this mode of programme delivery.

Background: Nonspecific low back pain (LBP) can progress to chronic disability and prolonged absence from work. Despite clinical and professional guidelines, physiotherapists often fail to address ...

IntroductionVentilator-associated pneumonia (VAP) is a medical complication associated with prolonged mechanical ventilation. Most studies looking at VAP originate from major, tertiary intensive care units (ICUs). Our understanding of VAP in regional hospitals is limited. Given that patient characteristics often differ between metropolitan and regional centres, it is important to investigate VAP in a regional non-tertiary ICU. This project will establish and report the incidence, case characteristics and outcomes including mortality and length of stay related to VAP in a regional non-tertiary Australian ICU. Furthermore, it will compare the incidence of VAP in accordance with consultant diagnosed cases in the medical record, and by a post hoc screening of all cases against a list of previously published diagnostic criteria.Methods and analysisThis retrospective clinical audit study will screen medical records from the period 1 January 2013 to 31 December 2016. All cases requiring mechanical ventilation for ≥72 hours will be screened against previously reported diagnostic criteria for VAP. At the same time, their medical records will be screened for a documented diagnosis of VAP.Ethics and disseminationThis study has been granted ethical approval from the Central Queensland Hospital and Health Service (CQHHS) Human Research Ethics Committee (HREC/17/QCQ/11) and the Central Queensland University Human Research Ethics Committee (H17/05-102). This study will be submitted for publication in a peer-reviewed scientific journal and presented at internal workshops (within Queensland Health) and national and/or international scientific conferences.

Prospective population-based open-ended study. This paper is part of the Stockholm-Thessaloniki Acute Traumatic Spinal Cord Injury Study.To calculate incidence and evaluate the epidemiological profile of the incident population with traumatic spinal cord injury (TSCI).The greater Thessaloniki region in Greece and the greater Stockholm region in Sweden.TSCI individuals, older than 15 years of age, who had survived the first 7 days post-trauma, were identified through an active surveillance system. The forms of the Nordic Spinal Cord Injury Registry were used.87 individuals were injured in the greater Thessaloniki and 49 in the greater Stockholm region. Annual crude incidence was 33.6 per million for Thessaloniki and 19.5 per million for the Stockholm region. The leading causes of injury for the Thessaloniki region were transportation accidents (51%) and falls (37%), and those for the Stockholm region were falls (47%) and transportation accidents (23%). A significantly larger number of individuals of the Thessaloniki group were injured in transportation accidents. There was no significant difference between regions with regard to the type of resulting impairment.Incidence of TSCI was considerably higher in the Thessaloniki region as compared with that in the Stockholm region, probably chiefly reflecting differences in preventative measures with regard to driving.

We used Lamotrigine LTG (50-600mg /24h) in 12 patients, 58-to 95-years-old (A Group) and other antiepileptics in nine patients (B Group) with the diagnosis of probable Alzheimer's disease (AD) and seizures. We also administered LTG (50-700mg/24h) in 16 patients (C Group) and other antiepileptics in nine patients (D Group) with other neurological disorders with cognitive disorders and seizures. The results showed that in eight from 12 patients with AD, and in nine from 16 with other neurological disorders, seizures stopped after treatment with LTG—while in five from nine patients with AD and six from 18 with other neurological disorders, seizures stopped after treatment with other antiepileptic drugs. Side effects in 28 patients treated with LTG included only three mild rashes, while side effects in 18 patients treated with other antiepileptic drugs included—six patients with fatigue, two with rashes, one with dizziness, one with low platelets, one with sleepiness and one with loss of hair. Conclusively, this study shows that LTG is an effective and safe monotherapy in patients with cognitive disorders and AD.

Twenty patients diagnosed as having multiple sclerosis (MS) were examined by MRI and 9 neuropsychological scales: MMSE, BCRS, RMB, SDMT, BNT, VM, FAS, Benton and Hamilton. The number and distribution of the lesions, and cerebral and corpus callosum atrophy were evaluated by MRI. MR images were generated by a 0.5 Tesla instrument utilizing T1WI, PD and T2WI imaging techniques. The results reveal (1) that patients with MS are impaired in a broad range of cognitive functions but mainly memory is affected; (2) number of lesions in the corona radiata, insula and hippocampus is correlated with cognitive impairment, and (3) enlargement of the IIIrd ventricle is an indicator of memory impairment in MS patients.

Prospective, population-based study. This paper is part of the Stockholm Thessaloniki Acute Traumatic Spinal Cord Injury Study (STATSCIS).To characterize patient populations and to compare acute management after traumatic spinal cord injury (TSCI).The Greater Thessaloniki region in Greece and the Greater Stockholm region in Sweden.Inception cohorts with acute TSCI that were hospitalized during the study period, that is September 2006 to October 2007, were identified. Overall, 81 out of 87 cases consented to inclusion in Thessaloniki and 47 out of 49 in Stockholm. Data from Thessaloniki were collected through physical examinations, medical record reviews and communication with TSCI cases and medical teams. Data from Stockholm were retrieved from the Nordic Spinal Cord Injury Registry.There were no significant differences between study groups with regard to core clinical characteristics. In contrast, there were significant differences in (1) transfer logistics from the scene of trauma to a tertiary-level hospital (number of intermediate admissions, modes of transportation and duration of transfer) and (2) acute key therapeutic interventions, that is, the use of mechanical ventilation (49% in Thessaloniki versus 20% in Stockholm), and performance of tracheostomy (36% in Thessaloniki versus 15% in Stockholm); spinal surgery was performed significantly more often and earlier in Stockholm than in Thessaloniki.Despite largely similar core clinical characteristics, Stockholm and Thessaloniki cases underwent significantly different acute management, most probably to be attributed to adaptations to the differing regional approaches of care one following a systematic approach of SCI care and the other not.

Prospective, population-based study. This paper is part of the Stockholm Thessaloniki Acute Traumatic Spinal Cord Injury Study (STATSCIS). To evaluate and compare outcomes, length of stay (LOS), associated conditions and medical complications at 1-year post-trauma. The Greater Thessaloniki region, Greece, and the Greater Stockholm region, Sweden. While Stockholm follows a SCI system of care, Thessaloniki follows a fragmented ‘non-system’ approach. Out of the 87 cases in Thessaloniki and the 49 cases in Stockholm who comprised the study population of STATSCIS, 75 and 42 cases respectively were successfully followed-up during the first year post-trauma. Significantly superior outcomes (that is, survival with neurological recovery, functional ability and discharge to home) and shorter LOS for initially motor complete cases occurred in Stockholm. Management routines known to increase long-term morbidity, for example, long-term tracheostomy and indwelling urethral catheters were significantly more common in Thessaloniki. Major medical complications, that is, multiple pressure ulcers, heterotopic ossification and bacteremia/sepsis were more frequent in Thessaloniki. Our findings show how two rather similar cohorts of TSCI manifest large discrepancies in terms of 1-year outcomes and complications, depending on the type of management they receive. As the major difference between regions was the presence or absence of a SCI system of care, rather than differences in availability of modern medicine, the mere presence of the latter does not seem to be sufficient to guarantee adequate outcomes. This study provides strong evidence as to the urgent need of implementing a SCI system of care in Greece.

Background Despite the extensive clinical use of oxcarbazepine for indications such as epilepsy, neuropathic pain and bipolar disorders, its' effects on corticomotor excitabilility have not been investigated in detail. We have recently shown that the main neurophysiological effect of the drug is an elevation of corticomotor threshold (Exp Brian Res). Whether this effect is mediated by the parent drug or its' metabolites is currently unknown.

Little is known about the possible impact of the system of care on mortality during the first year after acute traumatic spinal cord injury (TSCI).To evaluate late mortality (i.e.,7 days after trauma) during the first year after acute TSCI in 2 European Union (EU) regions, Thessaloniki in Greece and Stockholm in Sweden.This paper is part of the Stockholm Thessaloniki Acute Traumatic Spinal Cord Injury Study (STATSCIS), which is a prospective, population-based study. Incidence cohorts of TSCI cases were identified and followed up in both study regions through STATSCIS. Data from Thessaloniki region were collected through physical examination, medical records review, and interviews with TSCI individuals and the medical teams. Data from Stockholm were retrieved mainly from the Nordic Spinal Cord Injury Registry, as well as from direct contact with all intensive care facilities of the region.The annual case mortality rate after acute TSCI was nearly 20% in Thessaloniki and 0% in Stockholm. The mean time of survival after trauma for the 12 mortality cases of Thessaloniki was 47 days (median = 24, SD +/- 67, range = 8-228). Factors associated with mortality were higher age and presence of comorbid spinal disorders but also the inefficient transfer logistics, initially missed spinal instability, and unsuccessfully treated complications.The annual case mortality rate in Thessaloniki was dramatically higher than in Stockholm. The different approaches to care, one systematic and the other not, is postulated to be an important factor leading to such major discrepancies between the outcomes of these 2 EU regions.