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OBJECTIVE: To determine the potential longer-term effects of maternal antenatal respiratory syncytial virus (RSV) vaccination, we examined the association between cord-blood RSV-neutralizing antibodies (RSV-NA) and RSV infections in the first 2-years of life, RSV-NA at 3-years, and respiratory health to age 5-years. METHODS: Two community-based Australian birth cohorts were combined. For children with at least one atopic parent, paired serum RSV-NA levels were compared in cord-blood and at age 3-years. Weekly nasal swabs were collected in one cohort and during acute respiratory infections (ARI) in the other. Wheeze history up to age 5-years and physician-diagnosed asthma at 5-years was collected by parent report. RESULTS: In 264 children, each log10 increase of cord-blood RSV-NA level was associated with 37% decreased risk (adjusted incidence-rate-ratio (aIRR) 0.63; 95% confidence interval (CI): 0.40-1.01) of RSV-ARI and 49% decreased risk (aIRR 0.51; 95%CI: 0.25-1.02) of RSV acute lower respiratory infections (ALRI) at 12-24 months of age. However, higher cord-blood RSV-NA was associated with increased risk of all-cause ALRI (aIRR 1.29; 95%CI: 0.99-1.69), wheeze-associated ALRI (aIRR 1.75; 95%CI: 1.08-2.82) and severe ALRI (aIRR 2.76; 95%CI: 1.63-4.70) at age 6

There are few effective treatments for acute whiplash-associated disorders (WADs). Early features of central sensitisation predict poor recovery. The effect of pregabalin on central sensitisation might prevent chronic pain after acute whiplash injury. This double blind, placebo-controlled randomised controlled trial examined feasibility and potential effectiveness of pregabalin compared with placebo for people with acute WAD. Twenty-four participants with acute WAD (48 hours) and at risk of poor recovery (pain ≥5/10) were recruited from hospital emergency departments in Queensland, Australia, and randomly assigned by concealed allocation to either pregabalin (n = 10) or placebo (n = 14). Pregabalin was commenced at 75 mg bd, titrated to 300 mg bd for 4 weeks, and then weaned over 1 week. Participants were assessed at 5 weeks and 3, 6, and 12 months. Feasibility issues included recruitment difficulties and greater attrition in the placebo group. For the primary clinical outcome of neck pain intensity, attrition at 5 weeks was pregabalin: 10% and placebo: 36% and at 12 months was pregabalin: 10% and placebo: 43%. Pregabalin may be more effective than placebo for the primary clinical outcome of neck pain intensity at 3 months (mean difference: -4.0 [95% confidence interval -6.2 to -1.7]) on an 11-point Numerical Rating Scale. Effects were maintained at 6 months but not 12 months. There were no serious adverse events. Minor adverse events were more common in the pregabalin group. A definitive large randomised controlled trial of pregabalin for acute whiplash injury is warranted. Feasibility issues would need to be addressed with modifications to the protocol.

Background and aims Shift workers face an increased risk of cardiovascular disease (CVD), type-2 diabetes and obesity. Eating during the night is a likely contributing factor, as it coincides with the time at which postprandial metabolism is least efficient. In this pilot randomised crossover trial, we examine the effects of a short overnight fast on CVD risk markers (primarily postprandial triglyceride and glucose response) of night shift workers. Methods and results Night shift workers with abdominal obesity underwent 4-week intervention and control periods, separated by ≥ 2 weeks washout. In the intervention period, an overnight fast (0100 h–0600 h) was implemented, by redistributing 24-h energy intake. Usual dietary habits were followed in the control period. Outcomes between intervention and control were compared using mixed effects linear regression models. Nineteen adults completed the trial [13 females, mean (±SD) age 41 ± 10 years, BMI 30.7 ± 5.7 kg/m2]. Postprandial triglyceride and glucose response post intervention were not different to post control. The overnight fast was well-tolerated by participants with an adherence rate of 95%, assessed by weekly 24-h dietary recalls. Exploratory analysis indicates lower mean body weight post intervention compared to post control (mean difference: −0.9 kg, 95% CI: −1.3 to −0.4). Conclusions Night shift workers who habitually ate during their night shifts were able to rearrange their meal times to maintain a small overnight fast, which may have promoted small weight changes. This warrants further investigation into the role of meal timing in mitigating the metabolic consequences of night shift work. Trial registration Australian New Zealand Clinical Trials Registry (http://anzctr.org.au/) registered on the 30th May 2017 (ACTRN12617000791336).

Evaluate the validity of the Clinical Test of Sensory Integration of Balance (CTSIB) scored using Kids-Balance Evaluation Systems Test (Kids-BESTest) criteria compared to laboratory measures of postural control. Participants were 58 children, 7–18 years, 17 with ambulant cerebral palsy (CP) (GMFCS I–II), and 41 typically developing (TD). Postural control in standing was assessed using CTSIB items firm and foam surfaces, eyes open (EO) then closed (EC). Face validity was evaluated comparing clinical Kids-BESTest scores between groups. Correlating force plate centre-of-pressure (CoP) data and clinical scores allowed evaluation of concurrent and content validity. Face validity: TD children scored higher for all CTSIB conditions when compared to children with CP. Concurrent validity: the agreement between clinical and CoP derived scores was poor to excellent (Firm-EO = 76%, Firm-EC = 76%, Foam-EO = 59%, Foam-EC = 94%). Clinical scores of “2-unstable” and “3-stable” were not distinguished reliably by force plate measures. Content validity: significant correlations were found between clinical scores and CoP data for the two intermediate conditions (Firm-EC: rs −0.40 to −0.72; Foam-EO: rs −0.12 to −0.50), but not the easier (Firm-EO: rs −0.41 to −0.36) or harder conditions (Foam-EC: rs −0.25 to −0.27). Face validity of Kids-BESTest CTSIB criteria was supported. Content and concurrent validity were partially supported. Improved Kids-BESTest scoring terms were recommended to describe postural characteristics of “2-unstable.”IMPLICATIONS FOR REHABILITATIONFace validity of the Kids-BESTest criteria for the CTSIB was confirmed.The Kids-BESTest criteria for the CTSIB can identify children with atypical postural control.Concurrent validity and content validity were partially supported, since children with CP resorted to a range of different balance strategies when “unstable.”To improve CTSIB Kids-BESTest criteria, new terms were recommended to better describe postural characteristics of “2-unstable.” Face validity of the Kids-BESTest criteria for the CTSIB was confirmed. The Kids-BESTest criteria for the CTSIB can identify children with atypical postural control. Concurrent validity and content validity were partially supported, since children with CP resorted to a range of different balance strategies when “unstable.” To improve CTSIB Kids-BESTest criteria, new terms were recommended to better describe postural characteristics of “2-unstable.”

To examine interrater agreement and validity of the Functional Communication Classification System (FCCS) for young children with cerebral palsy (CP) aged 2 or 3 years.Speech-language pathologist (SLP) and parent FCCS ratings for 31 children with CP (aged 2y, n=16; aged 3y, n=15; 18 males, 13 females) were examined for interrater agreement using a weighted Cohen's kappa statistic. Relationships between FCCS (SLP) ratings and: (1) concurrent validity with the Language Use Inventory, a standardized pragmatic assessment for children aged 18 to 47 months, (2) gross motor and fine motor function, (3) associated impairments (visual and intellectual), and (4) primary expressive communication mode were examined using Spearman's correlation coefficients.Almost perfect interrater agreement between SLP and parent FCCS ratings were found (kThe FCCS has excellent interrater agreement and validity for communication classification of children with CP aged 2 or 3 years and is highly suitable for surveillance and research purposes. What this paper adds The Functional Communication Classification System (FCCS) is a valid instrument for children with cerebral palsy (CP) aged 2 or 3 years. Excellent agreement exists between speech-language pathologist and parent FCCS ratings. The FCCS has excellent correlation with intelligence, pragmatic function, and primary expressive mode. Stronger correlations with the Gross Motor Function Classification System and vision exist for children aged 2 or 3 years. Weaker correlations with manual ability exist when compared to older children with CP.

Respiratory syncytial virus (RSV) is the most common virus identified in children hospitalised with acute respiratory infections. However, less is known about RSV in community settings. This report describes RSV epidemiology in the community, including acute illness episodes, healthcare burden, and risk factors in Australian children during the first 2-years of life. A community-based, birth cohort from Brisbane, Australia, followed children until their second birthday. Parents completed daily respiratory symptom and illness-burden diaries. Weekly parent-collected nasal swabs were analysed for RSV by real-time polymerase chain reaction assays. Serum RSV-neutralising antibodies were assayed at age 3 years. Overall, 158 children provided 11,216 swabs, of which 104 were RSV-positive (85 incident episodes). RSV incidence in the first 2 years of life was 0.46 (95% CI = 0.37-0.58) episodes per child-year. Incidence increased with age and formal childcare attendance and was highest in autumn. Of 82 episodes linked with symptom data, 60 (73.2%) were symptomatic, 28 (34.1%) received community-based medical care, and 2 (2.4%) led to hospitalisation. Viral load was higher in symptomatic than asymptomatic infections. In 72 children, RSV-specific antibody seroprevalence was 94.4% at age 3 years.Conclusion: RSV incidence increased after age 6-months with approximately three-quarters of infections symptomatic and most infections treated in the community. What is known •RSV is a major cause of hospitalisation for acute lower respiratory infections in infants and young children, especially in the first 6 months of life. •However, limited data exist on the overall burden in young children at the community level. What is new •RSV incidence in the community increases after age 6 months, and by 3 years, most children have been infected. •About one-quarter of RSV infections were asymptomatic in children aged < 2 years, and approximately 60% of children with RSV-related symptoms had a healthcare contact of any kind with most managed within the community.

Background We explored the nasal microbiota in Indigenous Australian children in relation to ear and nasal health. Methods In total, 103 Indigenous Australian children aged 2–7 years (mean 4.7 years) were recruited from 2 Queensland communities. Children’s ears, nose, and throats were examined and upper respiratory tract (URT) swabs collected. Clinical histories were obtained from parents/medical records. URT microbiota were characterized using culturomics with Matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) identification. Real-time PCR was used to quantify otopathogen (Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis) loads and detect respiratory viruses. Data were analyzed using beta diversity measures, regression modeling, and a correlation network analysis. Results Children with historical/current otitis media (OM) or URT infection (URTI) had higher nasal otopathogen detection and loads and rhinovirus detection compared with healthy children (all P < .04). Children with purulent rhinorrhea had higher nasal otopathogen detection and loads and rhinovirus detection (P < .04) compared with healthy children. High otopathogen loads were correlated in children with historical/current OM or URTI, whereas Corynebacterium pseudodiphtheriticum and Dolosigranulum pigrum were correlated in healthy children. Conclusions Corynebacterium pseudodiphtheriticum and D. pigrum are associated with URT and ear health. The importance of the main otopathogens in URT disease/OM was confirmed, and their role relates to co-colonization and high otopathogens loads.

Background Following high influenza activity in 2017, the state of Queensland, Australia, funded a quadrivalent inactivated influenza vaccination program for children aged 6 months to Methods A matched case-control study was conducted. Cases were identified using Queensland 2018 influenza notification data among children age-eligible for funded vaccination. Controls were drawn from Australian Immunisation Register records of Queensland resident children age-eligible for funded influenza vaccine. Up to 10 controls per case were matched for location and birthdate. First dose vaccination was valid if received ≥14 days prior to specimen collection; a second dose was valid if received ≥28 days after first dose receipt. VE was calculated for vaccine doses and adherence to national recommendations for two doses in the first season (schedule completeness) and adjusted (VEadj) for sex and First Nations status. Results There were 1,125 cases and 10,645 matched controls analysed. Overall VEadj against laboratory-confirmed influenza was 51% (95% confidence interval (CI) 41–60). VEadj was 60% (95% CI 46–70) for children who received two doses in 2018, and 60% (95% CI 48–69) for children vaccinated appropriately according to schedule completeness. VE increased with age. Conclusions Moderate vaccine effectiveness was observed for children eligible for the funded program in Queensland in 2018, adding to the sparse evidence for influenza vaccine use in Australian children. Adhering to the national first season two dose schedule for influenza vaccine receipt in children ensures maximum protection.

Background: In comparison to the general population, people who are homeless have poorer health and health-related outcomes, including for vaccine-preventable diseases. Vaccination is safe, effective and cost-effective, and many vaccination guidelines specifically recommend vaccination in people who are homeless. This systematic review will identify interventions which are effective in delivering vaccination to, and/or at improving vaccination rates in, people who are homeless. Methods/Design: This systematic review is presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches will be undertaken on eight electronic databases, using combinations of search terms and subject headings or index terms. Citation chaining will also be undertaken. Literature will be screened for relevance against inclusion/exclusion criteria firstly by title/abstract and secondly by full text. The selected studies will be assessed for quality using an evidence-based tool appropriate to their methods. Data relevant to the topic will be extracted and examined using meta-analysis and narrative synthesis. Discussion: This systematic review will address an important gap in the literature about vaccination in people who are homeless. The review’s findings are particularly relevant considering the current coronavirus disease (COVID-19) pandemic, which is likely to be managed through vaccination.

Nutrition assessment is multidimensional; however, much of the literature examining the nutritional status of children with cerebral palsy (CP) focuses on a single dimension.The aim of the study was to evaluate nutritional status in children and adolescents with CP by comparing results from the Pediatric Subjective Global Nutrition Assessment (SGNA) with results from traditional anthropometric measures.This study was a cross-sectional observational study.This study was conducted in a tertiary hospital outpatient setting in Brisbane, Australia, from February 2017 to March 2018. A total of 89 children (63 boys) with CP aged between 2 and 18 years of age were included. All Gross Motor Function Classification System levels were observed. The majority of children were in Gross Motor Function Classification System I and II (57, 64%) compared with Gross Motor Function Classification System III to V (32, 36%). Children with feeding tubes and those acutely unwell or hospitalized were excluded.Children were classified as well nourished, moderately malnourished, or severely malnourished by dietitians using the SGNA. Weight, height, body mass index (BMI), triceps skinfold thickness, subscapular skinfold thickness, and mid upper arm circumference were measured and converted to z scores to account for age and sex differences. Moderate malnutrition was defined by z scores -2.00 to -2.99 and severe malnutrition as ≤-3.00 z scores.Multinomial logistic analyses were used to compare results from the SGNA and each single measurement. Continuous outcomes were transformed into z scores. Agreement was assessed with 2 categories: not malnourished and malnourished. Comparison statistics included percent agreement, sensitivity, and specificity.More children were classified as moderately or severely malnourished by SGNA than any of the anthropometric z score cutoffs. The majority of children were well nourished (n = 63) with 20 (22%) moderately malnourished and 6 (7%) severely malnourished by SGNA. The SGNA classified 11 children as malnourished that were not classified as malnourished by BMI. Children with moderate or severe malnutrition by SGNA had lower weight (P.001, P.001), BMI (P.001, P.001), mid upper arm circumference (P.001, P.001), triceps skinfold thickness (P = .01, P = .007), and subscapular skinfold thickness (P = .005, P = .02) z scores than well-nourished children.The SGNA identified more potentially malnourished children including children classified as well nourished by the single measurements such as BMI, height, and weight. The SGNA provided a clinically useful multidimensional approach to nutrition assessment for children with CP.

AIM To describe development of gross motor capacity and mobility performance in children with cerebral palsy. METHOD This longitudinal cohort study measured gross motor capacity with the Gross Motor Function Measure and mobility performance with the Pediatric Evaluation of Disability Inventory (PEDI) between 18 months and 5 years, and the PEDI - Computer Adaptive Test (PEDI-CAT) between 8 years and 12 years. Longitudinal analyses used mixed-effects regression modelling with interaction between age and Gross Motor Function Classification System (GMFCS). Stability of GMFCS levels over time was measured using agreement. RESULTS Two hundred and twenty-two children provided 871 observations (median 4 observations, range 1-7). Children classified in GMFCS level I improved in both capacity and performance until 8 to 12 years. Children classified in GMFCS levels II and III continued to develop mobility performance after gross motor capacity had plateaued at 5 years. Children classified in GMFCS level IV plateaued at 5 years in capacity and performance. Children classified in GMFCS level V showed no changes in capacity or performance between 18 months and 8 to 12 years. Stability of GMFCS levels was 73%. INTERPRETATION Change in mobility performance over time somewhat reflected gross motor capacity trajectories. Continued improvement in mobility performance after plateau of gross motor capacity for children classified in GMFCS levels II and III suggests importance of other personal or environmental factors.

Limited evidence exists on the effects of weight loss on chronic disease risk and patient-reported outcomes in breast cancer survivors. Breast cancer survivors (stage I-III, body mass index 25–45 kg/m2) were randomized to a 12-month, remotely delivered (22 telephone calls, mailed material, optional text messages) weight loss (diet and physical activity) intervention (n = 79) or usual care (n = 80). Weight loss (primary outcome), body composition, metabolic syndrome risk score and components, quality of life, fatigue, musculoskeletal pain, menopausal symptoms, fear of recurrence, and body image were assessed at baseline, 6 months, 12 months (primary endpoint), and 18 months. Participants were 55 ± 9 years and 10.7 ± 5.0 months post-diagnosis, retention was 81.8% (12 months) and 80.5% (18 months). At 12-months, intervention participants had significantly greater improvements in weight (−4.5% [95%CI: −6.5,−2.5], p &lt, 0.001), fat mass (−3.3 kg [−4.8,−1.9], 0.001), metabolic syndrome risk score (−0.19 [−0.32,−0.05], p = 0.006), waist circumference (−3.2 cm [−5.5,−0.9], p = 0.007), fasting plasma glucose (−0.23 mmol/L [−0.44,−0.02], p = 0.032), physical quality of life (2.7 [0.7,4.6], p = 0.007, Cohen’s effect size (d) = 0.40), musculoskeletal pain (−0.5 [−0.8,−0.2], p = 0.003, d = 0.49), and body image (−0.2 [−0.4,−0.0], p = 0.030, d = 0.31) than usual care. At 18 months, effects on weight, adiposity, and metabolic syndrome risk scores were sustained, however, significant reductions in lean mass were observed (−1.1 kg [−1.7,−0.4], 0.001). This intervention led to sustained improvements in adiposity and metabolic syndrome risk.

Background: Data on the health of adolescents with intellectual disability are scarce. This study describes carer-reported symptoms, chronic illnesses, level of functioning, and behaviour among Australian adolescents with intellectual disability. We compare students attending mainstream and special schools. Methods: Cross-sectional questionnaire data were obtained from a cohort of 592 adolescents (10–21 years) with intellectual disability attending school and living in South-East Queensland, Australia, in May 2007. We analysed data from a subset (176) who completed a health check before visiting their general practitioners. Results: Adolescents had significant health needs, and those in special education schools had worse health than those from mainstream schools. There was a discrepancy between the prevalence of significant psychopathology detected via the short form Developmental Behaviour Checklist (DBC-P24) and psychiatric conditions reported by carers. Conclusions: Given the significant health needs of this population, carefully designed and targeted programs, potentially including medical visits to these schools, are needed.

The timing and nature of initial infections by potentially vaccine-preventable gastrointestinal viruses (group-F adenoviruses, classic human astrovirus, norovirus I/II, and sapovirus I/II/IV/V) was investigated in a community-based birth cohort. Weekly stool samples were collected from 158 children aged2 years in an Australian subtropical city. Median age at initial infection was lowest for norovirus II (13.8 months) followed by sapovirus (14.3 months) and classic human astrovirus (17.6 months), and was24 months for the remaining viruses. Norovirus II and sapovirus were most often associated with acute gastroenteritis symptoms (57% and 44%, respectively). Overall, healthcare was sought for 45% of symptomatic initial infections, which varied between 17% for norovirus I to 55% for norovirus II. Age at initial infection was lower when participants were exposed to other children. Norovirus II and sapovirus were the most important pathogens in this cohort, providing further evidence for them being priority targets for vaccine development.

Background Establishing worldwide incidence of general surgical site infections (SSI) is imperative to understand the extent of the condition to assist decision-makers to improve the planning and delivery of surgical care. This systematic review and meta-analysis aimed to estimate the worldwide incidence of SSI and identify associated factors in adult general surgical patients. Materials and methods A systematic review was undertaken using MEDLINE (Ovid), CINAHL (EBSCO), EMBASE (Elsevier) and the Cochrane Library to identify cross-sectional, cohort and observational studies reporting SSI incidence or prevalence. Studies of less than 50 participants were excluded. Data extraction and quality appraisal were undertaken independently by two review authors. The primary outcome was cumulative incidence of SSI occurring up to 30 days postoperative. The secondary outcome was the severity/depth of SSI. The I2 statistic was used to explore heterogeneity. Random effects models were used in the presence of substantial heterogeneity. Subgroup, meta-regression sensitivity analyses were used to explore the sources of heterogeneity. Publication bias was assessed using Hunter's plots and Egger's regression test. Results Of 2091 publications retrieved, 62 studies were included. Of these, 57 were included in the meta-analysis across six anatomical locations with 488,594 patients. The pooled 30-day cumulative incidence of SSI was 11% (95% CI 10%–13%). No prevalence data were identified. SSI rates varied across anatomical location, surgical approach, and priority (i.e., planned, emergency). Multivariable meta-regression showed SSI is significantly associated with duration of surgery (estimate 1.01, 95% CI 1.00–1.02, P = .014). Conclusions and Relevance: 11 out of 100 general surgical patients are likely to develop an infection 30 days after surgery. Given the imperative to reduce the burden of harm caused by SSI, high-quality studies are warranted to better understand the patient and related risk factors associated with SSI.

Refereed/Peer-reviewed This is a protocol for a Cochrane Review (intervention). The objectives are as follows: to assess the benefits and harms of interventions for Morton's neuroma.

Objective: The longer-term effectiveness of silicone and pressure burn scar interventions was evaluated at 12-months postburn. Design: Parallel group, randomised trial. Setting: Hospital outpatient clinics, research centre. Participants: Children referred for burn scar management following grafted or spontaneously healed acute burn injuries or scar reconstruction surgery. Interventions: Participants were randomised to: (1) topical silicone gel only, (2) pressure garment only, or (3) combined topical silicone gel and pressure garment. Main measures: Primary outcomes were scar thickness (blinded ultrasound measurement) and itch intensity (caregiver proxy-report, numeric rating scale). Results: Of 153 participants randomised who received the interventions (silicone n = 51, pressure garment n = 49, combined n = 53), 86 were followed-up at 12-months postburn ( n = 34, n = 28, n = 24). No differences were identified for the primary outcomes using intention-to-treat analysis. Scar thickness mean difference (95% confidence interval) = 0.00 cm (−0.04, 0.05); −0.03 cm (−0.07, 0.02); 0.03 cm (−0.02, 0.08) and scar itch = 0.09 (−0.88, 1.06); −0.21 (−1.21, 0.79); 0.30 (−0.73, 1.32) for silicone vs pressure; silicone vs combined and combined vs pressure respectively. No serious adverse effects occurred. Conclusion: Similar to short-term results, the combined intervention offered no statistically or clinically significant benefit for improving the primary outcomes compared to each intervention alone. No differences in the primary outcomes were identified between the silicone and pressure alone groups.

Recurrent vulvovaginal candidiasis (RVVC) is a subtype of vulvovaginal candidiasis, with debilitating effects on physical and emotional well-being affecting up to 10% of Australian women. Current evidence suggests that the induction and maintenance approach for RVVC is not particularly effective with post-treatment relapse rates as high as 57%. Frequently accessed Australasian RVVC prescribing resources and guidelines were examined showing a variety of adaptations of current evidence-based induction and maintenance therapies, making it difficult to select best treatment in clinical practice. The ways to introduce more clarity and consistency into these guidelines are outlined.

IntroductionUsing patient-reported outcome measures (PROMs) with children have been described as ‘giving a voice to the child’. Few studies have examined the routine use of these measures as potentially therapeutic interventions. This study aims to investigate: (1) the effectiveness of feedback using graphical displays of information from electronic PROMs (ePROMs) that target health-related quality of life, to improve health outcomes, referrals and treatment satisfaction and (2) the implementation of ePROMs and graphical displays by assessing acceptability, sustainability, cost, fidelity and context of the intervention and study processes.Methods and analysisA hybrid II effectiveness-implementation study will be conducted from February 2020 with children with life-altering skin conditions attending two outpatient clinics at a specialist paediatric children’s hospital. A pragmatic randomised controlled trial and mixed methods process evaluation will be completed. Randomisation will occur at the child participant level. Children or parent proxies completing baseline ePROMs will be randomised to: (1) completion of ePROMs plus graphical displays of ePROM results to treating clinicians in consultations, versus (2) completion of ePROMs without graphical display of ePROM results. The primary outcome of the effectiveness trial will be overall health-related quality of life of children. Secondary outcomes will include other health-related quality of life outcomes (eg, child psychosocial and physical health, parent psychosocial health), referrals and treatment satisfaction. Trial data will be primarily analysed using linear mixed-effects models; and implementation data using inductive thematic analysis of interviews, meeting minutes, observational field notes and study communication mapped to the Consolidated Framework for Implementation Research.Ethics and disseminationEthical approval was obtained from Children’s Health Queensland Human Research Ethics Committee (HREC/2019/QCHQ/56290), The University of Queensland (2019002233) and Queensland University of Technology (1900000847). Dissemination will occur through stakeholder groups, scientific meetings and peer-reviewed publications.Trial registration numberAustralian New Zealand Clinical Trials Registry (ACTRN12620000174987).

IntroductionPeripherally inserted central catheters (PICCs) are vital for the delivery of medical therapies, but up to 30% of PICCs are associated with complications such as deep vein thrombosis or infection. The integration of antimicrobial and hydrophobic catheter materials, and pressure-activated valves, into polyurethane PICCs are innovations designed to prevent infective and/or thrombotic complications.Methods and analysisA multicentre, parallel group, superiority randomised controlled trial with two experimental arms ((1) hydrophobic PICC (with pressure-activated valve); (2) chlorhexidine gluconate-impregnated PICC (with external clamp)) and one control group ((3) conventional polyurethane PICC (with external clamp)). Recruitment of 1098 adult and paediatric patients will take place over 2 years at three tertiary-referral hospitals in Queensland, Australia. Patients are eligible for inclusion if their PICC is to be inserted for medical treatment, with a vascular size sufficient to support a 4-Fr PICC or larger, and with informed consent. The primary outcome is PICC failure, a composite of thrombotic (venous thrombosis, breakage and occlusion) and infective complications (PICC-associated bloodstream infection and local infection). Secondary outcomes include: all-cause PICC complication; thrombotic complications; infective complications; adverse events (local or systemic reaction); PICC dwell time; patient/parent satisfaction; and healthcare costs. Differences between both intervention groups and the control group will be compared using Cox proportional hazards regression. Effect estimates will be presented as HRs with corresponding 95% CI.Ethics and disseminationEthical approval from Queensland Health (HREC/QCHQ/48682) and Griffith University (Ref. No. 2019/094). Results will be published.Trial registration numberACTRN12619000022167.

BACKGROUND: Longitudinal data on medication use in adults with intellectual disability (ID) are scarce. We describe the longitudinal use of and factors associated with psychotropic medication prescribing in adults with ID living in the Australian community. METHODS: Longitudinal data were obtained from adults with ID in the community in Queensland, Australia, between 1999 and 2015. Participant characteristics and medication use information were extracted from baseline questionnaires and health check booklets. Logistic regression was used to investigate the associations between participant characteristics and psychotropic medication use, commencement or cessation. RESULTS: Longitudinal data were available for 138 participants on 697 reviews. The proportion of participants prescribed psychotropic medications increased from 43% to 54% between 1999 and 2015. The rates of commencement and cessation of psychotropic medications between consecutive time periods ranged from 9% to 18% and 7% to 15%, respectively. Challenging behaviour was associated with psychotropic medication use (adjusted odds ratio = 4.1; 95% confidence interval: 2.1-7.9). Presence of challenging behaviour, either consistent or newly identified, was positively associated with ongoing use or commencement of psychotropic medications. CONCLUSIONS: Psychotropic medications are commonly prescribed to adults with ID. Challenging behaviour is positively associated with ongoing use and commencement.

Summary Background Bronchiectasis guidelines recommend antibiotics for the treatment of acute respiratory exacerbations, but randomised placebo-controlled trials in children are lacking. We hypothesised that oral amoxicillin–clavulanate and azithromycin would each be superior to placebo in achieving symptom resolution of non-severe exacerbations in children by day 14 of treatment. Methods In this multicentre, three-arm, parallel, double-dummy, double-blind, randomised placebo-controlled trial at four paediatric centres in Australia and New Zealand, we enrolled children aged 1–18 years with CT-confirmed bronchiectasis unrelated to cystic fibrosis, who were under the care of a respiratory physician and who had had at least two respiratory exacerbations in the 18 months before study entry. Participants were allocated (1:1:1) at exacerbation onset to receive oral suspensions of amoxicillin–clavulanate (45 mg/kg per day) plus placebo azithromycin, azithromycin (5 mg/kg per day) plus placebo amoxicillin–clavulanate, or both placebos for 14 days. An independent statistician prepared a computer-generated, permuted-block (size 2–8) randomisation sequence, stratified by centre, age, and cause. Participants, caregivers, study coordinators, and investigators were masked to treatment assignment until data analysis was completed. The primary outcome was the proportion of children with exacerbation resolution by day 14 in the intention-to-treat population. Treatment groups were compared using generalised linear models. Statistical significance was set at p

Background: Pregnant women and infants

Vertical transmission from mother-to-child is an important mode of hepatitis B virus (HBV) infection, accounting for up to half of all incident cases globally. We evaluated the uptake of HBV neonatal vaccination and immunoglobulin delivery in Queensland, Australia, between 2001 and 2013. We identified HBV-positive mothers using linked notifiable conditions, hospitalisation, and perinatal administrative data. Perinatal receipt of monovalent HBV vaccine and hepatitis B immunoglobulin were examined. Of 710,859 live births, with 5753 infants (0.81%) born to identified HBV-positive mothers; 91.7% received HBV neonatal vaccine. Immunoglobulin uptake was 20.0% in 2012 and 36.6% in 2013. Uptake was higher when the mother's HBV-positive status was recorded in perinatal records (69.6% if maternal HBV status recorded on perinatal data collection vs 9.5% otherwise). Delivery of neonatal HBV vaccination in Queensland was high. Improved identification and documentation of HBV-positive mothers' status during the antenatal period was associated with increased immunoglobulin administration.

Objective To evaluate the reproducibility, including reliability and agreement, of the Kids Balance Evaluation Systems Test (Kids-BESTest) and the short form of Kids-BESTest (Kids-Mini-BESTest) for measuring postural control in school-aged children with cerebral palsy. Design Psychometric study of intrarater, interrater, and test-retest reliability and agreement. Setting Clinical laboratory and home. Participants Convenience sample of children (N=18) aged 8 to 17 years with ambulant cerebral palsy (CP) (Gross Motor Function Classification System I-II) with spastic or ataxic motor type. Intervention Not applicable. Main Outcome Measures Postural control was assessed using the Kids-BESTest and the Kids-Mini-BESTest. An experienced physiotherapist assessed all children in real time and the testing session was videotaped. The same physiotherapist viewed and scored the video twice, at least 2 weeks apart, to assess intrarater reproducibility. Another experienced physiotherapist scored the same video to determine interrater reproducibility. Thirteen children returned for a repeat assessment with the first physiotherapist within 6 weeks and their test-retest performance was rated in real time and with video. Results Excellent reliability was observed for both the Kids-BESTest (intraclass correlation coefficient [ICC] 0.96-0.99) and Kids-Mini-BESTest (ICC 0.79-0.98). The smallest detectable change was good to excellent for all Kids-BESTest agreement analyses (5%-9%), but poor to good for Kids-Mini-BESTest analyses (9%-16%). Conclusion The Kids-BESTest shows an excellent ability to discriminate postural control abilities of school-aged children with CP and it has a low smallest detectable change, suitable for use as a preintervention and postintervention outcome measure. Although the Kids-Mini-BESTest is 5 to 10 minutes shorter to administer, it has poorer reproducibility and focuses only on falls-related balance, which excludes 2 domains of postural control.

Aim To develop and validate a screening tool for feeding/swallowing difficulties and/or undernutrition in children with cerebral palsy (CP). Method This cross‐sectional, observational study included 89 children with CP (63 males, 26 females; median age 6y 0mo; interquartile range 4y 0mo–8y 11mo), across all Gross Motor Function Classification System levels. Children with feeding tubes were excluded. Children were classified as well‐nourished or moderately to severely undernourished, using the paediatric Subjective Global Nutrition Assessment. Eating and drinking abilities were classified using the Eating and Drinking Ability Classification System (EDACS) from mealtime observation and videofluoroscopic swallow studies when indicated. Parents/caregivers answered 33 screening questions regarding their child's feeding/swallowing abilities and nutritional status. The diagnostic ability of each question for identifying children with feeding/swallowing difficulties and undernutrition was calculated and the combination of questions with the highest sensitivity and specificity identified. Results Feeding difficulties impacted on swallow safety in 26 children (29%) and 26 children (29%) were moderately or severely undernourished. The 4‐item final tool had high sensitivity and specificity for identifying children with feeding/swallowing difficulties (81% and 79% respectively) and undernutrition (72% and 75% respectively). The tool successfully identified 100 per cent of children with severe undernutrition and 100 per cent of those classified as EDACS level IV or V. Interpretation Screening for feeding/swallowing difficulties and undernutrition will enable early identification, assessment, and management for those children in need. What this paper adds A screening tool with high sensitivities and specificities for identifying children with feeding/swallowing difficulties and undernutrition.The tool identified 100 per cent of children with severe undernutrition.The tool identified 100 per cent of children in Eating and Drinking Ability Classification System levels IV or V., What this paper adds A screening tool with high sensitivities and specificities for identifying children with feeding/swallowing difficulties and undernutrition.The tool identified 100 per cent of children with severe undernutrition.The tool identified 100 per cent of children in Eating and Drinking Ability Classification System levels IV or V. This article's abstract has been translated into Spanish and Portuguese. Follow the links from the http://onlinelibrary.wiley.com/doi/10.1111/dmcn.14220/abstract to view the translations.

Background There is a limited body of literature exploring referral relationships between general dental practitioners and periodontists. Clinical and non-clinical factors associated with the referral process are rarely considered however a better understanding of these will improve the general dentist practitioner and periodontal specialist relationship and benefit patient management. This study investigated which non-clinical factors have an association with the referral of patients by general dental practitioners to periodontists in Tasmania, Australia. Methods A questionnaire was emailed to registered general dental practitioners in Tasmania, Australia and information collected on demographics, referral patterns, and potential factors which may influence referral. Results Response rate was 44.5%. Non-clinical factors that influenced referral were previous treatment by a periodontist (70.8%), a complex medical history (56.8%), the patient's reluctance to undergo periodontal treatment, medico-legal reasons, patient awareness of periodontal disease (47.3%), and lack of training (43.2%). Patients frequently declined periodontal referral due to cost (66.2%), oral health not being a priority (55.4%), or inconvenience (46.6%). The most important periodontist qualities were their reputation (84.0%), patient feedback (81.3%), ease of communication (72.0%), report quality (68.0%), and location (62.7%). Conclusion Non-clinical factors, such as practice type-, general dental practitioner-, patient-, periodontist-related factors are associated with referral by general dental practitioners to periodontists for periodontal management.

Background Most acute respiratory infection (ARI) research focuses on severe disease and overlooks the burden of community-managed illness. For community-based studies, home-based specimen collection by parents could be a resource-saving alternative to collection by healthcare workers (HCWs). In this study, we compared parent and HCW groups for their likelihood to collect specimens and the timeliness and quality of such collection. Methods In this unblinded randomized controlled trial, parents from Brisbane, Australia, were taught to identify new ARI episodes in their children aged, Parents and HCWs obtained samples in similar proportions of ARI episodes, but the parents collected the samples fewer days after ARI onset and with a resulting higher likelihood of pathogen identification.

To examine the stability over time of the Manual Ability Classification System (MACS) levels in children with cerebral palsy (CP) aged 18 to 60 months.This was a prospective longitudinal population-based study of 252 Australian children (160 males [63%] 92 females [37%]; mean age [SD] 41.7mo [14], range 17.2mo-69.2mo) with CP. Children were classified at 18 months (n=70), 24 months (n=131), 30 months (n=173), 36 months (n=209), 48 months (n=226), and 60 months (n=221) of age. Stability of the MACS was examined using the proportion of specific positive agreement and transition proportions, which are measures of agreement.There were 1030 unique observations, with each of the 252 participants seen between two and six occasions (median=4). Average specific positive agreement over the study period was 76% for MACS level I, 67% for level II, 50% for level III, 51% for level IV, and 83% for level V. MACS levels I and V have the highest degree of stability, while levels III and IV have the lowest. We show how this may be explained by the proportion of children in each MACS level.Using measures of agreement rather than measures of reliability provides accurate information when measuring stability over time of an ordinal classification system. The relative stability of MACS levels can be explained by the proportion of children in each level.Children classified in Manual Ability Classification System (MACS) levels III and IV change levels at next assessment about 50% of the time. Children should be assessed with the MACS regularly, particularly those in levels III and IV. Stability within ordinal classification level categories can be predicted using a measurement error model. Transition proportions or specific agreement is recommended for reporting stability of ordinal classification systems.Estabilidade do Sistema de Classificação da Habilidade Manual (MACS) em crianças jovens com paralisia cerebral OBJETIVO: Examinar a estabilidade ao longo do tempo dos níveis do Sistema de Classificação da Habilidade Manual (MACS) em crianças com paralisia cerebral (PC) com idade entre 18 e 60 meses. MÉTODO: Este foi um estudo prospectivo de caráter longitudinal, com amostra baseada no estudo da população de 252 crianças Australianas (160 meninos [63%], 92 meninas [37%]; idade média [desvio padrão] de 41,7 meses [14], variação de 17, 2 a 69, 2 meses de idade]) com PC. As crianças foram classificadas aos 18 meses (n = 70), 24 meses (n = 131), 30 meses (n = 173), 36 meses (n = 209), 48 meses (n = 226), e aos 60 meses (n = 221) de idade. A estabilidade do MACS foi examinada utilizando a proporção de concordância positiva específica e proporções de transição, sendo estas as medidas de concordância. RESULTADOS: Foram realizadas um total de 1.030 observações com os 252 participantes, os quais foram avaliados individualmente entre dois e seis momentos (média = 4). A média de concordância específica positiva durante o estudo foi de 76% para MACS nível I, 67% para nível II, 50% para nível III, 51% para nível IV, e 83% para nível V. Os classificados com MACS nível I e V tiveram os maiores graus de estabilidade, enquanto os classificados com os níveis III e IV tiveram os menores graus de estabilidade. Estes resultados podem ser explicados pela proporção de crianças classificadas em cada nível do MACS. INTERPRETAÇÃO: A utilização de medidas de concordância ao invés de medidas de confiabilidade proporciona informações mais precisas quando se mensura estabilidade ao longo do tempo com um sistema de classificação ordinal. A estabilidade relativa dos níveis do MACS pode ser explicada pela proporção de crianças classificadas em cada nível.Estabilidad del Sistema de Clasificación de Habilidad Manual (MACS) en niños pequeños con parálisis cerebral OBJETIVO: Examinar la estabilidad en el tiempo de los niveles del Sistema de Clasificación de Habilidad Manual (MACS) en niños con parálisis cerebral (PC) de 18 a 60 meses. MÉTODO: Este fue un estudio prospectivo longitudinal basado en la población de 252 niños australianos (160 [63%] hombres, 92 mujeres [37%]; edad media [DE] 41.7mo [14], rango 17.2mo-69.2mo]) con PC. Los niños se clasificaron a los 18 meses (n = 70), 24 meses (n = 131), 30 meses (n = 173), 36 meses (n = 209), 48 meses (n = 226) y 60 meses (n = 221) de edad. La estabilidad del MACS se examinó utilizando la proporción de acuerdo positivo específico y las proporciones de transición, que son medidas de acuerdo. RESULTADOS: Con cada uno de los 252 participantes vistos entre dos y seis ocasiones (mediana = 4) hubo 1030 observaciones únicas. La concordancia positiva específica promedio durante el período de estudio fue de 76% para MACS nivel I, 67% para nivel II, 50% para nivel III, 51% para nivel IV y 83% para nivel V. Los niveles I y V de MACS son los más altos de estabilidad, mientras que los niveles III y IV tienen los más bajos. Mostramos cómo esto puede explicarse por la proporción de niños en cada nivel de MACS. INTERPRETACIÓN: El uso de medidas de acuerdo - en lugar de medidas de confiabilidad - proporciona información precisa cuando se mide la estabilidad en el tiempo de un sistema de clasificación ordinal. La estabilidad relativa de los niveles de MACS puede explicarse por la proporción de niños en cada nivel.

Background Most respiratory bacterial carriage studies in children are based on cross‐sectional samples or longitudinal studies with infrequent sampling points. The prospective Observational Research in Childhood Infectious Diseases birth cohort study intensively evaluated the community‐based epidemiology of respiratory viruses and bacteria during the first 2‐years of life. Here we report the bacteriologic findings. Methods Pregnant women in Brisbane, Australia were recruited between September 2010 and October 2012, and their healthy newborn children were followed for the first 2‐years of life. Parents kept a daily symptom diary for the study child, collected a weekly anterior nose swab and completed an illness burden diary when their child met pre‐defined illness criteria. Specimens were tested for respiratory bacteria by real‐time polymerase chain reaction (PCR) assays and those containing human genomic DNA, deemed as high‐quality, were analyzed. Results Altogether 8100 high‐quality nasal swab specimens from 158 enrolled children were analyzed. Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae were detected in 42.4%, 38.9%, and 14.8% of these samples, respectively. Concomitant detection of bacteria was common. In contrast, Bordetella pertussis, B. parapertussis, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Simkania negevensis were rarely identified. The prevalence of the three major bacteria was higher with increasing age and in the winter and spring months. Siblings and childcare attendance were the other risk factors identified. Conclusions We confirmed the feasibility of frequent nasal swabbing by parents for studying bacterial colonization. PCR detected the major respiratory tract bacteria with expected high frequencies, but atypical bacteria were found rarely in this cohort.

Background Burns are a painful and traumatic experience, particularly in children. Reduced pain and anxiety positively influences re-epithelialisation rates in paediatric burn patients, however current literature fails to fully explain the effects of pain and anxiety and their links with wound healing. This study will determine if Burnaid® hydrogel dressing is an effective treatment for reducing pain in the acute period of a burn injury. It is hypothesised that a reduction in pain will then improve re-epithelialisation time in comparison to plastic wrap, which is standard practice at our institution — a metropolitan tertiary paediatric hospital located in Brisbane, Australia. Methods/design A randomised controlled trial will be conducted to assess the effectiveness of Burnaid® as an analgesic adjunct to cold running water first aid for the treatment of paediatric burns. Participants will include children aged between 0 and 16 years with an acute thermal burn injury (total burn surface area

Background Otitis media (OM) imposes a great burden of disease in indigenous populations around the world, despite a variety of treatment and prevention programs. Improved understanding of the pathogenesis of OM in indigenous populations is required to advance treatment and reduce prevalence. We conducted a systematic review of the literature exploring the upper airway and middle ear microbiota in relation to OM in indigenous children. Methods Papers targeting microbiota in relation to OM in children

To describe longitudinal development of self-care and its relationship to manual ability in children with cerebral palsy (CP) aged 18 months to 5 years across all functional abilities.This was a prospective longitudinal population-based study of 290 children with CP (178 [61%] males, 112 [39%] females). Self-care was assessed using the Pediatric Evaluation of Disability Inventory (PEDI). At 60 months (n=242), children were classified using the Manual Ability Classification System (MACS); 113 in level I (47%), 61 in MACS level II (25%), 24 in MACS level III (10%), 14 in MACS level IV (6%), and 30 in MACS level V (12%). Measures were taken at 18 months, 24 months, 30 months, 36 months, 48 months, and 60 months of age. Longitudinal analyses were performed using mixed-effects linear regression models.Self-care development achieved by 60 months was negatively associated with the severity of manual ability impairment. Distinct self-care developmental trajectories were found with estimated changes in PEDI self-care scaled scores per month: 0.61 for MACS level I, 0.46 for MACS levels II, 0.31 for MACS level III, 0.16 for MACS level IV, and 0.03 for MACS level V. Children classified in MACS level V had the lowest level of self-care skills at 18 months and showed no progress in self-care development.This study reports rate of self-care development in preschool children with CP. Self-care performance was highest in children with greatest manual ability. Clinicians may use rates of change to predict or monitor self-care performance. PEDI trajectories inform goal setting in discussions with families regarding expected levels of independence in self-care.Distinct self-care developmental trajectories in children with cerebral palsy were found according to Manual Ability Classification System (MACS) levels. Children in MACS levels IV and V with epilepsy did not show any significant change in self-care. Children in MACS levels IV and V without epilepsy demonstrated small yet significant gains in self-care performance.AUTOCUIDADO Y HABILIDAD MANUAL EN NIÑOS PREESCOLARES CON PARÁLISIS CEREBRAL: UN ESTUDIO LONGITUDINAL: OBJETIVO: Describir el desarrollo longitudinal del autocuidado en niños con parálisis cerebral (PC) de edades comprendidas entre los 18 meses y los 5 años de edad en todas las habilidades funcionales y su relación con la habilidad manual. MÉTODO: Se trata de un estudio prospectivo longitudinal basado en una población de 290 niños con PC (178 [61%] niños, 112 [39%] niñas). El autocuidado se evaluó utilizando el Inventario de Evaluación Pediátrica de Discapacidad (Pediatric Evaluation of Disability Inventory, PEDI). A los 60 meses (n=242), los niños se clasificaron usando el Sistema de Clasificación de la Habilidad Manual (Manual Ability Classification System, MACS); 113 en el nivel I (47%), 61 en el nivel MACS II (25%), 24 en el nivel MACS III (10%), 14 en el nivel MACS IV (6%), y 30 en el nivel MACS V (12%). Las mediciones se tomaron a los 18 meses, 24 meses, 30 meses, 36 meses, 48 meses, y 60 meses de edad. Los análisis longitudinales se realizaron utilizando modelos de regresión lineal de efectos mixtos. RESULTADOS: El desarrollo del autocuidado logrado a los 60 meses se asoció negativamente a la severidad de la alteración de la habilidad manual. Se encontraron trayectorias del desarrollo del autocuidado distintas con cambios estimados de los puntajes escalados del autocuidado de PEDI por mes: 0,61 para el nivel MACS de I, 0,46 para el nivel MACS de II, 0,31 para el nivel MACS de III, 0,16 para el nivel MACS de IV, y 0,03 para el nivel MACS de V. Los niños clasificados con el nivel MACS de V tuvieron el nivel más bajo de las destrezas de autocuidado a los 18 meses y no mostraron progreso en el desarrollo del autocuidado. INTERPRETACIÓN: Este estudio informa sobre la tasa de desarrollo del autocuidado en niños preescolares con PC. El desempeño del autocuidado fue mayor en niños con la mayor habilidad manual. Los profesionales podrian utilizar las tasas de cambio para predecir o monitorizar el desempeño del autocuidado. Las trayectorias de PEDI informan el establecimiento de objetivos, mediante un dialogo con las familias, basados en los niveles de independencia esperados en el autocuidado.AUTO-CUIDADO E HABILIDADE MANUAL EM CRIANÇAS PRÉ-ESCOLARES COM PARALISIA CEREBRAL: UM ESTUDO LONGITUDINAL: OBJETIVO: Descrever o desenvolvimento longitudinal do auto-cuidado em crianças com paralisia cerebral (PC) com idades entre 18 meses e 5 anos em todos os níveis de capacidade funcional e sua relação com a habilidade manual. MÉTODO: Este estudo populacional com desenho prospectivo e longitudinal incluiu 290 crianças com PC (178 [61%] do sexo masculino, 112 [39%] do sexo feminino). O auto-cuidado foi avaliado usando o Inventário pediátrico de avaliação da disfunção (PEDI). Aos 60 meses (n=242), as crianças foram classificadas usando o Sistema de Classificação da Habilidade Manual (MACS); 113 no nível I (47%), 61 no nível MACS II (25%), 24 no nível MACS III (10%), 14 no nível MACS level IV (6%), e 30 no nível MACS V (12%). As medidas foram realizadas aos 18, 24, 30, 36, 48 e 60 meses de idade. RESULTADOS: O desenvolvimento do auto-cuidado atingido aos 60 meses foi negativamente associado com a severidade do comprometimento da habilidade manual. Trajetórias distintas do desenvolvimento do auto-cuidado foram encontradas com mudanças estimadas nos scaled escores de auto-cuidado do PEDI por mês: 0,61 para nível MACS I, 0.46 para nível MACS II, 0,31 para nível MACS III, 0,16 para nível MACS IV, e 0,03 para nível MACS V. Crianças classificadas no nível MACS V tiveram o menor nível de habilidades de auto-cuidado aos 18 meses e não mostraram nenhum progresso no desenvolvimento do auto-cuidado. INTERPRETAÇÃO: Este estudo relata a taxa do desenvolvimento do auto-cuidado em crianças pré-escolares com PC. O desempenho do auto-cuidado foi o mais alto em crianças com maior habilidade manual. Clínicos podem usar as taxas de mudança para predizer ou monitorar o desempenho do auto-cuidado. As trajetórias do PEDI informam o estabelecimento de objetivos nas discussões com as famílias com relação aos níveis esperados de independência no auto-cuidado.

The aim of the study was to determine if a Beacon model of integrated care utilising general practitioners (GPs) with special interests could achieve similar clinical outcomes to a hospital-based specialist diabetes outpatient clinic. This pragmatic non-inferiority multisite randomised controlled trial assigned individuals with complex type 2 diabetes to care delivered by a Beacon clinic or to usual care delivered by a hospital outpatient department, in a 3:1 ratio. Owing to the nature of the study, researchers were only blinded during the allocation process. Eligible participants were aged 18 or over, had been referred by their usual GP to the hospital central referral hub with type 2 diabetes and had been triaged to be seen within 30 or 90 days. The intervention consisted of diabetes management in primary care by GPs with a special interest who had been upskilled in complex diabetes under the supervision of an endocrinologist. The primary outcome was HbA1c at 12 months post-recruitment. The non-inferiority margin was 4.4 mmol/mol (0.4%). Both per-protocol and intention-to-treat analyses are reported. Between 27 November 2012 and 14 July 2015, 352 individuals were recruited and 305 comprised the intention-to-treat sample (71 in usual care group and 234 in the Beacon model group). The Beacon model was non-inferior to usual care for both the per-protocol (difference −0.38 mmol/mol [95% CI −4.72, 3.96]; −0.03% [95% CI −0.43, 0.36]) and the intention-to-treat (difference −1.28 mmol/mol [95% CI −5.96, 3.40]; −0.12% [95% CI −0.55, 0.31]) analyses. Non-inferiority was sustained in a sensitivity analysis at 12 months. There were no statistically or clinically significant differences in the secondary outcomes of BP, lipids or quality of life as measured by the 12 item short-form health survey (SF-12v2) and the diabetes-related quality of life (DQoL-Brief) survey. Safety indicators did not differ between groups. Participant satisfaction on the eight-item client satisfaction questionnaire (CSQ-8) was good in both groups, but scores were significantly higher in the Beacon model group than the usual care group (mean [SD] 28.4 [4.9] vs 25.6 [4.9], respectively, p

Summary Background Although amoxicillin–clavulanate is the recommended first-line empirical oral antibiotic treatment for non-severe exacerbations in children with bronchiectasis, azithromycin is also often prescribed for its convenient once-daily dosing. No randomised controlled trials involving acute exacerbations in children with bronchiectasis have been published to our knowledge. We hypothesised that azithromycin is non-inferior to amoxicillin-clavulanate for resolving exacerbations in children with bronchiectasis. Methods We did this parallel-group, double-dummy, double-blind, non-inferiority randomised controlled trial in three Australian and one New Zealand hospital between April, 2012, and August, 2016. We enrolled children aged 1–19 years with radiographically proven bronchiectasis unrelated to cystic fibrosis. At the start of an exacerbation, children were randomly assigned to oral suspensions of either amoxicillin–clavulanate (22·5 mg/kg, twice daily) and placebo or azithromycin (5 mg/kg per day) and placebo for 21 days. We used permuted block randomisation (stratified by age, site, and cause) with concealed allocation. The primary outcome was resolution of exacerbation (defined as a return to baseline) by 21 days in the per-protocol population, with a non-inferiority margin of −20%. We assessed several secondary outcomes including duration of exacerbation, time to next exacerbation, laboratory, respiratory, and quality-of-life measurements, and microbiology. This trial was registered with the Australian/New Zealand Registry (ACTRN12612000010897). Findings We screened 604 children and enrolled 236. 179 children had an exacerbation and were assigned to treatment: 97 to amoxicillin–clavulanate, 82 to azithromycin). By day 21, 61 (84%) of 73 exacerbations had resolved in the azithromycin group versus 73 (84%) of 87 in the amoxicillin–clavulanate group. The risk difference showed non-inferiority (−0·3%, 95% CI −11·8 to 11·1). Exacerbations were significantly shorter in the amoxicillin–clavulanate group than in the azithromycin group (median 10 days [IQR 6–15] vs 14 days [8–16]; p=0·014). Adverse events were attributed to the trial medication in 17 (21%) of 82 children in the azithromycin group versus 23 (24%) of 97 in the amoxicillin–clavulanate group (relative risk 0·9, 95% CI 0·5 to 1·5). Interpretation By 21 days of treatment, azithromycin is non-inferior to amoxicillin–clavulanate for resolving exacerbations in children with non-severe bronchiectasis. In some patients, such as those with penicillin hypersensitivity or those likely to have poor adherence, azithromycin provides another option for treating exacerbations, but must be balanced with risk of treatment failure (within a 20% margin), longer exacerbation duration, and the risk of inducing macrolide resistance. Funding Australian National Health and Medical Research Council.

Children with cerebral palsy (CP) have lower habitual physical activity (HPA) than their typically developing peers. There are limited studies of HPA in young children with CP under the age of 5 years.To investigate the relationships between HPA, sedentary time, motor capacity and capability in children with CP aged 4-5 years.Sixty-seven participants were classified using Gross Motor Function Classification System (GMFCS), assessed for motor capacity using Gross Motor Function Measure (GMFM) and wore accelerometers for three days to measure HPA and sedentary time. Motor capability was assessed using parent-reported Pediatric Evaluation of Disability Inventory (PEDI) functional skills of mobility domain. Mixed-effects regression models were used for analyses.GMFM was positively associated with HPA (mean difference (MD) = 19.6 counts/min; 95%CI = 16.6 to 22.7, p 0.001) and negatively associated with sedentary time (MD = -0.6%; 95%CI = -0.7 to -0.5, p 0.001). The PEDI was also positively associated with HPA (MD = 16.0 counts/min; 95%CI = 13.1 to 18.8, p 0.001) and negatively associated with sedentary time (MD = -0.5%; 95%CI = -0.6 to -0.4, p 0.001). After stratification for ambulatory status, GMFM and PEDI were associated with HPA and sedentary time in ambulant participants but not in non-ambulant participants.Gross motor capacity and motor capability are related to HPA and sedentary time in ambulant children with CP aged 4-5 years.

Objectives Point-of-care ultrasound (POCUS) diagnosis of distal forearm fractures relies on the identification of buckling or breach of hyperechoic bone cortex. We describe the pronator quadratus hematoma (PQH) formation visualized on POCUS, the PQH sign, as it may aid diagnosis of pediatric distal forearm cortical breach fractures. Methods A prospective cohort of children presenting to an emergency department with isolated, clinically non-angulated distal forearm injuries received POCUS by an expert emergency physician sonologist who identified the presence or absence of the PQH sign. They secondarily recorded the difference between the size of the pronator quadratus (PQ) muscle on both the affected and non-affected forearms (PQ delta thickness). Children received an x-ray subsequent to POCUS and were diagnosed based on an x-ray reported by a radiologist masked to POCUS findings. Results Thirty-eight children were recruited. All 22 patients with cortical breach fracture had PQH sign present (100%; 95%CI: 85-100%), while all 16 patients without cortical breach fracture had PQH sign absent (100%; 95%CI: 79-100%). PQ delta thickness ranged from 2.1 to 10.2 mm in cortical breach fractures, 0.0 to 1.1 mm in buckle fractures, and 0.2 to 0.8 mm in patients without fracture. Conclusions The PQH sign correctly distinguished all children with, and without, cortical breach fractures. All PQ delta thicknesses were ≧2.1 mm when cortical breach fracture was present and ≦1.1 mm when cortical breach fracture was absent. The PQH sign and PQ delta thickness are promising measurements to identify pediatric distal forearm cortical breach fractures, and their utility should be confirmed in larger studies with sonologists of different abilities.

Background: Individuals who experience an initial episode of invasive pneumococcal disease (IPD) are at increased risk of recurrent episodes. However, the magnitude of risk has not been well-quantified in the pneumococcal conjugate vaccine era. Individuals with a previous episode of IPD are not commonly identified as a high-risk group in vaccination guidelines. Methods: Australian residents with at least one case of IPD between 1991 and 2016 were identified using routine public health surveillance data which included identified IPD risk factors. Incidence of recurrent IPD was calculated from 2001 onwards (after IPD became nationally notifiable) using time-to-event analyses with individuals contributing person-time at risk of recurrence if they survived greater than 14 days after initial episode onset. Results: From 1991 to 2016 there were 28,809 IPD episodes in 28,218 individuals. A total of 512 (1.8%) persons experienced 591 recurrent episodes. From 2001 to 2016 the incidence of recurrent IPD was 216.2 per 100,000 person-years, 27 times greater than the population rate of primary IPD during this period (8.0 per 100,000 population per year). Between 2011 and 2016, more than one-quarter of individuals experiencing recurrence had no IPD risk factors identified at first episode. Conclusions: There is substantially increased risk of recurrent IPD after an initial episode. At least one-quarter of those with recurrent episodes have no identified risk factors at the initial episode. Given the potential preventability of future episodes, those with a previous IPD episode should be identified as a high-risk group and receive pneumococcal vaccination.

Background: Peripheral intravenous catheters (PIVCs) are medical devices used to administer intravenous therapy but can be complicated by soft tissue or bloodstream infection. Monitoring PIVC safety and quality through clinical auditing supports quality infection prevention however is labour intensive. We sought to determine the optimal patient ‘number’ for clinical audits to inform evidence-based surveillance. Methods: We studied a dataset of cross-sectional PIVC clinical audits collected over five years (2015–2019) in a large Australian metropolitan hospital. Audits included adult medical, surgical, women's, cancer, emergency and critical care patients, with audit sizes of 69–220 PIVCs. The primary outcome was PIVC complications for one or more patient reported symptom/auditor observed sign of infection or other complications. Complication prevalence and 95% confidence interval (CI) were calculated. We modelled scenarios of low (10%), medium (20%) and high (50%) prevalence estimates against audit sizes of 20, 50, 100, 150, 200, 250, and 300. This was used to develop a decision-making tool to guide audit size. Results: Of 2274 PIVCs evaluated, 475 (21%) had a complication. Complication prevalence per round varied from 7.8% (95% CI, 4.2–12.9) to 39% (95% CI, 32.0–46.4). Precision improved with larger audit size and lower complication rates. However, precision was not meaningfully improved by auditing >150 patients at a complication rate of 20% (95% CI 13.9%–27.3%), nor >200 patients at a complication rate of 50% (95% CI 42.9%–57.1%). Conclusion: Audit sizes should be 100 to 250 PIVCs per audit round depending on complication prevalence.

Approximately 80% of patients admitted to acute hospitals have at least one peripheral intravenous catheter inserted during their admission, for the administration of fluids and medicines, and/or diagnostic tests, so the failure rate is concerning. New technology may decrease these rates even when used by inexperienced inserters. The choice of insertion site for an intravenous catheter is a known predictor of catheter failure. Therefore, the objective for this study was to evaluate the utility of vessel locating devices for novice clinicians to select catheter insertion sites in the forearm.An inter-subject incomplete counterbalanced research design was employed with healthy volunteers. Novice clinicians used either a vessel locating device using light or sound waves or they used palpation to identify relatively superficial veins in the forearm. This was compared to site selection performed by an expert clinician using palpation method only. Measurements of differences were analysed from photos of chosen sites. Bland-Altman agreement analysis was used to plot novice expert agreement. The STROBE checklist was followed in reporting this study (Techniques to select site of insertion for a peripheral intravenous catheter with vessel locating devices (Appendix S1)).A total of 32 novice clinicians used three vessel locating devices and a palpation technique. Novice clinicians did not choose more veins for optimum catheter placement when assisted with vessel locating devices compared to palpation techniques. All methods had a similar mean difference between novice and expert measurements and a similar percentage difference in distance from the expert choice. Bland-Altman agreement analysis did not identify any advantage for the novice with vessel locating devices over palpation.Vessel locating devices do not enhance the ability of novice clinicians any greater than palpation when selecting suitable forearm veins. If vessel locating device approaches are to be adopted in clinical practice to support better insertion outcomes then current PIVC teaching techniques should include structured vessel locating devices theory and practice.Successful insertion of a peripheral intravenous catheter (PIVC) on the first attempt is a challenging procedure for nurses. Careful consideration of the selected site of insertion could modify this risk factor for catheter failure. The choice of PIVC insertion site by a novice clinician compared to an expert does not necessarily improve with the use of vein locating technology. While there is a range of technological devices available to assist with locating vessels, there needs to be more emphasis from educators on how to select an appropriate insertion site for intravenous therapy.

Background Psychotropic medications are sometimes used off-label and inappropriately. This may cause harm to adolescents with intellectual disability. However, few studies have analysed off-label or inappropriate prescribing to this group. Aims To examine the appropriateness of psychotropic prescribing to adolescents with intellectual disability living in the community in south-east Queensland, Australia. Method Off-label medication use was determined based on whether the recorded medical condition treated was approved by the Australian Therapeutic Goods Administration. Clinical appropriateness of medication use was determined based on published guidelines and clinical opinion of two authors who specialise in developmental disability medicine (J.N.T. and D.H.). Results We followed 429 adolescents for a median of 4.2 years. A total of 107 participants (24.9%) were prescribed psychotropic medications on at least one occasion. Of these, 88 (82.2%) were prescribed their medication off-label or inappropriately at least once. Off-label or inappropriate use were most commonly associated with challenging behaviours. Conclusions Off-label or inappropriate use of psychotropic medications was common, especially for the management of challenging behaviours. Clinical decision-making accounts for individual patient factors and is made based on clinical experience as well as scientific evidence, whereas label indications are developed for regulatory purposes and, although appropriate at a population level, cannot encompass the foregoing considerations. Education for clinicians and other staff caring for people with intellectual disability, and a patient-centred approach to prescribing with involvement of families should encourage appropriate prescribing. The effect of the National Disability Insurance Scheme on the appropriateness of psychotropic medication prescribing should be investigated.

BACKGROUND AND OBJECTIVES: The coronavirus (CoV) disease 2019 pandemic has drawn attention to the CoV virus family. However, in community settings, there is limited information on these viruses in healthy children. We explored the epidemiology of the 4 endemic (non–severe acute respiratory syndrome CoV 2) human coronaviruses (HCoVs) by species, including acute illness episodes, risk factors, and health care burden in Australian children in the first 2 years of life. METHODS: The Observational Research in Childhood Infectious Diseases community-based cohort was a prospective study of acute respiratory illnesses in children from birth until their second birthday. Parents recorded daily symptoms, maintained an illness-burden diary, and collected weekly nasal swabs, which were tested for 17 respiratory viruses, including HCoVs, by real-time polymerase chain reaction assays. RESULTS: Overall, 158 children participating in Observational Research in Childhood Infectious Diseases provided 11 126 weekly swabs, of which 168 were HCoV-positive involving 130 incident episodes. HCoV-NL63 and HCoV-OC43 were most commonly detected, accounting for two-thirds of episodes. Whereas 30 children had different HCoVs detected on different occasions, 7 were reinfected with the same species. HCoV incidence in the first 2 years of life was 0.76 episodes per child-year (95% confidence interval [CI] 0.63 to 0.91), being greatest in the second year (1.06; 95% CI 0.84 to 1.33) and during winter (1.32; 95% CI 1.02 to 1.71). Fifty percent of HCoV episodes were symptomatic, and 24.2% led to health care contact. CONCLUSIONS: In children, HCoV infections are common, recurrent, and frequently asymptomatic. In future studies, researchers should determine transmission pathways and immune mechanisms.

Background Children frequently present to the emergency department (ED) with forearm injuries and often have x-rays to determine if there is a fracture. Bedside ultrasound, also known as point-of-care ultrasound (POCUS), is an alternative diagnostic test used to rapidly diagnose a fracture at the time of examination, without exposing children to ionising radiation. Prospective studies have demonstrated high agreement between POCUS and x-ray findings. However, whether the initial imaging modality affects the patient’s medium-term physical function is unknown. Methods This is a multicentre, open-label, non-inferiority randomised controlled trial conducted in Australian EDs. Recruitment will continue until 112 children with distal forearm injuries (including 48 buckle fractures) per trial arm have achieved the primary outcome measure. Patients aged 5–15 years presenting with an isolated, acute, clinically non-angulated, distal forearm injury with suspected fracture will have their initial diagnostic approach randomised to either POCUS, performed by a credentialled practitioner, or x-ray imaging. If a cortical breach fracture is identified on POCUS, the patient will receive x-rays and have usual care. If a buckle fracture is identified, the patient will have their forearm placed in a splint and be discharged home. Patients will be followed up at 1, 4 and 8 weeks. The primary outcome is upper limb physical function at 4 weeks, as determined by the Pediatric Upper Extremity Short Patient-Reported Outcomes Measurement Information System (PROMIS) tool. Secondary outcomes include healthcare costs, satisfaction, pain, complications, rates of imaging, ED length of stay and diagnostic accuracy. Discussion If POCUS is non-inferior to x-ray in terms of patient’s medium-term physical function, it may have an effect on overall health care resource use, including the number of x-ray performed and earlier ED discharge. Although prospective studies have confirmed the accuracy of POCUS, this will be the first RCT to assess non-inferiority of functional outcomes of POCUS to diagnose non-angulated paediatric distal forearm injuries, compared to x-ray. POCUS may be of particular importance in settings where access to x-ray imaging can be limited either during or after-hours, as it can aid the triaging and management of patients. Trial registration Prospectively registered with the ANZCTR on 29 May 2020 (ACTRN12620000637943).

This study aimed to identify which MRI and clinical assessments, alone or in combination, from (i) early (32 weeks postmenstrual age, PMA), (ii) term equivalent age (TEA) and (iii) 3 months corrected age (CA) are associated with motor or cognitive outcomes at 2 years CA in infants born31 weeks gestation.Prospective cohort study of 98 infants who underwent early and TEA MRI (n = 59 males; median birth gestational age 28 + 5 weeks). Hammersmith Neonatal Neurological Examination (HNNE), NICU Neonatal Neurobehavioural Scale and General Movements Assessment (GMs) were performed early and at TEA. Premie-Neuro was performed early and GMs, Test of Infant Motor Performance and visual assessment were performed at TEA and 3 months CA. Neurodevelopmental outcomes were determined using Bayley Scales of Infant and Toddler Development 3rd edition.The best combined motor outcome model included 3-month GMs (β = -11.41; 95% CI = -17.34, -5.49), TEA MRI deep grey matter score (β = -6.23; 95% CI = -9.47, -2.99) and early HNNE reflexes (β = 3.51; 95% CI = 0.86, 6.16). Combined cognitive model included 3-month GMs (β = -10.01; 95% CI = -15.90, -4.12) and TEA HNNE score (β = 1.33; 95% CI = 0.57, 2.08).Early neonatal neurological assessment improves associations with motor outcomes when combined with term MRI and 3-month GMs. Term neurological assessment combined with 3-month GMs improves associations with cognitive outcomes.We present associations between 32- and 40-week MRI, comprehensive clinical assessments and later 2-year motor and cognitive outcomes for children born31 weeks gestation. MRI and clinical assessment of motor, neurological and neurobehavioural function earlier than term equivalent age in very preterm infants is safe and becoming more available in clinical settings. Most of these children are discharged from hospital before term age and so completing assessments prior to discharge can assist with follow up. MRI and neurological assessment prior to term equivalent age while the child is still in hospital can provide earlier identification of children at highest risk of adverse outcomes and guide follow-up screening and intervention services.

Volatile organic compound (VOC) breath testing of lung and head and neck squamous cell carcinoma (SCC) has been widely studied, however little is known regarding VOC profiles of in-situ SCC. A prospective study of VOC in patients with histologically proven SCC, either in-situ or advanced, and controls. Breath samples were analysed using the E-nose Cyranose ®320 and by gas chromatography/mass spectroscopy. Predictive models were developed using bootstrap forest using all 32 sensors. Data from 55 participants was analysed: 42 SCC cases comprising 20 bronchial (10 in-situ, 10 advanced) and 22 laryngeal (12 in-situ, 10 advanced), and 13 controls. There were 32 (76%) male SCC cases with mean age 63.6 (SD = 9.5) compared with 11 (85%) male controls with mean age 61.9 (SD = 10.1). Predictive models for in situ cases had good sensitivity and specificity compared to controls (overall, 95% and 69%; laryngeal, 100% and 85%; bronchial, 77% and 80%). When distinguishing in-situ and advanced tumours, sensitivity and specificity 82% and 75% respectively. For different tumour types (bronchial versus advanced laryngeal) sensitivity and specificity were 100% and 80% respectively. VOCs isolated from in-situ cancers included some previously demonstrated in advanced cancers and some novel VOCs. In-situ bronchial and laryngeal cancer can be detected by VOC analysis. Distinction from normal controls and between the two tumour types could allow screening in high risk groups for these curable lesions.

Aim: To test the efficacy of functional electrical stimulation (FES) cycling, goal-directed training, and adapted cycling, compared with usual care, to improve function in children with cerebral palsy (CP). Method: The intervention was delivered between 2017 and 2019 and included three sessions per week for 8 weeks (2×1h sessions at a children’s hospital, and 1h home programme/week). Hospital sessions included 30 minutes of FES cycling and 30 minutes of goal-directed training. Home programmes included goal-directed training and adapted cycling. The comparison group continued usual care. Primary outcomes were gross motor function assessed by the Gross Motor Function Measure (GMFM) and goal performance/satisfaction assessed using the Canadian Occupational Performance Measure (COPM). Secondary outcomes were sit-to-stand and activity capacity, participation in home, school, and community activities, and power output. Linear regression was used to determine the between-group mean difference immediately post-training completion after adjusting for baseline scores. Results: This randomized controlled trial included 21 participants (mean age=10y 3mo, standard deviation [SD]=3y; Gross Motor Function Classification System level: II=7, III=6, IV=8) who were randomized to the intervention (n=11) or usual care group (n=10). Between-group differences at T2 favoured the intervention group for GMFM-88 (mean difference=7.4; 95% confidence interval [CI]: 2.3–12.6; p=0.007), GMFM-66 (mean difference=5.9; 95% CI: 3.1–8.8; p

Objective: Evaluate the validity of the Kids-Balance Evaluation Systems Test (Kids-BESTest) clinical criteria for the Functional Reach Test (FRT) forward and lateral with laboratory measures of postural control in children with cerebral palsy (CP). Design: Psychometric study of face, concurrent, and content validity. Setting: Clinical laboratory. Participants: Children (N=58) aged 7-18 years (ambulant CP n=17, typically developing [TD] n=41). Intervention: Not applicable. Main Outcome Measures: Stability limits in standing were assessed using the Kids-BESTest items for FRT forwards (FRTFORWARD), FRT lateral preferred (FRTLATERAL(P)), and FRT lateral nonpreferred (FRTLATERAL(NP)). Force platforms and kinematic markers were used to collect information on center of pressure (CoP) and joint movement during reach. Analyses included face validity (Kids-BESTest scores compared between CP and TD groups), concurrent validity (agreement between Kids-BESTest scores and digitally derived scores), and content validity (relations between Kids-BESTest scores with kinematic and CoP data). Results: Face validity of Kids-BESTest criteria was demonstrated with lower scores for CP compared to TD groups for FRTFORWARD (P

IntroductionInfants born very preterm are at risk of adverse neurodevelopmental outcomes, including cognitive deficits, motor impairments and cerebral palsy. Earlier identification enables targeted early interventions to be implemented with the aim of improving outcomes.Methods and analysisProtocol for 6-year follow-up of two cohorts of infants born AimsExamine the ability of early neonatal MRI, EEG and concurrent clinical measures at 32 weeks PMA to predict motor, cognitive, language, academic achievement and mental health outcomes at 6 years CA.Determine if early brain abnormalities persist and are evident on brain MRI at 6 years CA and the relationship to EEG and concurrent motor, cognitive, language, academic achievement and mental health outcomes.Ethics and disseminationEthical approval has been obtained from Human Research Ethics Committees at Children’s Health Queensland (HREC/19/QCHQ/49800) and The University of Queensland (2019000426). Study findings will be presented at national and international conferences and published in peer-reviewed journals.Trial registration numberACTRN12619000155190p.Web address of trialhttp://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12619000155190p