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Hypothesis This study aimed to examine whether three-dimensionally printed models (3D models) could improve interobserver and intraobserver agreement when classifying proximal humeral fractures (PHFs) using the Neer system. We hypothesized that 3D models would improve interobserver and intraobserver agreement compared with x-ray, two-dimensional (2D) and three-dimensional (3D) computed tomography (CT) and that agreement using 3D models would be higher for registrars than for consultants. Methods Thirty consecutive PHF images were selected from a state-wide database and classified by fourteen observers. Each imaging modality (x-ray, 2D CT, 3D CT, 3D models) was grouped and presented in a randomly allocated sequence on two separate occasions. Interobserver and intraobserver agreements were quantified with kappa values (k), percentage agreement, and 95% confidence intervals (CIs). Results Seven orthopedic registrars and seven orthopedic consultants classified 30 fractures on one occasion (interobserver). Four registrars and three consultants additionally completed classification on a second occasion (intraobserver). Interobserver agreement was greater with 3D models than with x-ray (k ¼ 0.47, CI: 0.44-0.50, 66.5%, CI: 64.6-68.4% and k ¼ 0.29, CI: 0.26-0.31, 57.2%, CI: 55.1-59.3%, respectively), 2D CT (k ¼ 0.30, CI: 0.27-0.33, 57.8%, CI: 55.5-60.2%), and 3D CT (k ¼ 0.35, CI: 0.33-0.38, 58.8%, CI: 56.7-60.9%). Intraobserver agreement appeared higher for 3D models than for other modalities; however, results were not significant. There were no differences in interobserver or intraobserver agreement between registrars and consultants. Conclusion Three-dimensionally printed models improved interobserver agreement in the classification of PHFs using the Neer system. This has potential implications for using 3D models for surgical planning and teaching

Background Abnormalities in gait have been associated with high plantar pressures and diabetes-related plantar foot ulcers. Whether these are a transient response to the ulcer or are representative of long-term lower limb biomechanical abnormalities is currently unknown. Objective The aim of this study was to examine whether 12 gait parameters identified as being associated with nonhealing diabetes-related plantar foot ulcers at baseline remained associated during a 6-month follow-up period. Design This was a longitudinal observational case-control study. Methods Gait assessments were performed at entry and twice during follow-up over a 6-month period in 12 participants with nonhealing diabetes-related plantar foot ulcers (case participants) and 62 people with diabetes and no history of foot ulcers (control participants) using a standardized protocol. Linear mixed-effects random-intercept models were used to identify gait parameters that consistently differed between case participants and control participants at all assessments after adjustment for age, sex, body mass index, presence of peripheral neuropathy, and follow-up time. Standardized mean differences (SMD) were used to measure effect sizes. Results Five of the 12 gait parameters were significantly different between case participants and control participants at all 3 time points. Case participants had a more abducted foot progression angle (SMD = 0.37), a higher pelvic obliquity at toe-off (SMD = −0.46), a greater minimum pelvic obliquity (SMD = −0.52), a lower walking speed (SMD = −0.46), and a smaller step length (SMD = −0.46) than control participants. Limitations The limitations included a small sample size, the observational nature of the study, and the inability to evaluate the impact of gait on wound healing. Conclusions This study identified abnormal gait parameters consistently associated with nonhealing diabetes-related plantar foot ulcers. Further research is needed to test the clinical importance of these gait characteristics.

Background: Skin autofluorescence has been used to assess longer term glycemic control and risk of complications. There is however no agreed site at which autofluorescence should be measured. This study evaluated the within- and between-site agreement in measurement of skin autofluorescence using a noninvasive advanced glycation end product (AGE) reader. Methods: Overall, 132 participants were included: 16 with diabetes-related foot ulcers (DFU), 63 with diabetes but without foot ulcers (DMC), 53 without diabetes or foot ulcers (HC). Skin autofluorescence was measured using the AGE Reader (DiagnOptics technologies BV, the Netherlands). Three consecutive skin autofluorescence measurements were each performed at six different body sites: the volar surfaces of both forearms (arms), dorsal surfaces of both calves (legs), and plantar surfaces of both feet (feet). Within- and between-site agreements were analyzed with concordance correlation coefficients (CCC) and 95% confidence intervals (95% CI), absolute mean differences (±standard deviation), and Bland-Altman limits of agreement. Results: The agreement between repeat assessments at the same site was almost perfect (CCC [95% CI] ranging from 0.94 [0.91-0.96] for assessments in the right foot to 0.99 [0.99-0.99] for assessments in the left arm). The limits of agreement were narrow within ±0.5 arbitrary units for all sites. The between-site agreement in measurements was poor (CCC < 0.65) with large maximum absolute mean differences (±SD) in arbitrary units (DFU = 3.40 [±2.04]; DMC = 3.15 [±2.45]; HC = 2.72 [±1.83]) and wide limits of agreement. Conclusions: Skin autofluorescence measurements can be repeated at the same site with adequate repeatability but measurements at different sites in the same patient have marked differences. The reason for this variation across sites and whether this has any role in diabetes-related complications needs further investigation.

BACKGROUND: Surgical site infection (SSI) after dermatologic surgery is associated with poor outcomes including increased recovery time, poor cosmesis, and repeat visits to doctors. Prophylactic antibiotics are prescribed to reduce these adverse outcomes. Identifying risk factors for SSI will facilitate judicious antibiotic prophylaxis. OBJECTIVE: To identify risk factors for SSI after minor dermatologic surgery. METHODS: Individual patient data from four large randomized controlled trials were combined to increase statistical power. A total of 3,819 adult patients requiring minor skin procedures at a single facility were recruited over a 10-year period. The main outcome measure was SSI. MAIN RESULTS: A total of 298 infections occurred, resulting in an overall incidence of 7.8% (95% confidence interval [CI], 5.8–9.6), although the incidence varied across the four studies (P = .042). Significant risk factors identified were age (relative risk [RR], 1.01; 95% CI, 1.001–1.020; P = .008), excisions from the upper limbs (RR, 3.03; 95% CI, 1.76–5.22; P = .007) or lower limbs (RR, 3.99; 95% CI, 1.93–8.23; P = .009), and flap/two-layer procedures (RR, 3.23; 95% CI, 1.79–5.85; P = .008). Histology of the excised lesion was not a significant independent risk factor for infection. CONCLUSIONS: This study demonstrated that patients who were older, underwent complex excisions, or had excisions on an extremity were at higher risk of developing an SSI. An awareness of such risk factors will guide evidence-based and targeted antibiotic prophylaxis.

Background. The impact of caring for a child with a chronic disease on caregivers and their family functioning contributes to the child’s adaptation to the disease. Objectives. To determine the impact of caregiver burden on the health-related quality of life (HRQOL) and family functioning of carers of children with epilepsy (CWE), and to determine factors associated with a high impact of caregiver burden. Method. A cross-sectional study was conducted among primary caregivers of CWE attending the Charlotte Maxeke Johannesburg Academic Hospital, South Africa. Participants had been involved in childcare for at least 6 months before study enrolment and all gave informed consent. Data regarding sociodemographic and epilepsy-related variables were obtained from questionnaires, including the 36-item family impact module of the Pediatric Quality of Life assessment tool. Scores in the lower quartile were considered indicative of a negative impact on HRQOL and poor family functioning. Results. Participants identified as experiencing a high impact of paediatric epilepsy care reported raw scores ≤31.3 for both caregiver burden and family functioning. The family functioning score correlated strongly with the caregivers’ HRQOL score ( p =0.78; p

Aim: Anaemia during pregnancy is common worldwide. In Australia between 7.1% and 11% of mothers have been reported to have anaemia in pregnancy. Higher rates are reported for Aboriginal and Torres Strait Islander women (Townsville: 34.2%, remote Northern Territory: 50%). The present study describes anaemia in pregnancy among Aboriginal and Torres Strait Islander women of Far North Queensland. Methods: Health service information was analysed for 2076 Aboriginal and Torres Strait Islander women who gave birth between 2006 and 2010. The prevalence of anaemia in pregnancy, characteristics of the mothers and pregnancy outcomes were described. Logistic regression for bivariate analyses and multivariable linear modelling with and without imputed data were used to compare those mothers who had anaemia in pregnancy with those who did not. Results: More than half of Aboriginal and Torres Strait Islander women (54.5% (95% CI: 52.4%, 56.7%)) had anaemia in pregnancy. For mothers who gave birth in 2009 and 2010 (n = 1796) with more complete data, those who were iron deficient during pregnancy were more likely to be anaemic (RR: 1.40, P =

AIM To determine factors correlated with postoperative radial shortening in patients with distal radius fractures treated with volar locking distal radius plates. METHODS A total of 250 patients with a distal radius fracture stabilised with volar locking plates between January 2010 and December 2014 were included in a multicentre retrospective cohort study. We measured the distance of the distal locking screws to the joint line immediately postoperatively and then measured radial shortening after six to eight weeks using the change in ulnar variance. RESULTS Multivariate linear regression analysis showed that there was a significant linear association between the distance of the screws from the joint line and radial shortening. No other patient, injury, or treatment-related characteristic significantly influenced radial shortening in multivariate analysis. CONCLUSION Distal locking screws should be placed as close as possible to the subchondral joint line to prevent postoperative loss of reduction.

INTRODUCTION: Aims of this study were to examine time delays in lung cancer referral pathways in North Queensland (NQ), Australia, and explore patients' perspective of factors causing these delays. METHODS: Prospective study of patients attending three cancer centres in Townsville, Cairns and Mackay in NQ from 2009 to 2012. Times along referral pathway were divided as follows: Onset of symptoms to treatment (T1), symptoms to general practitioner(GP) (T2), GP to specialist (T3), and Specialist to treatment (T4). Quantitative and qualitative methods were used for analysis. RESULTS: 252 patients participated. T1 was influenced by remoteness (125 days in Townsville vs. 170 days for Remote, p=0.01), T2 by level of education (91 days for Primary education vs. 61 days for Secondary vs. 23 days for Tertiary/TAFE, p=0.006), and age group (14 days for 31-50 years, 61 days for 51-70 years, 45 days for >71 years, p=0.026), T3 by remoteness (15 days for Townville and 29.5 days for remote, p=0.02) and T4 by stage of disease (21 days for stage I, 11 days for Stage II, 34 days for Stage III 18 days for Stage IV, p=0.041). Competing priorities of family and work and cost & inconvenience of travel were perceived as rural barriers. CONCLUSION: Remoteness, age and level of education were related to delays in various time lines in lung cancer referral pathways in NQ. Provision of specialist services closer to home may decrease delays by alleviating burden of cost and inconvenience of travel.

Background: Primary care research is underfunded. Few randomised controlled trials (RCTs) are conducted in a primary care setting. However, it is important that clinical practice be informed by adequate primary care evidence so general practitioners (GPs) have tools and guidelines applicable to the patients they see. Objective: The aim of this article is to describe and reflect on the experience of conducting five RCTs between 2003 and 2017 in a general practice setting with minimal funding, in North Queensland. Discussion: Enabling factors include using grassroots research questions and engaging practice nurses. Barriers include ethics applications and insufficient funding. Recommendations: to reduce study costs include compensating practice nurses rather than GP time. The findings are designed to encourage grassroots GPs to consider participating in pragmatic, feasible projects. The success of the projects was underpinned by the fact that they were established by a group of GPs who had interesting questions that were relevant to their clinical practice and not answered by current evidence.

BACKGROUND: Preoperative skin antisepsis is routine practice. We compared alcoholic chlorhexidine with aqueous chlorhexidine for skin antisepsis to prevent surgical site infection after minor skin excisions in general practice. METHODS: We conducted this prospective, multicentre, randomized controlled trial in 4 private general practices in North Queensland, Australia, from October 2015 to August 2016. Consecutive adult patients presenting for minor skin excisions were randomly assigned to undergo preoperative skin antisepsis with 0.5% chlorhexidine in 70% ethanol (intervention) or 0.5% chlorhexidine aqueous solution (control). Our primary outcome was surgical site infection within 30 days of excision. We also measured the incidence of adverse reactions. RESULTS: A total of 916 patients were included in the study: 454 underwent antisepsis with alcoholic chlorhexidine and 462 with aqueous chlorhexidine. Of these, 909 completed follow-up. In the intention-to-treat analysis of cases available at follow-up, there was no significant difference in the incidence of surgical site infection between the alcoholic chlorhexidine arm (5.8%, 95% confidence interval [CI] 3.6% to 7.9%) and the aqueous chlorhexidine arm (6.8%, 95% CI 4.5% to 9.1%). The attributable risk reduction was 0.010 (95% CI –0.021 to 0.042), the relative risk was 0.85 (95% CI 0.51 to 1.41), and the number needed to treat to benefit was 100. Per protocol and sensitivity analyses produced similar results. The incidence of adverse reactions was low, with no difference between groups (p = 0.6). INTERPRETATION: There was no significant difference in efficacy between alcoholic and aqueous chlorhexidine for the prevention of surgical site infection after minor skin excisions in general practice. Trial registration:https://www.anzctr.org.au, no. ACTRN12615001045505

Objective: Early childhood anaemia affects health and neurodevelopment. This study describes anaemia among Aboriginal and Torres Strait Islander children of Far North Queensland. Methods: This retrospective cohort study used health information for children born between 2006 and 2010 and their mothers. We describe the incidence of early childhood anaemia and compare characteristics of children and mothers where the child had anaemia with characteristics of children and mothers where the child did not have anaemia using bivariate and multivariable analysis, by complete case (CC) and with multiple imputed (MI) data. Results: Among these (n=708) Aboriginal and Torres Strait Islander children of Far North Queensland, 61.3% (95%CI 57.7%, 64.9%) became anaemic between the ages of six and 23 months. Multivariable analysis showed a lower incidence of anaemia among girls (CC/MI p

Background/AimThis study aims to examine differences between outer regional (OR) and remote/very remote (RVR) patients in northern Queensland, Australia in the times taken to receive various aspects of head and neck cancer management.MethodsOur study prospectively recruited head and neck cancer patients presenting to three North Queensland regional hospitals from January 2009 to January 2011. Data on demographic and cancer-specific details, comorbidities and timing of presentation to various services, were collected using a self-administered questionnaire that included two questions in relation to possible reason for delays to health services. Multivariate linear regression analyses were conducted to assess the effects of various demographic characteristics on time delays. Survival and disease recurrence data were analysed in 2014.ResultsOne hundred and fifty-eight patients participated. RVR patients had significantly longer median times between diagnosis and first treatment compared with OR patients (P=0.015). Indigenous patients had significant delays from diagnosis to first treatment (P=0.013) and visit to first specialist and treatment (P=0.031) compared to non-Indigenous patients. Longer median times between symptoms and first treatment was associated with low income (P=0.03) and lower education level (P=0.04). Disease recurrence was higher for RVR patients compared with OR patients (P=0.04), without significant differences in overall survival. Possible reasons for delays included patient and professional factors.ConclusionSignificant delays in various aspects of head and neck cancer management were associated with remoteness, Indigenous and socioeconomic status. While patient and professional factors could be addressed at local levels, sustainable improvement in outcomes requires a state and national level approach.

Background: Foot ulceration associated with diabetic peripheral neuropathy is a global concern. Biomechanical investigation allows the identification of gait abnormalities that may adversely affect ulcer healing. The objective of this case-control study was to compare the gait parameters of cases with diabetes-related foot ulcers to controls. Methods: Three-dimensional movement analyses were performed on 21 people with diabetes-related neuropathic plantar foot ulcers (cases), 69 people with diabetes without a foot ulcer history (diabetes controls) and 56 healthy controls. Outcome data were reported as mean differences, 95% confidence intervals and Cohen's d effect sizes. Binary logistic regressions were used to adjust for age, sex and body mass index. Findings: People with foot ulcers had a smaller plantar flexion (Cohen's d = -0.6 vs. diabetes controls and d = -0.8 vs. healthy controls), knee flexion (d = -0.6 vs. diabetes controls and d = -1.0 vs. healthy controls) and pelvic obliquity (d = -0.9 vs. diabetes controls and d = -0.7 vs. healthy controls) (all P < 0.05). They also had a significantly greater range of anterior-posterior ground reaction force (d = 1.0 vs. diabetes controls and d = 1.7 vs. healthy controls) and total vertical ground reaction force (d = 0.9 vs. diabetes controls and d = 1.1 vs. healthy controls) and significantly slower walking speed and smaller step length compared to controls (all P < 0.05). Interpretation: People with plantar foot ulcers have considerably different gait parameters to controls. Whether the observed gait parameters contributed to the ulcer development or are a response to the ulcer is currently unclear and needs further investigation. Refereed/Peer-reviewed

Objectives There is limited published research studying the effect of antibiotic prophylaxis on surgical site infection (SSI) in dermatological surgery, and there is no consensus for its use in higher-risk cases. The objective of this study was to determine the effectiveness of a single oral preoperative 2 g dose of cephalexin in preventing SSI following flap and graft dermatological closures on the nose and ear. Design Prospective double-blinded, randomised, placebo-controlled trial testing for difference in infection rates. Setting Primary care skin cancer clinics in North Queensland, Australia, were randomised to 2 g oral cephalexin or placebo 40–60 min prior to skin incision. Participants 154 consecutive eligible patients booked for flap or graft closure following skin cancer excision on the ear and nose. Intervention 2 g dose of cephalexin administered 40–60 min prior to surgery. Results Overall 8/69 (11.6%) controls and 1/73 (1.4%) in the intervention group developed SSI (p=0.015; absolute SSI reduction 10.2%; number needed to treat (NNT) for benefit 9.8, 95% CI 5.5 to 45.5). In males, 7/44 controls and 0/33 in the intervention group developed SSI (p=0.018; absolute SSI reduction 15.9%; NNT for benefit 6.3, 95% CI 3.8 to 19.2). SSI was much lower in female controls (1/25) and antibiotic prophylaxis did not further reduce this (p=1.0). There was no difference between the study groups in adverse symptoms attributable to high-dose antibiotic administration (p=0.871). Conclusion A single oral 2 g dose of cephalexin given before complex skin closure on the nose and ear reduced SSI. Trial registration number ANZCTR 365115; Post-results.

Atrial fibrillation, characterized by rapid disorganized electrical activation of myocardium, is caused by and accompanied by remodeling of myocardial tissue. We applied nonlinear optical microscopy (NLOM) to visualize typical myocardial features and atrial fibrillation effects in order to test anon-destructive imaging technology that in principle can be applied in vivo.Coherent anti-Stokes Raman scattering, endogenous two-photon excited fluorescence, and second harmonic generation were used to inspect unstained human atrial myocardium from three patients who underwent surgical Cox-MAZE procedure with amputation of left atrial appendage. Using NLOM techniques, we collected detailrich pictures of unstained tissue that enable comprehensive characterization of myocardial characteristics like myocyte structure, collagen and lipofuscin deposition, intercalating disc width, and fatty degradation. Development of in vivo application of the NLOM technique may represent a revolutionary approach in characterizing atrial fibrillation associated myocardial remodeling with important implications for therapy individualization and monitoring.

Aims Low voltage areas (LVAs) represent advanced remodelling processes in left atrium in patients with atrial fibrillation (AF) and are associated with higher rates of arrhythmia recurrences. However, the prediction of LVA based on clinical parameters is understudied. Recently, we introduced APPLE score to predict rhythm outcomes after catheter ablation. The aim of this study was to analyse (i) LVA prediction using APPLE score and (ii) differences in biomarker profiles according to APPLE score in AF patients. Methods and results Patients undergoing first AF ablation were included. The APPLE score (one point for Age >65 years, Persistent AF, imPaired eGFR

Despite advances in medical therapies, disparity in outcome between rural and urban patients remain in Australia and many Western countries.To examine time delays in lung cancer referral pathways in North Queensland (NQ), Australia, and explore patients' perspective of factors causing these delays.Prospective study of patients attending three cancer centres in Townsville, Cairns and Mackay in NQ from 2009 to 2012. Times along referral pathway were divided as follows: Onset of symptoms to treatment (T1), symptoms to general practitioner (GP) (T2), GP to specialist (T3) and Specialist to treatment (T4). Quantitative and qualitative methods were used for analysis.In total, 252 patients were participated. T1 was influenced by remoteness (125 days in Townsville vs 170 days for remote, P = 0.01), T2 by level of education (91 days for primary education vs 61 days for secondary vs 23 days for tertiary/Technical and Further Education (TAFE), P = 0.006), and age group (14 days for 31-50 years, 61 days for 51-70 years, 45 days for71 years, P = 0.026), T3 by remoteness (15 days for Townville and 29.5 days for remote, P = 0.02) and T4 by stage of disease (21 days for Stage I, 11 days for Stage II, 34 days for Stage III 18 days for Stage IV, P = 0.041). Competing priorities of family and work and cost and inconvenience of travel were perceived as rural barriers.Remoteness, age and level of education were related to delays in various time lines in lung cancer referral pathways in NQ. Provision of specialist services closer to home may decrease delays by alleviating burden of cost and inconvenience of travel.

Objective: To develop, teach and evaluate a training workshop that could rapidly prepare large numbers of health professionals working in hospitals in the Philippines to detect and safely manage Ebola virus disease (EVD). The strategy was to train teams (each usually with five members) of key health professionals from public, private and local government hospitals across the Philippines who could then guide Ebola preparedness in their hospitals. Methods: The workshop was developed collaboratively by the Philippine Department of Health and the country office of the World Health Organization. It was evaluated using a pre- and post-workshop test and two evaluation forms. Chi-square tests and linear regression analyses were conducted comparing pre- and post-workshop test results. Results: A three-day workshop was developed and used to train 364 doctors, nurses and medical technologists from 78 hospitals across the Philippines in three initial batches. Knowledge about EVD increased significantly (P < 0.009) although knowledge on transmission remained suboptimal. Confidence in managing EVD increased significantly (P = 0.018) with 96% of participants feeling more prepared to safely manage EVD cases. Discussion: The three-day workshop to prepare hospital staff for EVD was effective at increasing the level of knowledge about EVD and the level of confidence in managing EVD safely. This workshop could be adapted for use as baseline training in EVD in other developing countries to prepare large numbers of hospital staff to rapidly detect, isolate and safely manage EVD cases.

Objective: To compare the incidence of infection after minor surgery conducted using non-sterile clean boxed gloves with surgery conducted using sterile gloves. Design: Prospective randomised controlled single-centre trial testing for non-inferiority in infection rates. Setting: Primary care regional centre, Queensland, Australia. Participants: Consecutive patients presenting to participating general practitioners for a minor skin excision, between 30 June 2012 and 28 March 2013, were eligible to participate. Intervention: The use of non-sterile clean boxed gloves was compared with normal treatment using sterile gloves in the control group. Main outcome measures: Wound infection, assessed at the time of removal of sutures, and other adverse events. Results: Four hundred and ninety-three consecutive patients presenting for minor skin excisions were randomly allocated to the two treatment groups: non-sterile clean boxed gloves (n = 250) or sterile gloves (n = 243). Four hundred and seventy-eight patients contributed data for analysis (241 non-sterile, 237 sterile gloves). The incidence of infection in the non-sterile gloves group (8.7%; 95% CI, 4.9%–12.6%) was significantly non-inferior compared with the incidence in the control group (9.3%; 95% CI, 7.4%–11.1%). The two-sided 95% CI for the difference in infection rate (− 0.6%) was − 4.0% to 2.9%, and did not reach the predetermined margin of 7% which had been assumed as the non-inferiority limit. Results of the intention-to-treat analysis were confirmed by per-protocol and sensitivity analyses. There were no important adverse effects. Conclusion: Our study suggests that in regard to wound infection, non-sterile clean boxed gloves are not inferior to sterile gloves for minor skin excisions in general practice.

Aim: To assess patient satisfaction with the rheumatology telemedicine service provided to a rural town in northern Australia. Methods: A prospective, questionnaire-based exploratory study of patients seen at the Mount Isa (rural town) rheumatology telemedicine clinics during 2012 was undertaken. Control groups included patients travelling over 3 h to be seen face-to-face in Townsville (tertiary referral centre), and patients seen at the infrequent face-to-face clinic in Mount Isa. A 5-point Likert scale was used to explore themes of communication, confidentiality, physical examination, rapport, medication safety and access. Results: This study evaluated 107 rheumatology outpatients (49 telemedicine, 46 face-to-face Townsville, 12 face-to-face Mount Isa). Patients seen in Mount Isa travelled a median of < 10 km for either the telemedicine or local face-to-face appointments. The patients attending the Townsville face-to-face clinic travelled a median of 354 km. New patients comprised 14% of consultations. Satisfaction with themes related to quality-of-care was high with over 90% selecting 'agree' or 'strongly agree' to these questions. Comparing models of care, there were no statistically significant differences in the rates of those selecting 'strongly agree' across questions, apart from a single question related to rapport which favored the Mount Isa face-to-face model (P = 0.018). When asked whether they would rather travel to Townsville than participate in a telemedicine consultation, 63% of patients selected 'disagree' (17%) or 'strongly disagree' (46%). Conclusions: These results suggest that patients are satisfied with a rheumatology telemedicine service, and may prefer this to extensive travelling. Evaluation in other settings is recommended before generalizing this finding.

Objective: High plantar pressures are implicated in the development of diabetes-related foot ulcers. Whether plantar pressures remain high in patients with chronic diabetes-related foot ulcers over time is uncertain. The primary aim of this study was to compare plantar pressures at baseline and three and six months later in participants with chronic diabetes-related foot ulcers (cases) to participants without foot ulcers (controls). Methods: Standardised protocols were used to measure mean peak plantar pressure and pressure-time integral at 10 plantar foot sites (the hallux, toes, metatarsals 1 to 5, mid-foot, medial heel and lateral heel) during barefoot walking. Measurements were performed at three study visits: baseline, three and six months. Linear mixed effects random-intercept models were utilised to assess whether plantar pressures differed between cases and controls after adjusting for age, sex, body mass index, neuropathy status and follow-up time. Standardised mean differences (Cohen’s d) were used to measure effect size. Results: Twenty-one cases and 69 controls started the study and 16 cases and 63 controls completed the study. Cases had a higher mean peak plantar pressure at several foot sites including the toes (p = 0.005, Cohen’s d = 0.36) and mid-foot (p = 0.01, d = 0.36) and a higher pressure-time integral at the hallux (p

Background Communication skills are essential for veterinarians who need to discuss animal health related matters with their clients. When dealing with an emerging zoonosis, such as Hendra virus (HeV), veterinarians also have a legal responsibility to inform their clients about the associated risks to human health. Here we report on part of a mixed methods study that examined the preparedness of, and difficulties experienced by, veterinarians communicating about HeV-related risks with their clients. Methods Phase 1 was an exploratory, qualitative study that consisted of a series of face-to-face, semi-structured interviews with veterinary personnel from Queensland, Australia (2009–10) to identify the barriers to HeV management in equine practices. Phase 2a was a quantitative study that surveyed veterinarians from the same region (2011) and explored the veterinarians’ preparedness and willingness to communicate about HeV-related risks, and the reactions of their clients that they experienced. The second study included both multiple choice and open-ended questions. Results The majority of the participants from Phase 2a (83.1%) declared they had access to a HeV management plan and over half (58.6%) had ready-to-use HeV information available for clients within their practice. Most (87%) reported “always or sometimes” informing clients about HeV-related risks when a horse appeared sick. When HeV was suspected, 58.1% of participants reported their clients were receptive to their safety directives and 24.9% of clients were either initially unreceptive, overwhelmed by fear, or in denial of the associated risks. The thematic analysis of the qualitative data from Phases 1 and 2a uncovered similar themes in relation to HeV-related communication issues experienced by veterinarians: “clients’ intent to adhere”; “adherence deemed redundant”; “misunderstanding or denial of risk”; “cost”; “rural culture”; “fear for reputation”. The theme of “emotional state of clients” was only identified during Phase 1. Conclusion Warning horse owners about health and safety issues that may affect them when present in a veterinary work environment is a legal requirement for veterinarians. However, emerging zoonoses are unpredictable events that may require a different communication approach. Future training programs addressing veterinary communication skills should take into account the particular issues inherent to managing an emerging zoonosis and emphasise the importance of maintaining human safety. Veterinary communication skills and approaches required when dealing with emerging zoonoses should be further investigated. Electronic supplementary material The online version of this article (doi:10.1186/s12917-017-0970-2) contains supplementary material, which is available to authorized users.

Highlights • We surveyed private equine veterinarians about their use of personal protective equipment when examining healthy, sick and dead horses. • Practices had official Hendra virus management guidelines and a dedicated field kit available but no standardised management protocols. • Not all participants used all possible personal protective equipment when attending horses, regardless of health status. • Personal protective equipment usage increased when the likelihood of a horse being infected with the zoonosis Hendra virus increased. • Those who had dealt with horses suspected of or were trained in Hendra virus management were more likely to use appropriate protective equipment., Following the emergence of Hendra virus (HeV), private veterinarians have had to adopt additional infection control strategies to manage this zoonosis. Between 1994 and 2010, seven people became infected with HeV, four fatally. All infected people were at a higher risk of exposure from contact with horses as they were either veterinary personnel, assisting veterinarians, or working in the horse industry. The management of emerging zoonoses is best approached from a One Health perspective as it benefits biosecurity as well as a public health, including the health of those most at risk, in this case private veterinarians. In 2011 we conducted a cross-sectional study of private veterinarians registered in Queensland and providing veterinary services to horses. The aim of this study was to gauge if participants had adopted recommendations for improved infection control, including the use of personal protective equipment (PPE), and the development of HeV specific management strategies during the winter of 2011. A majority of participants worked in practices that had a formal HeV management plan, mostly based on the perusal of official guidelines and an HeV field kit. The use of PPE increased as the health status of an equine patient decreased, demonstrating that many participants evaluated the risk of exposure to HeV appropriately; while others remained at risk of HeV infection by not using the appropriate PPE even when attending a sick horse. This study took place after Biosecurity Queensland had sent a comprehensive package about HeV management to all private veterinarians working in Queensland. However, those who had previous HeV experience through the management of suspected cases or had attended a HeV specific professional education programme in the previous 12 months were more likely to use PPE than those who had not. This may indicate that for private veterinarians in Queensland personal experience and face-to-face professional education sessions may be more effective in the improvement of HeV management than passive education via information packages. The role of different education pathways in the sustainable adoption of veterinary infection control measures should be further investigated.

Previous studies in rodent models and patients suggest that visceral adipose could play a direct role in the development and progression of abdominal aortic aneurysm (AAA). This study aimed to assess the association of visceral adiposity with AAA presence and growth. This study was a case–control investigation of patients that did ( n=196) and did not ( n=181) have an AAA who presented to The Townsville Hospital vascular clinic between 2003 and 2012. Cases were patients with AAA (infra-renal aortic diameter >30 mm) and controls were patients with intermittent claudication but no AAA (infra-renal aortic diameter

Background Measuring temperature is an essential part of nursing care. It has been widely accepted as an indication of a patients' clinical condition. Often this enables early intervention and/or treatment as a change in body temperature can indicate the presence of infection or disorders of the thermoregulatory system. Objective The purpose to this study was to investigate agreement between the BD digital thermometer, the Genius 2 ™ tympanic thermometer and the SureTemp ® Plus 692 thermometer. Method A comparative design was used to evaluate the level of agreement between each thermometer in preterm and term infants, ranging from 24 weeks gestation to post term. Results A total of 238 infants were enrolled in the study, 52 infants with less than 28 weeks gestation, 112 with 29–36 weeks, 69 infants with more than 36 weeks. In general, BD digital and SureTemp ® Plus 692 measurements were in closer agreement than the BD digital and the Genius 2™ tympanic thermometer. The mean difference between the BD digital and the SureTemp ® Plus 692 measurements was −0.185 (±2 SD: −0.561 to 0.91). The mean difference between the BD digital and Genius 2™ was −0.368 (±2 SD: −1.078 to 0.342). The BD digital and SureTemp ® Plsu692 showed a negative but non-significant ( r = −0.07; p = 0.273) correlation between the differences and the averages of the measurements. The correlation of the differences and the averages of the BD digital and Genius 2™ measurements was also negative and significant ( r = −0.53; p Conclusion The results of the study suggested that the SureTemp ® Plus 692 thermometer can be used as a reasonable alternative to the BD Digital thermometer in the neonatal population.

Background Current international guidelines advocate achieving at least a 30 % reduction in maximum plantar pressure to reduce the risk of foot ulcers in people with diabetes. However, whether plantar pressures differ in cases with foot ulcers to controls without ulcers is not clear. The aim of this study was to assess if plantar pressures were higher in patients with active plantar diabetic foot ulcers (cases) compared to patients with diabetes without a foot ulcer history (diabetes controls) and people without diabetes or a foot ulcer history (healthy controls). Methods Twenty-one cases with diabetic foot ulcers, 69 diabetes controls and 56 healthy controls were recruited for this case-control study. Plantar pressures at ten sites on both feet and stance phase duration were measured using a pre-established protocol. Primary outcomes were mean peak plantar pressure, pressure-time integral and stance phase duration. Non-parametric analyses were used with Holm’s correction to correct for multiple testing. Binary logistic regression models were used to adjust outcomes for age, sex and body mass index. Median differences with 95 % confidence intervals and Cohen’s d values (standardised mean difference) were reported for all significant outcomes. Results The majority of ulcers were located on the plantar surface of the hallux and toes. When adjusted for age, sex and body mass index, the mean peak plantar pressure and pressure-time integral of toes and the mid-foot were significantly higher in cases compared to diabetes and healthy controls (p

Background Several prospective studies have suggested that gait and plantar pressure abnormalities secondary to diabetic peripheral neuropathy contributes to foot ulceration. There are many different methods by which gait and plantar pressures are assessed and currently there is no agreed standardised approach. This study aimed to describe the methods and reproducibility of three-dimensional gait and plantar pressure assessments in a small subset of participants using pre-existing protocols. Methods Fourteen participants were conveniently sampled prior to a planned longitudinal study; four patients with diabetes and plantar foot ulcers, five patients with diabetes but no foot ulcers and five healthy controls. The repeatability of measuring key biomechanical data was assessed including the identification of 16 key anatomical landmarks, the measurement of seven leg dimensions, the processing of 22 three-dimensional gait parameters and the analysis of four different plantar pressures measures at 20 foot regions. Results The mean inter-observer differences were within the pre-defined acceptable level ( 0.9 for 100 % (7 of 7) of leg dimensions. The coefficients of variations (CVs) were within the pre-defined acceptable level (

Background The estimated likelihood of lower limb amputation is 10 to 30 times higher amongst people with diabetes compared to those without diabetes. Of all non-traumatic amputations in people with diabetes, 85% are preceded by a foot ulcer. Foot ulceration associated with diabetes (diabetic foot ulcers) is caused by the interplay of several factors, most notably diabetic peripheral neuropathy (DPN), peripheral arterial disease (PAD) and changes in foot structure. These factors have been linked to chronic hyperglycaemia (high levels of glucose in the blood) and the altered metabolic state of diabetes. Control of hyperglycaemia may be important in the healing of ulcers. Objectives To assess the effects of intensive glycaemic control compared to conventional control on the outcome of foot ulcers in people with type 1 and type 2 diabetes. Search methods In December 2015 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; Elsevier SCOPUS; ISI Web of Knowledge Web of Science; BioMed Central and LILACS. We also searched clinical trial databases, pharmaceutical trial databases and current international and national clinical guidelines on diabetes foot management for relevant published, non-published, ongoing and terminated clinical trials. There were no restrictions based on language or date of publication or study setting. Selection criteria Published, unpublished and ongoing randomised controlled trials (RCTs) were considered for inclusion where they investigated the effects of intensive glycaemic control on the outcome of active foot ulcers in people with diabetes. Non randomised and quasi-randomised trials were excluded. In order to be included the trial had to have: 1) attempted to maintain or control blood glucose levels and measured changes in markers of glycaemic control (HbA1c or fasting, random, mean, home capillary or urine glucose), and 2) documented the effect of these interventions on active foot ulcer outcomes. Glycaemic interventions included subcutaneous insulin administration, continuous insulin infusion, oral anti-diabetes agents, lifestyle interventions or a combination of these interventions. The definition of the interventional (intensive) group was that it should have a lower glycaemic target than the comparison (conventional) group. Data collection and analysis All review authors independently evaluated the papers identified by the search strategy against the inclusion criteria. Two review authors then independently reviewed all potential full-text articles and trials registry results for inclusion. Main results We only identified one trial that met the inclusion criteria but this trial did not have any results so we could not perform the planned subgroup and sensitivity analyses in the absence of data. Two ongoing trials were identified which may provide data for analyses in a later version of this review. The completion date of these trials is currently unknown. Authors’ conclusions The current review failed to find any completed randomised clinical trials with results. Therefore we are unable to conclude whether intensive glycaemic control when compared to conventional glycaemic control has a positive or detrimental effect on the treatment of foot ulcers in people with diabetes. Previous evidence has however highlighted a reduction in risk of limb amputation (from various causes) in people with type 2 diabetes with intensive glycaemic control. Whether this applies to people with foot ulcers in particular is unknown. The exact role that intensive glycaemic control has in treating foot ulcers in multidisciplinary care (alongside other interventions targeted at treating foot ulcers) requires further investigation.

Purpose Intermittent claudication is a common symptom of peripheral arterial disease. Currently, there is a lack of consensus on the most effective therapies for this problem. We conducted a meta-analysis of randomized trials assessing the efficacy of endovascular therapy (EVT) compared with noninvasive therapies for the treatment of intermittent claudication. Methods Randomized trials comparing the efficacy of EVT and noninvasive therapies, such as medical therapy (MT) and supervised exercise (SVE) in patients with intermittent claudication were identified by a systematic search. Data were pooled, and combined overall effect sizes (standardized differences of mean values) were calculated for a random effect model in terms of ankle-brachial index (ABI) and treadmill walking for initial claudication distance (ICD) and maximum walking distance (MWD). Nine eligible trials (873 participants) were included: two compared EVT and MT alone, four compared EVT and SVE, and three trials compared EVT plus SVE vs SVE alone. Results Heterogeneity between studies was marked. Quantitative data analysis suggested that EVT improved outcomes over MT alone at early follow-up evaluations. Outcomes of EVT plus SVE were better than those of SVE alone in terms of both ABI and treadmill walking at immediate, early, and intermediate follow-up. No substantial differences in outcomes of EVT alone compared with SVE alone were found. Conclusion In patients with intermittent claudication, current evidence supports improved ABI and treadmill walking when EVT is added to MT or SVE during early and intermediate follow-up. There is no evidence that EVT alone provides improved outcome over SVE alone. There is low confidence in these findings for a number of reasons, including the small number of trials, the small size of these studies, the heterogeneity in study design, and the limited use of quality of life tools in assessing outcomes. More consistent data from larger, more homogenous studies, including longer follow-up, are required.

Aim: First we aimed to assess the reproducibility of a computer tomography angiography (CTA) based technique for measuring infra-renal aortic volume and diameter. Second we sought to investigate whether changes in aortic volume and diameter were similar during follow-up. Materials and methods: A prospective series of 57 patients, with aortic diameter initially measuring between 25 and 55 mm, were assessed with 2 CTAs a median of 14 months apart. Aortic volume and maximum diameter (both axial and orthogonal) were measured by a semi-automated workstation protocol based on previously defined techniques. Intra- and inter-observer reproducibility were assessed by repeat assessment of the initial CTA images of the first 33 patients included in the study, in order to estimate the 95% limits of agreements. Changes in aortic dimensions between the first and follow-up CTA, were defined for volume and diameter separately as changes greater than their respective 95% limits of agreement. Results: Reproducibility of aortic volume and diameter was excellent with an average coefficient of variation

This study identified sex differences in clinical presentation and survival for primary cutaneous melanoma without clinical evidence of metastasis at diagnosis from 1976 to 2008 in southern Germany. Melanoma-specific survival curves and estimated survival probabilities were generated using the Kaplan-Meier method. Multivariate survival analyses were carried out using the Cox modeling. Male patients had significantly thicker and more frequently ulcerated tumors and a lower 10-year disease-specific survival (DSS) and recurrence-free survival probability compared with females among patients of 43 years old or younger (DSS: 86.1 vs. 93.2%, P

Background: Salmonella enterica serotype Virchow is the most common cause of invasive nontyphoid salmonellosis in North Queensland, particularly in infants, but the zoonotic source is unknown. This study aimed at determining (i) the prevalence of the introduced Asian house gecko, Hemidactylus frenatus, in houses in North Queensland and (ii) whether they were a potential source of Salmonella Virchow. Methods: Asian house geckos were collected in a random survey of houses in Townsville, North Queensland. Gut contents underwent microbiological analysis within 2 h of removal using both direct plating and enrichment broth methods. Any organism found to be a presumptive Salmonella spp. was then sent to a reference lab for confirmation of genus/species, serotyping, and phage typing if indicated. Results: One hundred Asian house geckos were collected from 57 houses. Geckos were present in 100% of houses surveyed, and prevalence of Salmonella in large intestinal contents was 7% (95% confidence interval 2, 12%). Three serotypes were found: Virchow (phage type 8), Weltevreden, and an untypable subspecies 1 serotype 11:-:1,7. Conclusion: Since Salmonella Virchow (phage type 8) is associated with invasive disease, the introduced Asian house gecko may play a significant role in the epidemiology of sporadic salmonellosis in places invaded by these peridomestic reptiles. These results justify more detailed epidemiological studies on the role of the Asian house gecko in sporadic salmonellosis and development of evidence-based strategies to decrease this potential zoonotic hazard.