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Background Studies from high income countries suggest improved survival for females as compared to males following trauma. However, data regarding differences in trauma outcomes between females and males is severely lacking from low- and middle-income countries. The objective of this study was to determine the association between sex and clinical outcomes amongst Indian trauma patients using the Australia-India Trauma Systems Collaboration database. Methods A prospective multicentre cohort study was performed across four urban public hospitals in India April 2016 through February 2018. Bivariate analyses compared admission physiological parameters and mechanism of injury. Logistic regression assessed association of sex with the primary outcomes of 30-day and 24-hour in-hospital mortality. Secondary outcomes included ICU admission, ICU length of stay, ventilator requirement, and time on a ventilator. Results Of 8,605 patients, 1,574 (18.3%) were females. The most common mechanism of injury was falls for females (52.0%) and road traffic injury for males (49.5%). On unadjusted analysis, there was no difference in 30-day in-hospital mortality between females (11.6%) and males (12.6%, p = 0.323). However, females demonstrated a lower mortality at 24-hours (1.1% vs males 2.1%, p = 0.011) on unadjusted analysis. Females were also less likely to require a ventilator (17.3% vs 21.0% males, p = 0.001) or ICU admission (34.4% vs 37.5%, p = 0.028). Stratification by age or by ISS demonstrated no difference in 30-day in-hospital mortality for males vs females across age and ISS categories. On multivariable regression analysis, sex was not associated significantly with 30-day or 24-hour in-hospital mortality. Conclusion This study did not demonstrate a significant difference in the 30-day trauma mortality or 24-hour trauma mortality between female and male trauma patients in India on adjusted analyses. A more granular data is needed to understand the interplay of injury severity, immediate post-traumatic hormonal and immunological alterations, and the impact of gender-based disparities in acute care settings.

To assess whether padded headgear was associated with incidence of suspected sports-related concussion, non-sports-related concussion head injury, and injuries to other body regions in junior Australian football.Prospective cohort injury surveillance.There were 400 junior players (42.5% female) enrolled across two seasons. Suspected sports-related concussion was defined by detection of observable signs on the field and medical assessment or missed match(es) due to suspected sports-related concussion. Non-sports-related concussion head injury and injuries to other body regions were defined as those that received medical assessment or resulted in a missed match.There were 20 teams monitored over 258 matches. 204 players (2484 player hours) wore mandated headgear throughout the season and 196 (2246 player hours) did not. The incidence rate of suspected sports-related concussion was 3.17 (95% confidence interval: 3.04-3.30) per 1000 player-hours and no differences were observed between males and females (risk ratio 1.11; 95% confidence interval: 0.40-3.06). Headgear use was not associated with suspected sports-related concussion (risk ratio 1.09; 95% confidence interval: 0.41-2.97), non-sports-related concussion head injury (risk ratio 0.27; 95% confidence interval: 0.06-1.31), or injuries to other body regions (risk ratio 1.41; 95% confidence interval: 0.79-2.53).Headgear use was not associated with reduced risk of suspected sports-related concussion, non-sports-related concussion head injury or injuries to other body regions. There was no difference in the rate of suspected sports-related concussion in female compared to male players, however, rates of non-sports-related concussion head injury and injuries to other body regions were higher in male players.

Purpose The purpose of this project was to identify additional facets of diabetes distress (DD) in veterans that may be present due to the veteran’s military-related experience. Methods The study team completed cognitive interviews with veterans with type 2 diabetes mellitus (T2DM) to examine how they answered the Diabetes Distress Scale (DD Scale), a tool that assesses DD. The DD Scale was used because of its strong associations with self-management challenges, physician-related distress, and clinical outcomes. Results The veterans sample (n= 15) was 73% male, mean age of 61 (SD = 8.6), 53% Black, 53% with glycosylated hemoglobin level Conclusions This study describes how a veteran’s military experience may contribute to DD in the context of T2DM self-management. Findings indicate clinicians and researchers should account for additional domains when developing self-management interventions and discussing self-management behaviors with individuals with T2DM.

Diabetes Distress (DD, i.e., regimen, emotional, interpersonal, clinician) in adults with type 2 diabetes (T2DM) is associated with poor glycemic control, poorer diet and exercise, and more T2DM complications. We describe a multi-phased study to develop and test a tailored intervention to reduce DD to improve health outcomes. Phases 1-3 identified factors related to DD in Veterans with T2DM to inform intervention development. We used an explanatory sequential mixed methods design to identify how Veterans with T2DM experienced DD. Veterans (n=210) completed measures (DD, depression, empowerment, stigma) . A subset of Veterans (n=36) also completed in-depth qualitative interviews. We fit a multivariable linear regression to examine associations with DD score. We completed thematic analysis on interview transcripts. We integrated measurement and interview data using matrices and analyzed results by medication type, hemoglobin A1c (HbA1c) , and severity of DD (low, moderate, high) . Mean age was 63 years (SD 10.2) ; 15% female; 69% non-white; 56% on insulin; mean A1c 8.9% (SD 2.0) ; mean DD score was 2.0 (SD 0.9) , indicating moderate distress. In the regression model, female gender (β= -0.31; 95% CI: -0.57, -0.04) , diagnosis of multiple mental health comorbidities vs. one condition (β=-0.29; 95% CI: -0.55, -0.03) , higher depression symptom (β=0.15; severity (95% CI: 0.08, 0.23) and stigma (β=0.02; 95% CI: 0.01, 0.04) were associated with higher DD. Higher T2DM self-efficacy (β=-0.34; 95% CI: -0.51, -0.18) was associated with lower DD. Interviews elaborated on themes including the impact of pain and comorbidities on DD. Integrating the measurement and interview data indicated that experiences of DD varies by many characteristics based on medication type, HbA1c, and severity of DD. Elucidating contributors to DD in Veterans using mixed methods will improve our ability to develop a tailored intervention addressing DD in a manner relevant to Veteran populations. Disclosure A.Lewinski: Other Relationship; Otsuka America Pharmaceutical, Inc., PhRMA Foundation. S.J.Barcinas: None. H.B.Bosworth: Advisory Panel; Sanofi, Board Member; preventics diagnostics, Consultant; VIDYA, webmed, Research Support; Boehringer Ingelheim International GmbH, improved Patient Outcomes, Merck & Co., Inc., Novo Nordisk, Otsuka America Pharmaceutical, Inc. M.J.Crowley: None. A.S.Jeffreys: None. C.Coffman: None. C.Whitfield: None. T.Howard: None. A.Shapiro: None. E.S.Mcconnell: None. P.Tanabe: None. Funding Durham Center of Innovation to Accelerate Discovery and Practice Transformation (CIN 13-4) and VA HSR&D grants #18-234 (to AAL) and #08-027 (to HBB) .

Introduction Trauma services within hospitals may vary considerably at different times across a 24 h period. The variable services may negatively affect the outcome of trauma victims. The current investigation aims to study the effect of arrival time of major trauma patients on mortality and morbidity. Method Retrospective analysis of the Australia-India Trauma Systems Collaboration (AITSC) registry established in four public university teaching centres in India Based on hospital arrival time, patients were grouped into “Office-hours” and “After-hours”. Outcome parameters were compared between the above groups. Results 5536 (68.4%) patients presented “after-hours” (AO) and 2561 (31.6%) during “office-hours” (OH). The in-hospital mortality for “after-hours” and “office-hours” presentations were 12.1% and 11.6% respectively. On unadjusted analysis, there was no statistical difference in the odds of survival for OH versus AH presentations. (OR,1.05, 95% CI 0.9‐1.2). Adjusting for potential prognostic factors (injury severity, presence of shock on arrival, referral status, sex, or extremes of age), there was no statistically significant odds of survival for OH versus AH presentations (OR,1.02, 95%CI 0.9–1.2).ICU length of stay and duration of mechanical ventilation was longer in the AH group. Conclusion The in-hospital mortality did not differ between trauma patients who arrived during “after-hours” compared to ‘“office-hours”.

Objective To explore the potential utility of head acceleration event (HAE) measurements to augment identification of players for further concussion screening in non-helmeted contact sport. Design Prospective observational pilot study. Participants 210 (118 female) professional Australian football players in 2017 season. Methods Players wore the X-Patch® accelerometer for one match each with data collected across 14 matches. Players with HAEs above thresholds associated with concussion, 95 g (males) or 85.5 g (females), were compared to players identified to have suspected concussion by club personnel during the inspected matches. Video review of matches was undertaken by a physician blinded to HAEs to identify players with concussive signs. Results Among 26 players (50% female) with HAEs above threshold, two players were screened for concussion. Of the remaining 24 players, nine were not visible on video at the HAE time, six sustained verifiable head impacts, and nine sustained verifiable body impacts with no head impacts. Among 184 players with HAEs below threshold, five players were screened. Conclusion Players were identified to have head impacts and suspected concussion in the absence of HAEs above threshold. Use of X-Patch® was not sufficiently reliable for identifying players for further concussion screening in professional Australian football. Video review of head impacts remains essential in concussion screening.

Each year approximately five million people die from injuries. In countries where systems of trauma care have been introduced, death and disability have decreased. A major component of developed trauma systems is a trauma quality improvement (TQI) program and trauma quality improvement meeting (TQIM). Effective TQIMs improve trauma care by identifying and fixing problems. But globally, TQIMs are absent or unstructured in most hospitals providing trauma care. The aim of this study was to implement and evaluate a checklist for a structured TQIM.This project was conducted as a prospective before-and-after study in four major trauma centres in India. The intervention was the introduction of a structured TQIM using a checklist, introduced with a workshop. This workshop was based on the World Health Organization (WHO) TQI Programs short course and resources, plus the developed TQIM checklist. Pre- and post-intervention data collection occurred at all meetings in which cases of trauma death were discussed. The primary outcome was TQIM Checklist compliance, defined by the discussion of, and agreement upon each of the following: preventability of death, identification of opportunities to improve care and corrective actions and a plan for closing the loop.There were 34 meetings in each phase, with 99 cases brought to the pre-intervention phase and 125 cases brought to the post-intervention phase. There was an increase in the proportion of cases brought to the meeting for which preventability of death was discussed (from 94% to 100%, p = 0.007) and agreed (from 7 to 19%, OR 3.7; 95% CI:1.4-9.4, p = 0.004) and for which a plan for closing the loop was discussed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p 0.001) and agreed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p 0.001).This study developed, implemented and evaluated a TQIM Checklist for improving TQIM processes. The introduction of a TQIM Checklist, with training, into four Indian trauma centres, led to more structured TQIMs, including increased discussion and agreement on preventability of death and plans for loop closure. A TQIM Checklist should be considered for all centres managing trauma patients.

The completeness of a trauma registry’s data is essential for its valid use. This study aimed to evaluate the extent of missing data in a new multicentre trauma registry in India and to assess the association between data completeness and potential predictors of missing data, particularly mortality. The proportion of missing data for variables among all adults was determined from data collected from 19 April 2016 to 30 April 2017. In-hospital physiological data were defined as missing if any of initial systolic blood pressure, heart rate, respiratory rate, or Glasgow Coma Scale were missing. Univariable logistic regression and multivariable logistic regression, using manual stepwise selection, were used to investigate the association between mortality (and other potential predictors) and missing physiological data. Data on the 4466 trauma patients in the registry were analysed. Out of 59 variables, most (n = 51; 86.4%) were missing less than 20% of observations. There were 808 (18.1%) patients missing at least one of the first in-hospital physiological observations. Hospital death was associated with missing in-hospital physiological data (adjusted OR 1.4; 95% CI 1.02–2.01; p = 0.04). Other significant associations with missing data were: patient arrival time out of hours, hospital of care, ‘other’ place of injury, and specific injury mechanisms. Assault/homicide injury intent and occurrence of chest X-ray were associated with not missing any of first in-hospital physiological variables. Most variables were well collected. Hospital death, a proxy for more severe injury, was associated with missing first in-hospital physiological observations. This remains an important limitation for trauma registries.

Introduction: Injuries are a major cause of disability and lost productivity. The case for a national trauma registry has been recognized by the Australian Commission on Safety and Quality in Health Care and at a policy level. Background: The need was flagged in 1993 by the Royal Australasian College of Surgeons and the Australasian Trauma Society. In 2003, the Centre of National Research and Disability funded the Australian and New Zealand National Trauma Registry Consortium, which produced three consecutive annual reports. The bi-national trauma minimum dataset was also developed during this time. Operations were suspended thereafter. Method: In response to sustained lobbying the Australian Trauma Quality Improvement Program including the Australian Trauma Registry (ATR) commenced in 2012, with data collection from 26 major trauma centres. An inaugural report was released in late 2014. Result: The Federal Government provided funding in December 2016 enabling the work of the ATR to continue. Data are currently being collected for cases that meet inclusion criteria with dates of injury in the 2017–2018 financial year. Since implementation, the number of submitted records has been increased from fewer than 7000 per year to over 8000 as completeness has improved. Four reports have been released and are available to stakeholders. Conclusion: The commitment shown by the College, other organizations and individuals to the vision of a national trauma registry has been consistent since 1993. The ATR is now well placed to improve the care of injured people. Published version

Introduction In India, more than a million people die annually due to injuries. Identifying the patients at risk of early mortality (within 24 hour of hospital arrival) is essential for triage. A bilateral Government Australia-India Trauma System Collaboration generated a trauma registry in the context of India, which yielded a cohort of trauma patients for systematic observation and interventions. The aim of this study was to determine the independent association of on-arrival vital signs and Glasgow Coma Score (GCS) with 24-hour mortality among adult trauma patients admitted at four university public hospitals in urban India. Methods We performed an analysis of a prospective multicentre observational study of trauma patients across four urban public university hospitals in India, between April 2016 and February 2018. The primary outcome was 24-hour in-hospital mortality. We used logistic regression to determine mutually independent associations of the vital signs and GCS with 24-hour mortality. Results A total of 7497 adult patients (18 years and above) were included. The 24-hour mortality was 1.9%. In univariable logistic regression, Glasgow Coma Score (GCS) and the vital signs systolic blood pressure (SBP), heart rate (HR), respiratory rate (RR) and peripheral capillary oxygen saturation (SpO2) had statistically significant associations with 24-hour mortality. These relationships held in multivariable analysis with hypotension (SBP 100bpm) and bradycardia (HR 20brpm) and severe (3-8) and moderate (9-12) GCS having strong association with 24-hour mortality. Notably, the patients with missing values for SBP, HR and RR also demonstrated higher odds of 24-hour mortality. The Injury Severity Scores (ISS) did not corelate with 24-hour mortality. Conclusion The routinely measured GCS and vital signs including SBP, HR, SpO2 and RR are independently associated with 24-hour in-hospital mortality in the context of university hospitals of urban India. These easily measured parameters in the emergency setting may help improve decision-making and guide further management in the trauma victims. A poor short-term prognosis was also observed in patients in whom these physiological variables were not recorded.

OBJECTIVE This retrospective observational study aimed to compare the impact of the Prevent Alcohol and Risk-Related Trauma Youth (P.A.R.T.Y.) Program when delivered as In-hospital or Outreach models to rural and regional students. METHODS The study population were consented participants from regional areas between 2013 and 2017 who completed pre-programme, immediately post-programme and 3-5 months post-programme surveys. Responses from the metropolitan In-hospital programme participants and regional Outreach programme participants were analysed within groups across the three time points. The primary outcome variable was a change in self-reported perception of driving after drinking alcohol. Secondary outcome variables were designating a safe driver after drinking, perception of risk of injury if not wearing a seatbelt, risks of injury if undertaking physical risk-taking activities and likelihood of the programme changing perceptions. RESULTS There were 1314 participants invited to participate and 547 (42%) sets of complete surveys were received, of whom 296 (54%) were Outreach participants. Pre-programme, a significantly lower proportion of Outreach participants reported 'definitely not' to driving after drinking (84% vs 91%), and perceived a 'definite' likelihood of sustaining injury if not wearing a seatbelt (57% vs 66%). Outreach participants displayed improvements in likelihood to drive after drinking alcohol immediately post-programme and on follow up (P = 0.028). Responses to all other secondary outcome measures demonstrated some improvement. CONCLUSIONS Although demographically similar, baseline perceptions toward alcohol, risk-taking and injury differed between groups. Improvements in perception were demonstrated across both models. These findings support P.A.R.T.Y. as an injury prevention initiative for regional youth.

Background Persistent poorly-controlled type 2 diabetes mellitus (PPDM), or maintenance of a hemoglobin A1c (HbA1c) ≥8.5% despite receiving clinic-based diabetes care, contributes disproportionately to the national diabetes burden. Comprehensive telehealth interventions may help ameliorate PPDM, but existing approaches have rarely been designed with clinical implementation in mind, limiting use in routine practice. We describe a study testing a novel telehealth intervention that comprehensively targets clinic-refractory PPDM, and was explicitly developed for practical delivery using existing Veterans Health Administration (VHA) clinical infrastructure. Methods Practical Telehealth to Improve Control and Engagement for Patients with Clinic-Refractory Diabetes Mellitus (PRACTICE-DM) is an ongoing randomized controlled trial comparing two 12-month interventions: 1) standard VHA Home Telehealth (HT) telemonitoring/care coordination; or 2) the PRACTICE-DM intervention, a comprehensive HT-delivered intervention combining telemonitoring, self-management support, diet/activity support, medication management, and depression management. The primary outcome is HbA1c. Secondary outcomes include diabetes distress, self-care, self-efficacy, weight, depressive symptoms, implementation barriers/facilitators, and costs. We hypothesize that the PRACTICE-DM intervention will reduce HbA1c by >0.6% versus standard HT over 12 months. Results Enrollment for this ongoing trial concluded in January 2020; 200 patients were randomized (99 to standard HT and 101 to the PRACTICE-DM intervention). The cohort has a mean age of 58 and is 23% female and 72% African American. Mean baseline HbA1c and BMI were 10.2% and 34.8 kg/m2. Conclusions Because it comprehensively targets factors underlying PPDM using existing clinical infrastructure, the PRACTICE-DM intervention may be well suited to lower the complications and costs of PPDM in routine practice.

Background: Trauma registries are known to drive improvements and optimise trauma systems worldwide. This is the first reported comparison of the epidemiology and outcomes at major centres across Australia. Methods: The Australian Trauma Registry was a collaboration of 26 major trauma centres across Australia at the time of this study and currently collects information on patients admitted to these centres who die after injury and/or sustain major trauma (Injury Severity Score (ISS) > 12). Data from 1 July 2016 to 30 June 2017 were analysed. Primary endpoints were risk adjusted length of stay and mortality (adjusted for age, cause of injury, arrival Glasgow coma scale (GCS), shock-index grouped in quartiles and ISS). Results: There were 8423 patients from 24 centres included. The median age (IQR) was 48 (28–68) years. Median (IQR) ISS was 17 (14–25). There was a predominance of males (72%) apart from the extremes of age. Transport-related cases accounted for 45% of major trauma, followed by falls (35.1%). Patients took 1.42 (1.03–2.12) h to reach hospital and spent 7.10 (3.64–15.00) days in hospital. Risk adjusted length of stay and mortality did not differ significantly across sites. Primary endpoints across sites were also similar in paediatric and older adult (>65) age groups. Conclusion: Australia has the capability to identify national injury trends to target prevention and reduce the burden of injury. Quality of care following injury can now be benchmarked across Australia and with the planned enhancements to data collection and reporting, this will enable improved management of trauma victims.

To investigate changes from baseline on SCAT3 as a result of football game exposure, and association with X2 Patch measured head acceleration events in amateur Australian footballers.Prospective cohort.Peak linear acceleration (PLA) of the head (10 g) was measured by wearable head acceleration sensor X2 Biosystems X-Patch in male (n=34) and female (n=19) Australian footballers. SCAT3 was administered at baseline (B) and post-game (PG).1394 head acceleration events (HEA)10 g were measured. Mean and median HEA PLA were recorded as 15.2 g (SD=9.2, range=10.0-115.8) and 12.4 g (IQR=11.0-15.6) respectively. No significant difference in median HEA PLA (g) was detected across gender (p=0.55), however, more HEAs were recorded in males (p=0.03). A greater number (p=0.004) and severity (p0.001) of symptoms were reported PG than at B. No significant association between number of HEA or median PLA, and SCAT3 change scores (p0.05 for all), was identified for either gender.Increase in symptom severity post game was not associated with X2 measured HEA. Males sustained more HEA, however HEA PLA magnitude did not differ across gender. Further work on the validation of head acceleration sensors is required and their role in sports concussion research and medical management.

BACKGROUND The role of prehospital endotracheal intubation (PETI) for traumatic brain injury is unclear. In Victoria, paramedics use rapid sequence induction (RSI) drugs to facilitate PETI, while in New South Wales (NSW) they do not have access to paralysing agents. We hypothesized that RSI would both increase PETI rates and improve mortality. METHODS Retrospective comparison of adult primary admissions (Glasgow Coma Scale 2) to either Victorian or NSW trauma centre, which were compared with univariate and logistic regression analysis to estimate odds ratio for mortality and intensive care unit (ICU) length of stay. RESULTS One hundred and ninety-two Victorian and 91 NSW patients did not differ in: demographics (males: 77% versus 79%; P = 0.7 and age: 34 (18-88) versus 33 (18-85); P = 0.7), Glasgow Coma Scale (3 (3-8) versus 5 (3-8); P = 0.07), and injury severity score (38 (26-75) versus 35 (18-75); P = 0.09), prehospital hypotension (15.4% versus 11.7%; P = 0.5) and desaturation (14.6% versus 17.5%; P = 0.5). Victorians had higher abbreviated injury scale head and neck (5 (4-5) versus 5 (3-6); P = 0.04) and more often successful PETI (85% versus 22%; P

OBJECTIVE The Prevent Alcohol and Risk-Related Trauma in Youth (P.A.R.T.Y.) Program at The Alfred uses vivid clinical reality to build resilience and prevent injury by following a trauma patient's journey through hospital. The present study aims to analyse the effect of P.A.R.T.Y. on safety perceptions of driving after alcohol, seat belt use and risk-taking activities. METHODS Pre-programme, immediately post-programme and 3-5 months post-programme surveys with questions focused on the programme aims were distributed to all consented participants. RESULTS There were 2502 participants during the study period and 1315 (53%) responses were received. The mean age was 16.2 (SD 0.8) years, 724 (56%) were women and 892 (68%) possessed a learner's permit for driving. Pre-programme, 1130 (86%) participants reported 'definitely not' likely to drive after drinking alcohol, that improved to 1231 (94%) immediately post-programme and 1215 (93%) at 3-5 months post-programme (P

Objective This systematic review aimed to determine the effect of prehospital notification systems for major trauma patients on overall (< 30 days) and early (< 24 hours) mortality, hospital reception and trauma team presence (or equivalent) on arrival, time to critical interventions and length of hospital stay. Methods Experimental and observational studies of pre-hospital notification compared with no notification or another type of notification in major trauma patients requiring emergency transport were included. Risk of bias was assessed using the Cochrane ACROBAT-NRSI tool. A narrative synthesis was conducted and evidence quality rated using the GRADE criteria. Results Three observational studies of 72,423 major trauma patients were included. All were conducted in high-income countries in hospitals with established trauma services, with two studies undertaking retrospective analysis of registry data. Two studies reported overall mortality, one demonstrating a reduction in mortality; (adjusted odds ratio (OR) 0.61, 95% confidence interval (CI) 0.39 to 0.94, 72,073 participants); and the other demonstrating a non-significant change (OR 0.61, 95% CI 0.23 to 1.64, 81 participants). The quality of this evidence was rated as very low. Conclusion Limited research on the topic constrains conclusive evidence on the effect of pre-hospital notification on patient-centred outcomes after severe trauma. Composite interventions that combine pre-hospital notification with effective actions on arrival to hospital such as trauma bay availability, trauma team presence and early access to definitive management may provide more robust evidence towards benefits of early interventions during trauma reception and resuscitation. This article is protected by copyright. All rights reserved

ObjectivesTo assess the effect of a mobile phone application for prehospital notification on resuscitation and patient outcomes.DesignLongitudinal prospective cohort study with preintervention and postintervention cohorts.SettingMajor trauma centre in India.ParticipantsInjured patients being transported by ambulance and allocated to red (highest) and yellow (medium) triage categories.InterventionA prehospital notification application for use by ambulance and emergency clinicians to notify emergency departments (EDs) of an impending arrival of a patient requiring advanced lifesaving care.Main outcome measuresThe primary outcome was the proportion of eligible patients arriving at the hospital for which prehospital notification occurred. Secondary outcomes were the availability of a trauma cubicle, presence of a trauma team on patient arrival, time to first chest X-ray, and ED and in-hospital mortality.ResultsData from January 2017 to January 2018 were collected with 208 patients in the preintervention and 263 patients in the postintervention period. The proportion of patients arriving after prehospital notification improved from 0% to 11% (pConclusionsThe prehospital notification application for severely injured patients had limited uptake but implementation was associated with improved trauma reception and reduction in early deaths. Quality improvement efforts with ongoing data collection using the trauma registry are indicated to drive improvements in trauma outcomes in India.Trial registration numberNCT02877342.

Objectives To assess the utility and functionality of the X-Patch® as a measurement tool to study head impact exposure in Australian Football. Accuracy, precision, reliability and validity were examined. Designs Laboratory tests and prospective observational study. Methods Laboratory tests on X-Patch® were undertaken using an instrumented Hybrid III head and neck and linear impactor. Differences between X-Patch® and reference data were analysed. Australian Football players wore the X-Patch® devices and games were video-recorded. Video recordings were analysed qualitatively for head impact events and these were correlated with X-Patch® head acceleration events. Wearability of the X-Patch® was assessed using the Comfort Rating Scale for Wearable Computers. Results Laboratory head impacts, performed at multiple impact sites and velocities, identified significant correlations between headform-measured and device-measured kinematic parameters (p Conclusions This study reinforces evidence that use of the current X-Patch® devices should be limited to research only and in conjunction with video analysis.

The role of prehospital endotracheal intubation (PETI) for traumatic brain injury is unclear. In Victoria, paramedics use rapid sequence induction (RSI) drugs to facilitate PETI, while in New South Wales (NSW) they do not have access to paralysing agents. We hypothesized that RSI would both increase PETI rates and improve mortality.Retrospective comparison of adult primary admissions (Glasgow Coma Scale 9 and abbreviated injury scale head and neck 2) to either Victorian or NSW trauma centre, which were compared with univariate and logistic regression analysis to estimate odds ratio for mortality and intensive care unit (ICU) length of stay.One hundred and ninety-two Victorian and 91 NSW patients did not differ in: demographics (males: 77% versus 79%; P = 0.7 and age: 34 (18-88) versus 33 (18-85); P = 0.7), Glasgow Coma Scale (3 (3-8) versus 5 (3-8); P = 0.07), and injury severity score (38 (26-75) versus 35 (18-75); P = 0.09), prehospital hypotension (15.4% versus 11.7%; P = 0.5) and desaturation (14.6% versus 17.5%; P = 0.5). Victorians had higher abbreviated injury scale head and neck (5 (4-5) versus 5 (3-6); P = 0.04) and more often successful PETI (85% versus 22%; P 0.05). On logistic regression analysis, mortality did not differ among groups (31.7% versus 26.3%; P = 0.34; OR = 0.84; 95% CI: 0.38-1.86; P = 0.67). Among survivors, Victorians had longer stay in ICU (364 (231-486) versus 144 (60-336) h), a difference that persisted on gamma regression (effect = 1.58; 95% CI: 1.30-1.92; P 0.05).Paramedics using RSI to obtain PETI in patients with traumatic brain injury had a higher success rate. This increase in successful PETI rate was not associated with an improvement in either mortality rate or ICU length of stay.

The Prevent Alcohol and Risk-Related Trauma in Youth (P.A.R.T.Y.) Program at The Alfred uses vivid clinical reality to build resilience and prevent injury by following a trauma patient's journey through hospital. The present study aims to analyse the effect of P.A.R.T.Y. on safety perceptions of driving after alcohol, seat belt use and risk-taking activities.Pre-programme, immediately post-programme and 3-5 months post-programme surveys with questions focused on the programme aims were distributed to all consented participants.There were 2502 participants during the study period and 1315 (53%) responses were received. The mean age was 16.2 (SD 0.8) years, 724 (56%) were women and 892 (68%) possessed a learner's permit for driving. Pre-programme, 1130 (86%) participants reported 'definitely not' likely to drive after drinking alcohol, that improved to 1231 (94%) immediately post-programme and 1215 (93%) at 3-5 months post-programme (P 0.01). Designating a safe driver after drinking was reported by 1275 (97%) pre-programme, 1295 (98%) immediately post-programme and 1286 (98.2%) 3-5 months post-programme (P = 0.02). The perception of sustaining 'definite' injury after a motor vehicle crash without a seat belt increased from 780 (60%) pre-programme to 1051 (80%) immediately post-programme and 886 (69%) 3-5 months post-programme (P 0.01). The possibility of sustaining 'definite' injury after risk-taking activities was reported by 158 (12%) pre-programme, 467 (36%) post-programme and 306 (23%) 3-5 months post-programme (P 0.01).The P.A.R.T.Y. Program at The Alfred engaged substantial numbers of youths and achieved significant improvements among key outcome measures. Objectives were sustained at 3-5 months post-programme, but demonstrated decay, highlighting the importance of continual reinforcement.

Introduction Prehospital notification of injured patients enables prompt and timely care in hospital through adequate preparation of trauma teams, space, equipment and consumables necessary for resuscitation, and may improve outcomes. In India, anecdotal reports suggest that prehospital notification, in those few places where it occurs, is unstructured and not linked to a well-defined hospital response. The aim of this manuscript is to describe, in detail, a study protocol for the evaluation of a formalised approach to prehospital notification. Methods and analysis This is a longitudinal prospective cohort study of injured patients being transported by ambulance to major trauma centres in India. In the preintervention phase, prospective data on patients will be collected on prehospital assessment, notification, inhospital assessment, management and outcomes and recorded in a new tailored multihospital trauma registry. All injured patients arriving by ambulance and allocated to a red or yellow priority category will be eligible for inclusion. The intervention will be a prehospital notification application to be used by ambulance clinicians to notify emergency departments of the impending arrival of a patient. The proportion of eligible patients arriving to hospital after notification will be the primary outcome measure. Secondary outcomes evaluated will be availability of a trauma cubicle, presence of a trauma team on patient arrival, time to first chest X-ray and inhospital mortality. Progress Ethical approval has been obtained from the All India Institute of Medical Sciences, New Delhi and site-specific approval granted by relevant trauma services. The trial has also been registered with the Monash University Human Research and Ethics Committee; Project number: CF16/1814 – 2016000929. Results will be fed back to prehospital and hospital clinicians via a series of reports and presentations. These will be used to facilitate discussions about service redesign and implementation. It is expected that evidence for improved outcomes will enable widespread adoption of this intervention among centres in all settings with less established tools for prehospital assessment and notification. Trial registration number NCT02877342; Pre-results.

Elevated low-density lipoprotein cholesterol (LDL-C) is a major modifiable risk factor for cardiovascular disease (CVD), a leading cause of death in the United States. Despite clinical practice guidelines aimed at facilitating LDL-C control, many Veterans do not achieve guideline-recommended LDL-C levels.We describe a study focused on VA healthcare system users at risk for CVD (i.e., LDL-C level130 mg/dl and/or80% cholesterol pill refill adherence in the last 12 months). We are conducting a two and a half year randomized controlled trial (i.e., intervention administered over 12 months) among Veterans with uncontrolled cholesterol receiving care at select VA-affiliated primary care clinics in North Carolina. We anticipate enrolling 250 diverse patients (10% women; 40% African American). Patients are randomized to an educational control group or intervention group. Intervention group participants' medication is provided in special blister packaging labeled for daily use that includes reminders; MeadWestvaco Corporation's pre-filled DosePak® contains standard doses of statins in accordance with the existing prescriptions.Pre-filled blister packaging may provide an inexpensive solution to improve medication adherence. Our study enrolls a diverse sample and provides information about whether an adherence packaging intervention can: 1) improve medication adherence; 2) improve patients' LDL-C levels; 3) be well received by patients and providers; and 4) provide a cost effective solution to improve medication adherence.

Aim To explore and compare call bell response times in two wards in a geriatric evaluation and management facility before and after the introduction of a suite of interventions aimed at decreasing patient falls. Method Data on call bell response times were collected over two periods. The first were before implementation of falls prevention initiatives. Data were retrieved from the call bell system that detailed the time taken to respond to every call bell activation. A second period of data collection was conducted six months after implementation of the initiatives. Results Prioritising call bell response and raising staff awareness improved response to patient calls. There was a slight decrease in falls although call bell activations did not decrease. Conclusion Strong leadership is necessary from nurse managers to stress the importance of prompt call bell response. Visual surveillance of high-risk fallers is important as they are generally unable to ring for assistance when required.

Hepatitis E virus (HEV) infection is an important cause of acute viral hepatitis in tropical and sub-tropical regions that occurs both as epidemic episodes and sporadic cases. The aim of this investigation was to estimate the prevalence of total immunoglobulin (Ig) anti-hepatitis E virus (anti-HEV) and the risk factors associated to two communities in Havana City. Serum samples (n=469) obtained from healthy individuals with no history of viral hepatitis were screened for total anti-HEV by enzyme immunoassay (EIA). An overall prevalence of 10% (47/469) (95% CI; 7.52-13.19%) was obtained. Higher anti-HEV prevalence was found in the municipality of Marianao (12.1%) compared to Playa (7.1%). Analysis of risk factors revealed a significant association of total anti-HEV prevalence in age group 41-60 years old, with a risk ratio of 3.21 (95% CI: 1.09-9.7) (P=0.01). No relation was found between anti-HEV and other variables such as gender, risk occupations, surgery and transfusions. The detection of total anti-HEV in individuals with no overt acute hepatitis suggests the existence of sub-clinical or anicteric HEV infection in these municipalities.

The purpose of this study was to examine what happens to goals over the course of a physical activity counseling trial in older veterans. At baseline, participants (N = 313) identified 1 health-related goal and 1 walking goal for their participation in the study and rated where they perceived themselves to be relative to that goal at the current time. They rated their current status on these same goals again at 6 and 12 mo. Growth-curve analyses were used to examine longitudinal change in perceived goal status. Although both the intervention and control groups demonstrated improvement in their perceived proximity to their health-related and walking goals (L = 1.19, p < .001), the rates of change were significantly greater in the intervention group (β = –.30, p < .05). Our results demonstrate that this physical activity counseling intervention had a positive impact on self-selected goals over the course of the intervention.

Physical activity (PA) has the potential to improve outcomes in both arthritis and diabetes, but these conditions are rarely examined together. Our objective was to explore whether persons with arthritis alone or those with both arthritis and diabetes could improve amounts of PA with a home-based counselling intervention.As part of the Veterans LIFE (Learning to Improve Fitness and Function in Elders) Study, veterans aged 70-92 were randomized to usual care or a 12-month PA counselling programme. Arthritis and diabetes were assessed by self-report. Mixed models were used to compare trajectories for minutes of endurance and strength training PA for persons with no arthritis (n = 85), arthritis (n = 178), and arthritis plus diabetes (n = 84).Recipients of PA counselling increased minutes of PA per week independent of disease status (treatment arm by time interaction p0.05 for both; endurance training time p = 0.0006 and strength training time p0.0001). Although PA was lower at each wave among persons with arthritis, and even more so among persons with arthritis plus diabetes, the presence of these conditions did not significantly influence response to the intervention (arthritis/diabetes group x time interactions p0.05 for both outcomes) as each group experienced a nearly twofold or greater increase in PA.A home-based PA intervention was effective in increasing minutes of weekly moderate intensity endurance and strength training PA in older veterans, even among those with arthritis or arthritis plus diabetes. This programme may serve as a useful model to improve outcomes in older persons with these pervasive diseases.

A new double-antigen sandwich-based enzyme-linked immunosorbent assay (ELISA) for the detection of total antibodies (immunoglobulin G [IgG] and IgM) specific for hepatitis E virus (HEV) was developed by utilizing well-characterized recombinant protein ET2.1 and its peroxidase-labeled counterpart. Our study showed that the ELISA detected all the positive patient samples ( n = 265) regardless of whether they contained IgM or IgG antibodies, or both, while it maintained an excellent specificity of 98.8% with samples from various patient or healthy control groups (total number of samples, 424). The test had a detection limit for anti-HEV IgG antibodies that was equivalent to 62 mIU/ml of the international reference. Compared with the serological status of the specimens determined on the basis of tests performed at the individual collection sites, the testing outcome generated by the new ELISA had a good agreement of 99.3%, with a kappa value of 0.985. The positive predictive value and the negative predictive value for the new test reached 98.1% and 100%, respectively. This ELISA had a positive delta value of 4.836 and a negative delta value of 3.314 (where delta is a measure of the number of standard deviations by which the cutoff is separated from the mean of the sample groups) (N. Crofts, W. Maskill, and I. D. Gust, J. Virol. Methods 22:51-59, 1988), indicating that it had an excellent ability to differentiate the infected and noninfected cohorts. Furthermore, the new design enables the detection of antibodies not only in human samples but also in pig samples. Our preliminary data showed that the ELISA could detect seroconversion in samples from pigs at as early as 14 days postinoculation. The potential utility of detecting specific antibodies in pigs will be an added advantage for managing the disease, with suggested zoonotic implications.

Objective This pilot study investigated SCAT3 from baseline to post-game among non-concussed amateur Australian Rules footballers, and association with game day head impacts. Design Peak linear acceleration (PLA) of the head (>10 g) was measured by wearable impact sensor X2Biosytems xPatch. SCAT3 was administered at baseline and post-game. Participants Amateur Australian Rules footballers n=68. Main results Common symptoms at baseline: fatigue, trouble falling asleep & neck pain. N=57 sustained 2088 impacts>10 g (Mean PLA=14.40 g, range 10–115.78 g). Measured PLA among males (M=15.11g, SD 3.51) and females (M=16.60g, SD 4.04), U=288.00, z=−1.24, p=0.217 did not differ, however, males (M=46.13, SD=50.4) sustained significantly more impacts than females (M=17.63, SD=13.20), U=214.00, z=−2.46, p=0.013. Greater symptom severity was found post-game (M=6.16, SD=8.17) compared to baseline (M=4.04, SD=6.34), z=−0.32, p=0.001, along with greater symptom total (p=0.011). Those with higher mean PLA demonstrated slower tandem gait. A similar pattern of SCAT change was observed for the No Impact group, and there were no significant group differences in SCAT change scores. Conclusions Consistent with previous findings players were not asymptomatic at baseline. Increase in symptom severity post-game was generally independent of head impact. Furthermore, the lack of association between PLA and SCAT3 change scores in this non-concussed Impact group suggests that other factors may contribute to such changes. Competing interests None.

Background There is a growing range of wearable non-helmet mounted devices on the market and/or in use that purport to measure head impact responses. There is potential for these devices to be useful tools in research and injury management programs. Objective Describe methods for assessing the validity of wearable head impact response devices. Design Laboratory and qualitative observational methods. Tests on an exemplar wearable head impact response measurement “device” were undertaken in a laboratory using an instrumented Hybrid III head and neck and linear impactor. Football players in competitive matches wore the device and games were videoed. A qualitative protocol was applied to correlated device head impact events were those observed on video to examine sensitivity and specificity. Setting Contact sport. Participants Community level Australian football players. Interventions None. Main Outcome Measurements Head impact responses in vitro (linear and angular accelerations) and vivo (observed head impact characteristics). Results Laboratory head impacts were performed at a number of impact sites and velocities. Laboratory tests identified significant correlations (p 30 g in game head impact events with observed head impacts, but in 18% events were not correlated with any head impact, and there were other errors. Conclusions A combination of laboratory and field tests are critical in establishing the validity of wearable head impact response devices and should be performed as the first stage of research with these devices.

In this study, the development of a dot blot assay to assess amoebic gill disease (AGD) using non-lethal gill mucus samples is described and its performance validated by comparing the assay with the indirect fluorescent antibody test (IFAT), the ‘gold standard’ test. The agreement between the two tests was high, with a positive predictive value of 95% and negative predictive value of 93%, with a corrected κ value of 0.88. The sensitivity and specificity of the test were 97 and 91%, respectively. The dot blot is both sensitive and specific for Paramoeba pemaquidensis and is formatted so that large numbers of samples can be conveniently analysed.

A qualitative study using individual semistructured interviews was undertaken to explore the perceptions and experiences of 23 aged care residents with mild dementia concerning the deaths of coresidents. The views of 25 facility staff members were also explored. The study was based in 3 aged residential facilities in Victoria, Australia. Interview data indicated that residents and staff had differing views. Residents reported that the impact of the death of a coresident was much less than staff members thought. Residents generally wanted to be told about the death of someone they knew and considered attempts to hide the death and the removal of the body both unnecessary and disrespectful. Both groups agreed that the celebration of the life of a resident was important, although they differed in their preferences for the way this is done. These findings have implications for staff education and practice.

Introduction: Triage, widely used by the military and emergency departments, has not been reported in community palliative care services. Policy designed to improve equitable provision of this care has led to the development of a triage tool. Methods: Retrospective data were collected (50 percent of referrals, n=204) and analyzed using the Wilcoxon signed-rank test to determine the accuracy of the tool in predicting patient status at the first visit. Semi-structured interviews (n=7) with palliative care service staff added qualitative data. Results: Although significant differences between triage scores compared to outcomes at first visit were observed, issues such as upgrading of triage category compared to priority score occurred in more than 30 percent of cases. When correction for this was made, the tool was found to be an accurate guide to patient needs. Conclusion: This tool, when used as intended, was effective in assessing the urgency of need, and it is potentially useful on a wider scale, subject to further evaluation.

Individuals diagnosed with impaired glucose tolerance (i.e., prediabetes) are at increased risk for developing diabetes. We proposed a clinical trial with a novel adaptive randomization designed to examine the impact of a home-based physical activity (PA) counseling intervention on metabolic risk in prediabetic elders. This manuscript details the lessons learned relative to recruitment, study design, and implementation of a 12-month randomized controlled PA counseling trial. A detailed discussion on how we responded to unforeseen challenges is provided. A total of 302 older patients with prediabetes were randomly assigned to either PA counseling or usual care. A novel adaptive design that reallocated counseling intensity based on self-report of adherence to PA was initiated but revised when rates of non-response were lower than projected. This study presents baseline participant characteristics and discusses unwelcome adaptations to a highly innovative study design to increase PA and enhance glucose metabolism when the best-laid plans went awry.

The primary aim was to explore whether arthritis is associated with poorer self-efficacy and motivation for, and participation in, two specific types of physical activity (PA): endurance training (ET) and strength training (ST). A further objective was to determine whether the added burden of diabetes contributes to a further reduction in these PA determinants and types.Self-efficacy and motivation for exercise and minutes per week of ET and ST were measured in 347 older veterans enrolled in a home-based PA counselling intervention. Regression analyses were used to compare high versus low self-efficacy and motivation and PA minutes in persons without arthritis, with arthritis alone, and with arthritis plus diabetes.Persons with arthritis alone reported lower self-efficacy for ET and ST than those without arthritis [odds ratio (OR)ET 0.71, 95% confidence interval (CI) 0.39–1.20; ORST 0.69, 95% CI 0.39–1.20]. A further reduction in self-efficacy for these two types of PA was observed for those with both arthritis and diabetes (ORET 0.65, 95% CI 0.44–0.92; ORST 0.64, 95% CI 0.44–0.93; trend p0.001). There was no trend towards a reduction in motivation for PA in those with arthritis alone or with arthritis and diabetes. Persons with arthritis exhibited higher motivation for ET than those without arthritis (ORET 1.85, 95% CI 1.12–3.33). There were no significant differences between the three groups in minutes of ET (p = 0.93), but persons with arthritis plus diabetes reported significantly less ST compared to individuals with arthritis only (p = 0.03).Despite reduced self-efficacy for ET and ST and less ST in older persons with arthritis, motivation for both PA types remains high, even in the presence of diabetes.

INTRODUCTION Most older adults are not regularly physically active [1]. Physical inactivity is associated with increased rates of morbidity, functional limitations, disability, and mortality. Concurrent with this finding are the continued reports of low numbers of individuals engaging in physical activity of sufficient stimulus to achieve a health benefit. Increasing physical activity is fundamental to prevention and treatment of physical limitations and many chronic diseases [2]. Low physical activity is highly associated with increased functional decline [3]. Difficulty walking, climbing stairs, performing usual daily tasks, and increasing social isolation are all hallmarks of functional decline [4-5]. This association is well documented and is independent of the presence of chronic illnesses [6-8]. Additionally, low physical activity is considered a primary marker of physical frailty, which predicts subsequent disability [9]. Interventions targeting physical inactivity in older adults are especially important given that rates of physical inactivity are highest among older adults, healthcare costs are higher among inactive than active adults, and the prevalence of chronic disease and disability increases with age [10]. Older veterans are of particular interest because they typically report significantly more physical difficulties than nonveterans [11] and about 50 percent of veterans over age 74 have a limiting disability [12]. Project LIFE--Learning to Improve Fitness and Function in Elders--is a randomized controlled trial (RCT) designed to assess whether physical activity counseling will increase physical function in older veterans who are being followed by Department of Veterans Affairs (VA) primary care and geriatric clinics. Project LIFE creates a unique partnership between the veteran, his/her primary care provider (PCP), and a health counselor through the innovative use of automatic telephone messaging. The primary care setting is ideal for this study because more than 90 percent of older adults visit their PCP at least once a year [13]. Older veterans with multiple chronic illnesses typically see their PCPs more frequently. In this article, we describe the design, methods, and baseline characteristics of Project LIFE. Its specific objectives are to determine (1) whether a multicomponent physical activity counseling program versus usual care improves physical function, with change in gait speed as the primary indicator of functional status; (2) whether this program results in significant changes in minutes per week of endurance and lower-limb strengthening physical activity; (3) whether this program secondarily promotes changes in other measures of physical performance (400 m walk time, chair stands, balance tests), self-reports of physical function, chronic illness, symptoms, pain, health-related quality of life (QOL), physical activity, self-efficacy, and motivation; and (4) the cost of the intervention. We also want to compare inpatient and outpatient healthcare costs in the two groups during the study period to establish the short-term economic impact of the proposed multicomponent physical activity counseling program. METHODS Project LIFE is a two-armed RCT conducted in primary care clinics at the Durham VA medical center (VAMC) in North Carolina. Individuals randomized to the intervention group receive a physical activity counseling intervention with five components: (1) in-person baseline physical activity counseling session tailored to the veteran's personal functional goals and limitations; (2) systematic telephone follow-up by the health counselor; (3) systematic automated telephone calls from the veteran's PCP; (4) PCP endorsement of physical activity during a clinic visit; and (5) individually prepared progress reports, mailed quarterly, summarizing achievement of physical activity goals. …

Surgical wound infections can be significantly reduced by appropriate administration of prophylactic antibiotics (ProAbx). The purpose of this study was to determine the effect of interventions, specifically, forced functions, designed to improve administration of ProAbx in a university hospital setting.We retrospectively reviewed charts from 1,622 consecutive patients, seen between March 2005 and June 2007, for evaluation of ProAbx administration to determine correct choice, appropriate timing of administration, and appropriate postoperative cessation of antibiotics. Processes designed to improve compliance were devising orders to limit ProAbx choice; requiring those orders in preadmission testing; administering ProAbx in the preparation and hold area, subsequently, at the time of the universal timeout; and standardizing postoperative orders in the computerized physician order entry.Specialty-specific standardized orders improved compliance from 76% to 91% (p0.001) concerning ProAbx choice. Regarding timing of preoperative administration, a baseline compliance of 55% improved to: 78% (p0.001) on requiring orders in the preadmission testing area; 90% (p0.008) on administering ProAbx in the preparation and hold area; and 95% (p0.07) when ProAbx were administered at the universal timeout. Standardization of postoperative orders in the computerized physician order entry improved compliance with cessation from 60% to 86%, p0.001.Despite hospital-wide education, improving compliance with evidence-based recommendations for ProAbx required processes that "forced" physician behavior, specifically: specialty-specific, preprinted physician orders limiting ProAbx choice; linking administration of preoperative ProAbx administration to the universal timeout; and standardization of the postoperative ProAbx order in the computerized physician order entry.

A rapid and reliable diagnostic assay for acute hepatitis E virus (HEV) infection is needed. We evaluated a rapid, immunochromatographic assay for IgM antibodies to HEV (ASSURE HEV IgM Rapid Test) using acute-phase HEV samples (n = 200) from Indonesia and Nepal and convalescent-phase HEV samples (n = 70) from Nepal. Blood donors in Thailand (n = 100), individuals with hepatitis A (n = 80), hepatitis B (n = 45), and hepatitis C (n = 50) in Thailand and Nepal, acute-phase sera of individuals with Epstein-Barr virus infection (n = 20), and rheumatoid factor-positive blood (n = 26) served as negative controls. The assay had a sensitivity of 93% (95% confidence interval [CI] = 88.5-96.1%) and a specificity of 99.7% (95% CI = 98.3-100%). The positive and negative predictive values were 99.5% (95% CI = 97.1-100%) and 95.8% (95% CI = 93.1-97.7%), respectively. These results suggest that this assay is a sensitive and specific tool for the rapid diagnosis of acute HEV infection.

An immunochromatographic test for rapid detection of IgM antibodies in patients with acute hepatitis E infection was developed utilizing the well-characterized recombinant protein EP2.1 and monoclonal antibody 4B2. The new rapid test based on a novel reverse-flow technology was able to generate a positive result within 2 to 3 min. Our study showed that this test was able to detect anti-HEV IgM antibodies in 96.7% of the patient samples tested ( n = 151) while maintaining an excellent specificity of 98.6% with samples from various patient or healthy control groups (total n = 208). Furthermore, this rapid test gave a good specificity of 90.9% when tested with rheumatoid factor (RF)-positive sera (RF value of ≤850 IU/ml; n = 11) although a higher concentration of RF in samples might cause cross-reactivity. The new test has a good agreement of 97.2% with a kappa value of 0.943 when compared with a reference enzyme-linked immunosorbent assay. The positive predictive value and the negative predictive value for the rapid test thus reached 98.0 and 97.6%, respectively. This is the first rapid, point-of-care test for hepatitis E and will be especially useful for the diagnosis of acute hepatitis E virus infection in field and emergency settings and in resource-poor countries.

In this paper we inestigate the application of independent component analysis (ICA) to multispectral image classification. In particular, the performance of Joint Approximate Diagonalization of Eigenmatrices (JADE) algorithm is studied. ICA is particularly useful for classifying objects with unknown spectral signatures in an unkown image scene, i.e., unsupervised classification, because it does not require any prior information about class signatures. Since the weight matrix in ICA is a square matrix for the purpose of mathematical tractability, the number of objects that can be classified is equal to the data dimensionality, i.e., the number of spectral bands. When the number of spectral bands is very small (e.g., 3-band CIR photograph), it is impossible to classify all the different objects present in an image scene with the original data. In order to solve this problem, we present a data dimensionality expansion technique to generate artificial bands for additional spectral measurements. The results from such a nonlinear band generation approach are compared with a linear band generation method using cubic spline interpolation of pixel spectral signatures. The experiments demonstrate that such a nonlinear band generation approach can expand the applicability of ICA and improve the classification accuracy.

Introduction . Background . Purpose and Scope . Streamflow Network Analysis . History of Streamflow Gaging in Texas . Network Evaluations in Texas Network Funding and Data Uses Major Objectives of a Core Network . Evaluation of the Existing Network . Hydrologic Regions . Regional Optimization Model . Flow Correlation . Proposed Core Network . Summary . References .

In assays based on most recombinant hepatitis E virus (HEV) antigens, the IgG antibody responses to HEV are observed commonly to wane or disappear after the acute phase of infection. Such IgG assays have therefore been used for the diagnosis of acute HEV infection, but they have limited usefulness in seroepidemiological studies. Using western immunoblotting, it was shown previously that the open reading frame (ORF) 2.1 antigen, representing the carboxy-terminal 267 amino acids (aa) of the capsid protein, exposes a conformational epitope which allows optimal detection of convalescent antibody compared to other proteins expressed in Escherichia coli. This conformational epitope is shown to be highly conserved between divergent human HEV isolates, and the development of a sensitive and highly specific enzyme immunoassay (ELISA) based on this recombinant antigen is described. The ORF2.1 ELISA allows the detection and quantitation of both acute- and convalescent phase HEV-specific IgG, and will help to define better the antibody responses to the virus and the prevalence of HEV infection worldwide.

We tested 54 reagents of human origin that were included in a number of diagnostic kits to be used as positive or negative control material, and for quality assurance, for the presence of antibodies to human immunodeficiency virus-1 (HIV-1). Of these, 12 (22%) reagents were found to give positive results for antibodies to HIV-1 by enzyme-linked immunosorbent assay and/or supplementary tests. These results suggest that some diagnostic reagents of human origin may be contaminated with HIV-1 and potentially may be infectious.

Two competitive anti-HIV ELISA screening assays (Behring and Wellcozyme) and two second generation assays using antigens generated by recombinant DNA technology (Abbott) and synthetic peptides (Biochrom) were evaluated against common panels of anti-HIV positive sera and sera known or thought likely to give false positive reactions. The assays were also tested on fresh sequential blood donations. Conventional estimates of sensitivity and specificity did not reveal a significant difference between the assays. Statistical analyses using log10 transformed data to determine delta values (the distance of the mean optical density (OD) ratio from the cut-off measured in standard deviation units) showed the Abbott assays to have the highest probability (greater than 99.99%) of detecting anti-HIV positive samples and the Behring assay as having the highest probability (greater than 99.99%) of correctly identifying anti-HIV negative specimens. The combined data from conventional estimates of sensitivity and specificity and delta values suggests that the Abbott assay is the test of choice for screening purposes.

To explore and compare call bell response times in two wards in a geriatric evaluation and management facility before and after the introduction of a suite of interventions aimed at decreasing patient falls.Data on call bell response times were collected over two periods. The first were before implementation of falls prevention initiatives. Data were retrieved from the call bell system that detailed the time taken to respond to every call bell activation. A second period of data collection was conducted six months after implementation of the initiatives.Prioritising call bell response and raising staff awareness improved response to patient calls. There was a slight decrease in falls although call bell activations did not decrease.Strong leadership is necessary from nurse managers to stress the importance of prompt call bell response. Visual surveillance of high-risk fallers is important as they are generally unable to ring for assistance when required.