A framework for considering the utility of models when facing tough decisions in public health: a guideline for policy-makers.

The COVID-19 pandemic has brought the combined disciplines of public health, infectious disease and policy modelling squarely into the spotlight. Never before have decisions regarding public health measures and their impacts been such a topic of international deliberation, from the level of individuals and communities through to global leaders. Nor have models-developed at rapid pace and often in the absence of complete information-ever been so central to the decision-making process. However, after nearly 3 years of experience with modelling, policy-makers need to be more confident about which models will be most helpful to support them when taking public health decisions, and modellers need to better understand the factors that will lead to successful model adoption and utilization. We present a three-stage framework for achieving these ends.

Risk factors for injuries in New Zealand older adults with complex needs: a national population retrospective study.

BACKGROUND: Falls and falls-related injuries are common among older adults. Injuries in older adults lead to poor outcomes and lower quality of life. The objective of our study was to identify factors associated with fall-related injuries among home care clients in New Zealand. METHODS: The study cohort consisted of 75,484 community-dwelling people aged 65 years or older who underwent an interRAI home care assessment between June 2012 and June 2018 in New Zealand. The injuries included for analysis were fracture of the distal radius, hip fracture, pelvic fracture, proximal humerus fracture, subarachnoid haemorrhage, traumatic subdural haematoma, and vertebral fracture. Unadjusted and adjusted competing risk regression models were used to identify factors associated with fall-related injuries. RESULTS: A total of 7414 (9.8%) people sustained a falls-related injury over the 6-year period, and most injuries sustained were hip fractures (4735 63.9%). The rate of injurious falls was 47 per 1000 person-years. The factors associated with injury were female sex, older age, living alone, Parkinson's disease, stroke/CVA, falls, unsteady gait, tobacco use, and being underweight. Cancer, dyspnoea, high BMI, and a decrease in the amount of food or fluid usually consumed, were associated with a reduced risk of sustaining an injury. After censoring hip fractures the risks associated with other types of injury were sex, age, previous falls, dyspnoea, tobacco use, and BMI. CONCLUSIONS: While it is important to reduce the risk of falls, it is especially important to reduce the risk of falls-related injuries. Knowledge of risk factors associated with these types of injuries can help to develop focused intervention programmes and development of a predictive model to identify those who would benefit from intervention programmes.

Risk factors for hip fracture in New Zealand older adults seeking home care services: a national population cross-sectional study.

BACKGROUND: Hip fractures are a common injury in older people. Many studies worldwide have identified various risk factors for hip fracture. However, risk factors for hip fracture have not been studied extensively in New Zealand. The interRAI home care assessment consists of 236 health questions and some of these may be related to hip fracture risk. METHODS: The cohort consisted of 45,046 home care clients aged 65 years and older, in New Zealand. Assessments ranged from September 2012 to October 2015. Hip fracture diagnosis was identified by linking ICD (International Classification of Diseases) codes from hospital admissions data (September 2012 to December 2015) to the interRAI home care data. Unadjusted and adjusted competing risk regressions, using the Fine and Gray method were used to identify risk factors for hip fracture. Mortality was the competing event. RESULTS: The cohort consisted of 61% female with a mean age of 82.7 years. A total of 3010 (6.7%) of the cohort sustained a hip fracture after assessment. After adjusting for sociodemographic and potentially confounding variables falls (SHR (Subhazard Ratio) = 1.17, 95% CI (Confidence interval): 1.05-1.31), previous hip fracture (SHR = 4.16, 95% CI: 2.93-5.89), female gender (SHR = 1.38, 95% CI: 1.22-1.55), underweight (SHR = 1.67, 95% CI = 1.39-2.02), tobacco use (SHR = 1.56, 95% CI = 1.25-1.96), Parkinson's disease (SHR = 1.45, 95% CI: 1.14-1.84), and Wandering (SHR = 1.36, 95% CI: 1.07-1.72) were identified as risk factors for hip fracture. Shortness of breath (SHR = 0.80, 95% CI: 0.71-0.90), was identified as being protective against hip fracture risk. Males and females had different significant risk factors. CONCLUSIONS: Risk factors for hip fracture similar to international work on risk factors for hip fracture, can be identified using the New Zealand version of the interRAI home care assessment.

Symptomatic hypercalcaemia following the use of calcium sulfate beads in periprosthetic joint infections.

Calcium sulfate beads (CSBs) are used as a method of delivery of antibiotics in periprosthetic joint infections, non-union and chronic osteomyelitis.[[1-3]] Symptomatic hypercalcaemia can occur as a complication following the insertion of CSBs however it is rare and few cases have been reported.[[4-7]] The cause of hypercalcaemia is poorly understood.

Improving the prescribing practice of junior doctors through interprofessional collaboration and evidence-based education.

The last decade (2010-2019) has seen calls to action to improve the prescribing practice of junior doctors. An in-depth investigation into the causes of prescribing errors by foundation trainees in relation to their medical education (the EQUIP study) in the UK reported a prescription error rate of 8.9% for all prescribed medicines, and although that is a UK study, there are similarities with New Zealand prevocational training programmes. The EQUIP study revealed that existing teaching strategies are not working. To believe a single intervention will prevent most prescribing errors is simplistic, and for improvement to occur, new prescribers need to learn from their mistakes. Traditionally, the education of junior doctors has focused on their competence and professional registration requirements. Working in healthcare is collective and multidisciplinary, and errors occur through human and system factors.

Institutional and behaviour-change interventions to support COVID-19 public health measures: a review by the Lancet Commission Task Force on public health measures to suppress the pandemic.

The Lancet COVID-19 Commission Task Force for Public Health Measures to Suppress the Pandemic was launched to identify critical points for consideration by governments on public health interventions to control coronavirus disease 2019 (COVID-19). Drawing on our review of published studies of data analytics and modelling, evidence synthesis and contextualisation, and behavioural science evidence and theory on public health interventions from a range of sources, we outline evidence for a range of institutional measures and behaviour-change measures. We cite examples of measures adopted by a range of countries, but especially jurisdictions that have, thus far, achieved low numbers of COVID-19 deaths and limited community transmission of severe acute respiratory syndrome coronavirus 2. Finally, we highlight gaps in knowledge where research should be undertaken. As countries consider long-term measures, there is an opportunity to learn, improve the response and prepare for future pandemics.

Global hepatitis C elimination: an investment framework.

WHO has set global targets for the elimination of hepatitis B and hepatitis C as a public health threat by 2030. However, investment in elimination programmes remains low. To help drive political commitment and catalyse domestic and international financing, we have developed a global investment framework for the elimination of hepatitis B and hepatitis C. The global investment framework presented in this Health Policy paper outlines national and international activities that will enable reductions in hepatitis C incidence and mortality, and identifies potential sources of funding and tools to help countries build the economic case for investing in national elimination activities. The goal of this framework is to provide a way for countries, particularly those with minimal resources, to gain the substantial economic benefit and cost savings that come from investing in hepatitis C elimination.

Providing departments with regular reports on intern experiences using an adapted version of the PHEEM: completing the feedback loop to enable change in the education and training environment.

AIM: Collating quality feedback from interns on their training and educational experiences allows training institutions to identify issues or concerns within the learning environment and provides an opportunity for continuous quality improvement. This study aimed to investigate whether feedback obtained from a modified version of the Postgraduate Hospital Educational Environment Measure (PHEEM) was used by departments to facilitate change and enhance the education and training experiences of interns at Canterbury District Health Board (CDHB). METHOD: Data from intern evaluations is collated and sent to departments at the end of each three-month period. A survey was undertaken to assess how much departments valued the reports they received and how, if at all, they utilise the information. The Directors of Training, Clinical Directors, and Service Managers of 16 departments were invited to respond to the survey. RESULTS: The response rate was 46%. Eighty-three percent responded that the reports they receive are useful, and 78% responded that they are easy to understand. Data which tracks the performance of their department over time was reported by 71% as being of particular use. Fifty-five percent of the respondents had implemented, or were in the process of implementing, change based on the information in the reports. A positive outcome was reported by 100% of those who had implemented change. CONCLUSION: Evaluations of clinical attachments by interns positively influences change in clinical departments if the information is presented to departments in an accessible and meaningful format.

The mechanisms responsible for 2-dimensional pattern formation in bacterial macrofiber populations grown on solid surfaces: fiber joining and the creation of exclusion zones.

BACKGROUND: When Bacillus subtilis is cultured in a complex fluid medium under conditions where cell separation is suppressed, populations of multicellular macrofibers arise that mature into ball-like structures. The final sedentary forms are found distributed in patterns on the floor of the growth chamber although individual cells have no flagellar-driven motility. The nature of the patterns and their mode of formation are described in this communication. RESULTS: Time-lapse video films reveal that fiber-fiber contact in high density populations of macrofibers resulted in their joining either by entwining or supercoiling. Joining led to the production of aggregate structures that eventually contained all of the fibers located in an initial area. Fibers were brought into contact by convection currents and motions associated with macrofiber self-assembly such as walking, pivoting and supercoiling. Large sedentary aggregate structures cleared surrounding areas of other structures by dragging them into the aggregate using supercoiling of extended fibers to power dragging. The spatial distribution of aggregate structures in 6 mature patterns containing a total of 637 structures was compared to that expected in random theoretical populations of the same size distributed in the same surface area. Observed and expected patterns differ significantly. The distances separating all nearest neighbors from one another in observed populations were also measured. The average distance obtained from 1451 measurements involving 519 structures was 0.73 cm. These spacings were achieved without the use of flagella or other conventional bacterial motility mechanisms. A simple mathematical model based upon joining of all structures within an area defined by the minimum observed distance between structures in populations explains the observed distributions very well. CONCLUSIONS: Bacterial macrofibers are capable of colonizing a solid surface by forming large multicellular aggregate structures that are distributed in unique two-dimensional patterns. Cell growth geometry governs in an hierarchical way the formation of these patterns using forces associated with twisting and supercoiling to drive motions and the joining of structures together. Joining by entwining, supercoiling or dragging all require cell growth in a multicellular form, and all result in tightly fused aggregate structures.

The dynamic behavior of bacterial macrofibers growing with one end prevented from rotating: variation in shaft rotation along the fiber's length, and supercoil movement on a solid surface toward the constrained end.

BACKGROUND: Bacterial macrofibers twist as they grow, writhe, supercoil and wind up into plectonemic structures (helical forms the individual filaments of which cannot be taken apart without unwinding) that eventually carry loops at both of their ends. Terminal loops rotate about the axis of a fiber's shaft in contrary directions at increasing rate as the shaft elongates. Theory suggests that rotation rates should vary linearly along the length of a fiber ranging from maxima at the loop ends to zero at an intermediate point. Blocking rotation at one end of a fiber should lead to a single gradient: zero at the blocked end to maximum at the free end. We tested this conclusion by measuring directly the rotation at various distances along fiber length from the blocked end. The movement of supercoils over a solid surface was also measured in tethered macrofibers. RESULTS: Macrofibers that hung down from a floating wire inserted through a terminal loop grew vertically and produced small plectonemic structures by supercoiling along their length. Using these as markers for shaft rotation we observed a uniform gradient of initial rotation rates with slopes of 25.6 degrees /min. mm. and 36.2 degrees /min. mm. in two different fibers. Measurements of the distal tip rotation in a third fiber as a function of length showed increases proportional to increases in length with constant of proportionality 79.2 rad/mm. Another fiber tethered to the floor grew horizontally with a length-doubling time of 74 min, made contact periodically with the floor and supercoiled repeatedly. The supercoils moved over the floor toward the tether at approximately 0.06 mm/min, 4 times faster than the fiber growth rate. Over a period of 800 minutes the fiber grew to 23 mm in length and was entirely retracted back to the tether by a process involving 29 supercoils. CONCLUSIONS: The rate at which growing bacterial macrofibers rotated about the axis of the fiber shaft measured at various locations along fibers in structures prevented from rotating at one end reveal that the rate varied linearly from zero at the blocked end to maximum at the distal end. The increasing number of twisting cells in growing fibers caused the distal end to continuously rotate faster. When the free end was intermittently prevented from rotating a torque developed which was relieved by supercoiling. On a solid surface the supercoils moved toward the end permanently blocked from rotating as a result of supercoil rolling over the surface and the formation of new supercoils that reduced fiber length between the initial supercoil and the wire tether. All of the motions are ramifications of cell growth with twist and the highly ordered multicellular state of macrofibers.

A new form of bacterial movement, dragging of multicellular aggregate structures over solid surfaces, is powered by macrofiber supercoiling.

Growing Bacillus subtilis macrofibers use twist and supercoiling to: power their own self-assembly, join fibers together into multiclonal aggregates, move themselves over solid surfaces, and to drag other structures (cargo) over solid surfaces. The dragging of multiclonal aggregates attached to the ends of growing macrofibers is analyzed here. The linkage between fibers and cargo arose naturally in macrofiber cultures. Dragging was triggered when growing macrofibers became linked to cargo at both of their ends. Such macrofibers supercoiled, reduced their length, and dragged the cargo toward one another. In parallel experiments immobile wire was used in place of cargo at one end of macrofibers that were linked to cargo at the other. The cargo was dragged toward the wire when these fibers supercoiled. To estimate the force required for dragging we determined the dimensions of the cargo, the buoyant density of macrofibers in the growth medium where dragging occurred, the rate and distance over which the aggregate structures were dragged, and the viscosity of the growth medium. Friction resulting from contact with the solid surface over which the structures were dragged was estimated using the measured parameters. The results indicate that the supercoiling tension required to overcome limiting friction must have been approximately 10 nN, while that needed to overcome fluid drag was of the order of 1 nN. These values suggest that only a small fraction of the total power available from macrofiber supercoiling was needed to drive this new form of multicellular bacterial movement.

Renegotiation of the Australian Health Care Agreements 2003-2008: from a state's perspective.

The renegotiation process for the next Australian Health Care Agreements 2003-2008 presents an opportunity for State and Territory Governments to suggest reforms to improve acute and sub acute health services and health outcomes. Four key issues to Victoria are discussed, emergency departments and primary care interface, workforce planning, aged care and the continuum of care.

A survey of personal digital assistant use in a sample of New Zealand doctors.

AIM: To gather information about handheld computing hardware and software usage by hospital based doctors in New Zealand (NZ). METHOD: An online tool (SurveyMonkey) was used to conduct the survey from 27 June to 10 September 2010. Distribution of the survey was via an email to all NZ District Health Boards (DHBs). RESULTS: There were 850 responses. About half of respondents (52%) used a personal digital assistant (PDA), 90% using it at least once daily. Usage varied greatly between DHBs (27-100%), perhaps related to institutional support. Among PDA users, the most common applications were the non-clinical; Scheduler (95%), Contacts (97%), and Tasks (83%). Users felt PDAs helped considerably with organisation and time saving. For non-users there were a range of barriers to usage, cost being a large factor. Another major barrier identified by both users and non-users was lack of organisational integration and support. CONCLUSIONS: Half of survey respondents used a PDA. PDA usage of responders from different DHBs varied considerably. Perceived barriers to PDA use included cost and lack of institutional support. A collaborative approach between clinical leadership and Information Technology teams to address barriers may result in increased utility and usage of PDAs in the NZ health system.

Cellular replacement and regenerative medicine therapies in ischemic stroke.

Worldwide, tissue engineering and cellular replacement therapies are at the forefront of the regenerative medicine agenda, and researchers are addressing key diseases, including diabetes, stroke and neurological disorders. It is becoming evident that neurological cell therapy is a necessarily complex endeavor. The brain as a cellular environment is complex, with diverse cell populations, including specialized neurons (e.g., dopaminergic, motor and glutamatergic neurons), each with specific functions. The population also contains glial cells (astrocytes and oligodendrocytes) that offer the supportive network for neuronal function. Neurological disorders have wide and varied pathologies; they can affect predominantly one cell type or a multitude of cell types, which is the case for ischemic stroke. Both neuronal and glial cells are affected by stroke and, depending on the region of the brain affected, different specialized cells are influenced. This review will address currently available therapies and focus on the application and potential of cell replacement, including stem cells and immortalized cell line-derived neurons as regenerative therapies for ischemic stroke, addressing current advances and challenges ahead.

Are doctors team players, and do they need to be?

Evidence suggests that teamwork failures contribute to poor outcomes in hospitals and that changes in healthcare delivery have at times worked against the development of effective healthcare teams. Doctors' engagement with the concept of healthcare teams, although variable, has generally been supportive and there have been several successful initiatives. However, lack of evidence on the critical components that improve the performance of healthcare teams impedes growth in our understanding and development of effective teams. In an endeavour to improve the function of healthcare teams through education and systems change, the psychology literature remains a useful framework for studying the critical components of team processes.