A multicentre case series of analytically confirmed gamma-hydroxybutyrate intoxications in Western Australian emergency departments: Pre-hospital circumstances, co-detections and clinical outcomes.

INTRODUCTION: Gamma-hydroxybutyrate (GHB) use is associated with high risk of accidental overdose. This study examined the pre-hospital circumstances, demographic characteristics and clinical outcomes of analytically confirmed GHB emergency department (ED) presentations in Western Australia (WA). METHODS: This case series was conducted across three WA EDs involved in the Emerging Drugs Network of Australia, from April 2020 to July 2022. Patient demographics, pre-hospital drug exposure circumstances and ED presentation and outcome characteristics were collected from ambulance and hospital medical records of GHB-confirmed cases. RESULTS: GHB was detected in 45 ED presentations. The median age was 34 years and 53.3% (n = 24) were female. Most patients arrived at the ED by ambulance (n = 37, 85.7%) and required immediate emergency care (Australasian Triage Score 1 or 2 = 97.8%). One-third of patients were admitted to intensive care (n = 14, 31.1%). Methylamphetamine was co-detected in 37 (82.2%) GHB-confirmed cases. Reduced conscious state was indicated by first recorded Glasgow Coma Scale of ≤8 (n = 29, 64.4%) and observations of patients becoming, or being found, 'unresponsive' and 'unconscious' in various pre-hospital settings (n = 28, 62.2%). 'Agitated' and/or 'erratic' mental state and behavioural observations were recorded in 20 (44.4%) cases. DISCUSSION AND CONCLUSIONS: Analytically verified data from ED presentations with acute toxicity provides an objective information source on drug use trends and emerging public health threats. In our study, patients presenting to WA EDs with GHB intoxication were acutely unwell, often requiring intensive care treatment. The unexpectedly high proportion of female GHB intoxications and methylamphetamine co-ingestion warrants further exploration.

Advances in electrochemical biosensor design for the detection of the stress biomarker cortisol.

The monitoring of stress levels in humans has become increasingly relevant, given the recent incline of stress-related mental health disorders, lifestyle impacts, and chronic physiological diseases. Long-term exposure to stress can induce anxiety and depression, heart disease, and risky behaviors, such as drug and alcohol abuse. Biomarker molecules can be quantified in biological fluids to study human stress. Cortisol, specifically, is a hormone biomarker produced in the adrenal glands with biofluid concentrations that directly correlate to stress levels in humans. The rapid, real-time detection of cortisol is necessary for stress management and predicting the onset of psychological and physical ailments. Current methods, including mass spectrometry and immunoassays, are effective for sensitive cortisol quantification. However, these techniques provide only single measurements which pose challenges in the continuous monitoring of stress levels. Additionally, these analytical methods often require trained personnel to operate expensive instrumentation. Alternatively, low-cost electrochemical biosensors enable the real-time detection and continuous monitoring of cortisol levels while also providing adequate analytical figures of merit (e.g., sensitivity, selectivity, sensor response times, detection limits, and reproducibility) in a simple design platform. This review discusses the recent developments in electrochemical biosensor design for the detection of cortisol in human biofluids. Special emphasis is given to biosensor recognition elements, including antibodies, molecularly imprinted polymers (MIPs), and aptamers, as critical components of electrochemical biosensors for cortisol detection. Furthermore, the advantages and limiting factors of various electrochemical techniques and sensing in complex biofluid matrices are overviewed. Remarks on the current challenges and future perspectives regarding electrochemical biosensors for stress monitoring are provided, including matrix effects (pH dependence and biological interferences), wearability, and large-scale production.

Long-Term Pattern and Associated Costs of Re-hospitalisations in Patients After Index Atrial Fibrillation Admission in Western Australia, 2011-2017.

AIMS: This study aimed to determine total and cardiovascular-specific re-hospitalisation patterns and associated costs within 2 years of index atrial fibrillation (AF) admission in Western Australia (WA). METHOD: Patients aged 25-94 years, surviving an index (first-in-period) AF hospitalisation (principal diagnosis) from 2011 to 2015 were identified from WA-linked administrative data and followed for 2 years. Person-level hospitalisation costs ($ Australian dollar) were computed using the Australian Refined Diagnosis Related Groups and presented as median with first and third quartile costs. RESULTS: The cohort comprised 17,080 patients, 59.0% men, mean age 69.6±13.3 (standard deviation) years, and 59.0% had a CHA2DS2-VA (one point for congestive heart failure, hypertension, diabetes mellitus, vascular disease or age 65-74 years; two points for prior stroke/transient ischaemic attack or age ≥75 years) score of 2 or more. Within 2 years, 13,776 patients (80.6%) were readmitted with median of 2 (1-4) readmissions. Among total all-cause readmissions (n=54,240), 40.1% were emergent and 36.6% were cardiovascular-related, led by AF (19.5%), coronary events (5.8%), and heart failure (4.2%). The median index AF admission cost was $3,264 ($2,899-$7,649) while cardiovascular readmission costs were higher, particularly stroke ($10,732 [$4,179-23,390]), AF ablation ($7,884 [$5,283-$8,878]), and heart failure ($6,759 [$6,081-$13,146]). Average readmission costs over 2 years per person increased by $4,746 (95% confidence interval [CI] $4,459-$5,033) per unit increase in baseline CHA2DS2-VA score. The average 2-year hospitalisation costs per patient, including index admission, was $27,820 (95% CI $27,308-$28,333) and total WA costs were $475.2 million between 2011 and 2017. CONCLUSIONS: Patients after index AF hospitalisation have a high risk of cardiovascular and other readmissions with considerable healthcare cost implications. Readmission costs increased progressively with baseline CHA2DS2-VA score. Better integrated management of AF and coexistent comorbidities is likely key to reducing readmissions and associated costs.

Characteristics and time course of benzodiazepine-type new psychoactive substance detections in Australia: results from the Emerging Drugs Network of Australia - Victoria project 2020-2022.

INTRODUCTION: The emergence of benzodiazepine-type new psychoactive substances (NPSs) are a growing international public health concern, with increasing detections in drug seizures and clinical and coronial casework. This study describes the patterns and nature of benzodiazepine-type NPS detections extracted from the Emerging Drugs Network of Australia - Victoria (EDNAV) project, to better characterise benzodiazepine-type NPS exposures within an Australian context. METHODS: EDNAV is a state-wide illicit drug toxicosurveillance project collecting data from patients presenting to an emergency department with illicit drug-related toxicity. Patient blood samples were screened for illicit, pharmaceutical and NPSs utilising liquid chromatography-tandem mass spectrometry. Demographic, clinical, and analytical data was extracted from the centralised registry for cases with an analytical confirmation of a benzodiazepine-type NPS(s) between September 2020-August 2022. RESULTS: A benzodiazepine-type NPS was detected in 16.5 % of the EDNAV cohort (n = 183/1112). Benzodiazepine-type NPS positive patients were predominately male (69.4 %, n = 127), with a median age of 24 (range 16-68) years. Twelve different benzodiazepine-type NPSs were detected over the two-year period, most commonly clonazolam (n = 82, 44.8 %), etizolam (n = 62, 33.9 %), clobromazolam (n = 43, 23.5 %), flualprazolam (n = 42, 23.0 %), and phenazepam (n = 31, 16.9 %). Two or more benzodiazepine-type NPSs were detected in 47.0 % of benzodiazepine-type NPS positive patients. No patient referenced the use of a benzodiazepine-type NPS by name or reported the possibility of heterogenous product content. CONCLUSION: Non-prescription benzodiazepine use may be an emerging concern in Australia, particularly amongst young males. The large variety of benzodiazepine-type NPS combinations suggest that consumers may not be aware of product heterogeneity upon purchase or use. Continued monitoring efforts are paramount to inform harm reduction opportunities.

Analytically confirmed illicit and novel psychoactive drug use in Western Australian emergency departments: initial results from the Emerging Drugs Network of Australia (EDNA).

INTRODUCTION: The burden of acute illicit drug use in Australia is largely unknown. Establishing a prospective drug surveillance system in emergency departments using analytical confirmation may facilitate the early identification of emerging drugs. We describe demographic data and acute toxicity patterns, stratified by analytical confirmation of illicit drugs and novel psychoactive substances, to emergency departments in Western Australia. METHODS: Patients presenting with severe and/or unusual clinical features consistent with recreational drug toxicity were identified across five Western Australian emergency departments participating in the Emerging Drugs Network of Australia between April 2020 and December 2021. Demographic and toxicology patterns in patients with and without analytically confirmed illicit drugs/novel psychoactive substances from blood samples were collected during the emergency department presentation. RESULTS: The cohort included 434 severe and/or unusual toxicology presentations; median age 33 years (first and third quartiles 25-40 years), 268 (61.8%) males. Any substance (illicit, novel psychoactive substance, pharmaceutical) was detected in 405 (93.3%) presentations. Illicit drugs/novel psychoactive substances were detected in 257 (59.2%) presentations, including 73 (28.3%) with more than one confirmed illicit drug/novel psychoactive substance. Frequent illicit drugs identified were metamfetamine (n = 201, 77.9%) and gamma-hydroxybutyrate (n = 30, 11.6%). Forty-eight novel psychoactive substances were detected within 43 (16.7%) presentations. Novel benzodiazepines were most frequently detected (n = 29, 60.4%). Frequent pharmaceuticals detected included diazepam (n = 100, 26.1%) and clonazepam (n = 40, 10.4%). One hundred and fifty-five (35.7%) presentations were discharged home and 56 (12.9%) were admitted to intensive care. Presentations with detected illicit drugs/novel psychoactive substances had a lower median intensive care length of stay compared to presentations without detected illicit drugs/novel psychoactive substances (32.6 h versus 50.8 h respectively, P < 0.001). CONCLUSIONS: Integration of clinical and analytic data in patients with severe and/or unusual toxicology presentations via the Emerging Drugs Network of Australia provides insight into illicit drug/novel psychoactive substance use responsible for acute harm across Western Australian emergency departments.

Unplanned Readmissions and Long-Term Mortality Risk After Incident Heart Failure Hospitalisation in Western Australia, 2001-2015.

AIMS: To investigate the frequency and predictors of unplanned readmissions after incident heart failure (HF) hospitalisation and the association between readmissions and mortality over two years. METHODS: We performed a retrospective cohort study using Western Australian morbidity and mortality data to identify all patients, aged 25-94 years, who survived an incident (first-ever) HF hospitalisation (principal diagnosis) between 2001-2015. Ordinal logistic regression models determined the covariates independently associated with unplanned readmission(s). Cox proportional hazards models with time-varying exposures determined the hazard ratios (HR) of one or more readmissions for mortality over two years after incident HF. RESULTS: Of 18,693 patients, 53.4% male, mean age 74.4 (standard deviation [SD] 13.6) years, 61.3% experienced 32,431 unplanned readmissions (39.7% cardiovascular-related) within two years. Leading readmission causes were HF (19.1%), respiratory diseases (12.6%), and ischaemic heart disease (9.6%). All-cause death occurred in 27.2% of the cohort, and the multivariable-adjusted mortality HR of 1 (versus 0) readmission was 2.5 (95% confidence interval [CI], 2.3-2.7) increasing to 5.0 (95% CI, 4.7-5.4) for 2+ readmissions. The adjusted mortality HR of 1 and 2+ (versus 0) HF-specific readmission was 2.0 (95% CI, 1.8-2.1) and 3.6 (95% CI, 3.2-3.9), respectively. Coexistent cardiovascular and other comorbidities were independently associated with increased readmission and mortality risk. CONCLUSION: This study underlines the high burden of recurrent unplanned cardiovascular and other readmissions within two years after incident HF hospitalisation, and their additive adverse impact on mortality. Integrated multidisciplinary management of concomitant comorbidities, in addition to HF-targeted treatments, is necessary to improve long-term prognosis in HF patients.

Unplanned 30-day readmissions, comorbidity and impact on one-year mortality following incident heart failure hospitalisation in Western Australia, 2001-2015.

BACKGROUND: Readmissions within 30 days after heart failure (HF) hospitalisation is considered an important healthcare quality metric, but their impact on medium-term mortality is unclear within an Australian setting. We determined the frequency, risk predictors and relative mortality risk of 30-day unplanned readmission in patients following an incident HF hospitalisation. METHODS: From the Western Australian Hospitalisation Morbidity Data Collection we identified patients aged 25-94 years with an incident (first-ever) HF hospitalisation as a principal diagnosis between 2001 and 2015, and who survived to 30-days post discharge. Unplanned 30-day readmissions were categorised by principal diagnosis. Logistic and Cox regression analysis determined the independent predictors of unplanned readmissions in 30-day survivors and the multivariable-adjusted hazard ratio (HR) of readmission on mortality within the subsequent year. RESULTS: The cohort comprised 18,241 patients, mean age 74.3 ± 13.6 (SD) years, 53.5% males, and one-third had a modified Charlson Comorbidity Index score of ≥ 3. Among 30-day survivors, 15.5% experienced one or more unplanned 30-day readmission, of which 53.9% were due to cardiovascular causes; predominantly HF (31.4%). The unadjusted 1-year mortality was 15.9%, and the adjusted mortality HR in patients with 1 and ≥ 2 cardiovascular or non-cardiovascular readmissions (versus none) was 1.96 (95% confidence interval (CI) 1.80-2.14) and 3.04 (95% CI, 2.51-3.68) respectively. Coexistent comorbidities, including ischaemic heart disease/myocardial infarction, peripheral arterial disease, pneumonia, chronic kidney disease, and anaemia, were independent predictors of both 30-day unplanned readmission and 1-year mortality. CONCLUSION: Unplanned 30-day readmissions and medium-term mortality remain high among patients who survived to 30 days after incident HF hospitalisation. Any cardiovascular or non-cardiovascular readmission was associated with a two to three-fold higher adjusted HR for death over the following year, and various coexistent comorbidities were important associates of readmission and mortality risk. Our findings support the need to optimize multidisciplinary HF and multimorbidity management to potentially reduce repeat hospitalisation and improve survival.

Emergent readmission and long-term mortality risk after incident atrial fibrillation hospitalisation.

OBJECTIVE: To assess the frequency and predictors of unplanned readmissions after hospitalisation for incident atrial fibrillation (AF) and the association of readmissions with mortality over 2 years. METHODS: We performed a retrospective cohort study using Western Australian morbidity and mortality data to identify all patients, aged 25-94 years, who survived incident (first-ever) hospitalisation for AF (principal diagnosis), between 2001 and 2015. Ordinal logistic models determined the covariates independently associated with unplanned readmission(s), and Cox proportional hazards models with time-varying exposures determined the hazard ratios (HR) of one or more readmissions for mortality over 2 years after incident AF. RESULTS: Of 22 956 patients, 57.7% male, mean age 67.9 (SD 13.8) years, 44.0% experienced 22 053 unplanned readmissions within 2 years, 50.6% being cardiovascular-related. All-cause death occurred in 8.0% of the cohort, and the multivariable-adjusted mortality HR of 1 (vs 0) readmission was 2.9 (95% CI 2.6 to 3.3), increasing to 5.6 (95% CI 5.0 to 6.5) for 3+ readmissions. First emergent readmission for AF, stroke, heart failure or myocardial infarction was independently associated with an increased hazard for mortality. Coexistent cardiovascular and other comorbidities were independently associated with increased readmission and mortality risk, whereas AF ablation was associated with reduced risk. CONCLUSION: This study highlights the large burden of unplanned all-cause and cardiovascular-specific readmissions within 2 years after being hospitalised for incident AF and their associated adverse impact on mortality. Concomitant comorbidities are independently associated with unplanned hospitalisations and mortality, which supports integrated multidisciplinary management of comorbidities, along with AF-targeted treatments, to improve long-term outcomes in patients with AF.

Corrigendum to: Evolution of non-fatal burden estimates for cardiovascular disease in Australia: a comparison of national and state-wide methodology of burden of disease.

Objective Burden of disease studies measure the impact of disease at the population level;however, methods and data sources for estimates of prevalence vary. Using a selection of cardiovascular diseases, we aimed to describe the implications of using different disease models and linked administrative data on prevalence estimation within three Australian burden of disease studies. Methods Three different methods (A = 2011 Australian Burden of Disease Study; B = 2015 Australian Burden of Disease Study; C = 2015 Western Australian Burden of Disease Study), which used linked data, were used to compare prevalence estimates of stroke, aortic aneurysm, rheumatic valvular heart disease (VHD) and non-rheumatic VHD. We applied these methods to 2015 Western Australian data, and calculated crude overall and age-specific prevalence for each condition. Results Overall, Method C produced estimates of cardiovascular prevalence that were lower than the other methods, excluding non-rheumatic VHD. Prevalence of acute and chronic stroke was up to one-third higher in Method A and B compared to Method C. Aortic aneurysms had the largest change in prevalence, with Method A producing an eight-fold higher estimate compared to Method C, but Method B was 10-20% lower. Estimates of VHD varied dramatically, with an up to six-fold change in prevalence in Method C due to substantial changes to disease models and the use of linked data. Conclusions Prevalence estimates require the best available data sources, updated disease models and constant review to inform government policy and health reform. Availability of nation-wide linked data will markedly improve future burden estimates.

Evolution of non-fatal burden estimates for cardiovascular disease in Australia: a comparison of national and state-wide methodology of burden of disease.

Objective Burden of disease studies measure the impact of disease at the population level;however, methods and data sources for estimates of prevalence vary. Using a selection of cardiovascular diseases, we aimed to describe the implications of using different disease models and linked administrative data on prevalence estimation within three Australian burden of disease studies. Methods Three different methods (A = 2011 Australian Burden of Disease Study; B = 2015 Australian Burden of Disease Study; C = 2015 Western Australian Burden of Disease Study), which used linked data, were used to compare prevalence estimates of stroke, aortic aneurysm, rheumatic valvular heart disease (VHD) and non-rheumatic VHD. We applied these methods to 2015 Western Australian data, and calculated crude overall and age-specific prevalence for each condition. Results Overall, Method C produced estimates of cardiovascular prevalence that were lower than the other methods, excluding non-rheumatic VHD. Prevalence of acute and chronic stroke was up to one-third higher in Method A and B compared to Method C. Aortic aneurysms had the largest change in prevalence, with Method A producing an eight-fold higher estimate compared to Method C, but Method B was 10-20% lower. Estimates of VHD varied dramatically, with an up to six-fold change in prevalence in Method C due to substantial changes to disease models and the use of linked data. Conclusions Prevalence estimates require the best available data sources, updated disease models and constant review to inform government policy and health reform. Availability of nation-wide linked data will markedly improve future burden estimates.

Unplanned 30-day readmission, comorbidity, and impact on mortality after incident atrial fibrillation hospitalization in Western Australia, 2001-2015.

Background: The healthcare burden of atrial fibrillation (AF) is dominated by hospitalizations, but data on 30-day unplanned readmissions after AF hospitalization and impact on mortality are limited. Objective: To assess causes and trends of 30-day unplanned readmission in incident (first-ever) hospitalized AF patients, and the risk of readmission for subsequent all-cause mortality. Methods: Patients aged 25-94 years, with an incident AF hospitalization (principal diagnosis) between 2001 and 2015, and surviving 30 days post discharge, were identified from linked Western Australian hospitalization and mortality data. Unplanned 30-day readmissions were categorized by principal diagnosis. Multivariable logistic and Cox regression analyses determined the independent predictors of readmission and the hazard ratio (HR) with 95% confidence intervals (CI) of readmission for subsequent 1-year mortality. Results: Of 22,814 patients, 57.7% male, mean age 67.8 ± 13.8 (standard deviation) years, 9.5% experienced 1 or more 30-day unplanned readmissions, with standardized rates increasing 2.0% annually (95% CI, 1.0%-3.1%). Among all readmissions, 64.8% were cardiovascular-related, with AF (31.7%), coronary events (12.2%), and heart failure (8.5%) being the most frequent. In 30-day survivors, 4.3% died within 1 year. Patients with any cardiovascular or noncardiovascular readmission (vs none) had a multivariable-adjusted mortality HR of 2.12 (95% CI, 1.82-2.45). Coexistent comorbidities were independently associated with 30-day unplanned readmission and 1-year mortality. Conclusion: Following incident AF hospitalization, 30-day unplanned readmissions were common, mostly cardiovascular-related, but any readmission, regardless of cause, was associated with a 2-fold higher adjusted mortality risk. Our findings also support the importance of comorbidity optimization within an integrated care pathway to reduce adverse outcomes in AF patients.

'Trial by fire': An online survey exploring confidence of junior doctors in managing toxicology presentations to the emergency department.

INTRODUCTION: The often unknown nature of acute drug intoxication, especially with illicit drugs and emerging novel psychoactive substances, can present a significant challenge for emergency clinicians. Less experienced clinicians are particularly vulnerable to the diagnostic dilemmas of complex toxicology emergencies. We sought to better understand the confidence of junior doctors in assessing and managing toxicological emergencies across two emergency departments in Perth, Australia. METHODS: An online survey was conducted between August 2020 and February 2021. Self-rated confidence was measured on a five-point Likert Scale across 10 statements. Two open-ended questions were included to capture perceived barriers and facilitators impacting clinical confidence. Quantitative data were analysed using descriptive methods and Fisher's exact test. Free-text responses were analysed using content analysis. RESULTS: A total of 104 surveys were completed (19.2% interns, 40.4% resident medical officers and 40.4% registrars). Self-rated confidence varied across statements and by staff type. The lowest confidence rating was for managing a patient who had overdosed from an unknown substance (31.7%) and the highest rating for referring a patient to psychiatry following deliberate self-poisoning (86.6%). Confidence increased with greater clinical experience for all statements. Qualitative analysis revealed perceptions of clinical preparedness, complexity of patients and a safe and supportive culture as key factors impacting confidence. DISCUSSION AND CONCLUSIONS: Overcoming perceived deficits in knowledge and clinical experience were key to building confidence. Our findings highlight the need for improved access to toxicology-specific curricula and training, and strategies to ensure adequate supervision from senior clinicians.

Undertriage of Geriatric Trauma Patients in Florida.

INTRODUCTION: Elderly undertriage rates are estimated up to 55% in the United States. This study examined risk factors for undertriage among hospitalized trauma patients in a state with high volumes of geriatric trauma patients. MATERIALS AND METHODS: This is a population-based retrospective cohort study of 62,557 patients admitted to Florida hospitals between 2016 and 2018 from the Agency for Healthcare Administration database. Severely injured trauma patients were defined by American College of Surgeons definitions and an International Classification of Disease Injury Severity Score <0.85. Undertriage was defined as definitive care of these severely injured patients at any Florida hospital other than a state-designated trauma center (TC). Univariate analyses were used to identify risk factors associated with inpatient mortality and undertriage. Multiple variable regression was used to estimate risk-adjusted odds of mortality after admission to either a designated or nondesignated TC. RESULTS: Undertriaged patients were more likely to have isolated traumatic brain injuries, lower International Classification of Disease Injury Severity Scores, multiple comorbidities, and older age. Trauma patients aged 65 and older were more than twice as likely to be undertriaged (34% versus 15.7%, P < 0.0001). Undertriaged patients of all ages were also more likely to suffer from pneumonia, urinary tract infection, arrhythmias, and sepsis. After risk adjustment, severely injured trauma patients admitted to non-TC were also more likely to be at risk for mortality (adjusted odds ratio, 1.27; 95% confidence interval, 1.17-1.38). CONCLUSIONS: Age and multiple comorbidities are significant predictors of mortality among undertriage of trauma patients. As a result, trauma triage guidelines should account for high-risk geriatric trauma patients who would benefit from definitive treatment at designated TCs.

Analysis of a Multi-Environment Trial for Black Raspberry (Rubus occidentalis L.) Quality Traits.

U.S. black raspberry (BR) production is currently limited by narrowly adapted, elite germplasm. An improved understanding of genetic control and the stability of pomological traits will inform the development of improved BR germplasm and cultivars. To this end, the analysis of a multiple-environment trial of a BR mapping population derived from a cross that combines wild ancestors introgressed with commercial cultivars on both sides of its pedigree has provided insights into genetic variation, genotype-by-environment interactions, quantitative trait loci (QTL), and QTL-by-environment interactions (QEI) of fruit quality traits among diverse field environments. The genetic components and stability of four fruit size traits and six fruit biochemistry traits were characterized in this mapping population following their evaluation over three years at four distinct locations representative of current U.S. BR production. This revealed relatively stable genetic control of the four fruit size traits across the tested production environments and less stable genetic control of the fruit biochemistry traits. Of the fifteen total QTL, eleven exhibited significant QEI. Closely overlapping QTL revealed the linkage of several fruit size traits: fruit mass, drupelet count, and seed fraction. These and related findings are expected to guide further genetic characterization of BR fruit quality, management of breeding germplasm, and development of improved BR cultivars for U.S. production.

Factors influencing participation among adults aging with long-term physical disability.

BACKGROUND: People aging with long-term physical disability (AwPD) experience barriers to participation and independent living. There are currently limited evidence-based interventions that address issues regarding participation for people AwPD. OBJECTIVE: This study examined factors influencing participation in personal and life activities among people AwPD to inform future interventions. METHODS: A cross-sectional study within an ongoing, community-based cohort study of participation was conducted. A purposive sample of people AwPD aged 45-65, living with a physical disability for at least five years, and who speak English was recruited through disability organizations, aging organizations, and social media. Participants answered open-ended questions about what supports they needed to successfully participate in nine activity categories derived from the Health and Retirement Study participation items (e.g., employment, community leisure). A content analysis was conducted using NVivo to categorize responses, and member checking occurred with four additional people AwPD. RESULTS: A total of 215 participants completed the survey. Eight categories of factors emerged from the data: physical environment factors, social factors, symptoms, economic factors, policy factors, body structure and functions, mental and emotional state, and temporal factors. Participant responses illuminated a combination of environmental and individual factors. Physical effects of disability and accelerated aging, such as pain and fatigue, paired with environmental factors, such as accessibility of transportation, were reported as influencing participation. CONCLUSIONS: People AwPD experience a range of factors that substantially impact their ability to remain independent and participate in society. By identifying barriers to participation, new interventions addressing these barriers may be developed, resulting in more effective service provision, enhanced participation in personal and life activities, and improved health and well-being.

Changing age-specific trends in incidence, comorbidities and mortality of hospitalised heart failure in Western Australia between 2001 and 2016.

BACKGROUND: Incident heart failure (HF) hospitalisation rates in most high-income countries are stable or declining. However, HF incidence may be increasing in younger people linked to changing risk factor profiles in the general population. We examined age and sex-specific patterns of incidence, comorbidities and mortality of hospitalised HF in Western Australia (WA) between 2001 and 2016. METHODS AND RESULTS: All WA residents aged 25-94 years, with an incident (first-ever) principal HF discharge diagnosis between 2001 and 2016 were included (n = 22,476). Poisson regression derived annual age and sex-standardised rates of incident HF and 1-year mortality overall, and by age groups (25-54, 55-74, 75-94), across the study period. Overall, the age and sex-standardised rates of incident HF increased marginally by 0.6% per year (95% confidence interval (CI), 0.3, 0.8) whereas incidence increased by 3.1% per year (95% CI, 2.2, 4.0) in the 25-54 year age-group (trend p < 0.0001). There was a high prevalence (≥15%) of obesity, diabetes mellitus, cardiomyopathy, hypertension, ischemic heart disease, atrial fibrillation, and chronic kidney disease in younger HF patients. Overall standardised 1-year mortality declined by -1.0% per year (95%CI, -0.4, -1.6), driven largely by the mortality decline in the 55-74 year age group. CONCLUSION: Incident HF hospitalisation rates have been rising in WA since 2006, notably in individuals under 55 years. The underlying reasons require further investigation, particularly the population-attributable risk related to increasing obesity and diabetes mellitus in the general population. Rising HF incidence along with declining mortality rates portends to an increasing HF burden in the community.

Incidence, predictors and mortality risk of new heart failure in patients hospitalised with atrial fibrillation.

OBJECTIVE: To determine the incidence, risk predictors and relative mortality risk of incident heart failure (HF) in patients following atrial fibrillation (AF) hospitalisation. METHODS: The Western Australian Hospitalisation Morbidity Data Collection was used to identify patients aged 25-94 years with index (first-in-period) AF hospitalisation, but without a prior HF admission, between 2000 and 2013. We evaluated the risk of incident HF hospitalisation within 3 years after AF admission, and the impact of HF hospitalisation on all-cause mortality. RESULTS: The cohort comprised 52 447 patients, 57.5% men, with a median age of 73.1 (IQR 63.2-80.8) years. At 3 years after AF discharge, the cumulative incidence of HF (n=6153) was 11.7% (95% CI 11.5% to 12.0%) and all-cause death (n=9702) was 18.5% (95% CI 18.2% to 18.8%). Independent predictors of incident HF included advancing age, any history of myocardial infarction (MI), peripheral vascular disease, valvular heart disease, chronic kidney disease, chronic obstructive pulmonary disease, hypertension, diabetes, obesity and excessive alcohol use (all p<0.001). Patients hospitalised for first-ever HF compared with those without HF hospitalisation had an adjusted HR of 3.3 (95% CI 3.1 to 3.4) for all-cause mortality (p<0.001). Independent predictors of HF were also shared with those for mortality, with the exception of hypertension. CONCLUSION: Hospitalisation for new HF is common in patients with AF and independently associated with a 3-fold hazard for death. The clinical predictors of incident HF emphasise the importance of integrated management of common comorbid conditions and lifestyle risk factors in patients with AF to reduce their morbidity and mortality.

Full recovery after 45 min of open cardiac massage for penetrating trauma: Resuscitation guided by end tidal CO2 and permissive hypotension.

We present a rare case of a patient who sustained a gunshot wound to the abdomen, injuring the aorta, IVC and right common iliac vein. After initially obtaining return of spontaneous circulation (ROSC) en route to the hospital, the patient again lost cardiac activity in the operating room during exploratory laparotomy. Resuscitative thoracotomy was performed and open cardiac massage was maintained for approximately 45 min while vessel injuries were repaired. During cardiac massage, end tidal CO2 was maintained between 15 and 31 mm Hg with 100% oxygen saturation and the patient received on-going transfusion of recycled whole blood and blood component therapy. Permissive hypotension was maintained to facilitate rapid repair of major vessels. Return of spontaneous circulation was achieved with a single 30 joule defibrillation. The patient was discharged home on hospital day 11, neurologically intact. This is the first report of survival after 45 min of open cardiac massage with aortic cross clamping, indicating that end tidal CO2 may act as an indicator of adequate end organ perfusion during protracted periods of hypotension.