Barriers and facilitators to women's access to sexual and reproductive health services in rural Australia: a systematic review.

BACKGROUND: Accessing sexual and reproductive health (SRH) services in rural Australia presents complex challenges that negatively impact women's health and exacerbate health inequities across the life course. This systematic review synthesises evidence on the barriers and facilitators to women's access to SRH services in rural Australia, considering both supply and demand dimensions. METHODS: We systematically searched peer-reviewed literature published between 2013 and 2023. Search terms were derived from three major topics: (1) women living in rural Australia; (2) spatial or aspatial access to SRH services; and (3) barriers or facilitators. We adopted the "best fit" approach to framework synthesis using the patient-centred access to healthcare model. RESULTS: Database searches retrieved 1,024 unique records, with 50 studies meeting the inclusion criteria. Most studies analysed access to primary care services (n = 29; 58%), followed by hospital services (n = 14; 28%), health promotion and prevention (n = 5; 10%), and specialist care (n = 2; 4%). The type of care accessed was mostly maternity care (n = 21; 42%), followed by abortion services (n = 11; 22%), screening and testing (n = 8; 16%), other women's health services (n = 6; 12%), and family planning (n = 4; 8%). There were numerous barriers and facilitators in access from supply and demand dimensions. Supply barriers included fragmented healthcare pathways, negative provider attitudes, limited availability of services and providers, and high costs. Demand barriers encompassed limited awareness, travel challenges, and financial burdens. Supply facilitators included health system improvements, inclusive practices, enhanced local services, and patient-centred care. Demand facilitators involved knowledge and awareness, care preferences, and telehealth accessibility. CONCLUSION: This review highlights the urgent need for targeted interventions to address SRH service access disparities in rural Australia. Understanding the barriers and facilitators women face in accessing SRH services within the rural context is necessary to develop comprehensive healthcare policies and interventions informed by a nuanced understanding of rural women's diverse needs.

An Unusual Case of Contralateral Hypoglossal and Recurrent Laryngeal Nerve Palsies Following Endotracheal Intubation.

We present an unusual case of a 62-year-old male presenting with contralateral hypoglossal and recurrent laryngeal nerve palsies following endotracheal intubation for emergency cardiac surgery. Postoperative, the patient was referred to Speech and Language Therapy due to concerns regarding the safety of his swallow. Oromotor assessment revealed left-sided tongue weakness and aphonia. Flexible endoscopic evaluation of swallowing (FEES) revealed a right vocal cord palsy and severe oropharyngeal dysphagia. There were no other focal neurological signs. An MRI head did not demonstrate a medial medullary stroke or other intracranial lesion. CT neck showed no abnormality identified in relation to the course of the right vagus nerve or recurrent laryngeal nerve at the skull base or through the neck respectively. The patient required a gastrostomy for nutrition and hydration. He continued to be assessed at several month intervals over the course of a year using FEES to obtain a range of voice, secretion and swallowing outcome measures. The patient commenced intensive dysphagia therapy targeting pharyngeal drive, hyolaryngeal excursion and laryngeal sensation. Swallow manoeuvres were trialled during FEES and a head-turn to the side of the vocal cord palsy during deglutition reduced aspiration risk which expedited return to oral intake. The patient had partial recovery over twelve months. Hypoglossal nerve palsy completely resolved. The right vocal cord remained paralysed however the left vocal cord compensated enabling the patient to produce a normal voice. The patient was able to take thin fluids and regular diet and the gastrostomy was removed.

Evaluating telehealth lifestyle therapy versus telehealth psychotherapy for reducing depression in adults with COVID-19 related distress: the curbing anxiety and depression using lifestyle medicine (CALM) randomised non-inferiority trial protocol.

BACKGROUND: There is increasing recognition of the substantial burden of mental health disorders at an individual and population level, including consequent demand on mental health services. Lifestyle-based mental healthcare offers an additional approach to existing services with potential to help alleviate system burden. Despite the latest Royal Australian New Zealand College of Psychiatrists guidelines recommending that lifestyle is a 'first-line', 'non-negotiable' treatment for mood disorders, few such programs exist within clinical practice. Additionally, there are limited data to determine whether lifestyle approaches are equivalent to established treatments. Using an individually randomised group treatment design, we aim to address this gap by evaluating an integrated lifestyle program (CALM) compared to an established therapy (psychotherapy), both delivered via telehealth. It is hypothesised that the CALM program will not be inferior to psychotherapy with respect to depressive symptoms at 8 weeks. METHODS: The study is being conducted in partnership with Barwon Health's Mental Health, Drugs & Alcohol Service (Geelong, Victoria), from which 184 participants from its service and surrounding regions are being recruited. Eligible participants with elevated psychological distress are being randomised to CALM or psychotherapy. Each takes a trans-diagnostic approach, and comprises four weekly (weeks 1-4) and two fortnightly (weeks 6 and 8) 90-min, group-based sessions delivered via Zoom (digital video conferencing platform). CALM focuses on enhancing knowledge, behavioural skills and support for improving dietary and physical activity behaviours, delivered by an Accredited Exercise Physiologist and Accredited Practising Dietitian. Psychotherapy uses cognitive behavioural therapy (CBT) delivered by a Psychologist or Clinical Psychologist, and Provisional Psychologist. Data collection occurs at baseline and 8 weeks. The primary outcome is depressive symptoms (assessed via the Patient Health Questionnaire-9) at 8 weeks. Societal and healthcare costs will be estimated to determine the cost-effectiveness of the CALM program. A process evaluation will determine its reach, adoption, implementation and maintenance. DISCUSSION: If the CALM program is non-inferior to psychotherapy, this study will provide the first evidence to support lifestyle-based mental healthcare as an additional care model to support individuals experiencing psychological distress. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12621000387820 , Registered 8 April 2021.

Use of an audit with feedback implementation strategy to promote medication error reporting by nurses.

AIMS AND OBJECTIVES: To outline the development and effect of an audit with feedback implementation strategy that intended to increase the rate of voluntary medication error reporting by nurses. BACKGROUND: Medication errors are a serious global health issue. Audit with feedback is a widely used implementation strategy that has potential to modify nurses' reporting behaviour and improve medication error reporting rates. DESIGN: Quasi-experimental implementation study (fulfilling the TIDieR checklist) with two pairs of matched wards at a private hospital in Australia was conducted from March 2015-September 2016. One ward from each pair was randomised to either the intervention or control group. METHOD: Nurses within intervention wards received audit with feedback on a quarterly basis over a 12-month implementation period. Control wards underwent quarterly audits only (without feedback). Feedback consisted of a one-page infographic poster, with content based on medication error data obtained from audits and the hospitals' risk management system (RiskMan). The primary outcome-rate of medication errors reported per month-was determined in both groups at pre-implementation, implementation and postimplementation phases. Differences between groups were compared using generalised linear mixed models with Poisson distribution and log link. RESULTS: A nonsignificant intervention effect was found for rate of medication errors reported per month. Interestingly, when combining data from both groups, a significant increasing time trend was observed for medication errors reported per month across pre-implementation and implementation phases (80% increase). CONCLUSIONS: The audit with feedback strategy developed in the present study did not effectively influence the voluntary reporting of medication errors by nurses. RELEVANCE TO CLINICAL PRACTICE: Despite the lack of intervention effects, the use of a published checklist to optimise the reporting quality of this study will contribute to the field by furthering the understanding of how to enhance audit with feedback implementation strategies for nurses.

Maternity service organisational interventions that aim to reduce caesarean section: a systematic review and meta-analyses.

BACKGROUND: Caesarean sections (CSs) are associated with increased maternal and perinatal morbidity, yet rates continue to increase within most countries. Effective interventions are required to reduce the number of non-medically indicated CSs and improve outcomes for women and infants. This paper reports findings of a systematic review of literature related to maternity service organisational interventions that have a primary intention of improving CS rates. METHOD: A three-phase search strategy was implemented to identify studies utilising organisational interventions to improve CS rates in maternity services. The database search (including Cochrane CENTRAL, CINAHL, MEDLINE, Maternity and Infant Care, EMBASE and SCOPUS) was restricted to peer-reviewed journal articles published from 1 January 1980 to 31 December 2017. Reference lists of relevant reviews and included studies were also searched. Primary outcomes were overall, planned, and unplanned CS rates. Secondary outcomes included a suite of birth outcomes. A series of meta-analyses were performed in RevMan, separated by type of organisational intervention and outcome of interest. Summary risk ratios with 95% confidence intervals were presented as the effect measure. Effect sizes were pooled using a random-effects model. RESULTS: Fifteen articles were included in the systematic review, nine of which were included in at least one meta-analysis. Results indicated that, compared with women allocated to usual care, women allocated to midwife-led models of care implemented across pregnancy, labour and birth, and the postnatal period were, on average, less likely to experience CS (overall) (average RR 0.83, 95% CI 0.73 to 0.96), planned CS (average RR 0.75, 95% CI 0.61 to 0.93), and episiotomy (average RR 0.84, 95% CI 0.74 to 0.95). Narratively, audit and feedback, and a hospital policy of mandatory second opinion for CS, were identified as interventions that have potential to reduce CS rates. CONCLUSION: Maternity service leaders should consider the adoption of midwife-led models of care across the maternity episode within their organisations, particularly for women classified as low-risk. Additional studies are required that utilise either audit and feedback, or a hospital policy of mandatory second opinion for CS, to facilitate the quantification of intervention effects within future reviews. PROSPERO REGISTRATION: CRD42016039458 ; prospectively registered.

Doxycycline versus prednisolone as an initial treatment strategy for bullous pemphigoid: a pragmatic, non-inferiority, randomised controlled trial.

BACKGROUND: Bullous pemphigoid is a blistering skin disorder with increased mortality. We tested whether a strategy of starting treatment with doxycycline gives acceptable short-term blister control while conferring long-term safety advantages over starting treatment with oral corticosteroids. METHODS: We did a pragmatic, multicentre, parallel-group randomised controlled trial of adults with bullous pemphigoid (three or more blisters at two or more sites and linear basement membrane IgG or C3). Participants were randomly assigned to doxycycline (200 mg per day) or prednisolone (0·5 mg/kg per day) using random permuted blocks of randomly varying size, and stratified by baseline severity (3-9, 10-30, and >30 blisters for mild, moderate, and severe disease, respectively). Localised adjuvant potent topical corticosteroids (<30 g per week) were permitted during weeks 1-3. The non-inferiority primary effectiveness outcome was the proportion of participants with three or fewer blisters at 6 weeks. We assumed that doxycycline would be 25% less effective than corticosteroids with a 37% acceptable margin of non-inferiority. The primary safety outcome was the proportion with severe, life-threatening, or fatal (grade 3-5) treatment-related adverse events by 52 weeks. Analysis (modified intention to treat [mITT] for the superiority safety analysis and mITT and per protocol for non-inferiority effectiveness analysis) used a regression model adjusting for baseline disease severity, age, and Karnofsky score, with missing data imputed. The trial is registered at ISRCTN, number ISRCTN13704604. FINDINGS: Between March 1, 2009, and Oct 31, 2013, 132 patients were randomly assigned to doxycycline and 121 to prednisolone from 54 UK and seven German dermatology centres. Mean age was 77·7 years (SD 9·7) and 173 (68%) of 253 patients had moderate-to-severe baseline disease. For those starting doxycycline, 83 (74%) of 112 patients had three or fewer blisters at 6 weeks compared with 92 (91%) of 101 patients on prednisolone, an adjusted difference of 18·6% (90% CI 11·1-26·1) favouring prednisolone (upper limit of 90% CI, 26·1%, within the predefined 37% margin). Related severe, life-threatening, and fatal events at 52 weeks were 18% (22 of 121) for those starting doxycycline and 36% (41 of 113) for prednisolone (mITT), an adjusted difference of 19·0% (95% CI 7·9-30·1), p=0·001. INTERPRETATION: Starting patients on doxycycline is non-inferior to standard treatment with oral prednisolone for short-term blister control in bullous pemphigoid and significantly safer in the long-term. FUNDING: NIHR Health Technology Assessment Programme.

Barriers and enablers to the delivery of psychological care in the management of patients with type 2 diabetes mellitus in China: a qualitative study using the theoretical domains framework.

BACKGROUND: China has the largest number of type 2 diabetes mellitus (T2DM) cases globally and individuals with T2DM have an increased risk of developing mental health disorders and functional problems. Despite guidelines recommending that psychological care be delivered in conjunction with standard T2DM care; psychological care is not routinely delivered in China. Community Health Centre (CHC) doctors play a key role in the management of patients with T2DM in China. Understanding the behavioural determinants of CHC doctors in the implementation of psychological care recommendations allows for the design of targeted and culturally appropriate interventions. As such, this study aimed to examine barriers and enablers to the delivery of psychological care to patients with T2DM from the perspective of CHC doctors in China. METHODS: Two focus groups were conducted with 23 CHC doctors from Shenzhen, China. The discussion guide applied the Theoretical Domains Framework (TDF) that examines current practice and identifies key barriers and enablers perceived to influence practice. Focus groups were conducted with an interpreter, and were digitally recorded and transcribed. Two researchers independently coded transcripts into pre-defined themes using deductive thematic analysis. RESULTS: Barriers and enablers perceived by doctors as being relevant to the delivery of psychological care for patients with T2DM were primarily categorised within eight TDF domains. Key barriers included: CHC doctors' knowledge and skills; time constraints; and absence of financial incentives. Other barriers included: societal perception that treating psychological aspects of health is less important than physical health; lack of opinion leaders; doctors' intentional disregard of psychological care; and doubts regarding the efficacy of psychological care. In contrast, perceived enablers included: training of CHC doctors in psychological skills; identification of afternoon/evening clinic times when recommendations could be implemented; introduction of financial incentives; and the creation of a professional role (e.g. diabetes educator), that could implement psychological care recommendations to patients with T2DM. CONCLUSIONS: The utilisation of the TDF allowed for the comprehensive understanding of barriers and enablers to the implementation of psychological care recommendations for patients with T2DM, and consequently, has given direction to future interventions strategies aimed at improving the implementation of such recommendations.

Measuring chlorine bleach in biology and medicine.

BACKGROUND: Chlorine bleach, or hypochlorous acid, is the most reactive two-electron oxidant produced in appreciable amounts in our bodies. Neutrophils are the main source of hypochlorous acid. These champions of the innate immune system use it to fight infection but also direct it against host tissue in inflammatory diseases. Neutrophils contain a rich supply of the enzyme myeloperoxidase. It uses hydrogen peroxide to convert chloride to hypochlorous acid. SCOPE OF REVIEW: We give a critical appraisal of the best methods to measure production of hypochlorous acid by purified peroxidases and isolated neutrophils. Robust ways of detecting it inside neutrophil phagosomes where bacteria are killed are also discussed. Special attention is focused on reaction-based fluorescent probes but their visual charm is tempered by stressing their current limitations. Finally, the strengths and weaknesses of biomarker assays that capture the footprints of chlorine in various pathologies are evaluated. MAJOR CONCLUSIONS: Detection of hypochlorous acid by purified peroxidases and isolated neutrophils is best achieved by measuring accumulation of taurine chloramine. Formation of hypochlorous acid inside neutrophil phagosomes can be tracked using mass spectrometric analysis of 3-chlorotyrosine and methionine sulfoxide in bacterial proteins, or detection of chlorinated fluorescein on ingestible particles. Reaction-based fluorescent probes can also be used to monitor hypochlorous acid during phagocytosis. Specific biomarkers of its formation during inflammation include 3-chlorotyrosine, chlorinated products of plasmalogens, and glutathione sulfonamide. GENERAL SIGNIFICANCE: These methods should bring new insights into how chlorine bleach is produced by peroxidases, reacts within phagosomes to kill bacteria, and contributes to inflammation. This article is part of a Special Issue entitled Current methods to study reactive oxygen species - pros and cons and biophysics of membrane proteins. Guest Editor: Christine Winterbourn.

Osteoid osteoma of the foot and ankle--A systematic review.

BACKGROUND: Osteoid osteomas are responsible for 10% of benign bone tumours. Treatment typically involves surgical excision or radio frequency ablation. The aim of this systematic review is to evaluate reported cases of foot and ankle osteoid osteomas. METHODS: We conducted a systematic review of the literature using the online databases Medline and EMBASE. We included studies reporting osteoid osteoma diagnosed either radiologically or histologically. RESULTS: 94 studies were included reporting 223 cases; 70.5% were male, mean age was 23 years, 69% reported night pain and 72% responded to NSAIDs. The commonest affected bone was the talus. CT scan was the most useful radiological investigation and MRI missed the diagnosis in 34% of cases. The majority of patients underwent surgical excision but an increasing trend of ablation therapy was demonstrated. CONCLUSIONS: A high index of suspicion based on salient history and appropriate imaging are essential for timely identification and treatment.

Ceruloplasmin is an endogenous inhibitor of myeloperoxidase.

Myeloperoxidase is a neutrophil enzyme that promotes oxidative stress in numerous inflammatory pathologies. It uses hydrogen peroxide to catalyze the production of strong oxidants including chlorine bleach and free radicals. A physiological defense against the inappropriate action of this enzyme has yet to be identified. We found that myeloperoxidase oxidized 75% of the ascorbate in plasma from ceruloplasmin knock-out mice, but there was no significant loss in plasma from wild type animals. When myeloperoxidase was added to human plasma it became bound to other proteins and was reversibly inhibited. Ceruloplasmin was the predominant protein associated with myeloperoxidase. When the purified proteins were mixed, they became strongly but reversibly associated. Ceruloplasmin was a potent inhibitor of purified myeloperoxidase, inhibiting production of hypochlorous acid by 50% at 25 nm. Ceruloplasmin rapidly reduced Compound I, the Fe(V) redox intermediate of myeloperoxidase, to Compound II, which has Fe(IV) in its heme prosthetic groups. It also prevented the fast reduction of Compound II by tyrosine. In the presence of chloride and hydrogen peroxide, ceruloplasmin converted myeloperoxidase to Compound II and slowed its conversion back to the ferric enzyme. Collectively, our results indicate that ceruloplasmin inhibits myeloperoxidase by reducing Compound I and then trapping the enzyme as inactive Compound II. We propose that ceruloplasmin should provide a protective shield against inadvertent oxidant production by myeloperoxidase during inflammation.

The potentiation of myeloperoxidase activity by the glycosaminoglycan-dependent binding of myeloperoxidase to proteins of the extracellular matrix.

BACKGROUND: Myeloperoxidase (MPO) is an abundant hemoprotein expressed by neutrophil granulocytes that is recognized to play an important role in the development of vascular diseases. Upon degranulation from circulating neutrophil granulocytes, MPO binds to the surface of endothelial cells in an electrostatic-dependent manner and undergoes transcytotic migration to the underlying extracellular matrix (ECM). However, the mechanisms governing the binding of MPO to subendothelial ECM proteins, and whether this binding modulates its enzymatic functions are not well understood. METHODS: We investigated MPO binding to ECM derived from aortic endothelial cells, aortic smooth muscle cells, and fibroblasts, and to purified ECM proteins, and the modulation of these associations by glycosaminoglycans. The oxidizing and chlorinating potential of MPO upon binding to ECM proteins was tested. RESULTS: MPO binds to the ECM proteins collagen IV and fibronectin, and this association is enhanced by the pre-incubation of these proteins with glycosaminoglycans. Correspondingly, an excess of glycosaminoglycans in solution during incubation inhibits the binding of MPO to collagen IV and fibronectin. These observations were confirmed with cell-derived ECM. The oxidizing and chlorinating potential of MPO was preserved upon binding to collagen IV and fibronectin; even the potentiation of MPO activity in the presence of collagen IV and fibronectin was observed. CONCLUSIONS: Collectively, the data reveal that MPO binds to ECM proteins on the basis of electrostatic interactions, and MPO chlorinating and oxidizing activity is potentiated upon association with these proteins. GENERAL SIGNIFICANCE: Our findings provide new insights into the molecular mechanisms underlying the interaction of MPO with ECM proteins.

Oxidation contributes to low glutathione in the airways of children with cystic fibrosis.

Glutathione is an important antioxidant in the lungs but its concentration is low in the airways of patients with cystic fibrosis. Whether this deficit occurs from an early age or how oxidative stress contributes to lowering glutathione is unknown. We measured glutathione, its oxidation products, myeloperoxidase, and biomarkers of hypochlorous acid in bronchoalveolar lavage from children with cystic fibrosis and disease controls using mass spectrometry and immunological techniques. The concentration of glutathione was lower in bronchoalveolar lavage from children with cystic fibrosis, whereas glutathione sulfonamide, a specific oxidation product of hypochlorous acid, was higher. Oxidised glutathione and glutathione sulfonamide correlated with myeloperoxidase and a biomarker of hypochlorous acid. The percentage of glutathione attached to proteins was higher in children with cystic fibrosis than controls. Pulmonary infections in cystic fibrosis resulted in lower levels of glutathione but higher levels of oxidised glutathione and glutathione sulfonamide in bronchoalveolar lavage. The concentration of glutathione is low in the airways of patients with cystic fibrosis from an early age. Increased oxidation of glutathione by hypochlorous acid and its attachment to proteins contribute to this deficiency. Therapies targeted against myeloperoxidase may boost antioxidant defence and slow the onset and progression of lung disease in cystic fibrosis.

The application of stepped-wedge cluster-randomized controlled trial study designs in oncology settings: A systematic review.

Stepped-wedge cluster-randomised trials (SW-CRTs) offer advantages for implementation research in healthcare and have been increasingly utilised in the oncology setting. Cancer-related SW-CRTs need to be robust to deliver impactful trial outcomes and support effective translation into practice. This review aimed to examine the application of the SW-CRT design in oncology settings including the trial design features and protocol deviations, the interventions tested, and the implementation aspects of those interventions. Five databases were searched from database inception to July 2023 for SW-CRTs which evaluated interventions in adults with cancer. Intervention characteristics, design features, protocol deviations, statistical approach, implementation strategies, and outcomes were described and evaluated narratively. The search yielded 3,395 unique records with representing 15 trials which are reported over 49 publications. The 15 trials (n=8 efficacy trials and n=7 implementation trials) described diverse interventions in healthcare settings. Trials supported implementation of the intervention via educating and training healthcare professionals (n=12; 80%), met or exceeded recruitment targets (n=10, 67%) and evaluated a new model of care (n=7; 47%). Despite implementation outcomes being reported in 14 (93%) trials, 12 (86%) did not use an established evaluation framework to guide the selection and reporting of implementation outcomes. SW-CRTs were a utilised design for implementing diverse and complex healthcare interventions in the oncology setting. Trialists should consider the need to incorporate implementation frameworks, strategies and outcomes into their trial planning and resource allocation. This strategic approach can enhance the design and impact of SW-CRTs, leading to improved patient outcomes and advancements in cancer care.

Barriers and enablers to effective weight management for people living with overweight and obesity: A rapid scoping review.

A scoping review was conducted to identify barriers and enablers to effective weight management in healthcare settings for people living with overweight and obesity in English-speaking high-income countries. Peer-reviewed and gray literature were systematically searched in June 2024. Data were analyzed using inductive thematic analysis. Of the 15,684 unique articles identified and screened for relevance, 216 studies were included. Healthcare-related barriers and enablers to weight management were organized under three themes: a) healthcare provider-related factors, b) provision of care, and c) policy/funding. Prominent barriers included healthcare provider knowledge deficits and low prioritization of obesity management, mainly in the primary care setting. Weight management beyond the primary care setting was found to be especially challenging, with poor referral pathways, service fragmentation, lack of multidisciplinary practice, and restricted eligibility criteria, hindering the accessibility of services. Developing consistent policies and guidelines, improving the education of healthcare providers, and increasing funding to provide low-cost comprehensive care, were identified as enablers to access and uptake of weight management services. Considerable overlap in the identified barriers existed across healthcare providers and settings. A whole health system approach to minimize barriers and strengthen enablers to weight management services is needed, to address rising obesity rates.

Clinical and cost-effectiveness of remote-delivered, online lifestyle therapy versus psychotherapy for reducing depression: results from the CALM non-inferiority, randomised trial.

Background: We conducted the first non-inferiority, randomised controlled trial to determine whether lifestyle therapy is non-inferior to psychotherapy with respect to mental health outcomes and costs when delivered via online videoconferencing. Methods: An individually randomised, group treatment design with computer-generated block randomisation was used. Between May 2021-April 2022, 182 adults with a Distress Questionnaire-5 score = ≥8 (indicative depression) were recruited from a tertiary mental health service in regional Victoria, Australia and surrounds. Participants were assigned to six 90-min sessions over 8-weeks using group-based, online videoconferencing comprising: (1) lifestyle therapy (targeting nutrition, physical activity) with a dietitian and exercise physiologist (n = 91) or (2) psychotherapy (Cognitive Behavioural Therapy) with psychologists (n = 91). The primary outcome was Patient Health Questionnaire-9 (PHQ-9) depression at 8-weeks (non-inferiority margin ≤2) using Generalised Estimating Equations (GEE). Cost-minimisation analysis estimated the mean difference in total costs from health sector and societal perspectives. Outcomes were assessed by blinded research assistants using Computer Assisted Telephone Interviews. Results are presented per-protocol (PP) and Intention to Treat (ITT) using beta coefficients with 95% Confidence Intervals (CIs). Findings: The sample was 80% women (mean: 45-years [SD:13.4], mean PHQ-9:10.5 [SD:5.7]. An average 4.2 of 6 sessions were completed, with complete data for n = 132. Over 8-weeks, depression reduced in both arms (PP: Lifestyle (n = 70) mean difference:-3.97, 95% CIs:-5.10, -2.84; and Psychotherapy (n = 62): mean difference:-3.74, 95% CIs:-5.12, -2.37; ITT: Lifestyle (n = 91) mean difference:-4.42, 95% CIs: -4.59, -4.25; Psychotherapy (n = 91) mean difference:-3.82, 95% CIs:-4.05, -3.69) with evidence of non-inferiority (PP GEE ß:-0.59; 95% CIs:-1.87, 0.70, n = 132; ITT GEE ß:-0.49, 95% CIs:-1.73, 0.75, n = 182). Three serious adverse events were recorded. While lifestyle therapy was delivered at lower cost, there were no differences in total costs (health sector adjusted mean difference: PP AUD$156 [95% CIs -$182, $611, ITT AUD$190 [95% CIs -$155, $651] ]; societal adjusted mean difference: PP AUD$350 [95% CIs:-$222, $1152] ITT AUD$ 408 [95% CIs -$139, $1157]. Interpretation: Remote-delivered lifestyle therapy was non-inferior to psychotherapy with respect to clinical and cost outcomes. If replicated in a fully powered RCT, this approach could increase access to allied health professionals who, with adequate training and guidelines, can deliver mental healthcare at comparable cost to psychologists. Funding: This trial was funded by the Australian Medical Research Future Fund (GA133346) under its Covid-19 Mental Health Research Grant Scheme.

Barriers to the implementation of preconception care guidelines as perceived by general practitioners: a qualitative study.

BACKGROUND: Despite strong evidence of the benefits of preconception interventions for improving pregnancy outcomes, the delivery and uptake of preconception care and periconceptional folate supplementation remain low. General practitioners play a central role in the delivery of preconception care. Understanding general practitioners' perceptions of the barriers and enablers to implementing preconception care allows for more appropriate targeting of quality improvement interventions. Consequently, the aim of this study was to examine the barriers and enablers to the delivery and uptake of preconception care guidelines from general practitioners' perspective using theoretical domains related to behaviour change. METHODS: We conducted a qualitative study using focus groups consisting of 22 general practitioners who were recruited from three regional general practice support organisations. Questions were based on the theoretical domain framework, which describes 12 domains related to behaviour change. General practitioners' responses were classified into predefined themes using a deductive process of thematic analysis. RESULTS: Beliefs about capabilities, motivations and goals, environmental context and resources, and memory, attention and decision making were the key domains identified in the barrier analysis. Some of the perceived barriers identified by general practitioners were time constraints, the lack of women presenting at the preconception stage, the numerous competing preventive priorities within the general practice setting, issues relating to the cost of and access to preconception care, and the lack of resources for assisting in the delivery of preconception care guidelines. Perceived enablers identified by general practitioners included the availability of preconception care checklists and patient brochures, handouts, and waiting room posters outlining the benefits and availability of preconception care consultations. CONCLUSIONS: Our study has identified some of the barriers and enablers to the delivery and uptake of preconception care guidelines, as perceived by general practitioners. Relating these barriers to a theoretical domain framework provides a clearer understanding of some of the psychological aspects that are involved in the behaviour of general practitioners towards the delivery and uptake of preconception care. Further research prioritising these barriers and the theoretical domains to which they relate to is necessary before a methodologically rigorous intervention can be designed, implemented, and evaluated.

A multi-professional survey of UK practice in the use of intra-articular corticosteroid injection for symptomatic first metatarsophalangeal joint osteoarthritis.

BACKGROUND: The first metatarsophalangeal joint is the most common site of osteoarthritis (OA) in the foot and ankle. Intra-articular corticosteroid injections are widely used for this condition, but little is known about their use in practice. This study explored current practice within the UK National Health Service (NHS) relating to the administration of intra-articular corticosteroids for people with painful first metatarsophalangeal joint (MTPJ) OA. METHODS: A cross-sectional survey using Qualtrics online survey platform (Qualtrics, Provo, UT, USA), distributed through professional bodies, special interest groups, and social media. RESULTS: One hundred forty-four healthcare professionals responded, including podiatrists (53/144; 39%), orthopaedic surgeons (28/144; 19%), podiatric surgeons (26/144; 17%) and physiotherapists (24/144; 16%). Half of respondents administered up to 25 corticosteroid injections per year (67/136; 49%) but some administered more than fifty (21/136; 15%). Injections were administered across the healthcare system but were most common in hospital settings (64/136; 44%) followed by community (38/136; 26%), with less delivered in primary care (11/136; 8%). Half of respondents routinely used image-guidance, either ultrasound or x-ray/fluoroscopy (65/136; 48%) although over one third used none (52/136; 38%). Imaging guidance was more common amongst medical professionals (21/31; 68%) compared to non-medical health professionals (45/105; 43%). Overall, methylprednisolone acetate was the most common corticosteroid used. Medical professionals mostly injected methylprednisolone acetate (n = 15/27; 56%) or triamcinolone acetonide (n = 11/27; 41%), whereas premixed methylprednisolone acetate with lidocaine hydrochloride was the most common preparation used by non-medical health professionals (41/85; 48%). When injecting non premixed steroid, lidocaine hydrochloride (15/35; 43%) was the most common choice of local anaesthetic for non-medical health professionals but medical professionals showed more variation between lidocaine hydrochloride (8/23; 35%) levobupivacaine hydrochloride (9/23; 39%) and bupivacaine hydrochloride (5/23; 22%). CONCLUSIONS: Multiple professional groups regularly administer intra-articular corticosteroids for symptomatic first MTPJ OA across a range of NHS healthcare settings. Overall, methylprednisolone acetate was the most commonly administered steroid and lidocaine hydrochloride the most common local anaesthetic. There was large variation in the use of imaging guidance, type and dose of steroid, local anaesthetic, and clinical pathways used in the intra-articular injection of corticosteroids for people with first MTPJ OA.

Overcoming challenges in conducting systematic reviews in implementation science: a methods commentary.

Consolidation of the literature using systematic reviews is a critical way to advance a discipline and support evidence-based decision-making in healthcare. However, unique challenges exist that impact the conduct of systematic reviews in implementation science. In this commentary, we reflect on our combined experience to describe five key challenges unique to systematic reviews of primary implementation research. These challenges include (1) descriptors used in implementation science publications, (2) distinction between evidence-based interventions and implementation strategies, (3) assessment of external validity, (4) synthesis of implementation studies with substantial clinical and methodological diversity, and (5) variability in defining implementation 'success'. We outline possible solutions and highlight resources that can be used by authors of primary implementation research, as well as systematic review and editorial teams, to overcome the identified challenges and optimise the utility of future systematic reviews in implementation science.

Clinical evaluation of the Immulite® 1000 chemiluminescent immunoassay for measurement of equine serum insulin.

Introduction: Accurate quantitative analysis of equine insulin in blood samples is critical for assessing hyperinsulinemia in horses. Although there are various laboratory methods for evaluating equine serum insulin, different immunoassays show significant discrepancies between the determined insulin concentrations and are often not comparable. The aim of this study was to evaluate the Immulite® 1000 chemiluminescent immunoassay (CLIA) to establish independent laboratory and assay-specific cut values to provide an accurate diagnosis of hyperinsulinemia in horses. Thus, the analytical and clinical performance of Immulite® 1000 CLIA in terms of precision (intra- and inter-assay coefficient of variance, CV) and recovery upon dilution were evaluated and compared with radioimmunoassay (RIA), which has been previously validated for use in horses. Material and methods: Archived serum samples (n = 106) from six Quarter horse mares enrolled in the glucose phase of a Frequently Sampled Insulin and Glucose Test (FSIGT) study were used to measure blood insulin. Results: The Immulite® 1000 CLIA had good precision with acceptable intra- and inter-assay CVs, adequate recovery on dilution, and a strong correlation with the RIA (r = 0.974, P < 0.0001), with constant bias resulting in consistently lower values. Discussion: On this basis, the Immulite® 1000 Insulin Assay is valid for measuring equine serum insulin for diagnostic and monitoring purposes when cut values are appropriately adjusted.