Being an adolescent with epilepsy during the transition from pediatric to adult hospital care: A qualitative descriptive study.

BACKGROUND: The transition from pediatric to adult care is challenging for adolescent patients despite numerous recommendations in recent decades. However, the perspective of the patients is sparsely investigated. AIM: To explore the experiences and needs of adolescents with epilepsy (AWE) during the transition from pediatric to adult hospital care. METHODS: We conducted 15 semi-structured interviews with AWEs aged 13-20 years and 10 h of field observations of consultations. Interviews were audio-recorded, transcribed, anonymized, and entered into NVivo (version 12, QSR International) with the transcribed field notes. Data were analyzed using systematic text condensation. RESULTS: Three themes were identified: (1) Navigating epilepsy in everyday life; (2) The difficult balance between concealment and openness about epilepsy; and (3) Being seen as an individual and not an illness. AWEs' needs in transition are closely associated with their experiences and perceptions of illness, treatment, consultations, and seizures. Notably, AWEs reveal a significant concern about being overlooked beyond their medical condition in appointments. CONCLUSIONS: This study highlights the vulnerability and challenges of AWEs transitioning to adult care. Overall, AWEs seek understanding, acceptance, and autonomy in managing their epilepsy and transitioning to adult care. Their experiences underscore the importance of holistic support and communication in healthcare settings. A concerted effort from healthcare professionals (HCP) is necessary to foster the recognition of AWEs as individuals with distinct personalities, needs, and capabilities.

Patient and families' perspectives on telepalliative care: A systematic integrative review.

BACKGROUND: Telepalliative care is increasingly used in palliative care, but has yet to be examined from a patient and family perspective. A synthesis of evidence may provide knowledge on how to plan and provide telepalliative care that caters specifically to patients and families' needs. OBJECTIVE: To synthesise evidence on patients and families' perspectives on telepalliative care. DESIGN: A systematic integrative review (PROSPERO #CRD42022301206) reported in accordance with PRISMA 2020 guidelines. Inclusion criteria; primary peer-reviewed studies published 2011-2022, patient and family perspective, >18 years, telepalliative care and English/Danish language. Quality was appraised using the mixed-methods appraisal tool, version 2020. Guided by Toronto and Remington, data were extracted, thematically analysed and synthesised. DATA SOURCES: MEDLINE, EMBASE, PsycINFO and CINAHL were searched in March 2022 and updated in February 2023. RESULTS: Forty-four studies were included. Analysis revealed five themes; the effect of the Covid-19 pandemic on telepalliative care, adding value for patients and families, synchronous and asynchronous telepalliative care, the integration of telepalliative care with other services and the tailoring and timing of telepalliative care. CONCLUSION: Enhanced access to care and convenience, as attributes of telepalliative care, are highly valued. Patients and families have varying needs during the illness trajectory that may be addressed by early integration of telepalliative care based on models of care that are flexible and combine synchronous and asynchronous solutions. Further research should examine telepalliative care in a post-pandemic context, use of models of care and identify meaningful outcome measures from patient and family perspectives for evaluation of telepalliative care.

Critical care staff wellbeing: A new paradigm for understanding burnout.

BACKGROUND: The wellbeing of paediatric intensive care unit (PICU) staff members influences their engagement with work and the quality of care they provide to patients. Baseline burnout measures in research provide inconclusive evidence of the determinants of burnout and how to target interventions to promote staff wellbeing. OBJECTIVES: The objectives of this study were to determine the prevalence of burnout using the Maslach Burnout Inventory (MBI) burnout-engagement workplace profiles in a sample of Australian PICU staff and investigate associations between demographic characteristics, meaningful work, satisfaction with life, and psychological distress on burnout. METHODS: A cross-sectional survey was administered to a multidisciplinary sample of PICU staff (target n = 464) from three tertiary paediatric hospitals in Australia. The survey tool was comprised of the MBI, Work and Meaning Inventory, Satisfaction with Life Scale, Kessler Psychological Distress Scale, and demographic questions. Hierarchical multiple regressions examined the relationships between burnout and these variables of interest. RESULTS: A sample of 258 participants (56%) completed the survey. For most respondents, burnout was scored as a low to moderate risk, with over half the participants scoring low risk for emotional exhaustion (EE) (56%) and depersonalisation (DP) (54%). Personal accomplishment (PA) was more evenly distributed (range of burnout risk: low, 32%; moderate, 32%; high, 36%). MBI scores were classified using the burnout-engaged workplace profile system, identifying low levels of burnout (8% burnout, 3% disengaged, 21% overextended, 29% ineffective, and 39% engaged). Psychological distress significantly increased burnout risk across all three dimensions EE (ß = 0.253, p < 0.001), DP (ß = 0.145, p < 0.05), and PA (ß = -0.13, p < 0.05), and being aged between 41 and 55 years was protective of depersonalisation (ß = -0.214, p < 0.05). CONCLUSION: Utilising MBI workplace profiles, this study has built upon the demand for a more comprehensive assessment of burnout. Research that helps improve our understanding of contributory factors to burnout and wellbeing will inform the development of effective interventions that promote wellbeing of staff.

The Causes and Consequences of Nonenzymatic Protein Acylation.

Thousands of protein acyl modification sites have now been identified in vivo. However, at most sites the acylation stoichiometry is low, making functional enzyme-driven regulation in the majority of cases unlikely. As unmediated acylation can occur on the surface of proteins when acyl-CoA thioesters react with nucleophilic cysteine and lysine residues, slower nonenzymatic processes likely underlie most protein acylation. Here, we review how nonenzymatic acylation of nucleophilic lysine and cysteine residues occurs; the factors that enhance acylation at particular sites; and the strategies that have evolved to limit protein acylation. We conclude that protein acylation is an unavoidable consequence of the central role of reactive thioesters in metabolism. Finally, we propose a hypothesis for why low-stoichiometry protein acylation is selected against by evolution and how it might contribute to degenerative processes such as aging.

Considerations for the Implementation of a Telestroke Network: A Systematic Review.

The application of telestroke has matured considerably since its inception in 1999. The use of telestroke is now recommended in several published guidelines. Consequently, jurisdictions without a telestroke service are seeking practical information on the best approach to implement telestroke. French et al. (2013) reviewed the challenges of implementing a telestroke network including studies between 2000 and 2010. At the time, telestroke networks were largely limited to the UK, USA, Canada and Europe and only one process evaluation had been conducted. Given the prolific expansion of telestroke services since 2010, we conducted a systematic review to determine factors associated with successful establishment, management, and sustainability of a contemporary telestroke services. A comprehensive search of telestroke studies was conducted in July 2021. Empirical studies published between 2010 and 2021 were included if they contained descriptive, evaluation or operational data on the implementation of a telestroke network. Studies were subsequently evaluated using the Consolidated Framework for Implementation Research (CFIR). The initial literature search revealed a total of 7415 potential studies; 38 of which met the inclusion criteria. The past decade of process evaluation studies has enabled a more nuanced investigations into how to implement and sustain a telestroke network. Pre-implementation planning is crucial to ensure clear telestroke processes, governance structures and stakeholder engagement. Sustainability of networks relies on securing long-term investment, providing adequate resources, and maintaining staff motivation and willingness. Recommendations are provided to overcome commonly identified barriers related to technology, staffing, planning and standardisation of processes, evaluation, and sustainability and scale-up. Further research needs to explore how new advancements in stroke care such as endovascular clot retrieval (EVT) and advanced brain imaging can be considered and planned for during the implementation of a new telestroke service.

MitoMiner v4.0: an updated database of mitochondrial localization evidence, phenotypes and diseases.

Increasing numbers of diseases are associated with mitochondrial dysfunction. This is unsurprising given mitochondria have major roles in bioenergy generation, signalling, detoxification, apoptosis and biosynthesis. However, fundamental questions of mitochondrial biology remain, including: which nuclear genes encode mitochondrial proteins; how their expression varies with tissue; and which are associated with disease. But experiments to catalogue the mitochondrial proteome are incomplete and sometimes contradictory. This arises because the mitochondrial proteome has tissue- and stage-specific variability, plus differences among experimental techniques and localization evidence types used. This leads to limitations in each technique's coverage and inevitably conflicting results. To support identification of mitochondrial proteins, we developed MitoMiner (http://mitominer.mrc-mbu.cam.ac.uk/), a database combining evidence of mitochondrial localization with information from public resources. Here we report upgrades to MitoMiner, including its re-engineering to be gene-centric to enable easier sharing of evidence among orthologues and support next generation sequencing, plus new data sources, including expression in different tissues, information on phenotypes and diseases of genetic mutations and a new mitochondrial proteome catalogue. MitoMiner is a powerful platform to investigate mitochondrial localization by providing a unique combination of experimental sub-cellular localization datasets, tissue expression, predictions of mitochondrial targeting sequences, gene annotation and links to phenotype and disease.

Ischaemic accumulation of succinate controls reperfusion injury through mitochondrial ROS.

Ischaemia-reperfusion injury occurs when the blood supply to an organ is disrupted and then restored, and underlies many disorders, notably heart attack and stroke. While reperfusion of ischaemic tissue is essential for survival, it also initiates oxidative damage, cell death and aberrant immune responses through the generation of mitochondrial reactive oxygen species (ROS). Although mitochondrial ROS production in ischaemia reperfusion is established, it has generally been considered a nonspecific response to reperfusion. Here we develop a comparative in vivo metabolomic analysis, and unexpectedly identify widely conserved metabolic pathways responsible for mitochondrial ROS production during ischaemia reperfusion. We show that selective accumulation of the citric acid cycle intermediate succinate is a universal metabolic signature of ischaemia in a range of tissues and is responsible for mitochondrial ROS production during reperfusion. Ischaemic succinate accumulation arises from reversal of succinate dehydrogenase, which in turn is driven by fumarate overflow from purine nucleotide breakdown and partial reversal of the malate/aspartate shuttle. After reperfusion, the accumulated succinate is rapidly re-oxidized by succinate dehydrogenase, driving extensive ROS generation by reverse electron transport at mitochondrial complex I. Decreasing ischaemic succinate accumulation by pharmacological inhibition is sufficient to ameliorate in vivo ischaemia-reperfusion injury in murine models of heart attack and stroke. Thus, we have identified a conserved metabolic response of tissues to ischaemia and reperfusion that unifies many hitherto unconnected aspects of ischaemia-reperfusion injury. Furthermore, these findings reveal a new pathway for metabolic control of ROS production in vivo, while demonstrating that inhibition of ischaemic succinate accumulation and its oxidation after subsequent reperfusion is a potential therapeutic target to decrease ischaemia-reperfusion injury in a range of pathologies.

Determining if Telehealth Can Reduce Health System Costs: Scoping Review.

BACKGROUND: Telehealth represents an opportunity for Australia to harness the power of technology to redesign the way health care is delivered. The potential benefits of telehealth include increased accessibility to care, productivity gains for health providers and patients through reduced travel, potential for cost savings, and an opportunity to develop culturally appropriate services that are more sensitive to the needs of special populations. The uptake of telehealth has been hindered at times by clinician reluctance and policies that preclude metropolitan populations from accessing telehealth services. OBJECTIVE: This study aims to investigate if telehealth reduces health system costs compared with traditional service models and to identify the scenarios in which cost savings can be realized. METHODS: A scoping review was undertaken to meet the study aims. Initially, literature searches were conducted using broad terms for telehealth and economics to identify economic evaluation literature in telehealth. The investigators then conducted an expert focus group to identify domains where telehealth could reduce health system costs, followed by targeted literature searches for corresponding evidence. RESULTS: The cost analyses reviewed provided evidence that telehealth reduced costs when health system-funded travel was prevented and when telehealth mitigated the need for expensive procedural or specialist follow-up by providing competent care in a more efficient way. The expert focus group identified 4 areas of potential savings from telehealth: productivity gains, reductions in secondary care, alternate funding models, and telementoring. Telehealth demonstrated great potential for productivity gains arising from health system redesign; however, under the Australian activity-based funding, it is unlikely that these gains will result in cost savings. Secondary care use mitigation is an area of promise for telehealth; however, many studies have not demonstrated overall cost savings due to the cost of administering and monitoring telehealth systems. Alternate funding models from telehealth systems have the potential to save the health system money in situations where the consumers pay out of pocket to receive services. Telementoring has had minimal economic evaluation; however, in the long term it is likely to result in inadvertent cost savings through the upskilling of generalist and allied health clinicians. CONCLUSIONS: Health services considering implementing telehealth should be motivated by benefits other than cost reduction. The available evidence has indicated that although telehealth provides overwhelmingly positive patient benefits and increases productivity for many services, current evidence suggests that it does not routinely reduce the cost of care delivery for the health system.

Pathogenic mutations of the human mitochondrial citrate carrier SLC25A1 lead to impaired citrate export required for lipid, dolichol, ubiquinone and sterol synthesis.

Missense mutations of the human mitochondrial citrate carrier, encoded by the SLC25A1 gene, lead to an autosomal recessive neurometabolic disorder characterised by neonatal-onset encephalopathy with severe muscular weakness, intractable seizures, respiratory distress, and lack of psychomotor development, often resulting in early death. Here, we have measured the effect of all twelve known pathogenic mutations on the transport activity. The results show that nine mutations abolish transport of citrate completely, whereas the other three reduce the transport rate by >70%, indicating that impaired citrate transport is the most likely primary cause of the disease. Some mutations may be detrimental to the structure of the carrier, whereas others may impair key functional elements, such as the substrate binding site and the salt bridge network on the matrix side of the carrier. To understand the consequences of impaired citrate transport on metabolism, the substrate specificity was also determined, showing that the human citrate carrier predominantly transports citrate, isocitrate, cis-aconitate, phosphoenolpyruvate and malate. Although D-2- and L-2 hydroxyglutaric aciduria is a metabolic hallmark of the disease, it is unlikely that the citrate carrier plays a significant role in the removal of hydroxyglutarate from the cytosol for oxidation to oxoglutarate in the mitochondrial matrix. In contrast, computer simulations of central metabolism predict that the export of citrate from the mitochondrion cannot be fully compensated by other pathways, restricting the cytosolic production of acetyl-CoA that is required for the synthesis of lipids, sterols, dolichols and ubiquinone, which in turn explains the severe disease phenotypes.

Mitochondrial oxodicarboxylate carrier deficiency is associated with mitochondrial DNA depletion and spinal muscular atrophy-like disease.

PURPOSE: To understand the role of the mitochondrial oxodicarboxylate carrier (SLC25A21) in the development of spinal muscular atrophy-like disease. METHODS: We identified a novel pathogenic variant in a patient by whole-exome sequencing. The pathogenicity of the mutation was studied by transport assays, computer modeling, followed by targeted metabolic testing and in vitro studies in human fibroblasts and neurons. RESULTS: The patient carries a homozygous pathogenic variant c.695A>G; p.(Lys232Arg) in the SLC25A21 gene, encoding the mitochondrial oxodicarboxylate carrier, and developed spinal muscular atrophy and mitochondrial myopathy. Transport assays show that the mutation renders SLC25A21 dysfunctional and 2-oxoadipate cannot be imported into the mitochondrial matrix. Computer models of central metabolism predicted that impaired transport of oxodicarboxylate disrupts the pathways of lysine and tryptophan degradation, and causes accumulation of 2-oxoadipate, pipecolic acid, and quinolinic acid, which was confirmed in the patient's urine by targeted metabolomics. Exposure to 2-oxoadipate and quinolinic acid decreased the level of mitochondrial complexes in neuronal cells (SH-SY5Y) and induced apoptosis. CONCLUSION: Mitochondrial oxodicarboxylate carrier deficiency leads to mitochondrial dysfunction and the accumulation of oxoadipate and quinolinic acid, which in turn cause toxicity in spinal motor neurons leading to spinal muscular atrophy-like disease.

MitoMiner v3.1, an update on the mitochondrial proteomics database.

Mitochondrial proteins remain the subject of intense research interest due to their implication in an increasing number of different conditions including mitochondrial and metabolic disease, cancer, and neuromuscular degenerative and age-related disorders. However, the mitochondrial proteome has yet to be accurately and comprehensively defined, despite many studies. To support mitochondrial research, we developed MitoMiner (http://mitominer.mrc-mbu.cam.ac.uk), a freely accessible mitochondrial proteomics database. MitoMiner integrates different types of subcellular localisation evidence with protein information from public resources, and so provides a comprehensive central resource for data on mitochondrial protein localisation. Here we report important updates to the database including the addition of subcellular immunofluorescent staining results from the Human Protein Atlas, computational predictions of mitochondrial targeting sequences, and additional large-scale mass-spectrometry and GFP tagging data sets. This evidence is shared across the 12 species in MitoMiner (now including Schizosaccharomyces pombe) by homology mapping. MitoMiner provides multiple ways of querying the data including simple text searches, predefined queries and custom queries created using the interactive QueryBuilder. For remote programmatic access, API's are available for several programming languages. This combination of data and flexible querying makes MitoMiner a unique platform to investigate mitochondrial proteins, with application in mitochondrial research and prioritising candidate mitochondrial disease genes.

Examining the Influence of E-Health Education on Professional Practice.

e-Health is steadily integrating into modern health services, making significant changes in the way health services are traditionally delivered. To work in this new environment, healthcare workers are required to have new knowledge, skills and competencies specific to e-Health. The aim of this study was to understand the self-reported perceptions of graduates regarding the influence of an e-Health postgraduate program on their professional careers. In addition, this paper will provide an overview of the e-Health postgraduate program. All graduates from 2005 to 2015 were surveyed using an online questionnaire that consisted of a mixture of closed and open-ended questions. The number of participants in the study was 32. Response rate was 62%. The main motivating factors for studying e-Health were 'relevance to current practice' and 'e-Health is the future'. The participants noted that the opportunity to 'acquiring relevant knowledge' and 'having exposure' were key benefits offered by the e-Health education program. The majority of graduates (n = 23, 72%) thought that the postgraduate e-Health program had an influence on their professional practice. A similar number of participants (n = 23, 72%) mentioned that they had worked in the field of e-Health since their graduation. Their professional roles mainly involved 'implementation of e-Health in health service settings' and the 'use of e-Health in clinical practice'. While e-Health may be steadily integrating into modern health services, e-Health specific job opportunities are still relatively limited. e-Health workforce development must be given priority.

Impact of a University-Based Outpatient Telemedicine Program on Time Savings, Travel Costs, and Environmental Pollutants.

OBJECTIVE: The objective of this study was to estimate travel-related and environmental savings resulting from the use of telemedicine for outpatient specialty consultations with a university telemedicine program. METHODS: The study was designed to retrospectively analyze the telemedicine consultation database at the University of California Davis Health System (UCDHS) between July 1996 and December 2013. Travel distances and travel times were calculated between the patient home, the telemedicine clinic, and the UCDHS in-person clinic. Travel cost savings and environmental impact were calculated by determining differences in mileage reimbursement rate and emissions between those incurred in attending telemedicine appointments and those that would have been incurred if a visit to the hub site had been necessary. RESULTS: There were 19,246 consultations identified among 11,281 unique patients. Telemedicine visits resulted in a total travel distance savings of 5,345,602 miles, a total travel time savings of 4,708,891 minutes or 8.96 years, and a total direct travel cost savings of $2,882,056. The mean per-consultation round-trip distance savings were 278 miles, average travel time savings were 245 minutes, and average cost savings were $156. Telemedicine consultations resulted in a total emissions savings of 1969 metric tons of CO2, 50 metric tons of CO, 3.7 metric tons of NOx, and 5.5 metric tons of volatile organic compounds. CONCLUSIONS: This study demonstrates the positive impact of a health system's outpatient telemedicine program on patient travel time, patient travel costs, and environmental pollutants.

Telehealth in paediatric surgery: Accuracy of clinical decisions made by videoconference.

AIM: Telehealth is a useful method of providing specialist consultation to a geographically diverse population. Canadian studies of telehealth for paediatric surgery demonstrate good accuracy, but have low numbers of cryptorchid patients in their cohorts. Our aim was to confirm Canadian studies for our cohort and to assess accuracy regarding cryptorchidism. METHODS: We conducted a cohort study of patients seen via paediatric surgical telehealth over a 12-month period, to determine accuracy of telediagnosis with respect to face-to-face diagnosis and plan. RESULTS: A total of 183 children had 224 videoconferences, resulting in 74 surgical bookings. There was high diagnostic concordance, except for undescended testes. One discharged patient, and two patients booked for review, have subsequently required an orchidopexy (false negatives). Of 15 patients booked for surgery, three did not require an operation (false positives). Other patients had their procedures upgraded (from open to laparoscopic) or downgraded (from laparoscopic to open) due to inaccuracies in far-end assessment. CONCLUSION: Telehealth for paediatric surgery is accurate for most conditions seen, but for cryptorchidism there are significant concerns.

The Development of a Telemedicine Planning Framework Based on Needs Assessment.

Providing equitable access to healthcare services in rural and remote communities is an ongoing challenge that faces most governments. By increasing access to specialty expertise, telemedicine may be a potential solution to this problem. Regardless of its potential, many telemedicine initiatives do not progress beyond the research phase, and are not implemented into mainstream practice. One reason may be that some telemedicine services are developed without the appropriate planning to ascertain community needs and clinical requirements. The aim of this paper is to report the development of a planning framework for telemedicine services based on needs assessment. The presented framework is based on the key processes in needs assessment, Penchansky and Thomas's dimensions of access, and Bradshaw's types of need. This proposed planning framework consists of two phases. Phase one comprises data collection and needs assessment, and includes assessment of availability and expressed needs; accessibility; perception and affordability. Phase two involves prioritising the demand for health services, balanced against the known limitations of supply, and the implementation of an appropriate telemedicine service that reflects and meets the needs of the community. Using a structured framework for the planning of telemedicine services, based on need assessment, may help with the identification and prioritisation of community health needs.

The delivery of specialist spinal cord injury services in Queensland and the potential for telehealth.

BACKGROUND: The Queensland Spinal Cord Injuries Service (QSCIS) is a statewide service in Brisbane at the Princess Alexandra Hospital (PAH). The QSCIS assists individuals with a spinal cord injury (SCI) through three services: the Spinal Injuries Unit (SIU), Transitional Rehabilitation Program (TRP) and the Spinal Outreach Team (SPOT). The aim of this study was to undertake a review of ambulatory services provided by the QSCIS (SIU and SPOT) to help identify where telehealth may potentially be useful. METHODS: Profiling of patients with SCI in Queensland was achieved using database records containing referral data. Services provided by SIU Outpatient Clinics and the SPOT during a 6-year period (January 2008 - December 2013), were analysed. Using postcodes, we estimated distances between place of residence and Brisbane. We compared the general population of SCI patients with patients managed through SIU Outpatient Clinics and the SPOT. RESULTS: During the 6-year period, 2073 patients were referred to the QSCIS (and living) at the time of the analysis. 74% of all patients were male. The median age was 51y (IQR 39y-61y). About two-thirds of all patients lived within 200 km of Brisbane. 24% of all patients registered with the QSCIS lived further than 200 km away from Brisbane. 7513 appointments were provided in the SIU outpatient clinic. 43,827 occasions of service were reported by the SPOT, including telephone consultations (66%) and home visits (26%). 72 outreach clinics were held in selected regional sites for up to 100 patients per year. 13 videoconference appointments reported. 90% of all patients who attended the SIU outpatient clinic lived within 200 km of Brisbane. About two-thirds of patients who received a service from the SPOT lived within 200 km of Brisbane. CONCLUSION: Since one third of all patients registered with the QSCIS live at least 200 km away from Brisbane; it appears that these patients may not be accessing the same services as Brisbane based patients. Telehealth models of care, which promote better engagement with local health service providers (such as general practitioners, nurse practitioners and allied health professionals) could improve equity of access and reduce the need for extensive travel.

Telehealth services in rural and remote Australia: a systematic review of models of care and factors influencing success and sustainability.

INTRODUCTION: With the escalating costs of health care, issues with recruitment and retention of health practitioners in rural areas, and poor economies of scale, the question of delivering people to services or services to people is a dilemma for health authorities around the world. People living in rural areas have poorer health outcomes compared to their urban counterparts, and the problem of how to provide health care and deliver services in rural locations is an ongoing challenge. Telehealth services can efficiently and effectively improve access to healthcare for people living in rural and remote areas of Australia. However, telehealth services are not mainstream or routinely available in many rural and remote locations. The barriers to integration of telehealth into mainstream practice have been well described, but not the factors that may influence the success and sustainability of a service. Our aim was to collate, review and synthesise the available literature regarding telehealth services in rural and remote locations of Australia, and to identify the factors associated with their sustained success. METHODS: A systematic literature review of peer-reviewed and grey literature was undertaken. Electronic databases were searched for potentially relevant articles. Reference lists of retrieved articles and the grey literature were also searched. Searches identified 970 potentially eligible articles published between 1988 and 2015. Studies and manuscripts of any type were included if they described telehealth services (store-and-forward or real-time videoconferencing) to provide clinical service or education and training related to health care in rural or remote locations of Australia. Data were extracted according to pre-defined criteria and checked for completeness and accuracy by a second reviewer. Any disagreements were resolved with discussion with a third researcher. All articles were appraised for quality and levels of evidence. Data were collated and grouped into categories including clinical speciality, disciplines involved, geographical location and the role of the service. Data relating to the success or sustainability of services were grouped thematically. RESULTS: Inclusion criteria were met by 116 articles that described 72 discrete telehealth services. Telehealth services in rural and remote Australia are described and we have identified six key factors associated with the success and sustainability of services: vision, ownership, adaptability, economics, efficiency and equipment. CONCLUSIONS: Telehealth has the potential to address many of the key challenges to providing health in Australia, with its substantial land area and widely dispersed population. This review collates information regarding the telehealth services in Australia and describes models of care and characteristics of successful and sustainable services. We identified a wide variety of telehealth services being provided in rural and remote areas of Australia. There is great potential to increase this number by scaling up and replicating successful services. This review provides information for policy makers, governments and public and private health services that wish to integrate telehealth into routine practice and for telehealth providers to enhance the sustainability of their service.

Telehealth services in rural and remote Australia: a systematic review of models of care and factors influencing success and sustainability.

INTRODUCTION: With the escalating costs of health care, issues with recruitment and retention of health practitioners in rural areas, and poor economies of scale, the question of delivering people to services or services to people is a dilemma for health authorities around the world. People living in rural areas have poorer health outcomes compared to their urban counterparts, and the problem of how to provide health care and deliver services in rural locations is an ongoing challenge. Telehealth services can efficiently and effectively improve access to healthcare for people living in rural and remote areas of Australia. However, telehealth services are not mainstream or routinely available in many rural and remote locations. The barriers to integration of telehealth into mainstream practice have been well described, but not the factors that may influence the success and sustainability of a service. Our aim was to collate, review and synthesise the available literature regarding telehealth services in rural and remote locations of Australia, and to identify the factors associated with their sustained success. METHODS: A systematic literature review of peer-reviewed and grey literature was undertaken. Electronic databases were searched for potentially relevant articles. Reference lists of retrieved articles and the grey literature were also searched. Searches identified 970 potentially eligible articles published between 1988 and 2015. Studies and manuscripts of any type were included if they described telehealth services (store-and-forward or real-time videoconferencing) to provide clinical service or education and training related to health care in rural or remote locations of Australia. Data were extracted according to pre-defined criteria and checked for completeness and accuracy by a second reviewer. Any disagreements were resolved with discussion with a third researcher. All articles were appraised for quality and levels of evidence. Data were collated and grouped into categories including clinical speciality, disciplines involved, geographical location and the role of the service. Data relating to the success or sustainability of services were grouped thematically. RESULTS: Inclusion criteria were met by 116 articles that described 72 discrete telehealth services. Telehealth services in rural and remote Australia are described and we have identified six key factors associated with the success and sustainability of services: vision, ownership, adaptability, economics, efficiency and equipment. CONCLUSIONS: Telehealth has the potential to address many of the key challenges to providing health in Australia, with its substantial land area and widely dispersed population. This review collates information regarding the telehealth services in Australia and describes models of care and characteristics of successful and sustainable services. We identified a wide variety of telehealth services being provided in rural and remote areas of Australia. There is great potential to increase this number by scaling up and replicating successful services. This review provides information for policy makers, governments and public and private health services that wish to integrate telehealth into routine practice and for telehealth providers to enhance the sustainability of their service.

Mitii™ ABI: study protocol of a randomised controlled trial of a web-based multi-modal training program for children and adolescents with an Acquired Brain Injury (ABI).

BACKGROUND: Acquired brain injury (ABI) refers to multiple disabilities arising from damage to the brain acquired after birth. Children with an ABI may experience physical, cognitive, social and emotional-behavioural impairments which can impact their ability to participate in activities of daily living (ADL). Recent developments in technology have led to the emergence of internet-delivered therapy programs. "Move it to improve it" (Mitii™) is a web-based multi-modal therapy that comprises upper limb (UL) and cognitive training within the context of meaningful physical activity. The proposed study aims to compare the efficacy of Mitii™ to usual care to improve ADL motor and processing skills, gross motor capacity, UL and executive functioning in a randomised waitlist controlled trial. METHODS/DESIGN: Sixty independently ambulant children (30 in each group) at least 12 months post ABI will be recruited to participate in this trial. Children will be matched in pairs at baseline and randomly allocated to receive either 20 weeks of Mitii™ training (30 min per day, six days a week, with a potential total dose of 60 h) immediately, or be waitlisted for 20 weeks. Outcomes will be assessed at baseline, immediately post-intervention and at 20 weeks post-intervention. The primary outcomes will be the Assessment of Motor and Process Skills and 30 s repetition maximum of functional strength exercises (sit-to-stand, step-ups and half kneel to stand). Measures of body structure and functions, activity, participation and quality of life will assess the efficacy of Mitii™ across all domains of the International Classification of Functioning, Disability and Health framework. A subset of children will undertake three tesla (3T) magnetic resonance imaging scans to evaluate functional neurovascular changes, structural imaging, diffusion imaging and resting state functional connectivity before and after intervention. DISCUSSION: Mitii™ provides an alternative approach to deliver intensive therapy for children with an ABI in the convenience of the home environment. If Mitii™ is found to be effective, it may offer an accessible and inexpensive intervention option to increase therapy dose. TRIAL REGISTRATION: ANZCTR12613000403730.

A retrospective review of telehealth services for children referred to a paediatric nephrologist.

BACKGROUND: Telemedicine has emerged as an alternative mode of health care delivery over the last decade. To date, there is very limited published information in the field of telehealth and paediatric nephrology. The aim of this study was to review our experience with paediatric telenephrology in Queensland, Australia. METHODS: A retrospective audit of paediatric nephrology telehealth consultations to determine the nature of the telehealth activity, reasons for referral to telehealth, and to compare costs and potential savings of the telehealth service. RESULTS: During a ten-year period (2004 - 2013), 318 paediatric telenephrology consultations occurred for 168 patients (95 male) with the median age of 8 years (range 3 weeks to 24 years). Congenital anomalies of the kidney and urinary tract (30 %), followed by nephrotic syndrome (16 %), kidney transplant (12 %), and urinary tract infection (9 %) were the most common diagnoses. The estimated cost savings associated with telehealth were $31,837 in 2013 (average saving of $505 per consultation). CONCLUSIONS: Our study suggests that paediatric telenephrology is a viable and economic method for patient assessment and follow up. The benefits include improved access to paediatric nephrology services for patients and their families, educational opportunity for the regional medical teams, and a substantial cost saving for the health care system.