Self-harm in adolescence and risk of crash: a 13-year cohort study of novice drivers in New South Wales, Australia.

INTRODUCTION: Self-harm and suicide are leading causes of morbidity and death for young people, worldwide. Previous research has identified self-harm is a risk factor for vehicle crashes, however, there is a lack of long-term crash data post licensing that investigates this relationship. We aimed to determine whether adolescent self-harm persists as crash risk factor in adulthood. METHODS: We followed 20 806 newly licensed adolescent and young adult drivers in the DRIVE prospective cohort for 13 years to examine whether self-harm was a risk factor for vehicle crashes. The association between self-harm and crash was analysed using cumulative incidence curves investigating time to first crash and quantified using negative binominal regression models adjusted for driver demographics and conventional crash risk factors. RESULTS: Adolescents who reported self-harm at baseline were at increased risk of crashes 13 years later than those reporting no self-harm (relative risk (RR) 1.29: 95% CI 1.14 to 1.47). This risk remained after controlling for driver experience, demographic characteristics and known risk factors for crashes, including alcohol use and risk taking behaviour (RR 1.23: 95% CI 1.08 to 1.39). Sensation seeking had an additive effect on the association between self-harm and single-vehicle crashes (relative excess risk due to interaction 0.87: 95% CI 0.07 to 1.67), but not for other types of crashes. DISCUSSION: Our findings add to the growing body of evidence that self-harm during adolescence predicts a range of poorer health outcomes, including motor vehicle crash risks that warrant further investigation and consideration in road safety interventions. Complex interventions addressing self-harm in adolescence, as well as road safety and substance use, are critical for preventing health harming behaviours across the life course.

Acculturation and risk of traffic crashes in young Asian-born Australian drivers.

The study examines changes over time in crash risk differences between young Australian drivers born in Asia and those born in Australia.Data from the 2003 baseline survey of the DRIVE cohort of 20 806 young drivers aged 17-24 years were linked to police, hospital and death data up until 2016. The association between country of birth and crash was investigated using flexible parametric survival models adjusted for confounders.Six months after baseline, the crash risk in Asian-born drivers was less than half that of their Australian-born counterparts (mean HR, MHR 0.41; 95% CI 0.29 to 0.57), only to increase steadily over time to resemble that of Australian-born drivers 13 years later (MHR 0.94; 95% CI 0.66 to 1.36).This is likely to be associated with acculturation and the adoption by young Asian-born Australian drivers of driving behaviour patterns akin to those born locally. This needs to be considered in future road safety campaigns.

Comparing survival in patients with chronic kidney disease across three countries - Results from the study of heart and renal protection-extended review.

AIM: This study examined whether survival and causes of death differed between participants enrolled from Australia (AUS), Malaysia (MYL), and New Zealand (NZ) in extended follow-up of the Study of Heart and Renal Protection (SHARP), a randomized controlled trial (RCT) of participants with moderate to severe chronic kidney disease comparing placebo to combination therapy with Simvastatin and Ezetimibe. METHODS: All participants alive at final SHARP study visit in participating centres were eligible for inclusion. Consenting participants were re-enrolled following final SHARP Study visit and followed for 5 years. Data collection included: significant medical events, hospital admissions and requirement for kidney replacement therapy. Data linkage was performed to national kidney and mortality registries. The primary outcome was all-cause mortality compared across the three countries. RESULTS: The SHARP trial randomized 2029 participants from AUS (1043/2029, 51%), MYL (701/2029, 35%), and NZ (285/2029, 14%), with 1136 participants alive and eligible for extended follow-up at the end of SHARP. In multivariable analysis, risk of death was increased for participants in MYL (HR 1.37, 95% CI 1.17-1.61, p < .001) and NZ (HR 1.28, 95% CI 1.04-1.57, p = .02) when compared to AUS participants. Adjustment for kidney transplantation as a competing risk did not explain the variation seen between countries. CONCLUSION: This study allows a better understanding of the differences in long-term mortality risk across participants from AUS, MYL, and NZ in extended follow-up of the SHARP study and demonstrates the feasibility and value of extended follow-up of participants enrolled in RCTs.

One Health Determinants of Escherichia coli Antimicrobial Resistance in Humans in the Community: An Umbrella Review.

To date, the scientific literature on health variables for Escherichia coli antimicrobial resistance (AMR) has been investigated throughout several systematic reviews, often with a focus on only one aspect of the One Health variables: human, animal, or environment. The aim of this umbrella review is to conduct a systematic synthesis of existing evidence on Escherichia coli AMR in humans in the community from a One Health perspective. PubMed, EMBASE, and CINAHL were searched on "antibiotic resistance" and "systematic review" from inception until 25 March 2022 (PROSPERO: CRD42022316431). The methodological quality was assessed, and the importance of identified variables was tabulated across all included reviews. Twenty-three reviews were included in this study, covering 860 primary studies. All reviews were of (critically) low quality. Most reviews focused on humans (20), 3 on animals, and 1 on both human and environmental variables. Antibiotic use, urinary tract infections, diabetes, and international travel were identified as the most important human variables. Poultry farms and swimming in freshwater were identified as potential sources for AMR transmission from the animal and environmental perspectives. This umbrella review highlights a gap in high-quality literature investigating the time between variable exposure, AMR testing, and animal and environmental AMR variables.

Communication functions of adult patients admitted to intensive care: A multicentre, binational point prevalence study.

BACKGROUND: Patient communication is profoundly impacted during the intensive care unit (ICU) stay. While the impacts of altered communication are recognised, there is a paucity of data on the prevalence of communication attempts as well as modes utilised by patients and unit practices to manage communication function. OBJECTIVE: The objectives of this study were to describe the prevalence and characteristics of observed communication attempts (nonverbal, verbal, and use of the staff call bell) in adult ICU patients and report on unit-level practices on communication management. METHODS: A prospective, binational, cross-sectional point-prevalence study was conducted across 44 Australia and New Zealand adult ICUs. Data on communication attempts, modes, ICU-level guidelines, training, and resources were collected in June 2019. RESULTS: Across 44 ICUs, 470 of 623 (75%) participants, including ventilated and nonventilated patients, were attempting to communicate on the study day. Of those invasively ventilated via an endotracheal tube for the entire study day, 42 of 172 (24%) were attempting to communicate and 39 of 45 (87%) patients with a tracheostomy were attempting to communicate. Across the cohort, the primary mode of communication was verbal communication, with 395 of 470 (84%) patients using speech; of those 371 of 395 (94%) spoke English and 24 of 395 (6%) spoke a language other than English. Participants attempting to communicate on the study day had a shorter length of stay (LOS), a mean difference of 3.8 days (95% confidence interval: 0.2; 5.1) shorter LOS in the ICU than those not attempting to communicate, and a mean difference 7.9 days (95% confidence interval: 3.1; 12.6) shorter LOS in hospital overall. Unit-level practices and supports were collected. Six of 44 (14%) ICUs had a protocol for communication management, training was available in 11 of 44 (25%) ICUs, and communication resources were available in 37 of 44 (84%) ICUs. CONCLUSION: Three-quarters of patients admitted to the ICU were attempting to communicate on the study day, with multiple methods used to support verbal and nonverbal communication regardless of ventilation status. Guidance and training were absent from the majority of ICUs, indicating a need for development and implementation of policies, training, and resources.

Dysphagia in adult intensive care patients: Results of a prospective, multicentre binational point prevalence study.

BACKGROUND: Dysphagia occurs in intensive care unit (ICU) patients. However, there is a lack of epidemiological data on the prevalence of dysphagia in adult ICU patients. OBJECTIVES: The objective of this study was to describe the prevalence of dysphagia in nonintubated adult patients in the ICU. METHODS: A prospective, multicentre, binational, cross-sectional point prevalence study was conducted in 44 adult ICUs in Australia and New Zealand. Data were collected in June 2019 on documentation of dysphagia, oral intake, and ICU guidelines and training. Descriptive statistics were used to report demographic, admission, and swallowing data. Continuous variables are reported as means and standard deviations (SDs). Precisions of estimates were reported as 95% confidence intervals (CIs). RESULTS: Of the 451 eligible participants, 36 (7.9%) were documented as having dysphagia on the study day. In the dysphagia cohort, the mean age was 60.3 years (SD: 16.37) vs 59.6 years (SD: 17.1) and almost two-thirds were female (61.1% vs 40.1%). The most common admission source for those patients with dysphagia were from the emergency department (14/36, 38.9%), and seven of 36 (19.4%) had a primary diagnosis of trauma (odds ratio: 3.10, 95% CI 1.25 - 7.66). There were no statistical differences in Acute Physiology and Chronic Health Evaluation (APACHE II) scores between those with and without a dysphagia diagnosis. Patients with dysphagia were more likely to have a lower mean body weight of 73.3 kg vs 82.1 kg than patients not documented as having dysphagia (95% CI of mean difference: 0.43 to 17.07) and require respiratory support (odds ratio: 2.12, 95% 1.06 to 4.25). The majority of patients with dysphagia were prescribed modified food and fluids in the ICU. Less than half of ICUs surveyed reported unit-level guidelines, resources, or training for management of dysphagia. CONCLUSIONS: The prevalence of documented dysphagia in adult ICU nonintubated patients was 7.9%. There were a higher proportion of females with dysphagia than previously reported. Approximately two-thirds of patients with dysphagia were prescribed oral intake, and the majority were receiving texture-modified food and fluids. Dysphagia management protocols, resources, and training are lacking across Australian and New Zealand ICUs.

Initial treatment with a single pill containing quadruple combination of quarter doses of blood pressure medicines versus standard dose monotherapy in patients with hypertension (QUARTET): a phase 3, randomised, double-blind, active-controlled trial.

BACKGROUND: Treatment inertia is a recognised barrier to blood pressure control, and simpler, more effective treatment strategies are needed. We hypothesised that a hypertension management strategy starting with a single pill containing ultra-low-dose quadruple combination therapy would be more effective than a strategy of starting with monotherapy. METHODS: QUARTET was a multicentre, double-blind, parallel-group, randomised, phase 3 trial among Australian adults (≥18 years) with hypertension, who were untreated or receiving monotherapy. Participants were randomly assigned to either treatment, that started with the quadpill (containing irbesartan at 37·5 mg, amlodipine at 1·25 mg, indapamide at 0·625 mg, and bisoprolol at 2·5 mg) or an indistinguishable monotherapy control (irbesartan 150 mg). If blood pressure was not at target, additional medications could be added in both groups, starting with amlodipine at 5 mg. Participants were randomly assigned using an online central randomisation service. There was a 1:1 allocation, stratified by site. Allocation was masked to all participants and study team members (including investigators and those assessing outcomes) except the manufacturer of the investigational product and one unmasked statistician. The primary outcome was difference in unattended office systolic blood pressure at 12 weeks. Secondary outcomes included blood pressure control (standard office blood pressure <140/90 mm Hg), safety, and tolerability. A subgroup continued randomly assigned allocation to 12 months to assess long-term effects. Analyses were per intention to treat. This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry, ACTRN12616001144404, and is now complete. FINDINGS: From June 8, 2017, to Aug 31, 2020, 591 participants were recruited, with 743 assessed for eligibility, 152 ineligible or declined, 300 participants randomly assigned to intervention of initial quadpill treatment, and 291 to control of initial standard dose monotherapy treatment. The mean age of the 591 participants was 59 years (SD 12); 356 (60%) were male and 235 (40%) were female; 483 (82%) were White, 70 (12%) were Asian, and 38 (6%) reported as other ethnicity; and baseline mean unattended office blood pressure was 141 mm Hg (SD 13)/85 mm Hg (SD 10). By 12 weeks, 44 (15%) of 300 participants had additional blood pressure medications in the intervention group compared with 115 (40%) of 291 participants in the control group. Systolic blood pressure was lower by 6·9 mm Hg (95% CI 4·9-8·9; p<0·0001) and blood pressure control rates were higher in the intervention group (76%) versus control group (58%; relative risk [RR] 1·30, 95% CI 1·15-1·47; p<0·0001). There was no difference in adverse event-related treatment withdrawals at 12 weeks (intervention 4·0% vs control 2·4%; p=0·27). Among the 417 patients who continued, uptitration occurred more frequently among control participants than intervention participants (p<0·0001). However, at 52 weeks mean unattended systolic blood pressure remained lower by 7·7 mm Hg (95% CI 5·2-10·3) and blood pressure control rates higher in the intervention group (81%) versus control group (62%; RR 1·32, 95% CI 1·16-1·50). In all randomly assigned participants up to 12 weeks, there were seven (3%) serious adverse events in the intervention group and three (1%) serious adverse events in the control group. INTERPRETATION: A strategy with early treatment of a fixed-dose quadruple quarter-dose combination achieved and maintained greater blood pressure lowering compared with the common strategy of starting monotherapy. This trial demonstrated the efficacy, tolerability, and simplicity of a quadpill-based strategy. FUNDING: National Health and Medical Research Council, Australia.

The incidence of falls after first and second eye cataract surgery: a longitudinal cohort study.

OBJECTIVE: To compare fall incidence, and visual acuity and refractive status, before surgery and after first and second eye cataract surgery. DESIGN, SETTING: Prospective observational study in eight tertiary referral ophthalmology clinics in public hospitals in Sydney, Melbourne, and Perth. PARTICIPANTS: People aged 65 years or more referred for bilateral age-related cataract surgery during 2013-16, followed for maximum of 24 months after study entry or until six months after second eye surgery, whichever was shorter. MAIN OUTCOME MEASURES: Primary outcome: age- and sex-adjusted incidence of falls. SECONDARY OUTCOMES: visual acuity and refractive error. RESULTS: The mean age of the 409 included participants was 75.4 years (SD, 5.4 years); 220 were women (54%). Age- and sex-adjusted fall incidence prior to surgery was 1.17 (95% CI, 0.95-1.43) per year, 0.81 (95% CI, 0.63-1.04) per year after first eye surgery, and 0.41 (95% CI, 0.29-0.57) per year after second eye surgery. For the 118 participants who underwent second eye surgery and participated in all follow-up visits, age- and sex-adjusted incidence before (0.80 [95% CI, 0.55-1.15] falls per year) and after first eye surgery (0.81 [95% CI, 0.57-1.15] falls per year) was similar, but was lower after second eye surgery (0.32 [95% CI 0.21-0.50] falls per year). Mean habitual binocular visual acuity (logMAR) was 0.32 (SD, 0.21) before surgery, 0.15 (SD, 0.17) after first eye surgery, and 0.07 (SD, 0.15) after second eye surgery. CONCLUSIONS: First eye surgery substantially improves vision in older people with cataract, but second eye surgery is required to minimise fall incidence. Timely cataract surgery for both eyes not only optimises vision in older people with cataract, but also reduces their risk of injury from falls.

The Language of Pain: Is There a Relationship Between Metaphor Use and Adjustment to Chronic Pain?

OBJECTIVE: Metaphor, frequently used in chronic pain, can function as a communicative tool, facilitating understanding and empathy from others. Previous research has demonstrated that specific linguistic markers exist for areas such as pain catastrophizing, mood, as well as diagnostic categories. The current study sought to examine potential associations between the types of pain metaphors used and diagnostic category, disability, and mood. DESIGN: Online cross-sectional survey in Sydney, Australia. SUBJECTS: People with chronic pain (n = 247, age 19-78 years, M = 43.69). METHODS: The data collected included demographics, pain metaphors, the Brief Pain Inventory (BPI) and the Depression, Anxiety, and Stress Scales (DASS-21). Associations between metaphor source domains, obtained via Systematic Metaphor Analysis, and scores on the BPI, DASS-21, as well as diagnostic group were considered using binary logistic analysis. RESULTS: Use of different pain metaphors was not associated with pain intensity, however the extent to which pain interfered with daily life did have a relationship with use of metaphorical language. Preliminary support was found for an association between the use of certain pain metaphors and self-reported diagnostic categories, notably Endometriosis, Complex Regional Pain Syndrome, and Neuropathic pain. CONCLUSIONS: There may be specific linguistic metaphorical markers to indicate pain interference and for particular diagnoses. Appreciation of pain metaphors has potential to facilitate communication and enhance understanding in interactions between clinicians and people with chronic pain.

Scaling-up food policies in the Pacific Islands: protocol for policy engagement and mixed methods evaluation of intervention implementation.

BACKGROUND: There is a crisis of non-communicable diseases (NCDs) in the Pacific Islands, and poor diets are a major contributor. The COVID-19 pandemic and resulting economic crisis will likely further exacerbate the burden on food systems. Pacific Island leaders have adopted a range of food policies and regulations to improve diets. This includes taxes and regulations on compositional standards for salt and sugar in foods or school food policies. Despite increasing evidence for the effectiveness of such policies globally, there is a lack of local context-specific evidence about how to implement them effectively in the Pacific. METHODS: Our 5-year collaborative project will test the feasibility and effectiveness of policy interventions to reduce salt and sugar consumption in Fiji and Samoa, and examine factors that support sustained implementation. We will engage government agencies and civil society in Fiji and Samoa, to support the design, implementation and monitoring of evidence-informed interventions. Specific objectives are to: (1) conduct policy landscape analysis to understand potential opportunities and challenges to strengthen policies for prevention of diet-related NCDs in Fiji and Samoa; (2) conduct repeat cross sectional surveys to measure dietary intake, food sources and diet-related biomarkers; (3) use Systems Thinking in Community Knowledge Exchange (STICKE) to strengthen implementation of policies to reduce salt and sugar consumption; (4) evaluate the impact, process and cost effectiveness of implementing these policies. Quantitative and qualitative data on outcomes and process will be analysed to assess impact and support scale-up of future interventions. DISCUSSION: The project will provide new evidence to support policy making, as well as developing a low-cost, high-tech, sustainable, scalable system for monitoring food consumption, the food supply and health-related outcomes.

Driving offences and risk of subsequent crash in novice drivers: the DRIVE cohort study 12-year follow-up.

BACKGROUND: Penalties are a key component to improve road user safety, but previous studies suggested that they might not be successful in reducing crashing in offending drivers. However, these studies were not able to consider important crash risk factors in the analysis that might confound the results. Using data from a large prospective cohort study of young drivers in New South Wales, Australia, we explored if novice drivers with driving offences have a higher rates of car crash and if these differences are explained by established crash risk factors. METHODS: We used data from a 2003/2004 Australian survey of young drivers, linked to police reported offence and crash data, hospital data and deaths data up to 2016. We used Poisson regression models adjusted for confounders to estimate the association between driving offences during 2003-2006 with car crash during 2007-2016. RESULTS: The study cohort comprised 20 781 young drivers of whom 7860 drivers (37.8%) had at least one driving offence and 2487 (12.0%) were involved in at least one crash. After adjusting for confounders in the regression model, drivers with three or more driving offences had 2.25 (95% CI 1.98 to 2.57), 2.87 (95% CI 1.60 to 5.17) and 3.28 (95% CI 2.28 to 4.72) times higher rates of any crash, crashes that resulted in hospital admission or death and single vehicle crashes compared with drivers with no driving offences. CONCLUSION: Measures that successfully mitigate the underlying risk factors for both, crashes and offences, have the potential to improve road safety.

Risk factors for incident kidney disease in older adults: an Australian prospective population-based study.

BACKGROUND AND AIM: To determine risk factors for incident chronic kidney disease (CKD) in a large population-based cohort. METHODS: This prospective opt-in population-based cohort study is based on the 45 and Up Study, where New South Wales residents aged ≥45 years were randomly sampled from the Services Australia database and agreed to complete the 45 and Up Study baseline questionnaire and have their responses linked to their health data in routinely collected databases. The primary outcome was the development of incident CKD, defined as eGFR < 60 mL/min/1.73 m2 . CKD incidence was calculated using Poisson regression. Risk factors for incident CKD were assessed using Cox regression in multivariable models. RESULTS: In 39 574 participants who did not have CKD at enrolment, independent factors associated with developing CKD included: older age, regional residence (HR 1.38 (1.27-1.50) for outer regional vs major city), smoking (1.13 (1.00-1.27) for current smoker vs non-smoker), obesity (1.25 (1.16-1.35) for obese vs normal body mass index), diabetes mellitus (1.41 (1.33-1.50)), hypertension (1.53 (1.44-1.62)), coronary heart disease (1.13 (1.07-1.20)), depression/anxiety (1.16 (1.09-1.24)) and cancer (1.29 (1.20-1.39)). Migrants were less likely to develop CKD compared with people born in Australia (0.88 (0.83-0.94)). Gender, partner status and socioeconomic factors were not independently associated with developing CKD. CONCLUSIONS: This large population-based study found multiple modifiable and non-modifiable factors were independently associated with developing CKD. In the Australian setting, the risk of CKD was higher with regional residence. Differences according to socioeconomic status were predominantly explained by age, comorbidities and harmful health-related behaviours.

Reciprocal relationships between employment status and psychological symptoms: findings from the Building a New Life in Australia study.

BACKGROUND: Finding work is an important priority for many refugees in the initial years following settlement in a host country. Difficulties in finding work could conceivably both contribute to and be a consequence of symptoms of posttraumatic stress disorder (PTSD) and psychological distress commonly reported by refugees. PURPOSE: We sought to determine the direction of these relationships and the possibility of a reciprocal association between employment status on one hand, and symptoms of PTSD and psychological distress on the other, in a large refugee sample. METHODS: A secondary analysis of three face-to-face interview assessments conducted across 5 years with 894 adult refugee participants (M = 39.9 years, SD = 12.8) from the Building a New Life in Australia study was conducted. Symptoms of psychological distress, posttraumatic stress, and employment status were assessed on each occasion. Preliminary analysis identified the cross-sectional relationships between psychological distress, PTSD symptoms, and employment status, while cross-lagged models were used to identify the longitudinal relationships between these respective symptoms. RESULTS: Symptoms of psychological distress and not being in paid work were significantly correlated with each other at each time point (ranging 0.09-0.25) and they reciprocally influenced each other over time. Likewise, PTSD symptoms and not being in paid work were correlated with each other after 3 years and 5 years (r = 0.21 and 0.23 respectively), and a reciprocal relationship between these was found over time. CONCLUSION: The current findings indicate that interventions which target either mental health or work opportunities could have multiple downstream benefits for refugees.

Sustaining acute speech-language therapists' implementation of recommended aphasia practices: A mixed methods follow-up evaluation of a cluster RCT.

BACKGROUND: While implementation studies in aphasia management have shown promising improvements to clinical practice, it is currently unknown if aphasia implementation outcomes are sustained and what factors may influence clinical sustainability. AIMS: To evaluate the sustainment (i.e., sustained improvement of aphasia management practices and domains influencing clinicians' practice) and sustainability (i.e., factors influencing sustainability) outcomes of the Acute Aphasia IMplementation Study (AAIMS). METHODS & PROCEDURES: A convergent interactive mixed-methods sustainability evaluation was conducted on two previously delivered implementation interventions (AAIMS). The AAIMS interventions were targeted at improving either written aphasia-friendly information provision (Intervention A) or collaborative goal-setting (Intervention B). Outcomes were collected 2 and 3 years post-implementation, addressing the research questions of sustainment (e.g., medical record audits and behavioural constructs questionnaires) and sustainability (e.g., post-study focus groups and organizational readiness surveys). Quantitative sustainability data were compared with post-implementation data, allowing for sustainment to be determined. Clinicians' perspectives on sustainability outcomes and challenges were analysed using framework analysis and integrated with the quantitative findings. OUTCOMES & RESULTS: A total of 35 speech-language therapists (SLTs) from four hospitals participated. The medical records of 79 patients were audited in the sustainability period compared with the 107 medical records audited during AAIMS. Overall, there was variable sustainment of the target behaviours; implementation for Intervention A was not sustained at either sustainability time point (2018 = 47.8% decrease; 2019 = 22.78% decrease), but implementation for Intervention B was sustained at both time points (2018 = 7.78% increase; 2019 = 18.1% increase). There was a pattern of sustained change in the behaviour change domains targeted by the implementation interventions, where scores of the targeted domains increased over time (0.13, 95% confidence interval (CI) = -0.05 to 0.30) and scores of the non-targeted domains declined (-0.03, 95% CI = -0.11 to 0.04). Factors influencing sustainability were mainly related to 'processes', 'the inner context' and 'SLT characteristics', and these interacted dynamically to account for variation between teams. CONCLUSIONS & IMPLICATIONS: Implementation outcomes (i.e., practice changes) were not sustained to the same level for three of the four participating SLT teams, with variable or partial sustainment most common. While the factors influencing sustainability differed depending on the context and individuals involved, the most important factor influencing outcomes seemed to be the level to which behaviour-change processes and strategies were embedded within the SLT department. Future implementation studies should incorporate sustainability measures from the onset and include follow-ups and monitoring systems to help support sustained change in the long term. WHAT THIS PAPER ADDS: What is already known on the subject In post-stroke aphasia management, there are few examples of long-term sustainability of implementation outcomes. It is therefore unknown what factors are potentially important to sustain implementation of best-practice recommendations in aphasia services. What this paper adds to existing knowledge There is potential for implementation outcomes to be sustained long term, but sustainment is impacted by a range of factors. Ongoing facilitation or follow-up after initial implementation may to useful to promote sustainment, but is not essential if processes are sufficiently embedded. Gradual implementation into practice may lead to better sustainment than rapid change that is quickly forgotten. What are the potential or actual clinical implications of this work? Future implementation efforts should incorporate sustainability measures from the onset. Applying a sustainability framework was useful to guide evaluations and explore factors influencing the sustainment outcomes and is recommended for those interested in sustainability. Results from our evaluation can be used to guide refinement and support future development of sustainable implementation interventions.

Effect of Oral Methylprednisolone on Decline in Kidney Function or Kidney Failure in Patients With IgA Nephropathy: The TESTING Randomized Clinical Trial.

Importance: The effect of glucocorticoids on major kidney outcomes and adverse events in IgA nephropathy has been uncertain. Objective: To evaluate the efficacy and adverse effects of methylprednisolone in patients with IgA nephropathy at high risk of kidney function decline. Design, Setting, and Participants: An international, multicenter, double-blind, randomized clinical trial that enrolled 503 participants with IgA nephropathy, proteinuria greater than or equal to 1 g per day, and estimated glomerular filtration rate (eGFR) of 20 to 120 mL/min/1.73 m2 after at least 3 months of optimized background care from 67 centers in Australia, Canada, China, India, and Malaysia between May 2012 and November 2019, with follow-up until June 2021. Interventions: Participants were randomized in a 1:1 ratio to receive oral methylprednisolone (initially 0.6-0.8 mg/kg/d, maximum 48 mg/d, weaning by 8 mg/d/mo; n = 136) or placebo (n = 126). After 262 participants were randomized, an excess of serious infections was identified, leading to dose reduction (0.4 mg/kg/d, maximum 32 mg/d, weaning by 4 mg/d/mo) and addition of antibiotic prophylaxis for pneumocystis pneumonia for subsequent participants (121 in the oral methylprednisolone group and 120 in the placebo group). Main Outcomes And Measures: The primary end point was a composite of 40% decline in eGFR, kidney failure (dialysis, transplant), or death due to kidney disease. There were 11 secondary outcomes, including kidney failure. Results: Among 503 randomized patients (mean age, 38 years; 198 [39%] women; mean eGFR, 61.5 mL/min/1.73 m2; mean proteinuria, 2.46 g/d), 493 (98%) completed the trial. Over a mean of 4.2 years of follow-up, the primary outcome occurred in 74 participants (28.8%) in the methylprednisolone group compared with 106 (43.1%) in the placebo group (hazard ratio [HR], 0.53 [95% CI, 0.39-0.72]; P < .001; absolute annual event rate difference, -4.8% per year [95% CI, -8.0% to -1.6%]). The effect on the primary outcome was seen across each dose compared with the relevant participants in the placebo group recruited to each regimen (P for heterogeneity = .11): full-dose HR, 0.58 (95% CI, 0.41-0.81); reduced-dose HR, 0.27 (95% CI, 0.11-0.65). Of the 11 prespecified secondary end points, 9 showed significant differences in favor of the intervention, including kidney failure (50 [19.5%] vs 67 [27.2%]; HR, 0.59 [95% CI, 0.40-0.87]; P = .008; annual event rate difference, -2.9% per year [95% CI, -5.4% to -0.3%]). Serious adverse events were more frequent with methylprednisolone vs placebo (28 [10.9%] vs 7 [2.8%] patients with serious adverse events), primarily with full-dose therapy compared with its matching placebo (22 [16.2%] vs 4 [3.2%]). Conclusions and Relevance: Among patients with IgA nephropathy at high risk of progression, treatment with oral methylprednisolone for 6 to 9 months, compared with placebo, significantly reduced the risk of the composite outcome of kidney function decline, kidney failure, or death due to kidney disease. However, the incidence of serious adverse events was increased with oral methylprednisolone, mainly with high-dose therapy. Trial Registration: ClinicalTrials.gov Identifier: NCT01560052.

Improving Parent-Child Relationships for Young Parents in the Shadow of Complex Trauma: A Single-Case Experimental Design Series.

This study provides a preliminary evaluation of a dyadic intervention for young parents with a history of complex trauma, Holding Hands Young Parents (HHYP). Four mothers (17-22 years) and toddlers (12-33 months) completed the intervention, designed to improve parent-child relationships, parental self-regulation, self-efficacy and mental health, and child behaviour/emotional problems. An A-B single case experimental design series with follow-up and randomised baseline, used observational and self-report measures throughout. Linear mixed models demonstrated improvement in reciprocity and parental sensitivity over the treatment phase, with no evidence of shifts in scores at beginning or end of treatment. There was no evidence for changes in child engagement, negative states, intrusiveness or withdrawal. Reliable Change Index indicated improvement in parent-reported self-regulation, self-efficacy, stress and child emotional/behavioural problems from baseline to follow-up for all four mothers; depression showed reliable change for three. This study demonstrates relational change between young parents and their toddlers and provides preliminary data on the HHYP protocol.

Incidence of early diaphragmatic dysfunction after lung transplantation: results of a prospective observational study.

BACKGROUND: Diaphragmatic dysfunction is common after cardiothoracic surgery, but few studies report its incidence and consequences after lung transplantation. We aimed to estimate the incidence of diaphragmatic dysfunction using ultrasound in lung transplant patients up to 3 months postoperatively and evaluated the impact on clinical outcomes. METHODS: This was a single-center prospective observational cohort study of 27 lung transplant recipients using diaphragmatic ultrasound preoperatively, at 1 day, 1 week, 1 month, and 3 months postoperatively. Diaphragmatic dysfunction was defined as excursion < 10 mm in men and < 9 mm in women during quiet breathing. Clinical outcomes measured included duration of mechanical ventilation, length of stay (LOS) in Intensive Care (ICU), and hospital LOS. RESULTS: Sixty-two percentage of recipients experienced new, postoperative diaphragmatic dysfunction, but the prevalence fell to 22% at 3 months. No differences in clinical outcomes were found between those with diaphragmatic dysfunction compared to those without. Patients who experienced diaphragmatic dysfunction at 1 day postoperatively were younger and had a lower BMI than those who did not. CONCLUSIONS: Diaphragmatic dysfunction is common after lung transplant, improves significantly within 3 months, and did not impact negatively on duration of mechanical ventilation, LOS in ICU or hospital, or discharge destination.

Influence of Including Patients with Premorbid Disability in Acute Stroke Trials: The HeadPoST Experience.

BACKGROUND: Patients with premorbid functional impairment are generally excluded from acute stroke trials. We aimed to determine the impact of including such patients in the Head Positioning in acute Stroke Trial (HeadPoST) and early additional impairment on outcomes. METHODS: Post hoc analyses of HeadPoST, an international, cluster-randomized crossover trial of lying-flat versus sitting-up head positioning in acute stroke. Associations of early additional impairment, defined as change in modified Rankin scale (mRS) scores from premorbid levels (estimated at baseline) to Day 7 ("early ΔmRS"), and poor outcome (mRS score 3-6) at Day 90 were determined with generalized linear mixed model. Heterogeneity of the trial treatment effect was tested according to premorbid mRS scores 0-1 versus 2-5. RESULTS: Of 8,285 patients (38.9% female, mean age 68 ± 13 years) with complete data, there were 1,984 (23.9%) with premorbid functional impairment (mRS 2-5). A significant linear association was evident for early ∆mRS and poor outcome (per 1-point increase in ΔmRS, adjusted odds ratio 1.20, 95% confidence interval 1.14-1.27; p < 0.0001). Patients with greater premorbid functional impairment were less likely to develop additional impairment, but their risk of poor 90-day outcome significantly increased with increasing (worse) premorbid mRS scores (linear trend p < 0.0001). There was no heterogeneity of the trial treatment effect by level of premorbid function. CONCLUSIONS: Early poststroke functional impairment that exceeded premorbid levels was associated with worse 90-day outcome, and this association increased with greater premorbid functional impairment. Yet, including premorbid impaired patients in the HeadPoST did not materially affect the subsequent treatment effect. CLINICAL TRIAL REGISTRATION: HeadPoST is registered at http://www.ClinicalTrials.gov (NCT02162017).

Risky youth to risky adults: Sustained increased risk of crash in the DRIVE study 13 years on.

The objective of this study was to investigate if drivers who exhibit risky driving behaviours during youth (aged 17-24 years) have an increased risk of car crash up to 13 years later. We used data from the DRIVE study, a 2003/04 survey of 20,806 young novice drivers in New South Wales, Australia. The data were linked with police crash, hospital and deaths data up to 2016. We analysed differences in crash associated with 13 items of risky driving behaviours using negative binominal regression models adjusted for driver demographics, driving exposure and known crash risk factors. The items were summarised in one index and grouped into quintiles for the analysis. After adjusting for confounding, drivers of the third (RR 1.16, 95% CI 1.05-1.30), fourth (RR1.22, 95% CI1.09-1.36) and fifth quintile (RR 1.36, 95% CI 1.21-1.53) had higher crash rates compared to the lowest risk-takers. Drivers with the highest scores on the risky driving measure had higher rates of crash related hospital admission or death (RR 1.92, 95% CI 1.13-3.27), crashes in wet conditions (RR 1.35,95% CI 1.05-1.73), crashes in darkness (RR 1.55, 95% CI 1.25-1.93) and head-on crashes (RR 2.14, 95% CI 1.07-4.28), compared with drivers with the lowest scores. Novice adolescent drivers who reported high levels of risky driving when they first obtained a driver licence remained at increased risk of crash well into adulthood. Measures that successfully reduce early risky driving, have the potential to substantially reduce road crashes and transport related injuries and deaths over the lifespan.

The Role of Comorbidity on Retention in HIV Care.

Retention is a central component of the Cascade, facilitating monitoring of comorbidity. Country-specific definitions differ and may suit stable and functioning clients, while not appropriately classifying complex clinical presentations characterized by comorbidity. A retrospective file review of 363 people living with HIV attending a Sydney HIV clinic was conducted. Retention was compared with Australian (attendance once/12-months) and World Health Organization (attendance 'appropriate to need') recommendations to identify those attending according to the Australian definition, but not clinician recommendations (AUnotWHO). Multivariable logistic regression analyses determined the impact of age/sex and clinician-assessed comorbidity on retention. Most (97%) participants were considered retained according to the Australian definition, but only 56.7% according to clinician recommendations. Those with psychosocial comorbidity alone were less likely to be in the AUnotWHO group (OR 0.51, 95%CI 0.27-0.96, p = 0.04). The interaction of physical and psychosocial comorbidity was predictive of poor retention (Wald test: χ2 = 6.39, OR 2.39 [95% CI 1.15-4.97], p = 0.01), suggesting a syndemic relationship.