Personalized Exercise Prescription in Long COVID: A Practical Toolbox for a Multidisciplinary Approach.

Objective: To describe our methodology and share the practical tools we have developed to operationalize a multidisciplinary Long COVID clinic that incorporates progressive, personalized exercise prescription as a cornerstone feature. Background: There is a lack of evidence-based guidance regarding optimal rehabilitation strategies for people with Long COVID. Existing guidelines lack precision regarding exercise dosage. As one of Australia's few established multidisciplinary Long COVID clinics, we describe our novel approach to safely incorporating exercise of both peripheral and respiratory muscles, with essential monitoring and management of post-exertional symptom exacerbation. Methods: Working closely with primary health-care providers, our multidisciplinary team screens referrals for people aged 16 and older with Long COVID. Staff apply a three tier model of triage, dependent on the consumer's presenting problems. Exercise-based interventions necessitate detailed monitoring for post-exertional symptom exacerbation both in the clinic and at home. Personalized exercise prescription includes resistance training at a submaximal threshold (4-6 exercises, 3 days/week); whole-body endurance exercise titrated to the individual's progress, at an intensity 4-6/10 (Rate of Perceived Exertion); and for those limited by dyspnoea, high-intensity inspiratory muscle training using a threshold-based handheld device (30 repetitions per day, ≥50% of their maximum inspiratory pressure). Discussion: We have used these approaches for the past 2 years in 250 consumers with no serious adverse events and promising consumer feedback. Our exercise prescription is less conservative than the methods advocated in international guidelines for people with Long COVID, and these more progressive tools may be valuable in other contexts. Conclusion: In our experience, a multidisciplinary clinic-based approach to safely prescribing progressive exercise in Long COVID is feasible. Both peripheral and inspiratory muscle exercise can be effectively titrated to each individual's symptoms, and careful monitoring for post-exertional symptom exacerbation is crucial.

Long COVID affects 5-10% of people following COVID infection. There is little specific guidance on how exercise can be safely prescribed in Long COVID. This paper is the first to provide a detailed description of an Australian multidisciplinary Long COVID clinic, including specific tools and guidance about how exercise can be prescribed while minimising post-exertional symptom exacerbation. The tools described could be valuable to other health facilities striving to optimise multidisciplinary care for people with Long COVID, incorporating safe exercise prescription.

An In vitro and in silico investigation of the antitrypanosomal activities of the stem bark extracts of Anopyxis klaineana (Pierre) Engl.

African Trypanosomiasis caused by trypanosome parasites continues to be a major neglected health problem, particularly in developing countries. Current treatments are marked by serious side effects, low effectiveness, high toxicity, and drug resistance prompting the need to develop novel, safe, effective, and alternative antitrypanosomal compounds. Anopyxis klaineana is an ethnomedicinal plant used in West Africa to treat many ailments including protozoan diseases. In this study, we investigated the antitrypanosomal potential of stem bark extracts of A. klaineana through in vitro and in silico approaches. A. klaineana extracts were tested for their antitrypanosomal activities against Trypanosoma brucei parasite in vitro using Alamar blue assay. In addition, the antioxidant and cytotoxic activities were determined. LC-ESI-QTOF-MS was used to identify potential bioactive compounds present in the A. klaineana extracts. Bioactive compounds identified were subjected to molecular docking studies against Trypanosoma brucei's trypanothione reductase (TR) and Uridine Diphosphate Galactose 4'-Epimerase (UDP). The A. klaineana extracts (methanol, hexane, chloroform, and ethyl acetate) exhibited potential anti-trypanosomal activities with IC50 values of 21.25 ± 0.755,4.35 ± 0.166,2.57 ± 0.153 and 22.92 ± 2.321 µg/mL respectively. Moreover, the methanolic crude extracts showed moderate cytotoxicity against HepG2 and PNT2 cells, with IC50 values of 68.0 ± 2.05 and 78.7 ± 2.63 µg/mL respectively. LC-MS analysis revealed the presence of 24 bioactive compounds with 5 being druglike. Risperidone, Ranolazine, Dihydro-7-Desacetyldeoxygedunin, 6 beta-Hydroxytriamcinolone acetonide, and Dimethylmatairesinol were identified as novel potential inhibitors of TR and UDP with binding affinities of -10.4, -7.9, -8.7, -8.4 and -7.1 kcal/mol respectively against TR and -10.8, -8.4, -8.4, -7.6 and -8.1 respectively against UDP. This study indicates that A. klaineana has potential antitrypanosomal properties and therefore may have the potential to be developed as a therapeutic intervention for treating African trypanosomiasis.

Computational Screening of Neuropilin-1 Unveils Novel Potential Anti-SARS-CoV-2 Therapeutics.

Neuropilin 1 (NRP-1) inhibition has shown promise in reducing the infectivity of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) and preventing the virus entry into nerve tissues, thereby mitigating neurological symptoms in COVID-19 patients. In this study, we employed virtual screening, including molecular docking, Molecular Dynamics (MD) simulation, and Molecular Mechanics-Poisson Boltzmann Surface Area (MM-PBSA) calculations, to identify potential NRP-1 inhibitors. From a compendium of 1930 drug-like natural compounds, we identified five potential leads: CNP0435132, CNP0435311, CNP0424372, CNP0429647, and CNP0427474, displaying robust binding energies of -8.2, -8.1, -10.7, -8.2, and -8.2 kcal/mol, respectively. These compounds demonstrated interactions with critical residues Tyr297, Trp301, Thr316, Asp320, Ser346, Thr349, and Tyr353 located within the b1 subdomain of NRP-1. Furthermore, MD simulations and MM-PBSA calculations affirmed the stability of the complexes formed, with average root mean square deviation, radius of gyration, and solvent accessible surface area values of 0.118 nm, 1.516 nm, and 88.667 nm2 , respectively. Notably, these lead compounds were estimated to penetrate the blood-brain barrier and displayed antiviral properties, with Pa values ranging from 0.414 to 0.779. The antagonistic effects of these lead compounds merit further investigation, as they hold the potential to serve as foundational scaffolds for the development of innovative therapeutics aimed at reducing the neuroinfectivity of SARS-CoV-2.

Instrumental swallowing assessment in adults in residential aged care homes: Practice patterns and opportunities.

OBJECTIVE: To describe practice patterns in the use of instrumental swallowing assessment (ISA) for older adults in residential aged care homes (RACHs). METHODS: A retrospective audit of medical records of residents living in RACHs in Melbourne, Australia to extract data on speech-language pathologist (SLP) involvement, indications for ISA and ISA practice patterns. RESULTS: Medical files of 323 residents across four Melbourne facilities were reviewed. 36% (n = 115) of residents were referred to SLP for swallowing assessment. Referral to SLP was related to length of stay (U = 7393.00, p < 0.001), dementia status (χ2 [1] = 7.06, p = 0.008), texture modification (χ2 [1] = 93.34, p < 0.001) and an existing dysphagia diagnosis (χ2 [1] = 112.89, p < 0.001). There were no referrals for ISA and no instances of ISA being used. Among 115 residents who were referred to SLP for swallowing assessment, there were 33 instances where ISA might be clinically relevant according to ISA indicators. CONCLUSIONS: Instrumental swallowing assessment is not being used for the management of swallowing in RACHs in Australia despite a clinical need for ISA and a potential role for ISA to improve swallowing care quality. Lack of timely ISA may fail to meet the complex health-care needs of older adults living with dysphagia in RACHs, increasing their vulnerability to complications of dysphagia and its management.

Optimal cytoreduction followed by chemoradiation in stage IVB uterine serous carcinoma.

OBJECTIVES: The prognosis of patients presenting with stage IVB uterine serous carcinoma (USC) remains extremely poor, with a reported 5-year survival of <20%. Here were evaluate the survival impact of cytoreductive surgery and identify other prognostic factors in stage IVB USC. METHODS: A multicenter retrospective analysis of patients with stage IVB USC was conducted from 2000 to 2018. Inclusion criteria were patients who had undergone comprehensive surgical staging/tumor debulking; followed by adjuvant chemotherapy+/-external beam radiation therapy (EBRT). Optimal cytoreduction (R1) was defined as residual disease ≤1 cm at completion of surgery, and suboptimal cytoreduction (R2) was defined as >1 cm. Progression free survival (PFS) and overall survival (OS) analysis was performed using Kaplan-Meier estimates. Multivariate analysis (MVA) was performed using Cox proportional hazards model. RESULTS: Final analysis included 68 patients. There was no difference in the frequency of treatment delays between regimens (p = 0.832). 96% of patients received platinum-based chemotherapy. There was no difference in the age (p = 0.227), race (p = 0.936), type of radiotherapy (p = 0.852) or chemotherapy regimen received (p = 0.996) between R1 and R2 cohorts. The median PFS for all patients was 8 months and the median OS was 13 months. Cytoreduction to R1 was associated with a median PFS of 9 months, compared to R2 with a median PFS of 4 months (p < 0.001, HR 0.32, 95% CI 7.4-14.1). Median OS was also improved with R1 vs. R2 cytoreduction (17 months vs. 7 months, respectively) (p < 0.001, HR 0.21, 95% CI 13.7-26.4). Compared to R1, cytoreduction to R0 was not associated with a survival benefit. The R0 median OS was 17 months versus 18 months in R1 (p = 0.67). The combination of adjuvant chemoradiation was associated with improved PFS (11 months vs. 7 months) (p = 0.024, HR 0.41, 95% CI 6.5-9.4) and OS (22 months vs 13 months) (p = 0.65, HR 0.25, 95% CI 10.5-15.4) compared to chemotherapy-alone, respectively. On MVA, only the amount of residual disease (p = 0.003, HR 0.39, 95% CI 0.2-0.7) and receipt of adjuvant chemoradiation (p = 0.010, HR 0.09, 95% CI 0.01-0.58) were independent predictors of survival. CONCLUSIONS: In stage IVB USC, optimal cytoreduction should be the goal at the time of primary surgery. The combination of chemoradiation was associated with superior survival compared to chemotherapy alone and should be further investigated in this patient population.

Incidental Finding of Schistosomiasis Mimicking as Endometriosis.

Schistosomiasis is a common endemic cause of abdominal pain outside the United States that can present with symptoms overlapping with endometriosis, a common cause of chronic pelvic pain in reproductive women. In this case, operative laparoscopy aided and resulted in the diagnosis of schistosomiasis.

Montessori mealtimes for dementia: A pathway to person-centred care.

PURPOSE: This study examined the impact of a Montessori mealtime intervention for people living with dementia to support the mealtime experience of residents and mealtime care practices of staff in a memory support unit. The mealtime intervention was part of a broader culture change project. METHOD: An observational research design was used to evaluate changes in the mealtime experience and care practices across three time points (baseline, post-implementation, maintenance), spanning 30 months. Five video recordings of the lunch time service (range: 19-32 min) were analysed. The coding protocol comprised pre-determined indicators related to accepted dimensions of person-centred care. Resident and staff behaviours were quantified across four categories: providing choice and preferences, promoting the social side of eating, supporting independence and showing respect towards residents. Staff behaviours that reflected personal enhancing actions and personal detractors were also coded during each mealtime service. RESULTS: A significant increase in staff providing residents with the opportunity for choice and a subsequent significant increase in residents demonstrating choice behaviours was evident. Staff and residents both significantly increased their interactional behaviours, with greater social interaction between staff and residents. Staff further demonstrated greater support for mealtime independence that reached and maintained significance during the final two sampling points. Significant gains observed post implementation were largely maintained and, on specific measures, further increased over time. A significant increase in staff use of personal enhancing actions during mealtime care was also evident. Variability in individual staff and resident behaviour highlighted the complexity of mealtime care and culture change processes. IMPLICATIONS: The study provides novel evidence to support the use of a Montessori mealtime intervention to achieve more person-centred mealtime care, and which resulted in a more respectful, enabling and social dining experience. Clinical implications and direction for future research are presented to build on these findings.

The Role of Instrumental Swallowing Assessment in Adults in Residential Aged Care Homes: A National Modified Delphi Survey Examining Beliefs and Practices.

Many adults in residential aged care homes (RACHs) live with oropharyngeal dysphagia (OD) and its physiological, psychosocial, and economic sequalae. Timely, evidence-based assessment of OD can help healthcare teams to create OD management plans that optimize consumer health and minimize healthcare costs. Instrumental swallowing assessment (ISA), specifically flexible endoscopic evaluation of swallowing (FEES) and videofluoroscopic swallowing studies (VFSS), is generally accepted to be an important component of dysphagia assessment and management in older adults. However, its role in RACHs has not been empirically examined. This study aimed to explore the role and use of ISA in adults in RACHs from the perspective of speech-language-pathologists (SLPs) experienced in a RACH setting and/or FEES and VFSS. A three-round electronic Delphi study was conducted to guide 58 SLPs in Australia towards consensus using a combination of multiple-choice questions, statements with five-point Likert scale agreement options, and open-ended questions. Participants' responses were analyzed using descriptive statistics and content analysis after each survey round. Feedback about group responses was provided before subsequent surveys. Consensus was defined as 70% or greater agreement. Participants reached consensus about obstacles and facilitators to the use of ISA in RACHs. Participants agreed that FEES was a valuable tool in RACHs and that a mobile service model may have advantages over standard off-site assessment. SLPs believed that appropriate governance processes, infrastructure and education were necessary to develop a safe, high-quality service. These views support equitable access to ISA across settings, aligning with person-centered care, re-ablement, and care-in-place.

An evaluation of a consumer directed care training program for nursing home staff.

OBJECTIVES: This study evaluated a training program to support the delivery of consumer directed care (CDC). It was hypothesized that both interventions, compared to the control condition, would demonstrate increased levels of CDC in nursing homes, increased staff practice of CDC, and improved resident QoL. The training plus support group was expected to show greater gains, compared to the training only group. MATERIALS AND METHODS: In a cluster RCT design, 33 nursing homes were randomly allocated to one of three conditions: training plus support, training only, and care as usual. Outcome measures included level of CDC within each home, staff practice of CDC, and resident QoL. RESULTS AND DISCUSSION: Hypotheses for this study were partially supported. Nursing homes became more CDC-oriented but with minimal changes in staff practice of CDC. Resident QoL also demonstrated limited change. The findings are discussed in terms of organizational barriers to change within nursing homes.

Supercritical-CO2 extraction, identification and quantification of polyprenol as a bioactive ingredient from Irish trees species.

This study ascertained the accumulation of polyprenol from four Irish conifer species Picea sitchensis, Cedrus atlantica 'Glauca', Pinus sylvestris and Taxus baccata and one flowering tree Cotoneaster hybrida using supercritical fluid extraction with carbon dioxide (SFE-CO2) and solvent extraction. The effects of SFE-CO2 parameters such as temperature (ranged from 40 to 70 [Formula: see text]), pressure (ranged from 100 to 350 bars) and dynamic time (from 70 min to 7 h) were analysed on the extraction efficiency of polyprenol. Qualitative and quantitative analysis of polyprenol was examined using high-performance liquid chromatography. Results showed that P. sylvestris accumulated the highest polyprenol yield of 14.00  ± [Formula: see text]mg g-1 DW when extracted with hexane:acetone (1:1 v/v). However, with SFE-CO2 conditions of 200 bars, 70 [Formula: see text], 7 h, with absolute ethanol as a cosolvent with a flow rate of 0.05 ml min-1, P. sitchensis accumulated the highest polyprenol yield of 6.35 ± [Formula: see text] mg g-1DW. This study emphasised the potential application of SFE-CO2 in the extraction of polyprenol as an environmentally friendly method to be used in pharmaceutical and food industries.

How Important Are Choice, Autonomy, and Relationships in Predicting the Quality of Life of Nursing Home Residents?

Older people face major challenges when they move into nursing homes, particularly in relation to independence and their ability to influence their activities of daily living (ADLs). This study evaluated the contribution of resident choice, as well as the staff-resident relationship, to promoting resident quality of life (QoL). A total of 604 residents from 33 nursing homes in Australia completed measures of QoL, perceived levels of choice in various ADLs, and the staff-resident relationship. A hierarchical regression demonstrated that the predictor variables accounted for 25% of the variance in QoL. Two of the four predictor variables (resident choice over socializing and the staff-resident relationship) significantly contributed to resident QoL. These findings reinforce the important contribution of autonomy and social relationships to resident QoL. Nursing home staff have a key role to play in supporting resident autonomy as a means of building residents' chosen social connections, and thereby promoting QoL.

Instrumental Swallowing Assessment in Adults in Residential Aged Care Homes: A Scoping Review.

OBJECTIVES: To systematically describe evidence on the use of instrumental swallowing assessment for residents of aged care homes. DESIGN: Scoping review using the Joanna Briggs Institute methodology for scoping reviews. SETTING AND PARTICIPANTS: Published peer-reviewed and gray literature written in English between 2000 and 2020 about instrumental swallowing assessment (ISA) in adults in residential aged care homes (RACHs). MEASURES: A systematic, 3-tiered search of databases including Medline, CINAHL, Embase, Scopus, and Cochrane Database of Systematic Reviews, and gray literature databases was conducted. Content analysis identified common themes. RESULTS: Forty-two sources, 30 from peer-reviewed journals, 12 gray literature publications, and 66 websites of mobile ISA providers that discussed videofluoroscopic swallowing studies (VFSS) and/or fiberoptic endoscopic evaluation of swallowing (FEES) use in RACHs were included. Most peer-reviewed sources were referenced narratives or surveys of speech pathology practice patterns (53.3%). Researchers in 3 studies used onsite mobile FEES and in 2 studies off-site VFSS, with adults living in RACHs, as part of their research design (16.7%). There were 66 mobile instrumental swallowing assessment provider websites, based within the United States. Three countries (Australia, United States, United Kingdom) had professional guidelines that stipulated minimal requirements for the safe and appropriate provision of ISA services across settings. Themes identified across sources included (1) the approach to swallowing management and clinical indicators for ISA, (2) the role of ISA, (3) service and consumer influences on ISA, and (4) mobile FEES. CONCLUSIONS AND IMPLICATIONS: There is a paucity of quality research on instrumental swallowing assessment in adults living in RACHs. There are broad regional and international variances in the way that videofluoroscopy and FEES are accessed and used. A more robust evidence base is required to guide health professionals to design tailored ISA care pathways for residents of RACHs, to achieve high-quality health, social, and economic outcomes.

Current Perspectives of Prenatal Sonographic Diagnosis and Clinical Management Challenges of Nuchal Cord(s).

Umbilical cord accidents preceding labor are uncommon. In contrast, nuchal cords are a very common finding at delivery, with reported incidences of a single nuchal cord of approximately between 20% and 35% of all singleton deliveries at term. Multiple loops occur less frequently, with reported incidence rates inverse to the number of nuchal cords involved. Rare cases of up to 10 loops of nuchal cord have been reported. While true knots of the umbilical cord have been associated with a 4-10-fold increased risk of stillbirth, nuchal cord(s) are most often noted at delivery of non-hypoxic non-acidotic newborns, without any evidence of subsequent adverse neonatal outcome. Prior to ultrasound, nuchal cords were suspected clinically following subtle (spontaneous or evoked) electronic fetal heart rate changes. Prenatal sonographic diagnosis, initially limited to real-time gray-scale ultrasound, currently entails additional sonographic modalities, including color Doppler, power Doppler, and three-dimensional sonography, which have enabled increasingly more accurate prenatal sonographic diagnoses of nuchal cord(s). In contrast to true knots of the umbilical cord (which are often missed at sonography, reflecting the inability to visualize the entire umbilical cord, and hence are often incidental findings at delivery), nuchal cord(s), reflecting their well-defined and sonographically accessible anatomical location (the fetal neck), lend themselves with relative ease to prenatal sonographic diagnosis, with increasingly high sensitivity and specificity rates. While current literature supports that single (and possibly double) nuchal cords are not associated with increased adverse perinatal outcome, emerging literature suggests that cases of ≥3 loops of nuchal cords or in the presence of a coexisting true knot of the umbilicus may be associated with an increased risk of stillbirth or compromised neonatal status at delivery. This commentary will address current perspectives of prenatal sonographic diagnosis and clinical management challenges associated with nuchal cord(s) in singleton pregnancies.

Fiberoptic endoscopic evaluation of swallowing and videofluoroscopy swallowing assessment in adults in residential care facilities: a scoping review protocol.

OBJECTIVE: This scoping review will identify and explore existing evidence on the use of instrumental swallowing assessment in the diagnosis and management of dysphagia in adults living in residential care facilities. INTRODUCTION: Oropharyngeal dysphagia is prevalent among adults living in residential care facilities. Videofluoroscopy and fiberoptic endoscopic evaluation of swallowing are instrumental assessment procedures commonly utilized in the evaluation of oropharyngeal dysphagia in hospital and community settings. However, little is known about the use of these procedures in residential care facilities. To ensure evidence-based assessment of oropharyngeal dysphagia and to guide future research, exploration of the current use and clinical utility of videofluoroscopy and fiberoptic endoscopic evaluation of swallowing in residential care facilities is needed. INCLUSION CRITERIA: Published and gray literature written in English from 2000 onward that discusses instrumental swallowing assessment of adults in residential care facilities will be included in the review. METHODS: A three-step search strategy will be used to explore relevant literature. All citations and articles retrieved during the searches will be imported into a software application for systematic reviews. Once duplicates are removed, two reviewers will screen the titles and abstracts against predefined inclusion criteria. Information will be extracted from literature that meets the selection criteria using a purposefully developed charting form. The search strategy and results will be illustrated through a Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram. Key findings and their relationship to the research questions will be summarized in a chart and discussed in interpretive narrative form.

Consumer directed care in residential aged care: an evaluation of a staff training program.

Objectives: The advent of Consumer-Directed Care (CDC, or individualized care) in Residential Aged Care Facilities (RACFs, or residential care) will require a paradigm shift in service delivery. This article evaluated the six-session Resident at the Centre of Care (RCC) staff training program designed to equip staff to implement a CDC model of care among residents.Method: There were two experimental conditions: RCC training program alone, RCC training program plus support, and a 'care as usual' condition. Outcome measures were resident quality of life (QoL) and resident working relationships with staff at 3-month follow-up. At Time 1, 92 residents from RACFs participated in the program. The RCC is six sessions that focus on the development of staff skills in communicating with residents, as well as the organizational change and transformational leadership that is needed for the implementation of CDC.Results: There were significant improvements in resident QoL. There was no major difference between the RCC Program plus support condition compared to the RCC Program alone condition, but both were associated with more positive changes in resident QoL than the 'care as usual' condition.Conclusion: This study demonstrates that training staff in strategies to implement CDC in RACFs can lead to an improvement in the wellbeing of many residents, and that additional support to assist staff to implement the strategies may not be required to produce such improvements. Longer term follow-up is necessary to determine if the improvements in resident QoL are sustained.

Resident perceptions of opportunity for communication and contribution to care planning in residential aged care.

BACKGROUND AND AIM: Irrespective of age, communication is a tool of expression and a key daily activity meeting the human need for social interaction and connection. The introduction of consumer-directed care (CDC) emphasises the importance of communication to provide consumers with the opportunity to exercise choice over the care they receive. As consumer-directed care progresses, it is hypothesised that the feasibility of shared decision-making and care planning in residential aged care will be largely determined by the communication opportunities afforded to the residents. Therefore, the aim of this study was to explore resident perceptions of the opportunities they have to communicate, including the opportunity to express their care preferences and contribute opinions about their care. DESIGN: A qualitative inductive design was adopted. METHODS: An individual interview format was used to gather the perspectives of 102 residents. Data were analysed using qualitative content analysis to generate themes illustrating patterns in participant views. FINDINGS: Overall, residents desired increased involvement in their care planning and increased opportunity for more meaningful communication and social opportunities. Residents described the negative impact of the communication difficulties they face on their communication and the need for support and activities to be tailored to residents' individual communication needs. CONCLUSIONS: To facilitate resident participation in CDC and meet resident desire for increased social communication, further investment in resources to support resident-staff communication and accommodate residents' individual communication needs is required. IMPLICATIONS FOR PRACTICE: By highlighting communication as a stand-alone activity and a priority of residents, the findings of this study raise the profile of communication and demonstrate the need for explicit allocation of care time and specialist services to support resident-staff communication and social communication in residential aged care. Such support must be tailored to meet residents' individual communication needs and be coupled with increased staff training in providing communication support. Without facilitating resident communication and increasing the opportunity to communicate, shared decision-making and care planning in residential aged care consistent with person-centred and consumer-directed models of care will be limited.

Is the speech-language pathology profession prepared for an ageing population? An Australian survey.

PURPOSE: This study profiled the demographic characteristics and practice patterns of speech-language pathologists working with older Australians to inform future workforce planning and service development in response to an ageing population and aged care sector reform. METHOD: Data were collected through snowball distribution of an online survey comprising six sections: demographic details; caseload and service delivery practices, degree of inter-professional practice; engagement with professional development and support; and assessment and management of swallowing, mealtime and communication difficulties. All data were analysed using descriptive statistics and chi-square to determine the independence of key variables. RESULT: Data from 145 speech-language pathologists highlight the need for increased numbers of clinicians working outside of metropolitan areas and greater workforce diversity, along with increased incentive, supervision and inter-professional support for new graduate and early career clinicians considering working outside of hospital settings. To ensure evidence-based practice, further research into the validity of current assessment and intervention methods used across aged care settings is needed. CONCLUSION: The findings highlight the need for an extended scope of practice and improved models of support for speech-language pathologists working with older people to better respond to the needs of an ageing population and on-going aged care sector reform.

Assessing pain in children in the perioperative setting.

Pain assessment and management in children is challenging for a number of reasons. This paper aims to identify these challenges and highlight strategies for effective pain assessment and management in children in the perioperative setting.

A randomized controlled trial to evaluate the effectiveness of a staff training program to implement consumer directed care on resident quality of life in residential aged care.

BACKGROUND: Residential Aged Care Facilities (RACFs) are moving towards a Consumer Directed Care (CDC) model of care. There are limited examples of CDC in ageing research, and no evaluation of a comprehensive CDC intervention in residential care was located. This study will implement and evaluate a staff training program, Resident at the Center of Care (RCC), designed to facilitate and drive CDC in residential care. METHODS: The study will adopt a cluster randomized controlled design with 39 facilities randomly allocated to one of three conditions: delivery of the RCC program plus additional organizational support, delivery of the program without additional support, and care as usual. A total of 834 staff (22 in each facility, half senior, half general staff) as well as 744 residents (20 in each facility) will be recruited to participate in the study. The RCC program comprises five sessions spread over nine weeks: Session 1 clarifies CDC principles; Sessions 2 to 5 focus on skills to build and maintain working relationships with residents, as well as identifying organizational barriers and facilitators regarding the implementation of CDC. The primary outcome measure is resident quality of life. Secondary outcome measures are resident measures of choice and control, the working relationship between resident and staff; staff reports of transformational leadership, job satisfaction, intention to quit, experience of CDC, work role stress, organizational climate, and organizational readiness for change. All measures will be completed at four time points: pre-intervention, 3-months, 6-months, and 12-month follow-up. Primary analyses will be conducted on an intention to treat basis. Outcomes for the three conditions will be compared with multilevel linear regression modelling. DISCUSSION: The RCC program is designed to improve the knowledge and skills of staff and encourage transformational leadership and organizational change that supports implementation of CDC. The overarching goal is to improve the quality of life and care of older people living in residential care. TRIAL REGISTRATION: ACTRN12618000779279; Registered 9 May 2018 with the Australian and New Zealand Clinical Trials Registry (ANZCTR; http://www.anzctr.org.au/ ).

A case report of unexpected pathology within an incarcerated ventral hernia.

INTRODUCTION: Incidence of hernial appendicitis is 0.008%, most frequently within inguinal and femoral hernias. Up to 2.5% of appendectomy patients are found to have Crohn's disease. Elucidating the etiology of inflammation is essential for directing management. PRESENTATION OF CASE: A 51-year-old female with achondroplastic dwarfism, multiple cesarean sections, and subsequent massive incisional hernia, presented with ruptured appendicitis within her incarcerated hernia. She underwent diagnostic laparoscopy, appendectomy, intra-abdominal abscess drainage, and complete reduction of ventral hernia contents. She developed a nonhealing colocutaneous fistula, causing major disruptions to her daily life. She elected to undergo hernia repair with component separation for anticipated lack of domain secondary to her body habitus. Her operative course consisted of open abdominal exploration, adhesiolysis, colocutaneous fistula repair, ileocolic resection and anastomosis, and hernia repair with bioresorbable mesh. She tolerated the procedure well. Unexpectedly, ileocolic pathology demonstrated chronic active ileitis, diagnostic of Crohn's disease. DISCUSSION: Only two cases of hernial Crohn's appendicitis have been reported, both within Spigelian hernias. Appendiceal inflammation inside a hernia sac may be attributed to ischemia from extraluminal compression of the hernia neck. This case demonstrates a rare presentation of multiple concurrent surgical disease processes, each of which impact the patient's treatment plan. CONCLUSION: This is the first report of incisional hernia appendicitis with nonhealing colocutaneous fistulas secondary to Crohn's. It is a lesson in developing a differential diagnosis of an inflammatory process within an incarcerated hernia and management of the complications related to laparoscopic hernial appendectomy in a patient with undiagnosed Crohn's disease.