The effectiveness of multidisciplinary, activity-based chronic pain interventions for adults of ethnoculturally diverse backgrounds: a systematic review with meta-analysis.

PURPOSE: The aim of this review was to assess the effectiveness of multidisciplinary, activity-based interventions on adults with chronic musculoskeletal or widespread pain who identify as ethnoculturally diverse (ECD) compared to adults belonging to the predominant culture of the host country. METHODS: Online databases Medline, CINAHL, AMED, Psych Info and PubMed were searched from the earliest date available until April 2023. The quality of the included studies were assessed against the Risk of Bias in Non Randomized Studies of Interventions (ROBINS-I). Postintervention data were analyzed using meta-analyses and the certainty of evidence determined using the Grading of Recommendation, Assessment, Development and Evaluation approach (GRADE). RESULTS: Nine cohort studies with 3467 participants living in America and north-western European countries were included. ECD adults had higher pain intensity (SMD 1.36, 95%CI 0.29 to 2.35, p = 0.03), higher levels of depression (SMD 0.96, 95%CI 0.40 to 1.52, p < 0.01) and a nonsignificant difference in pain-related disability (SMD -1.45, 95%CI -3.28 to 0.39, p = 0.12) following multidisciplinary pain intervention compared to adults of the predominant culture. CONCLUSION: Adults from ECD backgrounds in Western nations have poorer outcomes after multidisciplinary, activity-based chronic pain interventions compared to adults from predominant cultural groups in these countries suggesting program adaptations may be required.

Adults from ethnoculturally diverse backgrounds in Western nations have poorer outcomes after chronic pain interventions suggesting different approaches to management are needed.Programs can be adapted to reflect culture-specific beliefs, metaphors, language and concepts in their content to better address pain and improve outcomes among ethnoculturally diverse communities.

Does preoperative opioid use predict outcomes to 6 months following primary unilateral knee or hip arthroplasty for osteoarthritis? A data-linked retrospective study.

BACKGROUND: Few Australian studies have examined the incidence of prescribed opioid use prior to primary total knee or total hip arthroplasty (TKA, THA) and whether it predicts post-surgery outcomes. A recent Australian study demonstrated that the prevalence of pre-arthroplasty opioid use was approximately 16%. In the United States, approximately 24% of people undergoing TKA or THA are chronic opioid users preoperatively. PURPOSE: This study aimed to determine (i) the proportion of TKA and THA patients who use prescribed opioids regularly (daily) before surgery (i.e., opioid use reported between the time of waitlisting and any time up to 3 months before surgery), (ii) if opioid use before surgery predicts (a) complication/readmission rates to 6-months post-surgery, and (b) patient-reported outcomes to 6-months post-surgery. METHODS: A retrospective cohort study of patients who underwent TKA or THA between January 2013 and June 2018 from two Australian public hospitals was undertaken utilizing linked individual patient-level data from two prospectively collected independent databases comprising approximately 3,500 and 9,500 people (database contained known opioid usage data within the 5-year time frame). Inclusion criteria included (i) primary diagnosis of osteoarthritis of the index joint, (ii) primary elective THA or TKA, and (iii) age ≥ 18 years. Exclusion criteria included (i) revision arthroplasty, (ii) non-elective arthroplasty, (iii) hip hemiarthroplasty, (iv) uni-compartmental knee arthroplasty, and (v) previous unilateral high tibial osteotomy. RESULTS: Analysis was completed on 1,187 study participants (64% female, 69% TKA, mean (SD) age 67 [9.9]). 30% were using regular opioids preoperatively. Adjusted regression analyses controlling for multiple co-variates indicated no significant association between preoperative opioid use and complications/readmission rates or patient-reported outcomes to 6 months post-surgery. Model diagnostics produced poor discrimination for area under the curves and non-significant goodness of fit tests. Pre-arthroplasty opioid use was associated with lower health-related quality of life (EuroQol-Visual Analogue Scale) compared to non-opioid users undergoing primary THA (mean difference -5.04 [-9.87, -0.22], P = 0.04, Adjusted R2 = 0.06) CONCLUSION: In this study, 30% of patients were using prescribed opioids daily prior to primary TKA or THA. Pre-arthroplasty opioid use was not associated with postoperative adverse events or patient-reported pain, function, or global perceived improvement up to six months post-surgery.

Implementing a ward-level intervention to improve nursing handover communication with a focus on bedside handover-A qualitative study.

AIM: To improve the effectiveness of nursing clinical handover through a qualitative, tailored communication intervention. DESIGN: A multisite before and after intervention using qualitative ethnography combined with discourse analysis of nursing handover interactions. METHODS: We implemented a tailored ward-based intervention to redesign nursing handover practice with co-constructed recommendations for organisational and cultural change on seven wards across three affiliated metropolitan hospitals between February 2020 and November 2022. The intervention was informed by pre-implementation interviews and focus groups with nursing, medical and allied health staff and patients (n = 151) and observed and/or audio-recorded handover events (n = 233). Post-intervention we conducted interviews and focus groups (n = 79) and observed and/or audio-recorded handover events (n = 129) to qualitatively evaluate impact. RESULTS: Our translational approach resulted in substantial changes post-intervention. Nurses conducted more shift-to-shift handovers at the bedside, with greater patient interaction and better structured and more comprehensive information transfer, supported by revised handover documentation. Redesigned group handovers were focused and efficient, communicating critical patient information. CONCLUSION: Contextualised training combined with changes to ward-level systemic factors impeding communication results in improved nursing handovers. Practice change requires strong executive leadership and project governance, combined with effective ward-level leadership, collaboration and mentoring. The speed and degree of change post-intervention demonstrates the power of interdisciplinary collaborative research between hospital executive, ward leadership and communication specialists. RELEVANCE TO CLINICAL PRACTICE: Nurses are more likely to conduct efficient group handovers and informative, patient-centred bedside handovers in line with policy when they understand the value of handover and have practical strategies to support communication. Communication training should be combined with broader ward-level changes to handover practice tailored to the ward context. A multilevel approach results in more effective practice change. REPORTING METHOD: We adhered to the COREQ guidelines. PATIENT OR PUBLIC CONTRIBUTION: We interviewed patients on study wards pre and post intervention.

"IT's too much to do alone": A mixed-methods exploration of patient experiences implementing emergency department management plans for chronic pain.

OBJECTIVES: To explore the experiences of socio-culturally diverse community members attempting to manage their chronic pain and enact evidence-based management plans following an index Emergency Department (ED) visit. METHODS: A convergent parallel mixed-methods design with qualitative interviews and descriptive analysis was undertaken in two public hospitals in a multicultural region in Sydney, Australia. Consecutive adults were recruited from culturally and linguistically diverse (CALD: n = 45) or Australian-born (n = 45) backgrounds, who presented to the ED for a chronic neuromusculoskeletal pain condition. Consenting participants were prescribed an individualised chronic pain management plan following examination by a physiotherapist, who collected standardised measures of pain and health literacy. Six months later, participants underwent a structured phone survey regarding their pain status and whether they had actioned management plans. Participants were invited to participate in a semi-structured interview. RESULTS: Six-month data were available for 82 of 90 participants who attended the ED and consented to the baseline assessment (40 CALD and 42 Australian-born). Participants were 52% females, predominately middle-aged (mean age 54.7 years), with an overall mean symptom duration of 10 years (SD 9.0). At 6 months, there were nine representations by six CALD participants and 23 by nine Australian-born participants. Overall, 52% reported unchanged pain, 24% were worse and 23% improved, with similar action plan progress for CALD (58%) and Australian-born (53%) participants. Pain features and health literacy were similar, irrespective of progress with pain management plans. From 41 participants who consented to phone interviews, three themes emerged to explain their progress with recommendations: 'illness model', 'urgency' and 'control orientation'. CONCLUSIONS: Patients presenting to the ED with chronic pain might be more likely to action discharge recommendations if primary care providers identify patient-specific and contextual barriers to implementation.

High pain reported at 3 months post-total knee arthroplasty often persists for the next 3 years and is associated with reduced function and quality of life.

BACKGROUND AND AIMS: Five to ten percent of people having a knee arthroplasty for osteoarthritis continue to experience high pain levels more than 3 months after surgery. The primary aim of this study was to determine the relative risk (RR) of having high pain at 12 and 36 months based on the presence of high pain at 3 and 12 months, respectively. METHODS: A retrospective analysis of data from a prospective study of participants who had a total knee arthroplasty for osteoarthritis. A score of ≤14 on the Oxford Knee Pain Subscale was defined as 'High Pain', and RRs were calculated comparing those with high or low pain. RESULTS: There were 718 participants and 13.8% reported high pain at any time point, 2.5% reported high pain at all time points and 10.3% and 4.7% and 6.6% reported high pain at 3-, 12- and 36-months, respectively, post-surgery. For participants with high pain at 3 months, 33.8% had high pain at 12 months with a RR of 24.2 (95% CI 11.7-49.8, p < 0.001) and 35.1% had high pain at 36 months with a RR of 10.8 (95% CI 6.4-18.2, p < 0.001). For participants with high pain at 12 months, 67.6% had high pain at 36 months, with a RR of 19.3 (95% CI 12.2-30.4, p < 0.01). CONCLUSIONS: Although high pain rates are low overall following knee arthroplasty, once high pain is established there is an elevated RR of it persisting at 12- and 36 months post-surgery. TRIAL REGISTRATION: The data were collected in the Evidence-based Processes and Outcomes of Care (EPOC) study, ClinicalTrials.gov Identifier: NCT01899443.

Perspectives and experiences of COVID-19 vaccination in people with autoimmune and inflammatory rheumatic disease.

OBJECTIVE: People with autoimmune and inflammatory rheumatic disease (AIIRD) are at an increased risk of morbidity from COVID-19. While COVID-19 vaccination is effective at reducing disease complications, there have been significant levels of vaccine hesitancy in people with AIIRD. We aimed to understand vaccine hesitancy and promote shared decision-making by describing the experiences and perspectives of people with AIIRD who had concerns with COVID-19 vaccinations. METHODS: Adults with AIIRD on immunosuppressive medications who expressed concerns regarding the COVID-19 vaccination were purposively sampled until thematic saturation. Individual semi-structured interviews were conducted and analysed using reflexive thematic analysis. RESULTS: Sixteen adults with an AIIRD were interviewed. Thematic analysis yielded four themes: heightened sense of vulnerability; determining individual suitability; desperate for freedom and relief; deterred by scepticism. CONCLUSIONS: The perspectives of people with AIIRD towards the COVID-19 vaccination were shaped by a sense of vulnerability. The decision-making experience was challenging, resulting from struggles with handling information, dealing with external pressures, and facing negativity. PRACTICE IMPLICATIONS: A collaborative approach, involving close family and friends and avoiding negativity and pressure can improve engagement and support decision-making around COVID-19 vaccination. Clearly addressing potential risks of vaccination may prevent subsequent regret and hesitancy if they arise.

Cardiac dysfunction in solid tumours: scoping review.

Cardio-oncology is a dynamic field. Research has suggested that cancer itself can damage the heart, independent of cancer treatment-related cardiac dysfunction (CTRCD). The aim of this study was to establish the nature of cardiovascular abnormalities reported in cancer, excluding CTRCD. Scoping review search included cardiovascular abnormalities in adults with solid tumour malignancies, and excluded CTRCD and thrombotic events. Three databases (CINAHL, Embase, Medline) were searched, supplemented by a handsearch. All screening and data extraction was done by two researchers with consensus reached for any conflicts. Given the heterogeneous nature of the studies identified, data synthesis was narrative. The search identified 42 366 studies. Following deduplication and title/abstract screening, 195 studies were assessed for full-text eligibility. Forty-four studies are included in the final analysis. There are 19 prospective observational studies, 13 retrospective studies, 9 case reports and 3 cross-sectional studies. Types of abnormality identified include cardiomyopathy (16, including Takotsubo (9)), autonomic nervous system (ANS) dysfunction (10), biomarker disturbances (9), reduced myocardial strain (6) and others (3). Due to variable study design, the prevalence was not determined. Cardiovascular abnormalities were associated with morbidity (chest pain, dyspnoea, fatigue) and shortened prognosis. In conclusion: (1) There is evidence for cardiovascular dysfunction in patients with solid tumour malignancies, distinct from CTRCD. People with solid tumours have higher rates of cardiac disease, even when newly diagnosed and treatment naïve. (2) Abnormalities manifest mainly as cardiomyopathies, ANS dysfunction and raised biomarker levels and are associated with significant symptoms. (3) Treatment plans need to take account of these risks, and widen criteria for screening.

Comparison of short-term outcomes between people with and without a pre-morbid mental health diagnosis following surgery for traumatic hand injury: a prospective longitudinal study of a multicultural cohort.

BACKGROUND: Following traumatic hand injury, few studies have compared outcomes between people with and without a pre-morbid mental health diagnosis. This study aimed to compare sub-acute outcomes in a multicultural patient cohort with surgically managed traumatic hand injury with and without a pre-morbid mental health diagnosis. METHODS: A prospective, observational cohort study of people with traumatic hand injury presenting pre- surgically to a high-volume hand injury centre in a region of cultural and language diversity was conducted. Participants were assessed face-to-face (baseline) then via telephone (3-months post-surgery) and categorized according to a pre-morbid medically diagnosed mental health diagnosis. Baseline and follow-up assessments included global mental health, and the EuroQol (EQ) 'Health Today' analogue scale (0-100) and health domains. Return-to-work status, complications/symptomatic complaints, and hand function (QuickDASH) were also collected at follow-up. Adjusted analyses-accounting for covariates including cultural identity-were conducted to determine whether 3-month outcomes were associated with a pre-morbid mental health diagnosis. RESULTS: From 405 eligible patients, 386 were enrolled (76% male, mean age 38.9 (standard deviation 15.6)); 57% self-identified as Australian and 22% had a pre-morbid mental health diagnosis. Common injuries regardless of pre-morbid mental health diagnosis were skin (40%), tendon (17%) and bone (17%) injuries. None were complex mutilating injuries. Seventy-eight per cent of the cohort was followed-up. In adjusted analyses, a pre-morbid mental health diagnosis was associated with lower odds for reporting 'good or better' global mental health (Odds Ratio (OR) 0.23 (95% Confidence Interval (CI) 0.18, 0.47), p < 0.001), 'no' anxiety or depression (OR 0.21 (0.11, 0.40), p < 0.001) and no pain (OR 0.56 (0.31, 0.98), p = 0.04)(EQ domains), and worse EQ 'Health Today' (10 points on average (95%CI -14.9, -5.1, p < 0.001). QuickDASH scores, rates of complications/symptomatic complaints and return-to-work profiles were similar. CONCLUSIONS: Despite reporting worse mental and health-related quality-of-life outcomes post-surgery, people with a pre-morbid mental health diagnosis regardless of cultural identity experienced similar clinical and return-to-work outcomes. Future research assessing the value of screening for pre-morbid mental health conditions on post-surgical outcomes is required and should include people with more complex hand injuries.

A mixed methods approach to investigating physical activity in people with obesity participating in a chronic care programme awaiting total knee or hip arthroplasty.

AIMS: To describe patient-reported physical activity and step count trajectory and explore perceived barriers and enablers to physical activity amongst people with obesity participating in a chronic care programme whilst awaiting arthroplasty. DESIGN: Convergent parallel mixed-method study. METHOD: A patient cohort derived from a longitudinal sample of adults with end-stage osteoarthritis and obesity from a chronic care programme whilst awaiting primary total knee or hip arthroplasty (n = 97) was studied. Physical activity was measured at baseline (entry to the wait list) and before surgery (9-12 months waiting time) using the Lower Extremity Activity Scale (LEAS) and activity monitors (activPAL™). A subset of participants completed in-depth semi-structured interviews 6 months after being waitlisted to explore perceived barriers and enablers to physical activity. Themes were inductively derived and then interpreted through the COM-B model. RESULTS: Baseline LEAS and activPAL™ data were available from 97 and 63 participants, respectively. The proportion of community ambulant individuals reduced from 43% (95% CI 33%-53%) at baseline to 17% (95% CI 9%-28%) pre-surgery. Paired activPAL™ data (n = 31) for step count, upright time, and stepping time remained unchanged. Twenty-five participants were interviewed. Five themes underpinning physical activity were mapped to the COM-B model components of capability (physical capability), opportunity (accessibility and social norms), and motivation (self-efficacy and beliefs and physical activity). CONCLUSIONS: Participation in a chronic care programme did not improve physical activity levels for people with obesity awaiting arthroplasty. Programs cognisant of the COM-B model components may be required to address the natural trajectory of declining physical activity levels while awaiting arthroplasty.

The effect of body mass index and preoperative weight loss in people with obesity on postoperative outcomes to 6 months following total hip or knee arthroplasty: a retrospective study.

BACKGROUND: Few studies have investigated the association between obesity, preoperative weight loss and postoperative outcomes beyond 30- and 90-days post-arthroplasty. This study investigated whether body mass index (BMI) and preoperative weight loss in people with obesity predict postoperative complications and patient-reported outcomes 6 months following total knee or hip arthroplasty. METHODS: Two independent, prospectively collected datasets of people undergoing primary total knee or hip arthroplasty for osteoarthritis between January 2013 and June 2018 at two public hospitals were merged. First, the sample was grouped into BMI categories, < 35 kg/m2 and ≥ 35 kg/m2. Subgroup analysis was completed separately for hips and knees. Second, a sample of people with BMI ≥ 30 kg/m2 was stratified into participants who did or did not lose ≥ 5% of their baseline weight preoperatively. The presence of postoperative complications, Oxford Hip Score, Oxford Knee Score, EuroQol Visual Analogue Scale and patient-rated improvement 6 months post-surgery were compared using unadjusted and adjusted techniques. RESULTS: From 3,552 and 9,562 patients identified from the datasets, 1,337 were included in the analysis after merging. After adjustment for covariates, there was no difference in postoperative complication rate to 6 months post-surgery according to BMI category (OR 1.0, 95%CI 0.8-1.4, P = 0.8) or preoperative weight loss (OR 1.1, 95%CI 0.7-1.8, P = 0.7). There was no between-group difference according to BMI or preoperative weight change for any patient-reported outcomes 6 months post-surgery. CONCLUSION: Preoperative BMI or a 5% reduction in preoperative BMI in people with obesity was not associated with postoperative outcomes to 6 months following total knee or hip arthroplasty.

Why do some people with osteoarthritis and obesity awaiting hip or knee arthroplasty achieve successful weight management? A qualitative study.

AIM: To explore perceived barriers and enablers to weight management among people with obesity awaiting total knee or hip arthroplasty. DESIGN: A nested qualitative study within a multi-centre, quasi-experimental pilot study comparing usual care weight management to a dietitian-led weight-loss diet. METHODS: Semi-structured individual interviews were conducted with adults with end-stage osteoarthritis and a body mass index ≥30 kg/m2 waitlisted for primary total knee or hip arthroplasty. Participants with diverse sociodemographic characteristics and varied success with weight management in the pilot study were purposively sampled. Interviews were analysed using inductive thematic analysis, underpinned by constructivist-interpretivist epistemology. The Patient Activation Measure and Health Literacy Questionnaire were used for context when interpreting the findings. RESULTS: Twenty-five participant interviews were conducted with a sociodemographically varied sample (aged 44-80 years, 9 born in Australia, 6 in paid employment and 11 lost ≥5% of their baseline weight). Four identified themes underpinned successful weight management: beliefs, adaptability, navigating healthcare and sociocultural context. Beliefs about whether weight was perceived as a problem, the expectation of weight loss and treatment-related beliefs influenced participants' perspectives towards weight loss. Adaptability, the ability to overcome barriers to weight loss, comprised three subthemes; readiness to act, degree of independence and problem-solving skills. Approaches towards navigating healthcare influenced uptake and adherence to weight management recommendations. Importantly, these themes were dependent on social and environmental circumstances, which influenced the type of barriers experienced and resources available to the individual. CONCLUSION: Differences in a person's beliefs, their ability to adapt and navigate healthcare and sociocultural context appear to explain successful weight management among people with end-stage arthritis. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Clinicians should allow for individualisation cognisant of the identified themes when providing advice and treatment to promote adherence to weight management interventions. IMPACT: This study explored perceived barriers and enablers to weight management among people with obesity awaiting total knee or hip arthroplasty. Four identified themes underpinned successful weight management: beliefs, adaptability, navigating healthcare and sociocultural context. Beliefs about whether weight was perceived as a problem, the expectation of weight loss and treatment-related beliefs influenced participants' perspectives towards weight loss. Understanding and assessing the contribution of each factor may guide weight management from clinicians treating patients with obesity and osteoarthritis. REPORTING METHOD: The data are reported using the COREQ guidelines. PATIENT OR PUBLIC CONTRIBUTION: Patients contributed to the data collected.

Preliminary insights into patient preparedness for knee or hip arthroplasty: a descriptive survey study.

OBJECTIVE: Knowledge-based preparedness for surgery is achieved through education. It is unclear which of brief or extended education programs prior to knee or hip arthroplasty provides better patient preparedness. Using the Patient Preparedness for Surgery survey, we investigated whether people awaiting arthroplasty attending a hospital that provided education over multiple visits via a pre-surgery management program ('Extended') report superior preparedness compared to those attending a hospital in the same health district that only provides education at the pre-admission clinic assessment ('Brief'). RESULTS: A consecutive sample of 128 people (n = 101, 'Extended', n = 27 'Brief') completed the anonymized survey. COVID-19 related service disruptions undermined the sample size, reducing statistical power. The pre-specified superiority of the Extended program (a relative 20% more reporting 'agree'/'strongly agree') was not observed for 'Overall preparedness' [95% (Extended) vs. 89% (Brief), p = 0.36]. Between-group differences exceeding 20% relative superiority were observed for three preparedness sub-domains ['Alternatives explained' (52 vs. 33%, p = 0.09); 'Prepared for home' (85 vs. 57%, p < 0.01); 'Recall of complications' (42 vs 26%, p = 0.14)]. The preliminary findings suggest an extended education program potentially yields better patient-reported preparedness in some preparedness sub-domains, but not all.

'Without support CALD patients will be left behind': A mixed-methods exploration of culturally and linguistically diverse (CALD) client perspectives of telehealth and those of their healthcare providers.

INTRODUCTION: The rapid adoption of telehealth during the global pandemic has the potential to widen disparities for culturally and linguistically diverse (CALD) consumers. We explored the perspectives and experiences of CALD consumers accessing telehealth during the global pandemic and those of their healthcare providers. METHODS: A multistakeholder mixed-methods study involving two parallel samples comprising consumer-participants (n = 56) and healthcare provider-participants (n = 81). Multicultural consumer-participants, recruited from consecutive referrals to Health Language Services for telehealth support, were assisted to complete two surveys (before and after their clinical telehealth appointment) in their preferred language. A purposive sample of consumer-participants was interviewed to understand their perceived barriers and enablers of successful telehealth consultations. Simultaneously, all healthcare providers within the local health district were eligible to participate in an online survey if they had provided telehealth care to a consumer during the recruitment period. Closed-ended responses were descriptively summarised, while open-ended responses and interview transcripts were analysed thematically. RESULTS: Despite 86% of consumer-participants inexperienced with telehealth, 80% achieved a successful appointment with a healthcare provider. Consumer perceptions were shaped by cultural and diagnostic concepts of legitimacy, in the context of known accessibility and technology literacy challenges. Healthcare provider perspectives were less favourable towards telehealth, with equity of healthcare delivery a major concern. DISCUSSION: Our findings highlight unintended consequences arising from a rapid transition to telehealth. Adopting collaborative approaches to the design and implementation of telehealth is imperative to mitigate health inequities faced by CALD communities and maximise their opportunity to realise potential health benefits associated with telehealth.

The feasibility of implementing a cultural mentoring program alongside pain management and physical rehabilitation for chronic musculoskeletal conditions: results of a controlled before-and-after pilot study.

BACKGROUND: Culturally diverse communities face barriers managing chronic musculoskeletal pain conditions including navigation challenges, sub-optimal healthcare provider engagement and difficulty adopting self-management behaviours. OBJECTIVES: To explore the feasibility and trends of effectiveness of implementing a cultural mentoring program alongside clinical service delivery. METHODS: This quasi-experimental controlled before-and-after multiple case study was conducted in three hospital-based services that provide treatment for patients with musculoskeletal pain. Two prospective cohorts, a pre-implementation and a post-implementation cohort, of adults with chronic musculoskeletal pain who attended during the 6-month recruitment phase, were eligible if they self-identified with one of the cultures prioritised for mentoring by the clinic. The pre-implementation cohort received routine care for up to 3-months, while the post-implementation cohort received up to 3-months of cultural mentoring integrated into routine care (3 to 10 sessions), provided by a consumer (n = 6) with lived experience. Feasibility measures (recruitment and completion rates, attendance, satisfaction), and trends of effectiveness (Patient Activation Measure and Health Literacy Questionnaire items one and six) were collated over 3-months for both cohorts. Outcomes were presented descriptively and analysed using Mann-Whitney U-tests for between-group comparisons. Translation and transcription of post-treatment semi-structured interviews allowed both cohorts' perspectives of treatment to be analysed using a Rapid Assessment Process. RESULTS: The cultural mentor program was feasible to implement in clinical services with comparable recruitment rates (66% pre-implementation; 61% post-implementation), adequate treatment attendance (75% pre-implementation; 89% post-implementation), high treatment satisfaction (97% pre-implementation; 96% post-implementation), and minimal participant drop-out (< 5%). Compared to routine care (n = 71), patients receiving mentoring (n = 55) achieved significantly higher Patient Activation Measure scores (median change 0 vs 10.3 points, p < 0.01) at 3-months, while Health Literacy Questionnaire items did not change for either cohort over time. Three themes underpinned participant experiences and acceptability of the mentoring intervention: 'expectational priming', 'lived expertise' and 'collectivist orientation' to understand shared participant experiences and explore the potential differential effect of the mentoring intervention. CONCLUSION: Participant experiences and observations of improved patient activation provide support for the acceptability of the mentoring intervention integrated into routine care. These results support the feasibility of conducting a definitive trial, while also exploring issues of scalability and sustainability.

The Natural Helper approach to culturally responsive disease management: protocol for a type 1 effectiveness-implementation cluster randomised controlled trial of a cultural mentor programme.

INTRODUCTION: Chronic disease is a leading cause of death and disability that disproportionately burdens culturally and linguistically diverse (CALD) communities. Self-management is a cornerstone of effective chronic disease management. However, research suggests that patients from CALD communities may be less likely to engage with self-management approaches. The Natural Helper Programme aims to facilitate patient engagement with self-management approaches (ie, 'activation') by embedding cultural mentors with lived experience of chronic disease into chronic disease clinics/programmes. The Natural Helper Trial will explore the effect of cultural mentors on patient activation, health self-efficacy, coping efforts and health-related quality of life (HRQoL) while also evaluating the implementation strategy. METHODS AND ANALYSIS: A hybrid type-1 effectiveness-implementation cluster-randomised controlled trial (phase one) and a mixed-method controlled before-and-after cohort extension of the trial (phase 2). Hospital clinics in highly multicultural regions in Australia that provide healthcare for patients with chronic and/or complex conditions, will participate. A minimum of 16 chronic disease clinics (clusters) will be randomised to immediate (active arm) or delayed implementation (control arm). In phase 1, the active arm will receive a multifaceted strategy supporting them to embed cultural mentors in their services while the control arm continues with usual care. Each cluster will recruit an average of 15 patients, assessed at baseline and 6 months (n=240). In phase 2, clusters in the control arm will receive the implementation strategy and evaluate the intervention on an additional 15 patients per cluster, while sustainability in active arm clusters will be assessed qualitatively. Change in activation over 6 months, measured using the Patient Activation Measure will be the primary effectiveness outcome, while secondary effectiveness outcomes will explore changes in chronic disease self-efficacy, coping strategies and HRQoL. Secondary implementation outcomes will be collected from patient-participants, mentors and healthcare providers using validated questionnaires, customised surveys and interviews aligning with the Reach, Effectiveness, Adoption, Implementation, Maintenance framework to evaluate acceptability, reach, dose delivered, sustainability, cost-utility and healthcare provider determinants. ETHICS AND DISSEMINATION: This trial has full ethical approval (2021/ETH12279). The results from this hybrid trial will be presented at scientific meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12622000697785.

Myocardial strain: a clinical review.

BACKGROUND: Myocardial strain-change in myocardial fibre length over the cardiac cycle-is a measure of cardiac muscle function. It is obtained using conventional techniques such as echocardiography and magnetic resonance imaging, adding additional clinical information to augment the current techniques. METHODS: A narrative review of the current relevant literature with respect to myocardial strain, with a focus on strain measured by echocardiography. RESULTS: Myocardial strain identifies global and regional abnormalities in myocardial function and differentiates types of cardiomyopathy. It is an earlier marker of myocardial disease than ejection fraction and is predictive of cardiovascular adverse events. Accurate measurement requires high-quality images and experienced practitioners. CONCLUSION: This review explains advantages and disadvantages of myocardial strain imaging and explains why, through adding increased precision without additional burden, it should be a standard part of cardiac assessment.

From burden to benefit: a multi-site study of the impact of allied health work-based learning placements on patient care quality.

Allied health clinical placements take place within an increasingly overstretched health care system where demand for services often exceeds availability of resources. Within this environment, student placements are often perceived as an additional burden to an already overwhelmed workforce. This study explored whether the quality of patient care was enhanced when services were re-designed using a collaborative partnership approach to more purposefully integrate students into delivery of care. Using an embedded multiple case study design, data were collected through focus groups and interviews, patient experience surveys, and secondary administrative data sources. Cases were across physiotherapy and occupational therapy in six different hospital settings. Perception of care provided by students was viewed positively by all stakeholders, including patients. Perceived health outcomes of faster improvement of health condition, improved mobility and function identified through our qualitative findings were supported by quantitative service delivery markers such as increased therapy sessions, more patients being discharged home instead of to other care facilities and reduced length of stay. Health care providers and students alike perceived improvements in service efficiencies whilst maintaining high quality care. This study has provided preliminary evidence towards improved patient care when a partnering approach is adopted whereby students are intentionally integrated into services that otherwise might not have been delivered. Furthermore, it has shifted the associated narrative from students as additional burden to students as benefit.

Is inpatient rehabilitation a predictor of a lower incidence of persistent knee pain 3-months following total knee replacement? A retrospective, observational study.

BACKGROUND: Moderate to severe levels of persistent knee pain have been estimated to affect up to 25% of people 3-months or more after a total knee replacement. It is unknown whether the type of rehabilitation pathway is associated with persistent high pain after surgery. Using a prospectively followed Australian cohort who underwent total knee replacement for knee osteoarthritis, this study aimed to i) report the incidence of high-intensity knee pain (defined as a score ≤ 15 on the Oxford Knee Score pain subscale) across time and ii) identify whether referral to inpatient rehabilitation was one of the predictors of persistent pain at 3-months post-surgery. METHODS: A retrospective analysis of a large prospective study was conducted using the Oxford Knee Score pain subscale to determine if participants had high pain at 3-months, 12-months and 36-months post-surgery. Relative risks for high pain at 3-, 12- and 36-months between the type of rehabilitation pathway were determined using Poisson multivariable regression with robust standard errors. The same technique was also employed to determine potential predictors, including rehabilitation pathway, of high pain at 3 months. RESULTS: The incidence of high pain in all participants was 73% pre-surgery and 10, 5 and 6% at 3-, 12- and 36-months respectively following knee replacement. There was a significant interaction between time and rehabilitation pathway, suggesting that the effect of the rehabilitation pathway varied across time. The incidence of high pain at 3-months did not significantly differ between those who attended inpatient rehabilitation (11.6%) and those discharged directly home (9.5%). Multivariable Poisson regression analysis identified the pre-surgical presence of high pain, co-morbid low back pain or other lower limb problem, younger age and having a major complication within 3-months following surgery as significant predictors of persistent pain whilst discharge to inpatient rehabilitation was not. CONCLUSION: A small but clinically significant minority of people continued to have high pain levels at 3-, 12- and 36-months following a primary total knee replacement for osteoarthritis. Participation in an inpatient rehabilitation program does not appear to be an important predictor of ongoing knee pain. TRIAL REGISTRATION: The data were collected in the Evidence-based Processes and Outcomes of Care (EPOC) study, ClinicalTrials.gov Identifier: NCT01899443.

Cancer treatment-related cardiac dysfunction.

OBJECTIVES: This paper describes cardiotoxicity and cancer treatment-related cardiac dysfunction (CTRCD). Long-term sequelae of treatment are important, and changing, and may manifest when a patient is under the care of a supportive care service. METHODS: Key messages for supportive and palliative care clinicians are outlined to facilitate identification and management of CTRCD. RESULTS: Not all cardiotoxicity is alike. Types of cardiotoxicity, cardiac complications of immunotherapy, the challenge of autonomic nervous system dysfunction in cancer and management of cardiotoxicity are highlighted. CONCLUSIONS: The key strategies are early detection of cardiotoxicity, monitoring for development of CTRCD during treatment and surveillance in survivorship.