Continuous Positive Airway Pressure plus Mandibular Advancement Therapy (PAPMAT): study protocol for an adaptive randomised crossover trial comparing the benefits and costs of combining two established treatments for obstructive sleep apnoea.

BACKGROUND: Obstructive sleep apnoea (OSA) involves repeated breathing pauses during sleep due to upper airway obstruction. It causes excessive daytime sleepiness and has other health impacts. Continuous positive airway pressure (CPAP) therapy is effective first line treatment for moderate to severe OSA. Unfortunately, many patients have difficulty tolerating CPAP and pressure intolerance is probably an important contributing factor. Mandibular advancement devices (MAD) are an alternative to CPAP. They are worn in the mouth during sleep to reduce airway obstruction. There is some evidence that, when used in combination with CPAP, MADs improve airway anatomy enough to reduce the CPAP pressure required to treat OSA and that this combination therapy could improve CPAP adherence. METHODS: Consecutive patients starting on CPAP for moderate to severe OSA will be recruited at a regional NHS sleep service. Patients with high CPAP pressure requirements after initial titration, who satisfy all entry criteria and consent to participate, will undertake a 2-arm randomised crossover trial. The arms will be (i) standalone CPAP and (ii) CPAP + MAD therapy. Each arm will last 12 weeks, including 2 weeks acclimatisation. CPAP machines will be auto-titrating and with facility for data download, so the impact of MAD on CPAP pressure requirements and CPAP adherence can be easily measured. The primary outcome will be CPAP adherence. Secondary outcomes will include measures of OSA severity, patient-reported outcome measures including subjective daytime sleepiness, quality of life, and treatment preference at the trial exit and health service use. Cost-effectiveness analyses will be undertaken. DISCUSSION: If the intervention is shown to be effective and cost-effective in improving adherence in this standard CPAP-eligible OSA patient population it would be relatively straightforward to introduce into existing OSA treatment pathways, within the wider NHS and more widely. Both MAD and CPAP are already used by sleep services so their combination would require only minor adjustments to existing clinical pathways. It would be straightforward to disseminate the results of the study through regional, national, and international respiratory meetings. The health economics analysis would provide cost-effectiveness data to inform service planning and clinical guidelines through policy briefing papers, including those by NICE and SIGN. TRIAL REGISTRATION: PAPMAT was registered with ISRCTN prior to recruitment beginning (ISRCTN Registry 2021): https://www.isrctn.com/ISRCTN33966032 . Registered on 17th November 2021.

More than just body mass index: Using the Edmonton obesity staging system for pediatrics to define obesity severity in a multi-ethnic Australian pediatric clinical cohort.

Background: Despite advancements in the use of body mass index (BMI) to categorize obesity severity in pediatrics, its utility in guiding individual clinical decision making remains limited. The Edmonton Obesity Staging System for Pediatrics (EOSS-P) provides a way to categorize the medical and functional impacts of obesity according to the severity of impairment. The aim of this study was to describe the severity of obesity among a sample of multicultural Australian children using both BMI and EOSS-P tools. Methods: This cross-sectional study included children aged 2-17 years receiving obesity treatment through the Growing Health Kids (GHK) multi-disciplinary weight management service in Australia between January to December 2021. BMI severity was determined using the 95th percentile for BMI on age and gender standardized Centre for Disease Control and Prevention (CDC) growth charts. The EOSS-P staging system was applied across the four health domains (metabolic, mechanical, mental health and social milieu) using clinical information. Results: Complete data was obtained for 338 children (age 10.0 ± 3.66 years), of whom 69.5% were affected by severe obesity. An EOSS-P stage 3 (most severe) was assigned to 49.7% of children, the remaining 48.5% were assigned stage 2 and 1.5% were assigned stage 1 (least severe). BMI predicted health risk as defined by EOSS-P overall score. BMI class did not predict poor mental health. Conclusion: Used in combination, BMI and EOSS-P provide improved risk stratification of pediatric obesity. This additional tool can help focus resources and develop comprehensive multidisciplinary treatment plans.

Induction of labour for predicted macrosomia: study protocol for the 'Big Baby' randomised controlled trial.

INTRODUCTION: Large-for-gestational age (LGA) fetuses have an increased risk of shoulder dystocia. This can lead to adverse neonatal outcomes and death. Early induction of labour in women with a fetus suspected to be macrosomic may mitigate the risk of shoulder dystocia. The Big Baby Trial aims to find if induction of labour at 38+0-38+4 weeks' gestation, in pregnancies with suspected LGA fetuses, reduces the incidence of shoulder dystocia. METHODS AND ANALYSIS: The Big Baby Trial is a multicentre, prospective, individually randomised controlled trial of induction of labour at 38+0 to 38+4 weeks' gestation vs standard care as per each hospital trust (median gestation of delivery 39+4) among women whose fetuses have an estimated fetal weight >90th customised centile according to ultrasound scan at 35+0 to 38+0 weeks' gestation. There is a parallel cohort study for women who decline randomisation because they opt for induction, expectant management or caesarean section. Up to 4000 women will be recruited and randomised to induction of labour or to standard care. The primary outcome is the incidence of shoulder dystocia; assessed by an independent expert group, blind to treatment allocation, from delivery records. Secondary outcomes include birth trauma, fractures, haemorrhage, caesarean section rate and length of inpatient stay. The main trial is ongoing, following an internal pilot study. A qualitative reporting, health economic evaluation and parallel process evaluation are included. ETHICS AND DISSEMINATION: The study received a favourable opinion from the South West-Cornwall and Plymouth Health Research Authority on 23/03/2018 (IRAS project ID 229163). Study results will be reported in the National Institute for Health Research journal library and published in an open access peer-reviewed journal. We will plan dissemination events for key stakeholders. TRIAL REGISTRATION NUMBER: ISRCTN18229892.

Scale-up of prevention programmes: sustained state-wide use of programme delivery software is explained by normalised self-organised adoption and non-adoption.

BACKGROUND: Population-level health promotion is often conceived as a tension between "top-down" and "bottom-up" strategy and action. We report behind-the-scenes insights from Australia's largest ever investment in the "top-down" approach, the $45m state-wide scale-up of two childhood obesity programmes. We used Normalisation Process Theory (NPT) as a template to interpret the organisational embedding of the purpose-built software designed to facilitate the initiative. The use of the technology was mandatory for evaluation, i.e. for reporting the proportion of schools and childcare centres which complied with recommended health practices (the implementation targets). Additionally, the software was recommended as a device to guide the implementation process. We set out to study its use in practice. METHODS: Short-term, high-intensity ethnography with all 14 programme delivery teams across New South Wales was conducted, cross-sectionally, 4 years after scale-up began. The four key mechanisms of NPT (coherence/sensemaking, cognitive participation/engagement, collective action and reflexive monitoring) were used to describe the ways the technology had normalised (embedded). RESULTS: Some teams and practitioners embraced how the software offered a way of working systematically with sites to encourage uptake of recommended practices, while others rejected it as a form of "mechanisation". Conscious choices had to be made at an individual and team level about the practice style offered by the technology-thus prompting personal sensemaking, re-organisation of work, awareness of choices by others and reflexivity about professional values. Local organisational arrangements allowed technology users to enter data and assist the work of non-users-collective action that legitimised opposite behaviours. Thus, the technology and the programme delivery style it represented were normalised by pathways of adoption and non-adoption. Normalised use and non-use were accepted and different choices made by local programme managers were respected. State-wide, implementation targets are being reported as met. CONCLUSION: We observed a form of self-organisation where individual practitioners and teams are finding their own place in a new system, consistent with complexity-based understandings of fostering scale-up in health care. Self-organisation could be facilitated with further cross-team interaction to continuously renew and revise sensemaking processes and support diverse adoption choices across different contexts.

Multi-disciplinary team meetings with specialist radiologists may improve pre-operative clinico-radiological diagnostic accuracy in patients requiring orbital biopsy and offer reciprocal educational opportunities.

BACKGROUND: Accurate pre-operative diagnosis of orbital lesions supports appropriate prioritisation of patients into available theatre time. We examine the accuracy of pre-operative clinico-radiological diagnosis in a tertiary centre with weekly dedicated orbital clinics and associated multi-disciplinary team meetings. METHODS: A retrospective case notes review was undertaken for all patients who had an orbital biopsy performed at Bristol Eye Hospital between 2007 and 2017. In this centre, pre-operative clinico-radiological differential diagnoses are discussed during multi-disciplinary team meetings including two orbital specialist ophthalmologists and a specialist neuro-radiologist. Clinico-radiological diagnoses were compared with histopathological outcomes. Subcategory analysis according to histopathological diagnosis was undertaken to look for trends. RESULTS: 172 biopsies were taken from 156 patients, median age 59 years (range 3 months to 91 years). 60.9% of patient were females, with equal numbers of right and left-sided biopsies. 11 patients had inconclusive histopathology. 15 patients did not have a documented preoperative diagnosis or differential offered in available notes. 71 patients (49.0%) demonstrated an exact match between clinico-radiological and histopathological diagnosis, 93 (64.1%) demonstrated a category match (e.g. inflammatory, lymphoproliferative) and for 111 (76.6%), the histopathological diagnosis was considered within the list of proffered clinico-radiological differential diagnoses. CONCLUSIONS: Accuracy of pre-operative diagnosis of orbital lesions undergoing biopsy was higher in our series than previously reported by Koukoulli et al. Specialist head and neck radiology input via regular orbital multi-disciplinary meetings might be reciprocally educational and explain this difference. The authors recommend all surgeons who perform orbital surgery should have access to such multi-disciplinary meetings.

Bilateral Paraneoplastic Orbital Myositis Associated With Malignant Melanoma and Multiple Myeloma.

Paraneoplastic extraocular muscle enlargement has been reported in a small number of patients with cancers including breast or lymphoma, usually presenting with bilateral multiple muscle involvement. Such myositis may be autoimmune. Furthermore, orbital inflammation is a recognized complication of immune-modulation therapy used to treat melanoma, such as ipilimumab. Extraorbital myositis has been described in myeloma, and polymyositis in melanoma. We present a case of bilateral, asymmetrical extraocular muscle enlargement with spontaneous resolution in a patient with simultaneous new diagnoses of metastatic malignant melanoma and multiple myeloma. A similar episode 7 months before diagnosis also resolved spontaneously. The authors believe this to be the first reported case of paraneoplastic orbital myositis associated with multiple myeloma or untreated malignant melanoma.

Scale-up of the Physical Activity 4 Everyone (PA4E1) intervention in secondary schools: 24-month implementation and cost outcomes from a cluster randomised controlled trial.

BACKGROUND: Physical Activity 4 Everyone (PA4E1) is an evidence-based program effective at increasing adolescent physical activity (PA) and improving weight status. This study aimed to determine a) the effectiveness of an adapted implementation intervention to scale-up PA4E1 at 24-month follow-up, b) fidelity and reach, and c) the cost and cost-effectiveness of the implementation support intervention. METHODS: A cluster randomised controlled trial using a type III hybrid implementation-effectiveness design in 49 lower socio-economic secondary schools, randomised to a program (n = 24) or control group (n = 25). An adapted implementation intervention consisting of seven strategies was developed to support schools to implement PA4E1 over 24-months. The primary outcome was the proportion of schools implementing at least four of the 7 PA practices, assessed via computer assisted telephone interviews (CATI) with Head Physical Education Teachers. Secondary outcomes included the mean number of PA practices implemented, fidelity and reach, cost and cost-effectiveness. Logistic regression models assessed program effects. RESULTS: At baseline, no schools implemented four of the 7 PA practices. At 24-months, significantly more schools in the program group (16/23, 69.6%) implemented at least four of the 7 PA practices than the control group (0/25, 0%) (p < 0.001). At 24-months, program schools were implementing an average of 3.6 more practices than control schools (4.1 (1.7) vs. 0.5 (0.8), respectively) (P < 0.001). Fidelity and reach of the implementation intervention were high (> 75%). The total cost of the program was $415,112 AUD (2018) ($17,296 per school; $117.30 per student). CONCLUSIONS: The adapted implementation intervention provides policy makers and researchers with an effective and potentially cost-effective model for scaling-up the delivery of PA4E1 in secondary schools. Further assessment of sustainability is warranted. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12617000681358 prospectively registered 12th May 2017.

The Weight of Words: Co-Analysis of Thick Ethnographic Description and "Friction" as Methodological Strategies in a Health Policy Research Partnership.

Co-production partnerships between policymakers, practitioners, and researchers are designed to facilitate production of relevant and readily usable research in health policy and practice contexts. We describe methodological strategies for in-depth collaborative analysis based on a co-produced ethnography of health promotion practice, involving ethnographic researchers and government-based research partners. We draw on a co-production dialogue to reflect critically on the role and value of co-analyzing research findings using thick ethnographic descriptions. The ambiguity of ethnographic imagery allowed flexibility in interpretation of findings and also generated friction. Specific ethnographic images became focal points for productive friction that crystallized ethical and analytical imperatives underpinning the diverse expertise in the team. To make the most of co-analysis of thick ethnographic descriptions, we assert that friction points must be reflexively considered as key learning opportunities for (a) higher order analysis informed by diverse analytical perspectives and (b) more cohesive and useful interpretations of research findings.

Scale-up of the Physical Activity 4 Everyone (PA4E1) intervention in secondary schools: 12-month implementation outcomes from a cluster randomized controlled trial.

BACKGROUND: 'Physical Activity 4 Everyone' (PA4E1) was an efficacious multi-component school-based physical activity (PA) program targeting adolescents. PA4E1 has seven PA practices. It is essential to scale-up, evaluate effectiveness and assess implementation of such programs. Therefore, the aim is to assess the impact of implementation support on school practice uptake of the PA4E1 program at 12 and 24 months. METHODS: A cluster randomised controlled trial, utilising a type III hybrid implementation-effectiveness design, was conducted in 49 randomly selected disadvantaged Australian Government and Catholic secondary schools. A blinded statistician randomly allocated schools to a usual practice control (n = 25) or the PA4E1 program group (n = 24), with the latter receiving seven implementation support strategies to support school PA practice uptake of the seven practices retained from the efficacy trial. The primary outcome was the proportion of schools adopting at least four of the seven practices, assessed via telephone surveys with Head Physical Education Teachers and analysed using exact logistic regression modelling. This paper reports the 12-month outcomes. RESULTS: Schools were recruited from May to November 2017. At baseline, no schools implemented four of the seven practices. At 12 months significantly more schools in the program group had implemented four of the seven practices (16/24, 66.7%) than the control group (1/25, 4%) (OR = 33.0[4.15-1556.4], p < 0.001). The program group implemented on average 3.2 (2.5-3.9) more practices than the control group (p < 0.001, mean 3.9 (SD 1.5) vs 0.7 (1.0)). Fidelity and reach of the implementation support intervention were high (both > 80%). CONCLUSIONS: Through the application of multiple implementation support strategies, secondary schools were able to overcome commonly known barriers to implement evidence based school PA practices. As such practices have been shown to result in an increase in adolescent PA and improvements in weight status, policy makers and practitioners responsible for advocating PA in schools should consider this implementation approach more broadly when working with schools. Follow-up is required to determine whether practice implementation is sustained. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12617000681358 registered 12th May 2017.

Can an electronic monitoring system capture implementation of health promotion programs? A focussed ethnographic exploration of the story behind program monitoring data.

BACKGROUND: There is a pressing need for policy makers to demonstrate progress made on investments in prevention, but few examples of monitoring systems capable of tracking population-level prevention policies and programs and their implementation. In New South Wales, Australia, the scale up of childhood obesity prevention programs to over 6000 childcare centres and primary schools is monitored via an electronic monitoring system, "PHIMS". METHODS: Via a focussed ethnography with all 14 health promotion implementation teams in the state, we set out to explore what aspects of program implementation are captured via PHIMS, what aspects are not, and the implications for future IT implementation monitoring systems as a result. RESULTS: Practitioners perform a range of activities in the context of delivering obesity prevention programs, but only specific activities are captured via PHIMS. PHIMS thereby defines and standardises certain activities, while non-captured activities can be considered as "extra" work by practitioners. The achievement of implementation targets is influenced by multi-level contextual factors, with only some of the factors accounted for in PHIMS. This evidences incongruencies between work done, recorded and, therefore, recognised. CONCLUSIONS: While monitoring systems cannot and should not capture every aspect of implementation, better accounting for aspects of context and "extra" work involved in program implementation could help illuminate why implementation succeeds or fails. Failure to do so may result in policy makers drawing false conclusions about what is required to achieve implementation targets. Practitioners, as experts of context, are well placed to assist policy makers to develop accurate and meaningful implementation targets and approaches to monitoring.

Key Performance Indicators for program scale-up and divergent practice styles: a study from NSW, Australia.

Implementing programs at scale has become a vital part of the government response to the continuing childhood obesity epidemic. We are studying the largest ever scale-up of school and child care obesity prevention programs in Australia. Health promotion teams support primary schools and early childhood services in their area to achieve a number of specified, evidence-based practices aimed at organizational changes to improve healthy eating and physical activity. Key performance indicators (KPIs) were devised to track program uptake across different areas-measuring both the proportion of schools and early childhood services reached and the proportion of practices achieved in each setting (i.e. the proportion of sites implementing programs as planned). Using a 'tight-loose-tight' model, all local health districts receive funding and are held accountable to reaching KPI implementation targets. However, local teams have independent discretion over how to best use funds to reach targets. Based on 12 months of ethnographic fieldwork and interviews across all districts, this study examines variations in the decision making and strategizing processes of the health promotion teams. We identified three distinct styles of practice: KPI-driven practice (strategic, focussed on targets); relationship-driven practice (focussed on long-term goals); and equity-driven practice (directing resources to sites most in need). In adapting to KPIs, teams make trade-offs and choices. Some teams struggled to balance a moral imperative to attend to equity issues, with a practical need to meet implementation targets. We discuss how models of program scale-up and tracking could possibly evolve to recognize this complexity.

Campbelltown - Changing our Future: study protocol for a whole of system approach to childhood obesity in South Western Sydney.

BACKGROUND: In Australia, around 67% of adults and 25% of children (5-17 years) are currently overweight or obese (Australian Bureau of Statistics, 4364.0.55.001 - National Health Survey: First Results, 2017-18, 2018). The Campbelltown - Changing our Future study will translate 'a whole of system' approach, previously trialed in rural communities in Victoria and the Australian Capital Territoty, to Campbelltown Local Government Area (LGA), a socioeconomically and ethnically diverse urban community in south western Sydney, NSW. METHODS: The study intervention will use a five-step approach; 1 - set up a childhood obesity monitoring system by collecting baseline data from children in primary schools across Campbelltown LGA to give a local context to the community when developing the systems map; 2 - key stakeholders develop systems maps which inform the development of the interventions; 3 - key stakeholders and community groups identify priority areas for action and form working groups; 4 - implementation of the interventions; 5 - evaluation of the interventions. The study will adopt a longitudinal pre/post design with repeated measures at baseline, 2 years and 4 years. Both qualitative and quantitative methods will be used to collect and analyse the data. DISCUSSION: Addressing childhood overweight and obesity is complex and requires a multifaceted intervention. This approach has the capacity to impact a range of factors that influence childhood overweight and obesity utilising existing capacity of multiple partners with broad community reach. Findings will develop local responses which capture the complexity of obesity at a community level and further our understanding of the interrelationships and relative importance of local factors impacting childhood overweight and obesity. This study aims to provide evidence for systems methods and approaches suitable for adaption and scaling and may provide evidence of successful community intervention elements.

Capturing implementation knowledge: applying focused ethnography to study how implementers generate and manage knowledge in the scale-up of obesity prevention programs.

BACKGROUND: Bespoke electronic information management systems are being used for large-scale implementation delivery of population health programs. They record sites reached, coordinate activity, and track target achievement. However, many systems have been abandoned or failed to integrate into practice. We investigated the unusual endurance of an electronic information management system that has supported the successful statewide implementation of two evidence-based childhood obesity prevention programs for over 5 years. Upwards of 80% of implementation targets are being achieved. METHODS: We undertook co-designed partnership research with policymakers, practitioners, and IT designers. Our working hypothesis was that the science of getting evidence-based programs into practice rests on an in-depth understanding of the role programs play in the ongoing system of local relationships and multiple accountabilities. We conducted a 12-month multisite ethnography of 14 implementation teams, including their use of an electronic information management system, the Population Health Information Management System (PHIMS). RESULTS: All teams used PHIMS, but also drew on additional informal tools and technologies to manage, curate, and store critical information for implementation. We identified six functions these tools performed: (1) relationship management, (2) monitoring progress towards target achievement, (3) guiding and troubleshooting PHIMS use, (4) supporting teamwork, (5) evaluation, and (6) recording extra work at sites not related to program implementation. Informal tools enabled practitioners to create locally derived implementation knowledge and provided a conduit between knowledge generation and entry into PHIMS. CONCLUSIONS: Implementation involves knowing and formalizing what to do, as well as how to do it. Our ethnography revealed the importance of hitherto uncharted knowledge about how practitioners develop implementation knowledge about how to do implementation locally, within the context of scaling up. Harnessing this knowledge for local use required adaptive and flexible systems which were enabled by informal tools and technologies. The use of informal tools also complemented and supported PHIMS use suggesting that both informal and standardized systems are required to support coordinated, large-scale implementation. While the content of the supplementary knowledge required to deliver the program was specific to context, functions like managing relationships with sites and helping others in the team may be applicable elsewhere.

A cluster randomised trial of an intervention to increase the implementation of physical activity practices in secondary schools: study protocol for scaling up the Physical Activity 4 Everyone (PA4E1) program.

BACKGROUND: The implementation of interventions at-scale is required to maximise population health benefits. 'Physical Activity 4 Everyone (PA4E1)' was a multi-component school-based program targeting adolescents attending secondary schools in low socio-economic areas. An efficacy trial of the intervention demonstrated an increase in students' mean minutes of moderate-to-vigorous physical activity (MVPA) per day and lower weight gain at low incremental cost. This study aims to assess the effectiveness and cost effectiveness of a multi-component implementation support intervention to improve implementation, at-scale, of the evidence based school physical activity (PA) practices of the PA4E1 program. Impact on student PA levels and adiposity will also be assessed, in addition to the cost of implementation. METHODS: A cluster randomised controlled trial, utilising an effectiveness-implementation hybrid design, will be conducted in up to 76 secondary schools located in lower socio-economic areas across four health districts in New South Wales (NSW), Australia. Schools will be randomly allocated to a usual practice control arm or a multi-component implementation support intervention to embed the seven school PA practices of the PA4E1 program. The implementation support intervention incorporates seven strategies including executive support, in-School Champion, teacher training, resources, prompts, audit and feedback and access to an external Support Officer. The primary trial outcome will be the proportion of schools meeting at least four of the seven physical activity practices of the program, assessed via surveys with Head Physical Education teachers at 12 and 24-months. Secondary outcomes will be assessed via a nested evaluation of student PA and adiposity at 12-months (Grade 8 students) and 24 months (Grade 9 students) undertaken in 30 schools (15 per group). Resource use associated with the implementation intervention will be measured prospectively. Linear mixed effects regression models will assess program effects on the primary outcome at each follow-up period. DISCUSSION: This study is one of few evidence-based multi-component PA programs scaled-up to a large number of secondary schools and evaluated via randomised controlled trial. The use of implementation science theoretical frameworks to implement the evidence-based program and the rigorous evaluation design are strengths of the study. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12617000681358 registered 12th May 2017. Protocol Version 1.

Cross-sectional study protocol for the Arabic Healthy Weight Project promoting active living and healthy eating among Arabic-speaking communities in South Western Sydney.

INTRODUCTION: The South Western Sydney Local Health District (SWSLHD) is home to nearly 75 000 Arabic-speaking people. Of these, nearly three quarters are overweight or obese and suffer from a range of chronic diseases. To address this, the Health Promotion Service of SWSLHD will conduct a community-based overweight and obesity prevention intervention (Arabic Healthy Weight Project, 2018-2021) with Arabic community members aged between 18 and 50 years. The intervention's main activities will include a comprehensive social marketing campaign and an 'Eat-Move-Live Healthy' programme. METHODS AND ANALYSIS: The project will be evaluated using a pre-postintervention study design to measure changes in practices in relation to physical activity, consumption of vegetables and intake of sugar-sweetened beverages. The evaluation will apply mixed data collection methods. The quantitative data will be collected using a face-to-face survey of 1540 participants from two independent samples (pre: 770 and post: 770). Descriptive and inferential statistical tests will be used to analyse the quantitative data. The qualitative component will use focus group discussions and interviews to evaluate the formative, process and follow-up phases of data collection. A combination of deductive and inductive methods of data analysis will be conducted using NVivo software. ETHICS AND DISSEMINATION: The protocol has been approved by the Human Research Ethics Committee of SWSLHD (HREC/16/LPOOL/303). Findings will be published in peer-reviewed journals.

Codesign of the Population Health Information Management System to measure reach and practice change of childhood obesity programs.

INTRODUCTION: Childhood obesity prevalence is an issue of international public health concern and governments have a significant role to play in its reduction. The Healthy Children Initiative (HCI) has been delivered in New South Wales (NSW), Australia, since 2011 to support implementation of childhood obesity prevention programs at scale. Consequently, a system to support local implementation and data collection, analysis and reporting at local and state levels was necessary. The Population Health Information Management System (PHIMS) was developed to meet this need. Design and development: A collaborative and iterative process was applied to the design and development of the system. The process comprised identifying technical requirements, building system infrastructure, delivering training, deploying the system and implementing quality measures. Use of PHIMS: Implementation of PHIMS resulted in rapid data retrieval and reporting against agreed performance measures for the HCI. The system has 150 users who account for the monitoring and reporting of more than 6000 HCI intervention sites (early childhood services and primary schools). LESSONS LEARNT: Developing and implementing PHIMS presented a number of complexities including: applying an information technology (IT) development methodology to a traditional health promotion setting; data access and confidentiality issues; and managing system development and deployment to intended timelines and budget. PHIMS was successfully codesigned as a flexible, scalable and sustainable IT solution that supports state-wide HCI program implementation, monitoring and reporting.

Fetal growth surveillance - Current guidelines, practices and challenges.

Antenatal surveillance of fetal growth is an essential part of good maternity care, as lack of detection of fetal growth restriction is directly associated with stillbirth and perinatal morbidity. New algorithms and guidelines provide care pathways which rely on regular third trimester ultrasound biometry and plotting of estimated fetal weight in pregnancies considered to be at increased risk, and their implementation has increased pressures on ultrasound resources. Customised growth charts have improved the distinction between constitutional and pathological smallness and reduced unnecessary referrals. Their introduction, together with clinicians' training, e-learning and audit as the key elements of the growth assessment protocol, has resulted in increased antenatal detection of small for gestational age babies and a reduction in avoidable stillbirths. However, missed case audits highlight that further improvements are needed, and point to the need to address quality assurance and resource issues in ultrasound services.

Customized growth charts: rationale, validation and clinical benefits.

Appropriate standards for the assessment of fetal growth and birthweight are central to good clinical care, and have become even more important with increasing evidence that growth-related adverse outcomes are potentially avoidable. Standards need to be evidence based and validated against pregnancy outcome and able to demonstrate utility and effectiveness. A review of proposals by the Intergrowth consortium to adopt their single international standard finds little support for the claim that the cases that it identifies as small are due to malnutrition or stunting, and substantial evidence that there is normal physiologic variation between different countries and ethnic groups. It is possible that the one-size-fits-all standard ends up fitting no one and could be harmful if implemented. An alternative is the concept of country-specific charts that can improve the association between abnormal growth and adverse outcome. However, such standards ignore individual physiologic variation that affects fetal growth, which exists in any heterogeneous population and exceeds intercountry differences. It is therefore more logical to adjust for the characteristics of each mother, taking her ethnic origin and her height, weight, and parity into account, and to set a growth and birthweight standard for each pregnancy against which actual growth can be assessed. A customized standard better reflects adverse pregnancy outcome at both ends of the fetal size spectrum and has increased clinicians' confidence in growth assessment, while providing reassurance when abnormal size merely represents physiologic variation. Rollout in the United Kingdom has proceeded as part of the comprehensive Growth Assessment Protocol (GAP), and has resulted in a steady increase in antenatal detection of babies who are at risk because of fetal growth restriction. This in turn has been accompanied by a year-on-year drop in stillbirth rates to their lowest ever levels in England. A global version of customized growth charts with over 100 ethnic origin categories is being launched in 2018, and will provide an individualized, yet universally applicable, standard for fetal growth.

Intracranial hypotension mimicking chronic progressive external ophthalmoplegia.

Intracranial hypotension (ICH) is characterized by low cerebrospinal fluid pressure, postural headaches, and diffuse pachymeningeal enhancement on magnetic resonance imaging (MRI). A variety of ophthalmoparetic manifestations have been reported in the context of the ICH. The authors describe an unusual case of a 64-year-old woman who presented with rapid onset of headaches, bilateral upper-lid ptosis, and blurring of vision within 4 days after sustaining a trivial head injury. She was noted to have bilateral symmetrical ophthalmoplegia and ptosis-simulating chronic progressive external ophthalmoplegia. MRI revealed characteristic features of ICH. Subsequent autologous epidural patch therapy led to resolution of the headache and imaging findings; however, her ptosis and motility disorder persisted. Despite existing therapeutic measures for ICH, irreversible cranial nerve damage may ensue due to significant cerebral decent or ischemic injury.

Dynamics behind the scale up of evidence-based obesity prevention: protocol for a multi-site case study of an electronic implementation monitoring system in health promotion practice.

BACKGROUND: The effectiveness of many interventions to promote health and prevent disease has been well established. The imperative has therefore shifted from amassing evidence about efficacy to scale-up to maximise population-level health gains. Electronic implementation monitoring, or 'e-monitoring', systems have been designed to assist and track the delivery of preventive policies and programs. However, there is little evidence on whether e-monitoring systems improve the dissemination, adoption, and ongoing delivery of evidence-based preventive programs. Also, given considerable difficulties with e-monitoring systems in the clinical sector, scholars have called for a more sophisticated re-examination of e-monitoring's role in enhancing implementation. METHODS: In the state of New South Wales (NSW), Australia, the Population Health Information Management System (PHIMS) was created to support the dissemination of obesity prevention programs to 6000 childcare centres and elementary schools across all 15 local health districts. We have established a three-way university-policymaker-practice research partnership to investigate the impact of PHIMS on practice, how PHIMS is used, and how achievement of key performance indicators of program adoption may be associated with local contextual factors. Our methods encompass ethnographic observation, key informant interviews and participatory workshops for data interpretation at a state and local level. We use an on-line social network analysis of the collaborative relationships across local health district health promotion teams to explore the relationship between PHIMS use and the organisational structure of practice. DISCUSSION: Insights will be sensitised by institutional theory, practice theory and complex adaptive system thinking, among other theories which make sense of socio-technical action. Our working hypothesis is that the science of getting evidence-based programs into practice rests on an in-depth understanding of the role they play in the on-going system of local relationships and multiple accountabilities. Data will be synthesised to produce a typology to characterise local context, PHIMS use and key performance indicator achievement (of program implementation) across the 15 local health districts. Results could be used to continuously align e-monitoring technologies within quality improvement processes to ensure that such technologies enhance practice and innovation. A partnership approach to knowledge production increases the likelihood that findings will be put into practice.