Glacial changes in sea level modulated millennial-scale variability of Southeast Asian autumn monsoon rainfall.

Most paleoclimate studies of Mainland Southeast Asia hydroclimate focus on the summer monsoon, with few studies investigating rainfall in other seasons. Here, we present a multiproxy stalagmite record (45,000 to 4,000 years) from central Vietnam, a region that receives most of its annual rainfall in autumn (September-November). We find evidence of a prolonged dry period spanning the last glacial maximum that is punctuated by an abrupt shift to wetter conditions during the deglaciation at ~14 ka. Paired with climate model simulations, we show that sea-level change drives autumn monsoon rainfall variability on glacial-orbital timescales. Consistent with the dry signal in the stalagmite record, climate model simulations reveal that lower glacial sea level exposes land in the Gulf of Tonkin and along the South China Shelf, reducing convection and moisture delivery to central Vietnam. When sea level rises and these landmasses flood at ~14 ka, moisture delivery to central Vietnam increases, causing an abrupt shift from dry to wet conditions. On millennial timescales, we find signatures of well-known Heinrich Stadials (HS) (dry conditions) and Dansgaard-Oeschger Events (wet conditions). Model simulations show that during the dry HS, changes in sea surface temperature related to meltwater forcing cause the formation of an anomalous anticyclone in the Western Pacific, which advects dry air across central Vietnam, decreasing autumn rainfall. Notably, sea level modulates the magnitude of millennial-scale dry and wet phases by muting dry events and enhancing wet events during periods of low sea level, highlighting the importance of this mechanism to autumn monsoon variability.

Electron streaming dose measurements and calculations on a 1.5 T MR-Linac.

PURPOSE: To evaluate the accuracy of different dosimeters and the treatment planning system (TPS) for assessing the skin dose due to the electron streaming effect (ESE) on a 1.5 T magnetic resonance (MR)-linac. METHOD: Skin dose due to the ESE on an MR-linac (Unity, Elekta) was investigated using a solid water phantom rotated 45° in the x-y plane (IEC61217) and centered at the isocenter. The phantom was irradiated with 1 × 1, 3 × 3, 5 × 5, 10 × 10, and 22 × 22 cm2 fields, gantry at 90°. Out-of-field doses (OFDs) deposited by electron streams generated at the entry and exit surface of the angled phantom were measured on the surface of solid water slabs placed ±20.0 cm from the isocenter along the x-direction. A high-resolution MOSkin™ detector served as a benchmark due to its shallower depth of measurement that matches the International Commission on Radiological Protection (ICRP) recommended depth for skin dose assessment (0.07 mm). MOSkin™ doses were compared to EBT3 film, OSLDs, a diamond detector, and the TPS where the experimental setup was modeled using two separate calculation parameters settings: a 0.1 cm dose grid with 0.2% statistical uncertainty (0.1 cm, 0.2%) and a 0.2 cm dose grid with 3.0% statistical uncertainty (0.2 cm, 3.0%). RESULTS: OSLD, film, the 0.1 cm, 0.2%, and 0.2 cm, 3.0% TPS ESE doses, underestimated skin doses measured by the MOSkin™ by as much as -75.3%, -7.0%, -24.7%, and -41.9%, respectively. Film results were most similar to MOSkin™ skin dose measurements. CONCLUSIONS: These results show that electron streams can deposit significant doses outside the primary field and that dosimeter choice and TPS calculation settings greatly influence the reported readings. Due to the steep dose gradient of the ESE, EBT3 film remains the choice for accurate skin dose assessment in this challenging environment.

Characterizing magnetically focused contamination electrons by off-axis irradiation on an inline MRI-Linac.

PURPOSE: The aim of this study is to investigate off-axis irradiation on the Australian MRI-Linac using experiments and Monte Carlo simulations. Simulations are used to verify experimental measurements and to determine the minimum offset distance required to separate electron contamination from the photon field. METHODS: Dosimetric measurements were performed using a microDiamond detector, Gafchromic® EBT3 film, and MOSkinTM . Three field sizes were investigated including 1.9 × 1.9, 5.8 × 5.8, and 9.7 × 9.6 cm2 . Each field was offset a maximum distance, approximately 10 cm, from the central magnetic axis (isocenter). Percentage depth doses (PDDs) were collected at a source-to-surface distance (SSD) of 1.8 m for fields collimated centrally and off-axis. PDD measurements were also acquired at isocenter for each off-axis field to measure electron contamination. Monte Carlo simulations were used to verify experimental measurements, determine the minimum field offset distance, and demonstrate the use of a spoiler to absorb electron contamination. RESULTS: Off-axis irradiation separates the majority of electron contamination from an x-ray beam and was found to significantly reduce in-field surface dose. For the 1.9 × 1.9, 5.8 × 5.8, and 9.7 × 9.6 cm2 field, surface dose was reduced from 120.9% to 24.9%, 229.7% to 39.2%, and 355.3% to 47.3%, respectively. Monte Carlo simulations generally were within experimental error to MOSkinTM and microDiamond, and used to determine the minimum offset distance, 2.1 cm, from the field edge to isocenter. A water spoiler 2 cm thick was shown to reduce electron contamination dose to near zero. CONCLUSIONS: Experimental and simulation data were acquired for a range of field sizes to investigate off-axis irradiation on an inline MRI-Linac. The skin sparing effect was observed with off-axis irradiation, a feature that cannot be achieved to the same extent with other methods, such as bolusing, for beams at isocenter.

Rapamycin Alternatively Modifies Mitochondrial Dynamics in Dendritic Cells to Reduce Kidney Ischemic Reperfusion Injury.

Dendritic cells (DCs) are unique immune cells that can link innate and adaptive immune responses and Immunometabolism greatly impacts their phenotype. Rapamycin is a macrolide compound that has immunosuppressant functions and is used to prevent graft loss in kidney transplantation. The current study evaluated the therapeutic potential of ex-vivo rapamycin treated DCs to protect kidneys in a mouse model of acute kidney injury (AKI). For the rapamycin single (S) treatment (Rapa-S-DC), Veh-DCs were treated with rapamycin (10 ng/mL) for 1 h before LPS. In contrast, rapamycin multiple (M) treatment (Rapa-M-DC) were exposed to 3 treatments over 7 days. Only multiple ex-vivo rapamycin treatments of DCs induced a persistent reprogramming of mitochondrial metabolism. These DCs had 18-fold more mitochondria, had almost 4-fold higher oxygen consumption rates, and produced more ATP compared to Veh-DCs (Veh treated control DCs). Pathway analysis showed IL10 signaling as a major contributing pathway to the altered immunophenotype after Rapamycin treatment compared to vehicle with significantly lower cytokines Tnfa, Il1b, and Il6, while regulators of mitochondrial content Pgc1a, Tfam, and Ho1 remained elevated. Critically, adoptive transfer of rapamycin-treated DCs to WT recipients 24 h before bilateral kidney ischemia significantly protected the kidneys from injury with a significant 3-fold improvement in kidney function. Last, the infusion of DCs containing higher mitochondria numbers (treated ex-vivo with healthy isolated mitochondria (10 µg/mL) one day before) also partially protected the kidneys from IRI. These studies demonstrate that pre-emptive infusion of ex-vivo reprogrammed DCs that have higher mitochondria content has therapeutic capacity to induce an anti-inflammatory regulatory phenotype to protect kidneys from injury.

Accessibility and acceptability of health promotion services in New Zealand for minority refugee women.

Refugees are forced to flee their native country to escape war or oppression. They are resilient and generally have a high level of motivation to rebuild their lives, as well as to make a meaningful contribution to the host country. However, refugees in general have complex health needs and they often face significant barriers in accessing health services in their host countries. Health promotion has been identified as an effective approach for increasing service utilization by minority populations such as refugees, and contributing to their overall positive health outcomes. This qualitative study examined the accessibility and acceptability of health promotion services for Bhutanese refugee women who resettled in New Zealand. The study consisted of two phases: focus group discussions with 32 Bhutanese women and eight Bhutanese men, followed by individual interviews with 12 health professionals including five nurses, four doctors and three midwives. The data were collected in two regional towns of New Zealand in 2014. The study's conceptual framework utilized the strategies and actions underpinning the Ottawa Charter for Health Promotion. Findings of this study revealed that Bhutanese women were missing some essential health promotion services, such as antenatal education sessions mainly due to language and cultural barriers. This study recommends to develop health promotion resources in the Nepali language; and to deliver the health promotion sessions by culturally and linguistically competent providers. This study also uncovered resiliency and strengths of Bhutanese women that could be recognized, strengthened and utilized in promoting their health and well-being.

Effectiveness of Primary Health Care Services in Addressing Mental Health Needs of Minority Refugee Population in New Zealand.

Many people are displaced from their country of origin and become refugees, mostly due to armed conflicts, political violence and human rights abuse. Refugees have complex mental, physical, and social health problems related to their traumatic background and the experiences they have endured during their refugee journey. The aim of this qualitative exploratory study was to examine the effectiveness of primary health care services in addressing mental health needs of Bhutanese refugee women resettled in New Zealand. This study included focus group discussion with Bhutanese women and men followed by interviews with health service providers. The findings of this study highlighted inadequacies and constraints in addressing Bhutanese refugee women's mental health needs in New Zealand and provided evidence for recommendations to address these inadequacies.

Developing research priorities in Australian primary health care: a focus on nutrition and physical activity.

Research priority setting is an important component of research planning, particularly when research options exceed available resources. This study identified the research priorities for supporting healthy lifestyle behaviours in the Australian primary healthcare setting. A five-step stakeholder engagement process was undertaken. Ten stakeholder organisations participated in the process, including patient representatives, health professional associations, health educators, researchers, government advisors and policymakers. Each organisation was asked to provide up to three research questions deemed as a priority. Research questions were critically appraised by the project team for answerability, sustainability, effectiveness, potential for translation and potential to affect disease burden. A blinded scoring system was used to rank the appraised questions, with higher scores indicating higher priority (range of scores possible 87-156). Thirteen unique research questions were submitted by stakeholders and achieved a range of scores from 87 to 139 points. The highest scoring research questions focused on: (i) the effectiveness of different health professionals at facilitating healthy lifestyle behaviours; (ii) the effect of health literacy on behaviour change; and (iii) cost-benefit analysis of healthy lifestyle promotion in primary health care. These priorities can be used to ensure future research projects directly align with the needs and preferences of research end-users.

Using logic models to enhance the methodological quality of primary health-care interventions: guidance from an intervention to promote nutrition care by general practitioners and practice nurses.

The methodological designs underpinning many primary health-care interventions are not rigorous. Logic models can be used to support intervention planning, implementation and evaluation in the primary health-care setting. Logic models provide a systematic and visual way of facilitating shared understanding of the rationale for the intervention, the planned activities, expected outcomes, evaluation strategy and required resources. This article provides guidance for primary health-care practitioners and researchers on the use of logic models for enhancing methodological rigour of interventions. The article outlines the recommended steps in developing a logic model using the 'NutriCare' intervention as an example. The 'NutriCare' intervention is based in the Australian primary health-care setting and promotes nutrition care by general practitioners and practice nurses. The recommended approach involves canvassing the views of all stakeholders who have valuable and informed opinions about the planned project. The following four targeted, iterative steps are recommended: (1) confirm situation, intervention aim and target population; (2) document expected outcomes and outputs of the intervention; (3) identify and describe assumptions, external factors and inputs; and (4) confirm intervention components. Over a period of 2 months, three primary health-care researchers and one health-services consultant led the collaborative development of the 'NutriCare' logic model. Primary health-care practitioners and researchers are encouraged to develop a logic model when planning interventions to maximise the methodological rigour of studies, confirm that data required to answer the question are captured and ensure that the intervention meets the project goals.

A nurse-led model of chronic disease management in general practice: Patients' perspectives.

BACKGROUND: Evidence suggests that current models of chronic disease management within general practice are not effective in meeting the needs of the community. OBJECTIVE: The objective of this article is to examine patients' perceptions of a nurse-led collaborative model of care trialled in three general practices in Australia. METHODS: This article reports on the second phase of a mixed-methods study in which semi-structured interviews with purposively selected patients were conducted to elicit information about their perceptions of nurse-led care. RESULTS: Three themes emerged from the data - time, ambiance and dimensions of the nurse role. DISCUSSION: The results suggest that general practice nurses had a positive impact on patients' ability to manage their chronic disease. This infers that there is scope for general practice nurses to expand their role in chronic disease management to assist patients to better self-manage their chronic diseases.

Factors associated with relational coordination between health professionals involved in insulin initiation in the general practice setting for people with type 2 diabetes.

AIM: To examine associations between characteristics of general practice settings and primary healthcare providers (general practitioners and practice nurses) and the degree of relational coordination for the task of insulin initiation for type 2 diabetes between primary healthcare providers and diabetes specialists. BACKGROUND: Relational coordination is a component of effective chronic disease management and can be used to measure collaboration and communication between health professionals. High levels of relational coordination may be important to support insulin initiation in general practice. DESIGN: Cross-sectional study. METHODS: Surveys were completed by general practitioners and practice nurses participating in the Stepping Up trial. Data on demographics, practice characteristics and relational coordination were collected between October 2012-June 2014. Univariate and multivariate analyses examined factors associated with relational coordination. RESULTS: General practitioners (n = 174) and 115 practice nurses from 78 general practices were included in the analysis. General practice characteristics associated with relational coordination were geographical location and number of administrative staff. Female general practitioners and older practice nurses reported lower relational coordination. Practice nurses with diabetes educator qualifications and experience in insulin initiation reported higher relational coordination. CONCLUSION: An expanded role and experience of practice nurses in diabetes care increased relational coordination and has the potential to deliver more effective chronic disease management in general practice. Practice and health professional characteristics should be taken into account when designing models of care to increase insulin initiation.

Relational coordination amongst health professionals involved in insulin initiation for people with type 2 diabetes in general practice: an exploratory survey.

BACKGROUND: The majority of people with type 2 diabetes (T2D) receive their care in general practice and will eventually require initiation of insulin as part of their management. However, this is often delayed and frequently involves referral to specialists. If insulin initiation is to become more frequent and routine within general practice, coordination of care with specialist services may be required. Relational coordination (RC) provides a framework to explore this. The aim of this study was to explore RC between specialist physicians, specialist diabetes nurses (DNEs), generalist physicians in primary care (GPs) and generalist nurses (practice nurses (PNs)) and to explore the association between RC and the initiation of insulin in general practice, and the belief that it is appropriate for this task to be carried out in general practice. METHODS: A survey was distributed to a convenience sample of specialist physicians, DNEs, GPs and practice nurses. We collected data on demographics, models of care and RC in relation to insulin initiation. We expected that RC would be higher between specialists than between specialists and generalists. We expected higher RC between specialists and generalists to be associated with insulin initiation in general practice and with the belief that it is appropriate for insulin initiation to be carried out in general practice. We used descriptive statistics and non-parametric tests to explore these hypotheses. RESULTS: 179 health professionals returned completed surveys. Specialists reported higher RC with each other and lower RC with PNs. All groups except PNs reported their highest RC with DNEs, suggesting the potential for DNEs to serve as boundary spanners. Lower RC with specialists was reported by those working within a general practice model of care. Health professionals who felt that a general practice model was appropriate reported lower communication with specialist physicians and higher shared knowledge with GPs. CONCLUSION: Given the need for coordination between specialist and generalist care for the task of insulin initiation, this study's results suggest the need to build relationships and communication between specialist and generalist health professional groups and the potential for DNE's to play a boundary spanner role in this process.

Roles and relationships between health professionals involved in insulin initiation for people with type 2 diabetes in the general practice setting: a qualitative study drawing on relational coordination theory.

BACKGROUND: The majority of care for people with type 2 diabetes occurs in general practice, however when insulin initiation is required it often does not occur in this setting or in a timely manner and this may have implications for the development of complications. Increased insulin initiation in general practice is an important goal given the increasing prevalence of type 2 diabetes and a relative shortage of specialists. Coordination between primary and secondary care, and between medical and nursing personnel, may be important in achieving this. Relational coordination theory identifies key concepts that underpin effective interprofessional work: communication which is problem solving, timely, accurate and frequent and relationships between professional roles which are characterized by shared goals, shared knowledge and mutual respect. This study explores roles and relationships between health professionals involved in insulin initiation in order to gain an understanding of factors which may impact on this task being carried out in the general practice setting. METHOD: 21 general practitioners, practice nurses, diabetes nurse educators and physicians were purposively sampled to participate in a semi-structured interview. Transcripts of the interviews were analysed using framework analysis. RESULTS: There were four closely interlinked themes identified which impacted on how health professionals worked together to initiate people with type 2 diabetes on insulin: 1. Ambiguous roles; 2. Uncertain competency and capacity; 3. Varying relationships and communication; and 4. Developing trust and respect. CONCLUSIONS: This study has shown that insulin initiation is generally recognised as acceptable in general practice. The role of the DNE and practice nurse in this space and improved communication and relationships between health professionals across organisations and levels of care are factors which need to be addressed to support this clinical work. Relational coordination provides a useful framework for exploring these issues.

Revenue effects of practice nurse-led care for chronic diseases.

OBJECTIVE: To determine the economic feasibility in Australian general practices of using a practice nurse (PN)-led care model of chronic disease management. METHODS: A cost-analysis of item numbers from the Medicare Benefit Schedule (MBS) was performed in three Australian general practices, one urban, one regional and one rural. Patients (n =254; >18 years of age) with chronic conditions (type 2 diabetes, hypertension, ischaemic heart disease) but without unstable or major health problems were randomised into usual general practitioner (GP) or PN-led care for management of their condition over a period of 12 months. After the 12-month intervention, total MBS item charges were evaluated for patients managed for their stable chronic condition by usual GP or PN-led care. Zero-skewness log transformation was applied to cost data and log-linear regression analysis was undertaken. RESULTS: There was an estimated A$129 mean increase in total MBS item charges over a 1-year period (controlled for age, self-reported quality of life and geographic location of practice) associated with PN-led care. The frequency of GP and PN visits varied markedly according to the chronic disease. CONCLUSIONS: Medicare reimbursements provided sufficient funding for general practices to employ PNs within limits of workloads before the new Practice Nurse Incentive Program was introduced in July 2012.

The feasibility, acceptability and sustainability of nurse-led chronic disease management in Australian general practice: the perspectives of key stakeholders.

This was the first Australian study investigating the acceptability, feasibility and sustainability of a nurse-led model of chronic disease management in general practice. A concurrent mixed-methods design was used within a 12-month intervention of nurse-led care in three general practices. Adult patients with type 2 diabetes, hypertension and/or stable ischaemic heart disease were randomized into nurse-led or standard care. Semi-structured interviews explored perceptions of key stakeholders towards this model including patients in the nurse-led arm, and all practice staff pre- and posttrial. The data were thematically analysed and the emergent themes were: importance of time; collaborative relationships; nurse job satisfaction, confidence and competence; patient self-management and choice. Our findings showed that nurses provided chronic disease management that was acceptable, feasible and sustainable. The collaborative involvement of doctors was intrinsic to patient acceptability of nurse-led care that facilitated job satisfaction, and therefore retention and growth within this nursing speciality.

Outcomes and opportunities: a nurse-led model of chronic disease management in Australian general practice.

The Australian government's commitment to health service reform has placed general practice at the centre of its agenda to manage chronic disease. Concerns about the capacity of GPs to meet the growing chronic disease burden has stimulated the implementation and testing of new models of care that better utilise practice nurses (PN). This paper reports on a mixed-methods study nested within a larger study that trialled the feasibility and acceptability of a new model of nurse-led chronic disease management in three general practices. Patients over 18 years of age with type 2 diabetes, hypertension or stable ischaemic heart disease were randomised into PN-led or usual GP-led care. Primary outcomes were self-reported quality of life and perceptions of the model's feasibility and acceptability from the perspective of patients and GPs. Over the 12-month study quality of life decreased but the trend between groups was not statistically different. Qualitative data indicate that the PN-led model was acceptable and feasible to GPs and patients. It is possible to extend the scope of PN care to lead the routine clinical management of patients' stable chronic diseases. All GPs identified significant advantages to the model and elected to continue with the PN-led care after our study concluded.

The prevention access and risk taking in young people (PARTY) project protocol: a cluster randomised controlled trial of health risk screening and motivational interviewing for young people presenting to general practice.

BACKGROUND: There are growing worldwide concerns about the ability of primary health care systems to manage the major burden of illness in young people. Over two thirds of premature adult deaths result from risks that manifest in adolescence, including injury, neuropsychiatric problems and consequences of risky behaviours. One policy response is to better reorientate primary health services towards prevention and early intervention. Currently, however, there is insufficient evidence to support this recommendation for young people. This paper describes the design and implementation of a trial testing an intervention to promote psychosocial risk screening of all young people attending general practice and to respond to identified risks using motivational interviewing. MAIN OUTCOMES: clinicians' detection of risk-taking and emotional distress, young people's intention to change and reduction of risk taking. SECONDARY OUTCOMES: pathways to care, trust in the clinician and likelihood of returning for future visits. The design of the economic and process evaluation are not detailed in this protocol. METHODS: PARTY is a cluster randomised trial recruiting 42 general practices in Victoria, Australia. Baseline measures include: youth friendly practice characteristics; practice staff's self-perceived competency in young people's care and clinicians' detection and response to risk taking behaviours and emotional distress in 14-24 year olds, attending the practice. Practices are then stratified by a social disadvantage index and billing methods and randomised. Intervention practices receive: nine hours of training and tools; feedback of their baseline data and two practice visits over six weeks. Comparison practices receive a three hour seminar in youth friendly practice only. Six weeks post-intervention, 30 consecutive young people are interviewed post-consultation from each practice and followed-up for self-reported risk taking behaviour and emotional distress three and 12 months post consultation. DISCUSSION: The PARTY trial is the first to examine the effectiveness and efficiency of a psychosocial risk screening and counselling intervention for young people attending primary care. It will provide important data on health risk profiles of young people attending general practice and on the effects of the intervention on engagement with primary care and health outcomes over 12 months. TRIAL REGISTRATION: ISRCTN16059206.

Understanding the process of patient satisfaction with nurse-led chronic disease management in general practice.

AIMS: To investigate the process of patient satisfaction with nurse-led chronic disease management in Australian general practice. BACKGROUND: Nurses working in the primary care context of general practice, referred to as practice nurses, are expanding their role in chronic disease management; this is relatively new to Australia. Therefore, determining patient satisfaction with this trend is pragmatically and ethically important. However, the concept of patient satisfaction is not well understood particularly in relation to care provided by practice nurses. DESIGN: A grounded theory study underpinned by a relativist ontological position and a relativist epistemology. METHODS: Grounded theory was used to develop a theory from data collected through in-depth interviews with 38 participants between November 2007-April 2009. Participants were drawn from a larger project that trialled a practice nurse-led, collaborative model of chronic disease management in three Australian general practices. Theoretical sampling, data collection, and analysis were conducted concurrently consistent with grounded theory methods. RESULTS: Patients undergo a cyclical process of Navigating Care involving three stages, Determining Care Needs, Forming Relationship, and Having Confidence. The latter two processes are inter-related and a feedback loop from them informs subsequent cycles of Determining Care Needs. If any of these steps fails to develop adequately, patients are likely to opt out of nurse-led care. CONCLUSION: Navigating Care explains how and why time, communication, continuity, and trust in general practitioners and nurses are important to patient satisfaction. It can be used in identifying suitable patients for practice nurse-led care and to inform the practice and organization of practice nurse-led care to enhance patient satisfaction.

Potential roles for practice nurses in preventive care for young people - a qualitative study.

BACKGROUND: Increasing numbers of practice nurses and their expanding roles in Australian general practice suggest they can contribute to quality primary healthcare for young people. METHODS: Seventeen health and community professionals and a purposefully selected group of 12 practice nurses were interviewed about the role of the practice nurse in young people's healthcare. A directed content approach to analysis was applied. RESULTS: Participants recognised the psychosocial health burdens young people experience and the barriers they perceive in accessing healthcare. With good communication skills and appropriate training, practice nurses were perceived to be able to have an important role in the preventive care of young people. DISCUSSION: Practice nurses can contribute to breaking down barriers to healthcare for young people. This study is being reported on at an opportune time, considering the implications for young people of the 'Practice Nurse Incentive Program'.

Uptake of Medicare chronic disease management incentives - a study into service providers' perspectives.

BACKGROUND: Chronic disease is responsible for 80% of the burden of disease in Australia. The Australian Government Medicare Benefits Schedule (MBS) provides incentives through specific Medicare items to optimise chronic disease management (CDM), yet little is known about factors that influence their uptake. METHODS: Exploratory qualitative research was used, which incorporated focus groups and interviews with 26 staff from nine general practices in southeast Queensland, together with review of practice-specific data on CDM income. Content analysis of qualitative data was undertaken to identify barriers, enablers and service models associated with MBS CDM item uptake. Triangulation of methods and data sources facilitated confirmation of findings. RESULTS: Time pressures and unreliable MBS information were common barriers to uptake for general practitioners. Employing a nurse, team-based approaches, recall systems and using only selected MBS CDM item numbers were associated with best uptake. CONCLUSION: Improved systems within general practice and Medicare may increase the uptake of MBS CDM item numbers.

Intubation outcomes and practice trends during the initial New York SARS-COV-19 surge at an academic, level 1 trauma, urban emergency department.

OBJECTIVES: The goal of this study was to describe outcomes and associated characteristics of patients who were intubated during the initial (3/2020-4/2020) New York City surge of the severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic, during which time we were confronted by an unknown and unprecedented respiratory distress syndrome with extremely high degrees of morbidity and mortality. Our secondary aim was to analyze our physician's rapidly evolving approaches to COVID-19 airway management. METHODS: A retrospective cohort analysis of all patients intubated at two emergency departments (EDs) for COVID-19 suspected respiratory failure. In addition, a survey was done to analyze clinician airway management trends and attitudes as they evolved during that period. RESULTS: Ninety-five patients met inclusion criteria for the study. Primary outcomes looked at the spectrum of mortality outcomes ranging from died on arrival (DOA) to the ED, died in the ED (DED), died an inpatient (DIH), and survival to discharge. Overall mortalitywas 71.6% with an average age of 62.7 years. Female sex, as a demographic, was associated with higher rates of survival to discharge at 42.3% when compared to males at 23.2% (P < 0.001). Mean age was 70.8 years DOA, 65.6 years DED, 62.9 years DIH, and 60.0 years for survivors (P = 0.0037). Initial lactate levels were 8.15 mmol/L DED, 3.56 mmol/L DIH, and 2.61 mmol/L survivors (P < 0.0001). Initial creatinine levels were 3.38 mg/dL DED, 1.94 mg/dL DIH, and 1.77 mg/dL survivors (P = 0.0073). D-dimer levels were 7520.5 ng/mL DED, 5932.4 ng/mL DIH, and 1133.9 ng/mL survivors (P = 0.0045). Physician survey respondents reported high levels (69%) of laryngeal edema and prolonged post intubation hypoxia (>50% of time) and >80% remained concerned for their safety. There was a dramatic shift from early (73% of time) to late intubation strategies (67% of time) or non-invasive approaches (28% of time) as the first surge of the pandemic evolved. CONCLUSION: Our findings demonstrate that several demographic, clinical and laboratory parameters correlated with mortality in our cohort of patients intubated during the initial phase of the COVID-19 pandemic. These included male sex, advanced age, high levels of initial lactic acidosis, elevated D-dimer, and chronic kidney disease/acute kidney injury. In contrast, presenting respiratory characteristics were not correlated with mortality. In addition, our findings demonstrate that physician attitudes and strategies related to COVID-19 airway management evolved significantly and rapidly over the initial phase of the pandemic.