Platelet releasate normalises the compromised muscle regeneration in a mouse model of hyperlipidaemia.

NEW FINDINGS: What is the central question of this study? What is the impact of obesity-independent hyperlipidaemia on skeletal muscle stem cell function of ApoE-deficient (ApoE-/- ) mice? What is the main finding and its importance? Compromised muscle stem cell function accounts for the impaired muscle regeneration in hyperlipidaemic ApoE-/- mice. Importantly, impaired muscle regeneration is normalised by administration of platelet releasate. ABSTRACT: Muscle satellite cells are important stem cells for skeletal muscle regeneration and repair after injury. ApoE-deficient mice, an established mouse model of hyperlipidaemia and atherosclerosis, show evidence of oxidative stress-induced lesions and fat infiltration in skeletal muscle followed by impaired repair after injury. However, the mechanisms underpinning attenuated muscle regeneration remain to be fully defined. Key to addressing the latter is to understand the properties of muscle stem cells from ApoE-deficient mice and their myogenic potential. Muscle stem cells from ApoE-deficient mice were cultured both ex vivo (on single fibres) and in vitro (primary myoblasts) and their myogenic capacity was determined. Skeletal muscle regeneration was studied on days 5 and 10 after cardiotoxin injury. ApoE-deficient muscle stem cells showed delayed activation and differentiation on single muscle fibres ex vivo. Impaired proliferation and differentiation profiles were also evident on isolated primary muscle stem cells in culture. ApoE-deficient mice displayed impaired skeletal muscle regeneration after acute injury in vivo. Administration of platelet releasate in ApoE-deficient mice reversed the deficits of muscle regeneration after acute injury to wild-type levels. These findings indicate that muscle stem cell myogenic potential is perturbed in skeletal muscle of a mouse model of hyperlipidaemia. We propose that platelet releasate could be a therapeutic intervention for conditions with associated myopathy such as peripheral arterial disease.

Management of adult cardiac arrest in the COVID-19 era: consensus statement from the Australasian College for Emergency Medicine.

INTRODUCTION: The global pandemic of coronavirus disease 2019 (COVID-19) has caused significant worldwide disruption. Although Australia and New Zealand have not been affected as much as some other countries, resuscitation may still pose a risk to health care workers and necessitates a change to our traditional approach. This consensus statement for adult cardiac arrest in the setting of COVID-19 has been produced by the Australasian College for Emergency Medicine (ACEM) and aligns with national and international recommendations. MAIN RECOMMENDATIONS: In a setting of low community transmission, most cardiac arrests are not due to COVID-19. Early defibrillation saves lives and is not considered an aerosol generating procedure. Compression-only cardiopulmonary resuscitation is thought to be a low risk procedure and can be safely initiated with the patient's mouth and nose covered. All other resuscitative procedures are considered aerosol generating and require the use of airborne personal protective equipment (PPE). It is important to balance the appropriateness of resuscitation against the risk of infection. Methods to reduce nosocomial transmission of COVID-19 include a physical barrier such as a towel or mask over the patient's mouth and nose, appropriate use of PPE, minimising the staff involved in resuscitation, and use of mechanical chest compression devices when available. If COVID-19 significantly affects hospital resource availability, the ethics of resource allocation must be considered. CHANGES IN MANAGEMENT: The changes outlined in this document require a significant adaptation for many doctors, nurses and paramedics. It is critically important that all health care workers have regular PPE and advanced life support training, are able to access in situ simulation sessions, and receive extensive debriefing after actual resuscitations. This will ensure safe, timely and effective management of the patients with cardiac arrest in the COVID-19 era.

Demand for global health training among obstetrics and gynaecology trainees in Australia and New Zealand: Insights from the TIGHT study.

BACKGROUND: Global health (GH) training aims to equip clinicians with the skills and knowledge to practise in international and cross-cultural environments. Interest among obstetrics and gynaecology trainees is unknown. AIMS: The Trainee Interest in Global Health Training (TIGHT) study aimed to assess demand for GH training among specialty trainees in Australia and New Zealand. The primary objective was to quantify the number of trainees interested in undertaking a rotation in a resource-limited environment (RLE) in a low- or middle-income country during specialty training. This paper reports the results of a planned sub-group analysis of Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) trainees. MATERIALS AND METHODS: A cross-sectional study was conducted between August and October 2018. Data were collected using an anonymous, self-reporting, web-based survey. RESULTS: There were 210 respondents among 698 RANZCOG trainees, equating to a response rate of 30.1%. Overall, 77% (157/204) of respondents were keen to undertake a rotation in a RLE, with the vast majority (166/203, 81.8%) interested or very interested in having their GH accredited for training. Sixty-four percent (125/195) expressed interest in undertaking an integrated GH training or fellowship program as an adjunct to specialty training, and a majority (177/201, 88.1%) were keen to continue GH work as a specialist obstetrician and gynaecologist. CONCLUSION: There is significant demand for GH training among RANZCOG trainees. These findings should inform the development of accredited rotations in RLEs and the cultivation of safe and effective global women's health training pathways. Ideally, these arrangements should be underpinned by mutually beneficial partnerships with both educational and development objectives.

Genomic prediction accuracy for switchgrass traits related to bioenergy within differentiated populations.

BACKGROUND: Switchgrass breeders need to improve the rates of genetic gain in many bioenergy-related traits in order to create improved cultivars that are higher yielding and have optimal biomass composition. One way to achieve this is through genomic selection. However, the heritability of traits needs to be determined as well as the accuracy of prediction in order to determine if efficient selection is possible. RESULTS: Using five distinct switchgrass populations comprised of three lowland, one upland and one hybrid accession, the accuracy of genomic predictions under different cross-validation strategies and prediction methods was investigated. Individual genotypes were collected using GBS while kin-BLUP, partial least squares, sparse partial least squares, and BayesB methods were employed to predict yield, morphological, and NIRS-based compositional data collected in 2012-2013 from a replicated Nebraska field trial. Population structure was assessed by F statistics which ranged from 0.3952 between lowland and upland accessions to 0.0131 among the lowland accessions. Prediction accuracy ranged from 0.57-0.52 for cell wall soluble glucose and fructose respectively, to insignificant for traits with low repeatability. Ratios of heritability across to within-population ranged from 15 to 0.6. CONCLUSIONS: Accuracy was significantly affected by both cross-validation strategy and trait. Accounting for population structure with a cross-validation strategy constrained by accession resulted in accuracies that were 69% lower than apparent accuracies using unconstrained cross-validation. Less accurate genomic selection is anticipated when most of the phenotypic variation exists between populations such as with spring regreening and yield phenotypes.

Perspectives on the working hours of Australian junior doctors.

The working hours of junior doctors have been a focus of discussion in Australia since the mid-1990s. Several national organizations, including the Australian Medical Association (AMA), have been prominent in advancing this agenda and have collected data (most of which is self-reported) on the working hours of junior doctors over the last 15 years. Overall, the available data indicate that working hours have fallen in a step-wise fashion, and AMA data suggest that the proportion of doctors at high risk of fatigue may be declining. It is likely that these changes reflect significant growth in the number of medical graduates, more detailed specifications regarding working hours in industrial agreements, and a greater focus on achieving a healthy work-life balance. It is notable that reductions in junior doctors' working hours have occurred despite the absence of a national regulatory framework for working hours. Informed by a growing international literature on working hours and their relation to patient and practitioner safety, accreditation bodies such as the Australian Commission on Safety and Quality in Health Care (ACSQHC) and the Australian Medical Council (AMC) are adjusting their standards to encourage improved work and training practices.

Portfolio careers for medical graduates: implications for postgraduate training and workforce planning.

Portfolio careers in medicine can be defined as significant involvement in one or more portfolios of activity beyond a practitioner's primary clinical role, either concurrently or in sequence. Portfolio occupations may include medical education, research, administration, legal medicine, the arts, engineering, business and consulting, leadership, politics and entrepreneurship. Despite significant interest among junior doctors, portfolios are poorly integrated with prevocational and speciality training programs in Australia. The present paper seeks to explore this issue. More formal systems for portfolio careers in Australia have the potential to increase job satisfaction, flexibility and retention, as well as diversify trainee skill sets. Although there are numerous benefits from involvement in portfolio careers, there are also risks to the trainee, employing health service and workforce modelling. Formalising pathways to portfolio careers relies on assessing stakeholder interest, enhancing flexibility in training programs, developing support programs, mentorship and coaching schemes and improving support structures in health services.

Triage implementation in resource-limited emergency departments: sharing tools and experience from the Pacific region.

According to the World Health Organization's (WHO) Emergency Care Systems Framework, triage is an essential function of emergency departments (EDs). This practice innovation article describes four strategies that have been used to support implementation of the WHO-endorsed Interagency Integrated Triage Tool (IITT) in the Pacific region, namely needs assessment, digital learning, public communications and electronic data management.Using a case study from Vila Central Hospital in Vanuatu, a Pacific Small Island Developing State, we reflect on lessons learned from IITT implementation in a resource-limited ED. In particular, we describe the value of a bespoke needs assessment tool for documenting triage and patient flow requirements; the challenges and opportunities presented by digital learning; the benefits of locally designed, public-facing communications materials; and the feasibility and impact of a low-cost electronic data registry system.Our experience of using these tools in Vanuatu and across the Pacific region will be of interest to other resource-limited EDs seeking to improve their triage practice and performance. Although the resources and strategies presented in this article are focussed on the IITT, the principles are equally relevant to other triage systems.

Systematic review: What is the impact of triage implementation on clinical outcomes and process measures in low- and middle-income country emergency departments?

INTRODUCTION: Triage is widely regarded as an essential function of emergency care (EC) systems, especially in resource-limited settings. Through a systematic search and review of the literature, we investigated the effect of triage implementation on clinical outcomes and process measures in low- and middle-income country (LMIC) emergency departments (EDs). METHODS: Structured searches were conducted using MEDLINE, CENTRAL, EMBASE, CINAHL, and Global Health. Eligible articles identified through screening and full-text review underwent risk-of-bias assessment using the Newcastle-Ottawa Scale. The quality of evidence for each effect measure was summarized using GRADE. RESULTS: Among 10,394 articles identified through the search strategy, 58 underwent full-text review and 16 were included in the final synthesis. All utilized pre-/postintervention methods and a majority were single center. Effect measures included mortality, waiting time, length of stay, admission rate, and patient satisfaction. Of these, ED mortality and time to clinician assessment were evaluated most frequently. The majority of studies using these outcomes identified a positive effect, namely a reduction in deaths and waiting time among patients presenting for EC. The quality of the evidence was moderate for these measures but low or very low for all other outcomes and process indicators. CONCLUSIONS: There is moderate quality of evidence supporting an association between the introduction of triage and a reduction in deaths and waiting time. Although the available data support the value of triage in LMIC EDs, the risk of confounding and publication bias is significant. Future studies will benefit from more rigorous research methods.

Performance of the Interagency Integrated Triage Tool in a resource-constrained emergency department during the COVID-19 pandemic.

BACKGROUND: The Interagency Integrated Triage Tool (IITT) is a three-tier triage instrument recommended by the World Health Organization, but only the pilot version of the tool has been comprehensively assessed for its validity and reliability. This study sought to evaluate the performance of the IITT in a resource-constrained emergency department (ED) during the COVID-19 pandemic. METHODS: This prospective observational study was conducted at ANGAU Memorial Provincial Hospital in Lae, Papua New Guinea. The study period commenced approximately six weeks after introduction of the IITT, coinciding with a major COVID-19 wave. The primary outcome was sensitivity for the detection of time-critical illness, defined by eight pre-specified conditions. Secondary outcomes included the relationship between triage category and disposition. Inter-rater reliability was assessed using Cohen's Kappa. RESULTS: There were 759 eligible presentations during the study period. Thirty patients (4.0%) were diagnosed with one of the eight pre-specified time-critical conditions and 21 were categorised as red or yellow, equating to a sensitivity of 70.0% (95%CI 50.6-85.3). There was a clear association between triage category and disposition, with 22 of 53 red patients (41.5%), 72 of 260 yellow patients (27.7%) and 22 of 452 green patients (4.9%) admitted (p = <0.01). Negative predictive values for admission and death were 95.1% (95%CI 92.7-96.9) and 99.3% (95%CI 98.1-99.9) respectively. Among a sample of 106 patients, inter-rater reliability was excellent (κ = 0.83) and the median triage assessment time was 94 seconds [IQR 57-160]. CONCLUSION: In this single-centre study, the IITT's sensitivity for the detection of time-critical illness was comparable to previous evaluations of the tool and within the performance range reported for other triage instruments. There was a clear relationship between triage category and disposition, suggesting the tool can predict ED outcomes. Health service pressures related to COVID-19 may have influenced the findings.

Global health training and postgraduate medical education in Australia: the case for greater integration.

Global health (GH) training is well established overseas (particularly in North America) and reflects an increasing focus on social accountability in medical education. Despite significant interest among trainees, GH is poorly integrated with specialty training programs in Australia. While there are numerous benefits from international rotations in resource-poor settings, there are also risks to the host community, trainee and training provider. Safe and effective placements rely on firm ethical foundations as well as strong and durable partnerships between Australian and overseas health services, educational institutions and GH agencies. More formal systems of GH training in Australia have the potential to produce fellows with the skills and knowledge necessary to engage in regional health challenges in a global context.

A vertical study programme for medical students: peer-assisted learning in practice.

BACKGROUND: Monash University employs a vertically-integrated curriculum with cumulative knowledge testing throughout the course. To facilitate cross-year level revision, a vertical study programme (VESPA) was established using the principles of peer-assisted learning (PAL). AIM: To implement and evaluate VESPA in relation to defined objectives. METHODS: Following from a successful pilot, a working group organised five 2 h VESPA sessions over the course of 2009. Each was case-based and study materials were provided. Participants were allocated to a group of 10-15 students of all year levels, and pre-interns acted as facilitators. Sessions were evaluated using a 10-question survey. RESULTS: A total of 647 evaluation surveys were completed overall and participant numbers ranged from 79 to 182 per session. Of these, 624 (96%) agreed the case materials were easy to follow and 562 (87%) believed they allowed students from all year levels to contribute; 552 (85%) felt VESPA helped them understand curriculum content. There were no significant differences between sessions. CONCLUSIONS: VESPA represents an innovative application of PAL that has been well received by students. Potential benefits to participants include academic revision, the development of mentoring relationships and enhanced teaching and facilitation skills. This model of a structured revision programme would suit other settings with vertically-integrated curricula and assessment.

Unaccredited registrar positions in Australian public hospitals: is it time for a rethink?

Unaccredited registrar positions are a significant source of inefficiency in postgraduate medical training. Their educational value is debated due to a lack formal supervision, appraisal or assessment requirements. In the context of increasing numbers of trainees and escalating demand for public hospital services, the extent to which unaccredited registrar positions can be converted to accredited training posts warrants urgent examination. The major obstacle is meeting college standards, particularly with respect to caseload and supervision requirements. Notwithstanding the barriers to reform, this article describes how a coordinated process to accredit these posts would increase training capacity and enhance vertical integration in postgraduate medical education.

Multimodal learning for emergency department triage implementation: experiences from Papua New Guinea during the COVID-19 pandemic.

Background: Triage implementation in resource-limited emergency departments (EDs) has traditionally relied on intensive in-person training. This study sought to evaluate the impact of a novel digital-based learning strategy focused on the Interagency Integrated Triage Tool, a three-tier triage instrument recommended by the World Health Organization. Methods: A mixed methods study utilising pre-post intervention methods was conducted in two EDs in Papua New Guinea. The primary outcome was the mean change in knowledge before and after completion of a voluntary, multimodal training program, primarily delivered through a digital learning platform accessible via smartphone. Secondary outcomes included the change in confidence to perform selected clinical tasks, and acceptability of the learning methods. Findings: Among 136 eligible ED staff, 91 (66.9%) completed the digital learning program. The mean knowledge score on the post-training exam was 87.5% (SD 10.4), a mean increase of 12.9% (95% CI 10.7-15.1%, p < 0.0001) from the pre-training exam. There were statistically significant improvements in confidence for 13 of 15 clinical tasks, including undertaking a triage assessment and identifying an unwell patient.In an evaluation survey, 100% of 30 respondents agreed or strongly agreed the online learning platform was easy to access, use and navigate, and that the digital teaching methods were appropriate for their learning needs. In qualitative feedback, respondents reported that limited internet access and a lack of dedicated training time were barriers to participation. Interpretation: The use of digital learning to support triage implementation in resource-limited EDs is feasible and effective when accompanied by in-person mentoring. Adequate internet access is an essential pre-requisite. Funding: Development of the Kumul Helt Skul learning platform was undertaken as part of the Clinical Support Program (Phase II), facilitated by Johnstaff International Development on behalf of the Australian Government Department of Foreign Affairs and Trade through the PNG-Australia Partnership. RM is supported by a National Health and Medical Research Council Postgraduate Scholarship and a Monash Graduate Excellence Scholarship, while PC is supported by a Medical Research Future Fund Practitioner Fellowship. Funders had no role in study design, results analysis or manuscript preparation.

"When all else fails you have to come to the emergency department": Overarching lessons about emergency care resilience from frontline clinicians in Pacific Island countries and territories during the COVID-19 pandemic.

The COVID-19 pandemic continues to test health systems resilience worldwide. Low- and middle-income country (LMIC) health care systems have considerable experience in disasters and disease outbreaks. Lessons from the preparedness and responses to COVID-19 in LMICs may be valuable to other countries.This policy paper synthesises findings from a multiphase qualitative research project, conducted during the pandemic to document experiences of Pacific Island Country and Territory (PICT) frontline clinicians and emergency care (EC) stakeholders. Thematic analysis and synthesis of enablers related to each of the Pacific EC systems building blocks identified key factors contributing to strengthened EC systems.Effective health system responses to the COVID-19 pandemic occurred when frontline clinicians and 'decision makers' collaborated with respect and open communication, overcoming healthcare workers' fear and discontent. PICT EC clinicians demonstrated natural leadership and strengthened local EC systems, supporting essential healthcare. Despite resource limitations, PICT cultural strengths of relational connection and innovation ensured health system resilience. COVID-19 significantly disrupted services, with long-tail impacts on non-communicable disease and other health burdens.Lessons learned in responding to COVID-19 can be applied to ongoing health system strengthening initiatives. Optimal systems improvement and sustainability requires EC leaders' involvement in current decision-making as well as future planning. Search strategy and selection criteria: Search strategy and selection criteria We searched PubMed, Google Scholar, Ovid, WHO resources, Pacific and grey literature using search terms 'emergency care', 'acute/critical care', 'health care workers', 'emergency care systems/health systems', 'health system building blocks', 'COVID-19', 'pandemic/surge event/disease outbreaks' 'Low- and Middle-Income Countries', 'Pacific Islands/region' and related terms. Only English-language articles were included. Funding: Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Copyright of the original work on which this publication is based belongs to WHO. The authors have been given permission to publish this manuscript. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of WHO. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant. RM is supported by a National Health and Medical Research Council (NHMRC) Postgraduate Scholarship and a Monash Graduate Excellence Scholarship. GOR is supported by a NHMRC Early Career Research Fellowship. CEB is supported by a University of Queensland Development Research Fellowship. None of these funders played any role in study design, results analysis or manuscript preparation.

Informing the Alfred Registry for Emergency Care Project: An analysis of presenting complaint documentation in an emergency department.

OBJECTIVE: To assess the feasibility of an ED presenting complaint (PC) tool that categorised all ED PCs into 10 categories. METHODS: A retrospective analysis of 1445 consecutive patient encounters was conducted. The primary outcome was the frequency of use of the 10 PC categories. RESULTS: Of the 1203 patient encounters meeting inclusion criteria, the PC tool was completed by clinicians in 574 (47.7%). When completed, the tool's 10 options were selected for most presentations (72.3%). CONCLUSION: The PC tool captured the majority of presenting complaints in 10 categories. External validation is recommended.

Lessons from the frontline: The COVID-19 pandemic emergency care experience from a human resource perspective in the Pacific region.

Background: This study explores emergency care (EC) and other frontline healthcare worker (HCW) experiences responding to the COVID-19 pandemic in the Pacific region. The crisis has reinforced the crucial role well-trained, resourced, and supported EC providers play in supporting vital health systems and services in all global regions not only during 'business as usual' periods, but in times of tremendous stress and surge. Methods: Qualitative data were collected from EC providers and relevant stakeholders in three research phases in 2020 and 2021. Data on the World Health Organization's (WHO) Human Resources Building Block, adapted for the Pacific EC context, was thematically analysed. Key findings were further analysed to identify enablers and barriers to effective EC pandemic management. Findings: 116 participants from across the Pacific region participated in this study. Five themes emerged: (1) EC providers performed multiple pandemic roles; (2) Importance of authorities' valuing frontline HCWs; (3) HCW mental health and exhaustion; (4) HCW tension managing stigma, personal/professional expectations, and chronic health needs; and (5) Building health and human resource capacity. Interpretation: This study significantly contributes to the limited scientific literature on HCW experiences responding to COVID-19 across the Pacific. Recommendations arising out of this research align with consensus priorities and standards that were identified pre-pandemic by health stakeholders across the Pacific for enhancing EC system development. With limited HCWs available for many Pacific nations, it is imperative the dignity and welfare of local HCWs is genuinely prioritised. Funding: Epidemic Ethics/WHO, Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.

Emergency department triage and COVID-19: Performance of the Interagency Integrated Triage Tool during a pandemic surge in Papua New Guinea.

OBJECTIVE: To determine the sensitivity of the Interagency Integrated Triage Tool to identify severe and critical illness among adult patients with COVID-19. METHODS: A retrospective observational study conducted at Port Moresby General Hospital ED during a three-month Delta surge. RESULTS: Among 387 eligible patients with COVID-19, 63 were diagnosed with severe or critical illness. Forty-seven were allocated a high acuity triage category, equating to a sensitivity of 74.6% (95% CI 62.1-84.7) and a negative predictive value of 92.7% (95% CI 88.4-95.8). CONCLUSION: In a resource-constrained context, the tool demonstrated reasonable sensitivity to detect severe and critical COVID-19, comparable with its reported performance for other urgent conditions.