Risk Factors for Surgical Site Infection after Minor Dermatologic Surgery.

BACKGROUND: Surgical site infection (SSI) after dermatologic surgery is associated with poor outcomes including increased recovery time, poor cosmesis, and repeat visits to doctors. Prophylactic antibiotics are prescribed to reduce these adverse outcomes. Identifying risk factors for SSI will facilitate judicious antibiotic prophylaxis. OBJECTIVE: To identify risk factors for SSI after minor dermatologic surgery. METHODS: Individual patient data from four large randomized controlled trials were combined to increase statistical power. A total of 3,819 adult patients requiring minor skin procedures at a single facility were recruited over a 10-year period. The main outcome measure was SSI. MAIN RESULTS: A total of 298 infections occurred, resulting in an overall incidence of 7.8% (95% confidence interval [CI], 5.8-9.6), although the incidence varied across the four studies (P = .042). Significant risk factors identified were age (relative risk [RR], 1.01; 95% CI, 1.001-1.020; P = .008), excisions from the upper limbs (RR, 3.03; 95% CI, 1.76-5.22; P = .007) or lower limbs (RR, 3.99; 95% CI, 1.93-8.23; P = .009), and flap/two-layer procedures (RR, 3.23; 95% CI, 1.79-5.85; P = .008). Histology of the excised lesion was not a significant independent risk factor for infection. CONCLUSIONS: This study demonstrated that patients who were older, underwent complex excisions, or had excisions on an extremity were at higher risk of developing an SSI. An awareness of such risk factors will guide evidence-based and targeted antibiotic prophylaxis.

Women's attitudes and understanding of cervical cancer and the new National Cervical Screening Program.

ISSUES ADDRESSED: The new National Cervical Screening Program (NCSP) has recently been implemented. Little research is available on women's attitudes towards the program. This study aims to quantitatively assess Australian women's understanding and attitudes towards the new guidelines and their barriers to screening. METHOD: Authors designed a cross-sectional survey which was piloted and distributed as a waiting room survey to eligible women who attended a private general practice in North Queensland. RESULTS: Of the respondents, 53.8% had accurate knowledge of the new NCSP. Most participants (75.8%) believed they were not provided sufficient information about the NCSP and 60.2% wished to receive this information from their general practitioner. The screening test itself remains an issue, with embarrassment and discomfort listed as the most common barriers to screening. CONCLUSION: Many women do not have accurate knowledge of the new NCSP. Further health promotion in this area is warranted, where the general practitioner may play a key role. SO WHAT?: While the new NCSP will lead to further reduction in cervical cancer mortality, it appears from the data that women did not fully understand cervical cancer and its screening. This suggests the need for further health education to women about updated screening guidelines.

Australian women's self-perceived barriers to participation in cervical cancer screening: A systematic review.

BACKGROUND: Australia has recently introduced a new screening program for cervical cancer. There has also been a decline in participation rates for cervical screening. AIM: To complete a systematic literature review of the factors that prevent Australian women from participating in cervical screening. METHODS: Authors searched CINAHL, Medline, SCOPUS and the Cochrane Library to obtain articles discussing Australian women's self-identified barriers to cervical screening. Quantitative studies published in peer-reviewed journals after 1991 were considered. PROSPERO Registration Number: CRD42018105028. RESULTS: The final search produced 1749 studies, with 13 quantitative papers included in the narrative synthesis after screening by two independent reviewers. No articles were excluded due to bias. DISCUSSION: Self-identified barriers to screening were categorised into personal, practitioner, test-related and logistical factors. The most commonly stated barriers included lack of time, embarrassment, fear of results, irrelevance and male health professionals. The use of HPV triage in cervical screening was not a barrier to screening, however, some women regarded self-collected HPV testing as a barrier. Barriers to self-collection included desire for the general practitioner to complete the test, fear of doing the test incorrectly, wishing to include it in a general check-up and concerns about the test itself. CONCLUSION: A variety of personal, practitioner, test-related and logistical barriers negatively impact the screening participation of Australian women. Further research into barriers in the Australian population, and women's attitudes towards HPV testing and self-collection is required to create effective health interventions to improve participation in cervical screening.

A snapshot of current Objective Structured Clinical Examination (OSCE) practice at Australian medical schools.

Objective: The objective of this collaborative study was to compare current practices of conducting high-stake, exit-level Objective Structured Clinical Examinations (OSCEs) at all Australian medical schools. We aimed to document similarities and differences between schools, and compare existing practice against available gold standard, evidence-based practice. We also aimed to identify areas where gold standards do not currently exist, and could be developed in the future. Methods: A 72-item semi-structured questionnaire was sent to all 19 Australian medical schools with graduating students. Results: A total of 18/19 schools responded. Of these, 16/18 schools had summative exit-level OSCEs representing content from multiple medical specialties. The total number of OSCE stations varied from 8 to 16, with total OSCE testing time ranging from 70 to 160 min. All schools blueprinted their OSCE to their curriculum, and trained simulated patients and examiners. There was variation in the format of marking rubric used. Conclusions: This study has provided insight into the current OSCE practices of the majority of medical schools in Australia. Whilst the comparative data reveal a wide variation in OSCE practices between schools, many recommended "gold standard" OSCE practices are implemented. The collective awareness of our similarities and differences provides us with a baseline platform, as well as an impetus for iterative quality improvement. Such discourse also serves to develop new gold standards in practice where none have previously existed.

The effects of expressing antenatal colostrum in women with diabetes in pregnancy: A retrospective cohort study.

BACKGROUND: Some women with diabetes in pregnancy express and store colostrum in the antenatal period for the purposes of preventing and treating neonatal hypoglycaemia. AIMS: Our primary aim was to compare rates of neonatal hypoglycaemia in babies born to mothers who express and store antenatal colostrum to babies born to mothers who do not. MATERIALS AND METHODS: Retrospective cohort study involving 357 women with diabetes in pregnancy, who had live, singleton births delivered after 36 weeks gestation, in a regional hospital in North Queensland (2014-2015). Multivariable binary logistic regression modelling identified independent characteristics associated with primary outcomes. RESULTS: Eighty women (23%) expressed antenatal colostrum and 223 (62%) did not. One hundred and thirty-one babies (37%) were diagnosed with hypoglycaemia. Aboriginal and Torres Strait Islander women were less likely to express than Caucasian women (odds ratio (OR) 0.10, 95% confidence interval (CI) 0.01-0.77). There were no significant differences in the rates of hypoglycaemia, or median blood glucose levels in babies born to mothers who expressed antenatal colostrum compared to babies born to mothers who did not express. Babies born to mothers who expressed were significantly less likely to receive formula in hospital compared to babies born to mothers who did not (OR 0.12, 95% CI 0.05-0.32). CONCLUSIONS: We found no independent association of expressing antenatal colostrum on rates of neonatal hypoglycaemia or median blood glucose levels. Expressing antenatal colostrum may have some benefits to the newborn such as reduced formula consumption in hospital. Further research into other methods of reducing neonatal hypoglycaemia appears warranted.

Risk Factors for Surgical Site Infection in Minor Dermatological Surgery: A Systematic Review.

OBJECTIVE: To identify patient- and procedure-related risk factors for surgical site infection following minor dermatological surgery. DATA SOURCES: The MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Informit, and Scopus databases were searched for relevant literature on patient populations receiving minor surgery, where risk factors for surgical site infection were explicitly stated. STUDY SELECTION: Studies involving major dermatological surgery were excluded. The preliminary search yielded 820 studies after removing duplicates; 210 abstracts were screened, and 42 full texts were assessed for eligibility. A total of 13 articles were included. Studies were appraised using the Newcastle-Ottawa Quality Assessment Scale. DATA EXTRACTION: An electronic data collection tool was constructed to extract information from the eligible studies, and this information was distributed to participating authors. DATA SYNTHESIS: Risk factors identified included age, sex, diabetes mellitus, chronic obstructive pulmonary disease, use of antihypertensive or corticosteroid medications, smoking, surgery on the lower or upper extremities, excision of nonmelanocytic skin cancers, large skin excisions, and complex surgical techniques. No more than two studies agreed on any given risk factor, and there were insufficient studies for meta-analysis. CONCLUSIONS: Re-excision of skin cancer, below-knee excisions, and intraoperative hemorrhagic complications were predictive for infection in more than one study. More high-quality studies are required to accurately identify risk factors so they can be reliably used in clinical guidelines.

Clinician and client perspectives regarding transgender health: a North Queensland focus.

Background: Healthcare encounters are important in ensuring safe access to medical or surgical care for transgender people. Previous literature suggests many transgender people have had negative encounters with healthcare professionals. In Australia, there is limited research about this population and their healthcare, and less from regional locations. Aims: This study primarily aimed to explore both transgender client and clinician perspectives and experiences of healthcare interactions. A secondary aim was to investigate increased presentations to sexual health clinics in North Queensland by people wishing to transition. Methods: Semi-structured, in-depth interviews were used to gather data from 23 participants. Interview transcripts were inductively analyzed and themes developed. Results: Four themes emerged relating to healthcare encounters and the regional setting of North Queensland. These showed that support from family and peers is important for transgender mental health and wellbeing, and that person-centered clinicians who acknowledge a holistic approach to transgender care also form part of the support network for transgender individuals particularly in the regional setting. The internet was found to play a significant role in this study's findings. Discussion: A collaborative holistic approach to transgender healthcare should be taken by client and clinician to best support the transgender individual during transition. The establishment of Australian guidelines and online peer support groups would facilitate this approach, particularly in rural or regional areas where specialist services are limited.

Impact of new diagnostic criteria for gestational diabetes.

AIM: In January 2015, the diagnostic and therapeutic criteria for gestational diabetes changed, with the goal of increasing the sensitivity of diagnosis and improving overall glycemic control, and thus reducing adverse pregnancy outcomes. Our primary aim was to evaluate the effect of the new guidelines on the incidence of diagnosis of gestational diabetes and the incidence of therapeutic interventions. Our secondary aim was to look at the incidence of adverse pregnancy outcomes. METHODS: A retrospective clinical audit was conducted at a regional hospital to compare the incidence of gestational diabetes, and the specific maternal and neonatal outcomes before and after the change in guidelines was implemented. Data were collected via chart review for a 6-month period before and after the change in guidelines in January 2015. Data collected included demographics, neonatal and maternal outcomes, and the treatment type used for patients diagnosed with gestational diabetes. RESULTS: There was a significant increase in the incidence of diagnosis of gestational diabetes (9.8-19.6%; P < 0.001), and an overall increase in the use of pharmacological treatments for gestational diabetes. There was no significant difference in the incidence of the adverse outcomes measured, including cesarean delivery and macrosomia. There was no significant change in mean fetal weight. CONCLUSION: Despite a doubling of the incidence of diagnosis of gestational diabetes, and a consequent increase in pharmacological interventions, the change in diagnostic and therapeutic criteria did not significantly reduce the neonatal or maternal adverse outcomes measured.

Alcoholic versus aqueous chlorhexidine for skin antisepsis: the AVALANCHE trial.

BACKGROUND: Preoperative skin antisepsis is routine practice. We compared alcoholic chlorhexidine with aqueous chlorhexidine for skin antisepsis to prevent surgical site infection after minor skin excisions in general practice. METHODS: We conducted this prospective, multicentre, randomized controlled trial in 4 private general practices in North Queensland, Australia, from October 2015 to August 2016. Consecutive adult patients presenting for minor skin excisions were randomly assigned to undergo preoperative skin antisepsis with 0.5% chlorhexidine in 70% ethanol (intervention) or 0.5% chlorhexidine aqueous solution (control). Our primary outcome was surgical site infection within 30 days of excision. We also measured the incidence of adverse reactions. RESULTS: A total of 916 patients were included in the study: 454 underwent antisepsis with alcoholic chlorhexidine and 462 with aqueous chlorhexidine. Of these, 909 completed follow-up. In the intention-to-treat analysis of cases available at follow-up, there was no significant difference in the incidence of surgical site infection between the alcoholic chlorhexidine arm (5.8%, 95% confidence interval [CI] 3.6% to 7.9%) and the aqueous chlorhexidine arm (6.8%, 95% CI 4.5% to 9.1%). The attributable risk reduction was 0.010 (95% CI -0.021 to 0.042), the relative risk was 0.85 (95% CI 0.51 to 1.41), and the number needed to treat to benefit was 100. Per protocol and sensitivity analyses produced similar results. The incidence of adverse reactions was low, with no difference between groups (p = 0.6). INTERPRETATION: There was no significant difference in efficacy between alcoholic and aqueous chlorhexidine for the prevention of surgical site infection after minor skin excisions in general practice. Trial registration: https://www.anzctr.org.au, no. ACTRN12615001045505.

Topical antibiotics for preventing surgical site infection in wounds healing by primary intention.

BACKGROUND: Surgical site infections (SSI) can delay wound healing, impair cosmetic outcome and increase healthcare costs. Topical antibiotics are sometimes used to reduce microbial contaminant exposure following surgical procedures, with the aim of reducing SSIs. OBJECTIVES: The primary objective of this review was to determine whether the application of topical antibiotics to surgical wounds that are healing by primary intention reduces the incidence of SSI and whether it increases the incidence of adverse outcomes (allergic contact dermatitis, infections with patterns of antibiotic resistance and anaphylaxis). SEARCH METHODS: In May 2015 we searched: the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL. We also searched clinical trial registries for ongoing studies, and bibliographies of relevant publications to identify further eligible trials. There was no restriction of language, date of study or setting. The search was repeated in May 2016 to ensure currency of included studies. SELECTION CRITERIA: All randomized controlled trials (RCTs) and quasi-randomised trials that assessed the effects of topical antibiotics (any formulation, including impregnated dressings) in people with surgical wounds healing by primary intention were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies and independently extracted data. Two authors then assessed the studies for risk of bias. Risk ratios were calculated for dichotomous variables, and when a sufficient number of comparable trials were available, trials were pooled in a meta-analysis. MAIN RESULTS: A total of 10 RCTs and four quasi-randomised trials with 6466 participants met the inclusion criteria. Six studies involved minor procedures conducted in an outpatient or emergency department setting; eight studies involved major surgery conducted in theatre. Nine different topical antibiotics were included. We included two three-arm trials, two four-arm trials and 10 two-arm trials. The control groups comprised; an alternative topical antibiotic (two studies), topical antiseptic (six studies) and no topical antibiotic (10 studies), which comprised inert ointment (five studies) no treatment (four studies) and one study with one arm of each.The risk of bias of the 14 studies varied. Seven studies were at high risk of bias, five at unclear risk of bias and two at low risk of bias. Most risk of bias concerned risk of selection bias.Twelve of the studies (6259 participants) reported infection rates, although we could not extract the data for this outcome from one study. Four studies (3334 participants) measured allergic contact dermatitis as an outcome. Four studies measured positive wound swabs for patterns of antimicrobial resistance, for which there were no outcomes reported. No episodes of anaphylaxis were reported. Topical antibiotic versus no topical antibioticWe pooled the results of eight trials (5427 participants) for the outcome of SSI. Topical antibiotics probably reduce the risk of SSI in people with surgical wounds healing by primary intention compared with no topical antibiotic (RR 0.61, 95% CI 0.42 to 0.87; moderate-quality evidence downgraded once for risk of bias). This equates to 20 fewer SSIs per 1000 patients treated with topical antibiotics (95% CI 7 to 29) and a number needed to treat for one additional beneficial outcome (NNTB) (i.e. prevention of one SSI) of 50.We pooled the results of three trials (3012 participants) for the outcome of allergic contact dermatitis, however this comparison was underpowered, and it is unclear whether topical antibiotics affect the risk of allergic contact dermatitis (RR 3.94, 95% CI 0.46 to 34.00; very low-quality evidence, downgraded twice for risk of bias, once for imprecision). Topical antibiotic versus antiseptic We pooled the results of five trials (1299 participants) for the outcome of SSI. Topical antibiotics probably reduce the risk of SSI in people with surgical wounds healing by primary intention compared with using topical antiseptics (RR 0.49, 95% CI 0.30 to 0.80; moderate-quality evidence downgraded once for risk of bias). This equates to 43 fewer SSIs per 1000 patients treated with topical antibiotics instead of antiseptics (95% CI 17 to 59) and an NNTB of 24.We pooled the results of two trials (541 participants) for the outcome of allergic contact dermatitis; there was no clear difference in the risk of dermatitis between topical antibiotics and antiseptics, however this comparison was underpowered and a difference cannot be ruled out (RR 0.97, 95% CI 0.52 to 1.82; very low-quality evidence, downgraded twice for risk of bias and once for imprecision). Topical antibiotic versus topical antibioticOne study (99 participants) compared mupirocin ointment with a combination ointment of neomycin/polymyxin B/bacitracin zinc for the outcome of SSI. There was no clear difference in the risk of SSI, however this comparison was underpowered (very low-quality evidence downgraded twice for risk of bias, once for imprecision).A four-arm trial involved two antibiotic arms (neomycin sulfate/bacitracin zinc/polymyxin B sulphate combination ointment versus bacitracin zinc, 219 participants). There was no clear difference in risk of SSI between the combination ointment and the bacitracin zinc ointment. The quality of evidence for this outcome was low, downgraded once for risk of bias, and once for imprecision. AUTHORS' CONCLUSIONS: Topical antibiotics applied to surgical wounds healing by primary intention probably reduce the risk of SSI relative to no antibiotic, and relative to topical antiseptics (moderate quality evidence). We are unable to draw conclusions regarding the effects of topical antibiotics on adverse outcomes such as allergic contact dermatitis due to lack of statistical power (small sample sizes). We are also unable to draw conclusions regarding the impact of increasing topical antibiotic use on antibiotic resistance. The relative effects of different topical antibiotics are unclear.

Cardiorespiratory Optimisation By Arteriovenous fistula Ligation after renal Transplantation (COBALT): study protocol for a multicentre randomised interventional feasibility trial.

INTRODUCTION: Cardiovascular events are a major cause of mortality following successful kidney transplantation.Arteriovenous fistulas (AVFs) are considered the best option for haemodialysis, but may contribute to this excess mortality because they promote adverse cardiac remodelling and ventricular hypertrophy. This raises the question whether recipients with a well-functioning kidney transplant should undergo elective AVF ligation. METHODS AND ANALYSIS: The COBALT feasibility study is a multicentre interventional randomised controlled trial (RCT) that will randomise renal transplant patients with stable graft function and a working AVF on a 1:1 basis to standard care (continued conservative management) or to AVF ligation. All patients will perform cardiopulmonary exercise testing (CPET) on recruitment and 6 months later. Daily functioning and quality of life will be additionally assessed by questionnaire completion and objective measure of physical activity. The primary outcome-the proportion of approached patients who complete the study (incorporating rates of consent, receipt of allocated intervention and completion of both CPETs without withdrawal)-will determine progression to a full-scale RCT. Design of the proposed RCT will be informed by an embedded qualitative assessment of participant and healthcare professional involvement. ETHICS AND DISSEMINATION: This study has been approved by the East Midlands-Derby Research Ethics Committee (22/EM/0002) and the Health Research Authority. The results of this work will be disseminated academically through presentation at national and international renal meetings and via open access, peer-reviewed outputs. Existing networks of renal patient groups will also be used to disseminate the study findings to other key stakeholders. TRIAL REGISTRATION NUMBER: ISRCTN49033491.

A study protocol for a randomised controlled trial of ice to reduce the pain of immunisation: The ICE trial.

BACKGROUND AND OBJECTIVES: Vaccine injections commonly cause iatrogenic pain. Ice may reduce pain. This is a study protocol for a prospective randomised controlled trial aiming to investigate the efficacy of ice packs to decrease vaccine-related pain in adults. METHOD: The intervention group (n = 45) will receive ice packs (0 °C) and the control group (n = 45) receive placebo cold packs (10 °C) on the injection site for 30 seconds prior to vaccination. RESULTS: The primary outcomes will test the hypothesis that applying an ice pack will significantly reduce pain of vaccination when compared with a cold pack. The primary dependent variable will be pain score recorded on a visual analogue scale. Secondary outcomes aim to assess potential adverse reactions. The main analysis of data will follow the intention-to-treat principle. The primary dependent variable will be compared using an independent t-test or a Mann-Whitney U test. Multivariable logistic regression analysis may be used. DISCUSSION: The trial may guide general practitioners in the use of ice packs to reduce injection-related pain in adults.

A Randomised Controlled Trial of Ice to Reduce the Pain of Immunisation-The ICE Trial.

BACKGROUND AND OBJECTIVES: vaccine injections are a common cause of iatrogenic pain and anxiety, contributing to non-compliance with scheduled vaccinations. With injection-related pain being recognised as a barrier to vaccination uptake in both adults and children, it is important to investigate strategies to effectively reduce immunisation pain. This prospective randomised controlled trial investigated the effects of applying an ice pack on vaccine-related pain in adults. METHODS: medical students receiving the flu vaccination were randomised to receive an ice pack (intervention) or placebo cold pack (control) at the injection site for 30 s prior to needle insertion. Immediate post-vaccination pain (VAS) and adverse reactions in the proceeding 24 h were recorded. RESULTS: pain scores between the intervention (n = 19) and control groups (n = 16) were not statistically significant (intervention: median pain VAS = 7.00, IQR = 18; control: median pain VAS = 11, IQR = 14 (p = 0.26). There were no significant differences in the number of adverse events between the two groups (site pain p = 0.18; localised swelling (p = 0.67); bruising p = 0.09; erythema p = 0.46). DISCUSSION: ice did not reduce vaccination-related pain compared to cold packs. COVID-19 related restrictions impacted participant recruitment, rendering the study insufficiently powered to draw conclusions about the results.

Interobserver and intraobserver agreement of three-dimensionally printed models for the classification of proximal humeral fractures.

HYPOTHESIS: This study aimed to examine whether three-dimensionally printed models (3D models) could improve interobserver and intraobserver agreement when classifying proximal humeral fractures (PHFs) using the Neer system. We hypothesized that 3D models would improve interobserver and intraobserver agreement compared with x-ray, two-dimensional (2D) and three-dimensional (3D) computed tomography (CT) and that agreement using 3D models would be higher for registrars than for consultants. METHODS: Thirty consecutive PHF images were selected from a state-wide database and classified by fourteen observers. Each imaging modality (x-ray, 2D CT, 3D CT, 3D models) was grouped and presented in a randomly allocated sequence on two separate occasions. Interobserver and intraobserver agreements were quantified with kappa values (κ), percentage agreement, and 95% confidence intervals (CIs). RESULTS: Seven orthopedic registrars and seven orthopedic consultants classified 30 fractures on one occasion (interobserver). Four registrars and three consultants additionally completed classification on a second occasion (intraobserver). Interobserver agreement was greater with 3D models than with x-ray (κ = 0.47, CI: 0.44-0.50, 66.5%, CI: 64.6-68.4% and κ = 0.29, CI: 0.26-0.31, 57.2%, CI: 55.1-59.3%, respectively), 2D CT (κ = 0.30, CI: 0.27-0.33, 57.8%, CI: 55.5-60.2%), and 3D CT (κ = 0.35, CI: 0.33-0.38, 58.8%, CI: 56.7-60.9%). Intraobserver agreement appeared higher for 3D models than for other modalities; however, results were not significant. There were no differences in interobserver or intraobserver agreement between registrars and consultants. CONCLUSION: Three-dimensionally printed models improved interobserver agreement in the classification of PHFs using the Neer system. This has potential implications for using 3D models for surgical planning and teaching.

Knowledge and perspectives of the new National Cervical Screening Program: a qualitative interview study of North Queensland women-'I could be that one percent'.

OBJECTIVES: To investigate women's understanding and attitudes towards the National Cervical Screening Program (NCSP) and to explore methods to improve screening participation. DESIGN: Semi-structured face-to-face interviews were conducted through convenience and snowball sampling. Thematic analysis occurred using the interpretivist framework. SETTING: A private general practice in North Queensland. PARTICIPANTS: Women between the ages of 18 and 74 who attended the general practice were eligible to participate. Fourteen women between 20 and 58 years old were interviewed. RESULTS: Participants were concerned that the new NCSP would miss cancer due to longer screening intervals and reliance on primary human papilloma virus (HPV) testing. They believed that young women are at increased risk of cervical cancer, due to perceived HPV vaccine ineffectiveness and parent objection to vaccination. Most participants were not agreeable to self-sampling and preferred their doctor to perform screening. Personal and practitioner beliefs influenced a woman's screening participation. Personal factors include being healthy for themselves and their family, previous abnormal smears and family history of cancer. Emphasis was placed on feeling 'comfortable' with their practitioner which included patient rapport and gender preference. Proposed methods to improve cervical screening included education programmes, advertising campaigns, general practitioner interventions and improving accessibility. CONCLUSIONS: It is apparent that women are hesitant about the new NCSP. However, when provided with additional information they were more amenable to the changes. This highlights the need to improve awareness of cervical screening and the new NCSP.

Cooling to reduce the pain associated with vaccination: A systematic review.

BACKGROUND: Vaccine injections are the most common cause of iatrogenic pain in childhood and a cause of anxiety in adulthood. Skin cooling techniques, including icepacks and vapocoolants, may provide pain relief during intramuscular injections. OBJECTIVE: To identify the effects of skin cooling techniques on pain associated with immunisation. METHODS: MEDLINE (Ovid), CINAHL, EMCARE, INFORMIT and Scopus were searched for randomised controlled trials (RCTs) investigating the use of skin cooling techniques on pain associated with vaccination. Study and intervention details, outcomes measures and results were extracted and risk of bias assessed using the Cochrane Risk of Bias tool. Due to heterogeneity of studies, a narrative synthesis was performed. RESULTS: Thirteen trials were included, involving 689 paediatric and 829 adult participants. All studies used vapocoolant or ice as one of the interventions. Comparator groups included topical EMLA cream, breastfeeding, distraction techniques and tactile stimulation. Vapocoolant reduced vaccination-related pain in all adult studies and six paediatric studies however the use of ice packs in paediatric patients was not effective. CONCLUSION: The use of cooling techniques reduces pain associated with vaccinations in adults. Paediatric studies show mixed results for vapocoolants and an inability for ice to decrease vaccine-injection pain. Larger RCTs are required to determine the most effective administration techniques and optimise the analgesic effects of skin cooling.

Imaging to improve agreement for proximal humeral fracture classification in adult patient: A systematic review of quantitative studies.

Proximal humeral fracture classification has low reproducibility. Many studies have tried to increase inter- and intra-observer agreement with more sophisticated imaging. The aim of this review was to determine which imaging modality produces the best inter- and intra-observer agreement for proximal humeral fracture classification in adults and to determine if this varies with observer experience or fracture complexity. OvidMEDLINE, The Cochrane Library, EBSCO CINAHL and Elsevier Scopus were searched on July 22nd, 2018. Quantitative studies comparing at least two imaging modalities for inter- or intra-observer agreement of proximal humeral fracture classification in adults were eligible for inclusion in this systematic literature review. Two reviewers independently screened and extracted data. Study quality was appraised using a modified Downs and Black checklist. The search strategy identified 1987 studies, of which 15 met the eligibility criteria. All included studies addressed inter-observer agreement and 8 provided results for intra-observer agreement. A narrative synthesis was performed. Trends were compared between studies as clinical heterogeneity and the statistical measures used by included studies prevented meta-analysis. Inter- and intra-observer agreement was found to increase from radiographs (x-ray) to two-dimensional (2D) computed tomography (CT) to three-dimensional (3D) CT. 2D and 3D CT may improve inter-observer agreement to a greater extent in less experienced observers and in more complex fractures. Future studies should compare 2D and 3D CT with subgroups categorising surgeon experience and fracture complexity. X-ray should be used for initial assessment; however doctors should have a low threshold for ordering CT. PROSPERO number: CRD42018094307.

HIV pre-exposure prophylaxis: Knowledge and attitudes among general practitioners.

BACKGROUND AND OBJECTIVES: Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) was accepted on the Australian Pharmaceutical Benefits Scheme on 1 April 2018, allowing general practitioners (GPs) to prescribe to patients in general practice. This study provides a timely assessment of GP knowledge and attitudes towards HIV PrEP. METHOD: An explanatory mixed method approach was used. A content-validated questionnaire was distributed to GPs in the Mackay region to assess knowledge and attitudes towards PrEP, followed by individual in-depth interviews. RESULTS: Forty-five of 109 GPs (41.1%) responded. One-third (15 of 45) had previously heard of PrEP; 71.4% (30 of 42) indicated a lack of comfort with its prescription while 60% (27 of 45) reported that provision of formalised guidelines was likely to increase prescription confidence. Ten GPs were interviewed until data saturation was achieved. Results supported the quantitative findings. DISCUSSION: GPs expressed positive attitudes towards HIV PrEP. Limited knowledge could be overcome through formalised guidelines and education.

Effect of promoting current local research activities on large monitors on the population's interest in health-related research: a randomised controlled trial.

OBJECTIVE: The objectives of this study were threefold: to estimate people's interest in health-related research, to understand to what extent people appreciate being actively informed about current local health-related research and to investigate whether their interest can be influenced by advertising local current health-related research using large TV monitors. DESIGN: Randomised controlled trial using a stepped wedge design. SETTING: The emergency department waiting room at two public hospitals in northern Queensland, Australia. PARTICIPANTS: Waiting patients and their accompanying friends and relatives in the emergency department waiting room not requiring immediate medical attention. INTERVENTIONS: A TV monitor advertising local current health-related research. MAIN OUTCOME MEASURES: OR for the effect of intervention on changing the interest in health-related research compared with a control group while adjusting for gender, age and socioeconomic standard. RESULTS: The intervention significantly increased the short-term interest in health-related research with an OR of 1.3 (1.1-1.7, p=0.0063). We also noted that being female and being older was correlated to a higher interest in health-related research CONCLUSIONS: This study found that proactive information significantly increased the general populations' interest in health-related research. There are reasonable set up costs involved but the costs for maintaining the system were very low. Hence, it seems reasonable that research-active organisations should give much higher priority to this type of activity. TRIAL REGISTRATION NUMBER: ACTRN12617001085369.

Perspectives and experiences of collecting antenatal colostrum in women who have had diabetes during pregnancy: a North Queensland semistructured interview study.

OBJECTIVES: To explore and describe the experiences and perspectives of collecting and storing colostrum in the antenatal period in women who have had diabetes in pregnancy. DESIGN: Face-to-face, semistructured interviews analysed with purposive sampling and thematic analysis. SETTING: A regional hospital in North Queensland with a high prevalence of diabetes in pregnancy. PARTICIPANTS: Six women with a previous pregnancy complicated by diabetes who were advised to collect and store colostrum in pregnancy. RESULTS: Six themes were identified: wariness of medicalisation (adjusting to an 'abnormal' pregnancy, seeking continuity of care, determination to reduce formula, fear of invasive intervention); underlying altruism (providing the best for baby, preparing for complications, eager for milk donation); internal pressure to succeed (coping with confronting information, disheartened by failures, constant fear of insufficient supply, overwhelming guilt, concern for future breastfeeding success); self-management and ownership (adapting to awkwardness, developing strategies for success, actively seeking education, gaining confidence to request help, accepting personal limitations); frustrated by waste (encroaching on time, squandering a precious resource, ambiguous about necessity) and building fortitude for motherhood (physically preparing for breast feeding, symbolic of the imminent infant, establishing early relationships with supports, approaching challenges with realistic optimism). CONCLUSION: Women with diabetes in pregnancy experience guilt and stress about the added risk of hypoglycaemia to their babies and strive to provide the best for their babies by collecting and storing colostrum, even if this leads to distress to themselves. It is crucial that these women be provided accurate, realistic advice about the benefits and disadvantages of collecting colostrum in the antenatal period.