Multicomponent perioperative interventions to improve outcomes for frail patients: a systematic review.

BACKGROUND: Preoperative frailty is associated with increased risk of adverse outcomes. In 2017, McIsaac and colleagues' systematic review found that few interventions improved outcomes in this population and evidence was low-quality. We aimed to systematically review the evidence for multicomponent perioperative interventions in frail patients that has emerged since McIsaac et al.'s review. METHODS: PUBMED, EMBASE, Cochrane, and CINAHL databases were searched for English-language studies published since January 1, 2016, that evaluated multicomponent perioperative interventions in patients identified as frail. Quality was assessed using the National Institute of Health Quality Assessment Tool. A narrative synthesis of the extracted data was conducted. RESULTS: Of 2835 articles screened, five studies were included, all of which were conducted in elective oncologic gastrointestinal surgical populations. Four hundred and thirteen patients were included across the five studies and the mean/median age ranged from 70.1 to 87.0 years. Multicomponent interventions were all applied in the preoperative period. Two studies also applied interventions postoperatively. All interventions addressed exercise and nutritional domains with variability in timing, delivery, and adherence. Multicomponent interventions were associated with reduced postoperative complications, functional deterioration, length of stay, and mortality. Four studies reported on patient-centred outcomes. The quality of evidence was fair. CONCLUSIONS: This systematic review provides evidence that frail surgical patients undergoing elective oncologic gastrointestinal surgery may benefit from targeted multicomponent perioperative interventions. Yet methodological issues and substantial heterogeneity of the interventions precludes drawing clear conclusions regarding the optimal model of care. Larger, low risk of bias studies are needed to evaluate optimal intervention delivery, effectiveness in other populations, implementation in health care settings and ascertain outcomes of importance for frail patients and their carers.

How frail is frail in oncology studies? A scoping review.

AIMS: The frailty index (FI) is one way in which frailty can be quantified. While it is measured as a continuous variable, various cut-off points have been used to categorise older adults as frail or non-frail, and these have largely been validated in the acute care or community settings for older adults without cancer. This review aimed to explore which FI categories have been applied to older adults with cancer and to determine why these categories were selected by study authors. METHODS: This scoping review searched Medline, EMBASE, Cochrane, CINAHL, and Web of Science databases for studies which measured and categorised an FI in adults with cancer. Of the 1994 screened, 41 were eligible for inclusion. Data including oncological setting, FI categories, and the references or rationale for categorisation were extracted and analysed. RESULTS: The FI score used to categorise participants as frail ranged from 0.06 to 0.35, with 0.35 being the most frequently used, followed by 0.25 and 0.20. The rationale for FI categories was provided in most studies but was not always relevant. Three of the included studies using an FI > 0.35 to define frailty were frequently referenced as the rationale for subsequent studies, however, the original rationale for this categorisation was unclear. Few studies sought to determine or validate optimum FI categorises in this population. CONCLUSION: There is significant variability in how studies have categorised the FI in older adults with cancer. An FI ≥ 0.35 to categorise frailty was used most frequently, however an FI in this range has often represented at least moderate to severe frailty in other highly-cited studies. These findings contrast with a scoping review of highly-cited studies categorising FI in older adults without cancer, where an FI ≥ 0.25 was most common. Maintaining the FI as a continuous variable is likely to be beneficial until further validation studies determine optimum FI categories in this population. Differences in how the FI has been categorised, and indeed how older adults have been labelled as 'frail', limits our ability to synthesise results and to understand the impact of frailty in cancer care.

Hospital utilisation in Australia, 1993-2020, with a focus on use by people over 75 years of age: a review of AIHW data.

OBJECTIVES: To assess Australian hospital utilisation, 1993-2020, with a focus on use by people aged 75 years or more. DESIGN: Review of Australian Institute of Health and Welfare (AIHW) hospital utilisation data. SETTING, PARTICIPANTS: Tertiary data from all Australian public and private hospitals for the financial years 1993-94 to 2019-20. MAIN OUTCOME MEASURES: Numbers and population-based rates of hospital separations and bed utilisation (bed-days) (all and multiple day admissions) and mean hospital length of day (multiple day admissions), overall and by age group (under 65 years, 65-74 years, 75 years or more). RESULTS: Between 1993-94 and 2019-20, the Australian population grew by 44%; the number of people aged 75 years or more increased from 4.6% to 6.9% of the population. The annual number of hospital separations increased from 4.61 million to 11.33 million (146% increase); the annual hospital separation rate increased from 261 to 435 per 1000 people (66% increase), most markedly for people aged 75 years or more (from 745 to 1441 per 1000 people; 94% increase). Total bed utilisation increased from 21.0 million to 29.9 million bed-days (42% increase), but the bed utilisation rate did not change markedly (1993-94, 1192 bed-days per 1000 people; 2019-20, 1179 bed-days per 1000 people), primarily because the mean hospital length of stay for multiple day admissions declined from 6.6 days to 5.4 days; for people aged 75 years or more it declined from 12.2 to 7.1 days. However, declines in stay length have slowed markedly since 2017-18. Total bed utilisation was 16.8% lower than projected from 1993-94 rates, and was 37.3% lower for people aged 75 years or more. CONCLUSION: Hospital bed utilisation rates declined although admission rates increased during 1993-94 to 2019-20; the proportion of beds occupied by people aged 75 years or more increased slightly during this period. Containing hospital costs by limiting bed availability and reducing length of stay may no longer be a viable strategy.

Nutritional quality of children's menus in restaurants: does cuisine type matter?

OBJECTIVE: It is unknown whether the nutritional quality of children's menus varies depending on the cuisine type. This study aimed to investigate differences in the nutritional quality of children's menus by cuisine type in restaurants located in Perth, Western Australia (WA). DESIGN: Cross-sectional study. SETTING: Perth, WA. PARTICIPANTS: Children's menus (n 139) from the five most prevalent restaurant cuisine types in Perth (i.e. Chinese, Modern Australian, Italian, Indian and Japanese) were assessed using the Children's Menu Assessment Tool (CMAT; range -5-21 with lower scores denoting lower nutritional quality) and the Food Traffic Light system, evaluated against Healthy Options WA Food and Nutrition Policy recommendations. Non-parametric ANOVA was used to test for a significant difference in total CMAT scores among cuisine types. RESULTS: Total CMAT scores were low for all cuisine types (range -2-5), with a significant difference between cuisine types (Kruskal-Wallis H = 58·8, P < 0·001). The highest total CMAT score by cuisine type was Modern Australian (mean = 2·27, sd = 1·41) followed by Italian (mean = 2·02, sd = 1·02), Japanese (mean = 1·80, sd = 2·39), Indian (mean = 0·30, sd = 0·97) and Chinese (mean = 0·07, sd = 0·83). When using the Food Traffic Light for assessment, Japanese cuisine had the highest percentage of green food items (44 %), followed by Italian (42 %), Modern Australian (38 %), Indian (17 %) and Chinese (14 %). CONCLUSIONS: Overall, the nutritional quality of children's menus was poor regardless of cuisine type. However, children's menus from Japanese, Italian and Modern Australian restaurants scored better in terms of nutritional quality than children's menus from Chinese and Indian restaurants.

A prospective, observational study of frailty, quality of life and dialysis in older people with advanced chronic kidney disease.

BACKGROUND: Frailty is prevalent in older people with chronic kidney disease (CKD) and robust evidence supporting the benefit of dialysis in this setting is lacking. We aimed to measure frailty and quality of life (QOL) longitudinally in older people with advanced CKD and assess the impact of dialysis initiation on frailty, QOL and mortality. METHODS: Outpatients aged ≥65 with an eGFR ≤ 20ml/minute/1.73m2 were enrolled in a prospective observational study and followed up four years later. Frailty status was measured using a Frailty Index (FI), and QOL was evaluated using the EuroQol 5D-5L instrument. Mortality and dialysis status were determined through inspection of electronic records. RESULTS: Ninety-eight participants were enrolled. Between enrolment and follow-up, 36% of participants commenced dialysis and 59% died. Frailty prevalence increased from 47% at baseline to 86% at follow-up (change in median FI = 0.22, p < 0.001). Initiating dialysis was not significantly associated with change in FI. QOL declined from baseline to follow-up (mean EQ-5D-5L visual analogue score of 70 vs 63, p = 0.034), though commencing dialysis was associated with less decline in QOL. Each 0.1 increment in baseline FI was associated with 59% increased mortality hazard (HR = 1.59, 95%CI = 1.20 to 2.12, p = 0.001), and commencing dialysis was associated with 59% reduction in mortality hazard (HR = 0.41, 95%CI = 0.20 to 0.87, p = 0.020) irrespective of baseline FI. CONCLUSIONS: Frailty increased substantially over four years, and higher baseline frailty was associated with greater mortality. Commencing dialysis did not affect the trajectory of FI but positively influenced the trajectory of QOL from baseline to follow-up. Within the limitations of small sample size, our data suggests that frail participants received similar survival benefit from dialysis as non-frail participants.

Lived experiences of adolescents with fetal alcohol spectrum disorder.

AIM: To explore the lived experiences of adolescents with fetal alcohol spectrum disorder (FASD) to understand: the ways in which their challenges influence daily functioning; and the personal assets and external resources that facilitate participation. METHOD: Semi-structured interviews were conducted with four adolescents (one identified as non-binary, one male, and two female) with FASD aged 13 to 15 years. A photo elicitation approach facilitated participation, whereby adolescents first took photographs of their daily activities and environments. Photographs were subsequently used to generate discussion during the interviews. Data analysis involved using interpretative phenomenological analysis to generate themes. RESULTS: Two superordinate themes and three subthemes relating to participants' lived experiences emerged from the interviews: (1) 'anxiety challenges participation' (subthemes [i] 'need for external support'; [ii] 'the power of positive relationships'; and [iii] 'talents and interests facilitate participation') and (2) 'importance of a unique identity'. INTERPRETATION: Findings illustrated the barriers adolescents experienced regarding their daily functioning and independence. Additionally, incorporating strengths into daily activities appeared to reduce anxiety and improve participation, and adolescents desired for their unique characteristics to be recognized and appreciated. To support adolescents with FASD, service providers should consider incorporating strengths-based approaches and an explicit focus on facilitating the development of positive self-identities. WHAT THIS PAPER ADDS: Anxiety often prevented adolescents' independent participation in social activities, requiring caregiver assistance. Strengths (e.g. talents, positive relationships) facilitated adolescents' participation and reduced their anxiety. Clinicians and researchers should consider strengths-based approaches to interventions targeting participation. Interventions for adolescents with fetal alcohol spectrum disorder could focus on developing a positive self-identity.

Prevalence and factors associated with advance health directives in frail older inpatients.

BACKGROUND: Advance health directives (AHD) can be used to explore and document patient preferences for treatment and are therefore an important aspect of care planning. AIMS: To investigate the prevalence and factors associated with AHD among older inpatients. METHODS: This retrospective study included 6449 patients, aged ≥65 years referred for specialist geriatric consultation between 2007 and 2018 in Queensland, Australia. The interRAI-Acute Care Comprehensive Geriatric Assessment tool was used to calculate a frailty index (FI), range 0-1, based on 52 possible deficits, and categorised into intervals of 0.1 for analysis. FI was also grouped according to previously reported cut points: fit (FI ≤0.25), moderately frail (FI >0.25-0.4), frail (FI >0.4-0.6) and severely frail (FI >0.6). RESULTS: An AHD was present in 1032 (16.0%) of 6449 patients. Those with an AHD were significantly frailer than those without an AHD (mean FI 0.52 vs 0.45; P < 0.001). Higher frailty (odds ratio (OR): 1.34 (1.27-1.40)), older age (OR: 1.04 (1.03-1.05)), living in an institution (OR: 1.33 (1.01-1.73)) and recent hospitalisation (OR: 1.42 (1.23-1.62)) were significantly associated with higher prevalence of AHD. Prevalence of AHD increased over time, from 7.6% (n = 66) in 2008 to 35.4% (n = 99) in 2017. CONCLUSIONS: The presence of AHD is associated with sociodemographic factors, as well as higher frailty levels. Prevalence of AHD among inpatients has increased over the past decade but remains modest.

Frailty and solid-organ transplant candidates: a scoping review.

BACKGROUND: There is currently no consensus as to a standardized tool for frailty measurement in any patient population. In the solid-organ transplantation population, routinely identifying and quantifying frailty in potential transplant candidates would support patients and the multidisciplinary team to make well-informed, individualized, management decisions. The aim of this scoping review was to synthesise the literature regarding frailty measurement in solid-organ transplant (SOT) candidates. METHODS: A search of four databases (Cochrane, Pubmed, EMBASE and CINAHL) yielded 3124 studies. 101 studies (including heart, kidney, liver, and lung transplant candidate populations) met the inclusion criteria. RESULTS: We found that studies used a wide range of frailty tools (N = 22), including four 'established' frailty tools. The most commonly used tools were the Fried Frailty Phenotype and the Liver Frailty Index. Frailty prevalence estimates for this middle-aged, predominantly male, population varied between 2.7% and 100%. In the SOT candidate population, frailty was found to be associated with a range of adverse outcomes, with most evidence for increased mortality (including post-transplant and wait-list mortality), post-operative complications and prolonged hospitalisation. There is currently insufficient data to compare the predictive validity of frailty tools in the SOT population. CONCLUSION: Overall, there is great variability in the approach to frailty measurement in this population. Preferably, a validated frailty measurement tool would be incorporated into SOT eligibility assessments internationally with a view to facilitating comparisons between patient sub-groups and national and international transplant services with the ultimate goal of improved patient care.

Preconception interventions to reduce the risk of alcohol-exposed pregnancies: A systematic review.

BACKGROUND: The preconception period provides a unique opportunity to optimize the health of women and children. High rates of alcohol use and unintended pregnancies are common across many Western societies, and alcohol-exposed pregnancies (AEPs) are a possible unintended outcome. The aim of the current study was to evaluate preconception interventions for the prevention of AEPs. METHODS: A systematic search of four electronic databases (PubMed, Embase, CINAHL, and PsycINFO) was undertaken for relevant peer-reviewed articles published from 1970 onward. Studies were included if they enrolled women and/or their support networks during the preconception period. RESULTS: Nineteen studies met the inclusion criteria. The majority of studies (n = 14) evaluated CHOICES-based interventions, which incorporate motivational interviewing approaches to change alcohol and/or contraceptive behavior. The other five interventions included a range of different approaches and modes of delivery. The majority of interventions were successful in reducing AEP risk. Changes in AEP risk were more often driven by changes in contraceptive behavior, although some approaches led to changes in both alcohol and contraceptive behavior. CONCLUSIONS: The review indicated that many interventions were efficacious at reducing AEP risk during the preconception period through preventing unplanned pregnancy. The effectiveness estimated from these clinical trials may be greater than that seen in interventions when implemented in practice where there is a lack of blinding and greater attrition of participants during follow-up. Further research investigating the real-world effectiveness of these intervention approaches implemented across a wide range of clinical settings would be beneficial.

Translating research into practice: outcomes from the Healthy Living after Cancer partnership project.

BACKGROUND: Healthy Living after Cancer (HLaC) was a national dissemination and implementation study of an evidence-based lifestyle intervention for cancer survivors. The program was imbedded into existing telephone cancer information and support services delivered by Australian state-based Cancer Councils (CC). We report here the reach, effectiveness, adoption, implementation, and maintenance of the program. METHODS: In this phase IV study (single-group, pre-post design) participants - survivors of any type of cancer, following treatment with curative intent - received up to 12 nurse/allied health professional-led telephone health coaching calls over 6 months. Intervention delivery was grounded in motivational interviewing, with emphasis on evidence-based behaviour change strategies. Using the RE-AIM evaluation framework, primary outcomes were reach, indicators of program adoption, implementation, costs and maintenance. Secondary (effectiveness) outcomes were participant-reported anthropometric, behavioural and psychosocial variables including: weight; physical activity; dietary intake; quality-of-life; treatment side-effects; distress; and fear of cancer recurrence and participant satisfaction. Changes were evaluated using linear mixed models, including terms for timepoint (0/6 months), strata (Cancer Council), and timepoint x strata. RESULTS: Four of 5 CCs approached participated in the study. In total, 1183 cancer survivors were referred (mostly via calls to the Cancer Council telephone information service). Of these, 90.4% were eligible and 88.7% (n = 791) of those eligible consented to participate. Retention rate was 63.4%. Participants were mostly female (88%), aged 57 years and were overweight (BMI = 28.8 ± 6.5 kg/m2). Improvements in all participant-reported outcomes (standardised effect sizes of 0.1 to 0.6) were observed (p < 0.001). The program delivery costs were on average AU$427 (US$296) per referred cancer survivor. CONCLUSIONS: This telephone-delivered lifestyle intervention, which was feasibly implemented by Cancer Councils, led to meaningful and statistically significant improvements in cancer survivors' health and quality-of-life at a relatively low cost. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ANZCTR) - ACTRN12615000882527 (registered on 24/08/2015).

Prevention of Alcohol-Exposed Pregnancies and Fetal Alcohol Spectrum Disorder Among Pregnant and Postpartum Women: A Systematic Review.

BACKGROUND: Prenatal alcohol exposure can result in a wide range of adverse health outcomes, including in some cases fetal alcohol spectrum disorder (FASD), a lifelong neurodevelopmental disorder. Thus, there is pressing need for effective interventions to prevent alcohol-exposed pregnancies (AEPs). METHODS: A systematic review was undertaken to provide an up-to-date analysis of the current prevention literature. PubMed, Embase, CINAHL, and PsycINFO were searched for relevant English-language articles published from 1970 onward. Studies were eligible for the current systematic review if the interventions included pregnant and postpartum women and/or their support networks to prevent AEPs and FASD. Outcomes of interest included alcohol consumption, knowledge, contraceptive use, neonatal outcomes, family well-being or functioning, economics, and healthcare utilization outcomes. RESULTS: Thirty-four peer-reviewed studies met the inclusion criteria. Fifteen studies employed brief intervention (BI) methods, 6 used long-term/intensive strategies, and 5 were educational interventions. A further 3 studies assessed counseling approaches, 2 evaluated multicomponent interventions, and 3 assessed nutritional supplementation interventions. CONCLUSIONS: The current review identified variable results from available interventions to prevent alcohol use among pregnant and postpartum women. Preliminary evidence demonstrated that BIs may be effective among subgroups of pregnant women with higher initial alcohol consumption, those with partner involvement, and those who used alcohol and other substances concurrently. Some preliminary evidence relating to long-term interventions with pregnant women with polysubstance use emerged, specifically case management that not only focused on reduction in substance use, but also on addressing the complex interplay between health and social well-being of families. Overall, additional research is required to improve the effectiveness of preventative approaches during pregnancy and the postpartum period.

Experiences of Children with Fetal Alcohol Spectrum Disorder and Their Families: A Critical Review.

Evidence suggests that children with fetal alcohol spectrum disorder (FASD) experience challenges across many areas of their daily lives and often require interprofessional supports. Recent studies have emphasized the need for an integrated system of care for children with FASD, incorporating medical, allied health, and education services, to facilitate open communication and support for the complex needs that many children experience. To develop such a system of care, it is important to first understand the impact of FASD on children's functioning during daily activities in different environmental contexts. A critical review of existing research was conducted using a critical interpretive synthesis approach. Results revealed that while many studies discussed impacts at the body functions and structures level of children with FASD, they often did not consider the activity, participation, and environmental factors also contributing to the daily functioning of this population. Several studies discussed caregiver experiences and challenges raising a child with FASD; however, no studies investigated the lived experiences relating to impacts across activities and environments from children's perspectives. In addition, the focus on deficits overshadowed investigation into the strengths of children with FASD, leaving a gap in the picture of their daily lives. Further research is required to determine the strengths that children with FASD demonstrate and the challenges impacting their daily functioning within different environmental contexts. Insights gleaned from such research would support intervention practices to become more holistic and interprofessional.

Outcomes and needs of health and education professionals following fetal alcohol spectrum disorder-specific training.

AIM: Understanding professionals' views and needs can help advance service provision and improve future training opportunities, Therefore, the current study examined the experiences of Australian and New Zealand professionals who have attended fetal alcohol spectrum disorder (FASD)-specific training and the impact of this training on their current practices. METHODS: A total of 52 health and education professionals from Australia and New Zealand completed an online survey that asked about their training experiences; changes in practice following training; their experiences implementing assessments in their workplace; and, for Australian professionals, their experiences of using the recently released Australian Guide to FASD diagnosis. RESULTS: Respondents described a range of perceived practice changes following training attendance. These included increases in: asking about alcohol use during pregnancy; providing referrals for assessments; providing assessments and consultation with other professionals regarding FASD diagnosis. Qualitative findings also demonstrated themes of increased knowledge, awareness and/or confidence about providing neurodevelopmental assessments and FASD diagnosis following training. CONCLUSIONS: This is the first study to document training and practice experiences of Australian and New Zealand professionals in relation to FASD. Overall, training efforts were well received by professionals and were effective in changing professionals' self-reported practice. Future investment in FASD-specific training initiatives and increased resources to enable neurodevelopmental assessments for all complex presentations, including FASD, is warranted.

Fetal alcohol spectrum disorder: the importance of assessment, diagnosis and support in the Australian justice context.

Fetal alcohol spectrum disorder (FASD) is a neurodevelopmental condition with life-long implications. Individuals with FASD can experience communication, cognitive, behavioural, social and emotional difficulties that impact their functional capacity. Due to these brain-based impairments, previous research suggests that individuals with FASD are over-represented in the justice system. The current article outlines how individuals with FASD may experience inequities within the justice system, why assessment, diagnosis and intervention is important, and the role of health and justice partnerships in promoting more equitable outcomes for justice-involved individuals with FASD. Increased resources and collaborations between health and justice professionals are required to enable the provision of neurodevelopmental assessments for all complex presentations, including FASD.

Adverse health outcomes associated with fetal alcohol exposure: A systematic review focused on immune-related outcomes.

Prenatal alcohol exposure (PAE) has well-known teratogenic effects on the developing fetus, potentially resulting in neurologic impairments. However, there is increasing interest regarding other potential adverse health outcomes related to prenatal alcohol exposure. The objective of this study was to undertake a systematic review to identify all the available clinical and preclinical literature investigating immune-related outcomes in offspring with PAE. A systematic review searching four electronic databases (PubMed, CINAHL, Web of Science, and Embase) was conducted. Potential articles were screened against strict inclusion/exclusion criteria. This review specifically focused on evaluating studies related to immune-related outcomes following PAE. Twelve clinical studies were included in the current review. Six included allergy outcomes, four included infection outcomes, and two studies included both. Thirty-nine preclinical studies were identified examining a wide range of immune outcomes. The current review provides some preliminary clinical evidence that PAE can influence immune function, including atopic allergy and infection outcomes. However, there was variability in results across studies, particularly in the atopy area. Preclinical studies demonstrated some changes in lymphocytes and cytokines in offspring following PAE. More research investigating the effects of PAE on immune responses is warranted.

Adverse Health Outcomes in Offspring Associated With Fetal Alcohol Exposure: A Systematic Review of Clinical and Preclinical Studies With a Focus on Metabolic and Body Composition Outcomes.

Prenatal alcohol exposure (PAE) results in well-characterized neurological, behavioral, and cognitive deficits in offspring. However, the effects on other health outcomes have not been comprehensively described. We used a systematic review methodology to survey published clinical and preclinical studies investigating a broad range of health outcomes in offspring with PAE. This study specifically reports on outcomes related to metabolism and body composition. The literature was systematically searched across 4 electronic databases (PubMed, CINAHL, Embase, and Web of Science), resulting in 3,230 articles following duplicate removal. Titles and abstracts were reviewed against specific inclusion/exclusion criteria, with 242 articles meeting the criteria for full-text assessment of eligibility. Articles with ineligible study type were removed (127) and articles added from reference lists (15) and an updated search closer to submission (9) for a total of 139 studies. Although 5 health domains were identified, here we focus on metabolism and body composition. Details of alcohol exposure, offspring demographics, and sample sizes were tabulated and quality of reporting assessed. Findings were summarized for body composition (percentage fat mass), physiological and molecular outcomes related to glucose metabolism, and outcomes related to lipid metabolism. There were 32 included studies (2 case-control, 1 prospective longitudinal cohort, and 29 preclinical). Studies had a range of alcohol exposures, both dosage and timing, although all clinical studies had heavy PAE and/or evidence of fetal alcohol syndrome in offspring. The preclinical studies provided evidence of glucose intolerance and/or insulin resistance; dyslipidemia and/or hypercholesterolemia; and increased adiposity in offspring with PAE. Due to the paucity of clinical studies, we recommend further studies be conducted to obtain a complete assessment of long-term metabolic health outcomes in children and adults with PAE, particularly in those diagnosed with fetal alcohol spectrum disorder.

Protocol for the Yapatjarrathati project: a mixed-method implementation trial of a tiered assessment process for identifying fetal alcohol spectrum disorders in a remote Australian community.

BACKGROUND: Fetal alcohol spectrum disorder (FASD) is a highly prevalent neurodevelopmental disorder associated with prenatal alcohol exposure. Early identification can improve functioning for individuals and reduce costs to society. Gold standard methods of diagnosing FASD rely on specialists to deliver intensive, multidisciplinary assessments. While comprehensive, prevalence rates highlight that this assessment model cannot meet demand, nor is it feasible in remote areas where specialist services are lacking. This project aims to expand the capabilities of remote practitioners in north Queensland, Australia, where 23-94% of the community identify as First Nations people. Integrating cultural protocols with the implementation science theories of Knowledge-To-Action, Experience-Based Co-Design, and RE-AIM, remote practitioners with varying levels of experience will be trained in a co-designed, culturally appropriate, tiered neurodevelopmental assessment process that considers FASD as a potential outcome. This innovative assessment process can be shared between primary and tertiary health care settings, improving access to services for children and families. This project aims to demonstrate that neurodevelopmental assessments can be integrated seamlessly with established community practices and sustained through evidence-based workforce development strategies. METHODS: The Yapatjarrathati project (named by the local First Nations community and meaning 'to get well') is a mixed-method implementation trial of a tiered assessment process for identifying FASD within a remote Australian community. In collaboration with the community, we co-designed: (a) a culturally sensitive, tiered, neurodevelopmental assessment process for identifying FASD, and (b) training materials that up-skill remote practitioners with varying levels of expertise. Qualitative interviews for primary, secondary and end users will be undertaken to evaluate the implementation strategies. RE-AIM will be used to evaluate the reach, effectiveness, adoption, implementation and maintenance of the assessment and training process. DISCUSSION: Co-designed with the local community, integrated with cultural protocols, and based on implementation science theories, the assessment and training process from this project will have the potential to be scaled-up across other remote locations and trialed in urban settings. The Yapatjarrathati project is an important step towards increasing the availability of neurodevelopmental services across Australia and empowering remote practitioners to contribute to the FASD assessment process.

Applying a Developmental Framework to the Self-Regulatory Difficulties of Young Children with Prenatal Alcohol Exposure: A Review.

Prenatal alcohol exposure (PAE) can be associated with significant difficulties in self-regulatory abilities. As such, interventions have been developed that focus on improving varying aspects of self-regulation for this population. The application of a multilevel theoretical framework that describes the development of self-regulation during early childhood could further advance the field. First, this framework could assist in elucidating mechanisms in the trajectories of early adjustment problems in this population and, second, informing the development of more precise assessment and interventions for those affected by PAE. The aims of the current review were to provide an overview of the self-regulatory framework proposed by Calkins and colleagues (e.g., Calkins, 2007; Calkins and Fox, 2002); examine the self-regulatory difficulties that are commonly experienced during infancy (i.e., 0 to 2 years) and early childhood (i.e., 3 to 8 years) in children with PAE in the context of the developmental framework; and describe how the framework can inform the development of future assessment and intervention provision for young children with PAE. The application of a developmental framework, such as proposed by Calkins and colleagues, allows for a systematic and theoretically driven approach to assessment and intervention programs for young children with PAE.

Effect of Choline Supplementation on Neurological, Cognitive, and Behavioral Outcomes in Offspring Arising from Alcohol Exposure During Development: A Quantitative Systematic Review of Clinical and Preclinical Studies.

Prenatal alcohol exposure results in cognitive, behavioral, and neurological deficits in offspring. There is an urgent need for safe and effective treatments to overcome these effects. Maternal choline supplementation has been identified as a potential intervention. Our objective was to review preclinical and clinical studies using choline supplementation in known cases of fetal alcohol exposure to determine its effectiveness in ameliorating deficits in offspring. A systematic search of 6 electronic databases was conducted and studies selected by reviewing titles/abstracts against specific inclusion/exclusion criteria. Study characteristics, population demographics, alcohol exposure, and intervention methods were tabulated, and quality of reporting was assessed. Data on cognitive, behavioral, and neurological outcomes were extracted and tabulated. Quantitative analysis was performed to determine treatment effects for individual study outcomes. A total of 189 studies were retrieved following duplicate removal. Of these, 22 studies (2 randomized controlled trials, 2 prospective cohort studies, and 18 preclinical studies) met the full inclusion/exclusion criteria. Choline interventions were administered at different times relative to alcohol exposure, impacting on their success to prevent deficits for specific outcomes. Only 1 clinical study showed significant improvements in information processing in 6-month-old infants from mothers treated with choline during pregnancy. Preclinical studies showed significant amelioration of deficits due to prenatal alcohol exposure across a wide variety of outcomes, including epigenetic/molecular changes, gross motor, memory, and executive function. This review suggests that choline supplementation has the potential to ameliorate specific behavioral, neurological, and cognitive deficits in offspring caused by fetal alcohol exposure, at least in preclinical studies. As only 1 clinical study has shown benefit, we recommend more clinical trials be undertaken to assess the effectiveness of choline in preventing deficits across a wider range of cognitive domains in children.