Flexible Fiber-Optic Scope Use in Retrieval Medicine: A Case Series.

OBJECTIVE: The use of flexible fiber-optic scopes is increasing across critical care specialities, but there is limited literature on their use in retrieval medicine. This study aims to describe a case series in which flexible fiber-optic scopes were used by New South Wales Ambulance Aeromedical Operations critical care teams. METHODS: A retrospective case series was performed in our service from January 1, 2019, to December 31, 2021. We searched our electronic medical retrieval database for the terms "aScope," "Awake Fibreoptic Intubation (AFOI)," "Fibreoptic Intubation (FOI)," and "Nasal Endotracheal Tube (ETT)" to identify when a flexible fiber-optic scope was used. RESULTS: There were 16 uses of flexible fiber-optic scopes during the study period. The most common procedure was awake nasal fiber-optic intubation, which was performed during 9 cases, 7 of which were successful. Other procedures performed included 4 cases of intubation through a supraglottic airway, 1 case of an asleep fiber-optic intubation, 1 case of flexible nasoendoscopy for upper airway assessment, and 1 case of fiber-optic bronchoscopy via tracheostomy. These procedures were performed by anesthetic, emergency and intensive care doctors. This case series describes 4 of these cases in more detail. CONCLUSION: This case series demonstrates a variety of procedural and diagnostic uses for flexible fiber-optic scopes in retrieval medicine. These procedures can have an important bearing on decision making and patient management. The training and clinical governance provided by our service in this skill appears to be safe and robust with high success rates of awake fiber-optic intubations.

Aged care service use by Aboriginal and Torres Strait Islander people after aged care eligibility assessments, 2017-2019: a population-based retrospective cohort study.

OBJECTIVE: To characterise the socio-demographic characteristics, aged and health care needs, and aged care services used by older Aboriginal and Torres Strait Islander people assessed for aged care service eligibility. STUDY DESIGN: Population-based retrospective cohort study; analysis of Registry of Senior Australians (ROSA) National Historical Cohort data. SETTING, PARTICIPANTS: Aboriginal and Torres Strait Islander people aged 50 years or older who were first assessed for aged care service eligibility (permanent residential aged care, home care package, respite care, or transition care) during 1 January 2017 - 31 December 2019. MAJOR OUTCOME MEASURES: Socio-demographic and aged care assessment characteristics; health conditions and functional limitations recorded at the time of the assessment; subsequent aged care service use. RESULTS: The median age of the 6209 people assessed for aged care service eligibility was 67 years (interquartile range [IQR], 60-75 years), 3626 were women (58.4%), and 4043 lived in regional to very remote areas of Australia (65.1%). Aboriginal health workers were involved in 655 eligibility assessments (10.5%). The median number of health conditions was six (IQR, 4-8); 6013 (96.9%) had two or more health conditions, and 2592 (41.8%) had seven or more. Comorbidity was most frequent among people with mental health conditions: 597 of 1136 people with anxiety (52.5%) and 1170 of 2416 people with depression (48.5%) had seven or more other medical conditions. Geriatric syndromes were recorded for 2265 people (36.5%); assistance with at least one functional activity was required by 6190 people (99.7%). A total of 6114 people (98.5%) were approved for at least one aged care service, 3218 of whom (52.6%) subsequently used these services; the first services used were most frequently home care packages (1660 people, 51.6%). CONCLUSION: Despite the high care needs of older Aboriginal and Torres Strait Islander people, only 52% used aged care services for which they were eligible. It is likely that the health and aged care needs of older Aboriginal and Torres Strait Islander people are not being adequately met.

Predictive and protective factors for failing first pass intubation in prehospital rapid sequence intubation: an aetiology and risk systematic review with meta-analysis.

BACKGROUND: Prehospital rapid sequence intubation first pass success rates vary between 59% and 98%. Patient morbidity is associated with repeat intubation attempts. Understanding what influences first pass success can guide improvements in practice. We performed an aetiology and risk systematic review to answer the research question 'what factors are associated with success or failure at first attempt laryngoscopy in prehospital rapid sequence intubation?'. METHODS: MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched on March 3, 2023 for studies examining first pass success rates for rapid sequence intubation of prehospital live patients. Screening was performed via Covidence, and data synthesised by meta-analysis. The review was registered with PROSPERO and performed and reported as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Reasonable evidence was discovered for predictive and protective factors for failure of first pass intubation. Predictive factors included age younger than 1 yr, the presence of blood or fluid in the airway, restricted jaw or neck movement, trauma patients, nighttime procedures, chronic or acute distortions of normal face/upper airway anatomy, and equipment issues. Protective factors included an experienced intubator, adequate training, use of certain videolaryngoscopes, elevating the patient on a stretcher in an inclined position, use of a bougie, and laryngeal manoeuvres. CONCLUSIONS: Managing bloody airways, positioning well, using videolaryngoscopes with bougies, and appropriate training should be further explored as opportunities for prehospital services to increase first pass success. Heterogeneity of studies limits stronger conclusions. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42022353609).

Factors Associated With Desaturation in Prehospital Rapid Sequence Intubation in a Helicopter Emergency Medical Service.

OBJECTIVE: Desaturation during prehospital rapid sequence intubation (RSI) is common and is associated with patient morbidity. Past studies have identified oxygen saturations at induction, the grade of laryngoscopy, and multiple attempts to intubate as being associated with desaturation. This study aimed to investigate whether there are other factors, identifiable before RSI, associated with desaturation. METHODS: This was a study of a physician-paramedic critical care team operating as Aeromedical Operations, NSW Ambulance. Prehospital RSIs (using paralysis) were studied retrospectively via patient case notes, monitor data, and an airway database. The review occurred between April 1, 2016, and December 31, 2018. Desaturation was defined as monitor recordings of saturations ≤ 92%. Logistic regression was performed for factors likely to be associated with desaturation. RESULTS: Desaturation occurred in 67 of 350 (19.1%) RSIs. Factors significantly associated with desaturation included male sex, a chest injury, increased weight, and lower saturations pre-RSI. CONCLUSION: Increased weight, chest injuries, and lower oxygen saturations are associated with desaturation at RSI. The variable male sex may be a surrogate for other as-yet unidentified factors.

Integrating testing for sexually transmissible infections into annual health assessments for Aboriginal and Torres Strait Islander young people: a cross-sectional analysis.

BACKGROUND: In the context of an expanding syphilis epidemic, we assessed the integration of sexually transmissible infection (STI) testing within annual health assessments for Aboriginal and Torres Strait Islander young people aged 16-29years in Aboriginal Community Controlled Health Services between 2018 and 2020. METHODS: Using routinely collected electronic medical record data from a national sentinel surveillance system (ATLAS), we performed a cross-sectional analysis to calculate the proportion of assessments that integrated any or all of the tests for chlamydia, gonorrhoea, syphilis, and HIV. We used logistic regression to identify correlates of integration of any STI test. RESULTS: Of the 13 892 assessments, 23.8% (95% CI 23.1, 24.6) integrated a test for any STI and 11.5% (95% CI 10.9, 12.0) included all four STIs. Of assessments that included a chlamydia/gonorrhoea test, 66.9% concurrently included a syphilis test. Integration of any STI test was associated with patients aged 20-24years (OR 1.2, 95% CI 1.1-1.4) and 25-29years (OR 1.1, 95% CI 1.0-1.2) compared to 16-19years and patients residing in very remote (OR 4.2, 95% CI 3.7-4.8), remote (OR 2.4, 95% CI 2.1-2.8), and regional areas (OR 2.5, 95% CI 2.2-2.8) compared to metropolitan areas. There was no association with patient sex. CONCLUSIONS: Integration of STI testing into annual health assessments for Aboriginal and Torres Strait Islander young people was higher in remote areas where disease burden is greatest. Integration is similar in men and women, which contrasts with most studies that have found higher testing in women.

Barriers and Facilitators to Hepatitis C Virus (HCV) Treatment for Aboriginal and Torres Strait Islander Peoples in Rural South Australia: A Service Providers' Perspective.

This study explored the barriers and facilitators to hepatitis C virus (HCV) treatment for Aboriginal and Torres Strait Islander peoples in rural South Australia as viewed from a healthcare provider perspective in the era of direct acting antivirals (DAAs). Phase 1 was a qualitative systematic review examining the barriers and enablers to diagnosis and treatment amongst Indigenous peoples living with HCV worldwide. Phase 2 was a qualitative descriptive study with healthcare workers from six de-identified rural and regional Aboriginal Community-Controlled Health Services in South Australia. The results from both methods were integrated at the analysis phase to understand how HCV treatment could be improved for rural Aboriginal and Torres Strait Islander peoples. Five main themes emerged: the importance of HCV education, recognizing competing social and cultural demands, the impact of holistic care delivery and client experience, the effect of internal barriers, and overlapping stigma, discrimination, and shame determine how Indigenous peoples navigate the healthcare system and their decision to engage in HCV care. Continued efforts to facilitate the uptake of DAA medications by Aboriginal and Torres Strait peoples in rural areas should utilize a multifaceted approach incorporating education to community and cultural awareness to reduce stigma and discrimination.

Is the evidence-based medicine movement counter-productive: are randomised controlled trials the best approach to establish evidence in complex healthcare situations?

In the modern era, evidence-based medicine (EBM) has been embraced as the best approach to practising medicine, providing clinicians with 'objective' evidence from clinical research. However, for presentations with complex pathophysiology or from complex social environments, sometimes there remains no evidence, and no amount of research will obtain it. Yet, health researchers continue to undertake randomised controlled trials (RCT) in complex environments, ignoring the risk that participants' health may be compromised throughout the trial process. This paper examines the role of research that seeks to obtain evidence to support EBM. We provide examples of RCTs on ear disease in Aboriginal populations as a case-in-point. Decades of ear research have failed to yield statistically significant findings, demonstrating that when multiple factors are at play, study designs struggle to balance the known disease process drivers, let alone unknown drivers. This paper asks the reader to consider if the pursuit of research is likely to produce evidence in complex situations; or if perhaps RCTs should not be undertaken in these situations. Instead, clinicians could apply empirical evidence, tailoring treatments to individuals while taking into account the complexities of their life circumstances.

Out-of-Hospital Pediatric Video Laryngoscopy With an Adult Device: A Case Series Presented With a Contemporary Group Intubated With Direct Laryngoscopy.

OBJECTIVES: After introducing an adult video laryngoscope (VL) in our physician-paramedic prehospital and retrieval medical service, our quality assurance process identified this blade being used during pediatric intubations. We present a case series of pediatric intubations using this oversized adult VL alongside a contemporaneous group of direct laryngoscopy (DL) intubations. METHODS: We performed a retrospective review of intubated patients 15 years or younger in our electronic quality assurance registry from January 1, 2017, to December 31, 2020. Data collected were demographic details, intubation equipment, drug doses, the number of intubation attempts, and complications. Results are presented according to those intubated with C-MAC4 VL (Karl Storz) alongside age-appropriate DL sizes. RESULTS: Ninety-nine pediatric patients were intubated, 67 (67%) by CMAC4 and 32 (33%) by DL. Video laryngoscopy had a first-attempt success rate of 96% and DL 91%. A Cormach and Lehane view 1 or 2 was found in 66 VL (99%) and 29 DL patients (91%). Desaturation was reported in two VL and 1 DL patient. CONCLUSIONS: Adult VL became the most common method of intubation in patients older than 1 year during the study period. An adult C-MAC4 VL could be considered for clinicians who prefer VL when a pediatric VL is unavailable or as a second-line device if a pediatric VL is not present when intubating children older than 1 year.

Design of a treatment satisfaction measure for patients undergoing varicose vein treatment: Venous Treatment Satisfaction Questionnaire (VenousTSQ).

BACKGROUND: Established condition-specific patient-reported outcome measures for varicose veins are limited to the measurement of health status and function. A treatment satisfaction measure is needed to understand patient satisfaction with different treatment options. The aim of this study was to design a Venous Treatment Satisfaction Questionnaire (VenousTSQ) that would be ready for large-scale data collection and psychometric evaluation. METHODS: Relevant items were selected from the -TSQ Item Library and new items were designed where necessary. A draft VenousTSQ was prepared using the existing AneurysmTSQ as a template. Fifteen interviews were conducted from 4 days to 16 months after the procedure. The interviews were designed to elicit important sources of satisfaction or dissatisfaction before completion of draft questionnaires. The VenousTSQ drafts were modified between sets of interviews until no further changes were required. RESULTS: The final VenousTSQ consists of two questionnaires: VenousTSQ early (VenousTSQe) and VenousTSQ status (VenousTSQs). Items that need be asked only once are in the VenousTSQe, whereas those that can usefully be asked more than once are in the VenousTSQs. Of the 16 unique items forming the VenousTSQ, 12 were from the -TSQ Item Library. Only 1 of these 12 required significant modification. CONCLUSIONS: The VenousTSQ represents a condition-specific psychological outcome measure for varicose veins, enabling patient satisfaction or dissatisfaction with such treatments to be measured. Large-scale data collection is under way to establish optimal scoring, quantitative validity, and reliability of the VenousTSQ.

The prevalence and significance of gestational cannabis use at an Australian tertiary hospital.

BACKGROUND: Cannabis is one of the most common non-prescribed psychoactive substances used in pregnancy. The prevalence of gestational cannabis use is increasing. AIM: The aim was to examine the prevalence of gestational cannabis use and associated pregnancy and neonate outcomes. MATERIALS AND METHODS: A retrospective observational study involving pregnant women delivering in 2019 was conducted at a tertiary hospital in Perth, Western Australia. Gestational cannabis and other substance use records were based on maternal self-report. Pregnancy outcomes included neonatal gestational age, birthweight, birth length, head circumference, resuscitation measures, special care nursery admission, 5-min Apgar score and initial neonatal feeding method. RESULTS: Among 3104 pregnant women (mean age: 31 years), gestational cannabis use was reported by 1.6% (n = 50). Cannabis users were younger, more likely to use other substances and experience mental illness or domestic violence compared with non-users. Neonates born to cannabis users had a lower mean gestational age, birthweight and birth length compared to those born to non-cannabis users. Gestational cannabis use (odds ratio (OR) 3.3, 95% confidence interval (CI) 1.6-6.7) and tobacco smoking (OR 2.2, 95% CI 1.5-3.6) were associated with increased odds of a low-birthweight neonate. Combined cannabis and tobacco use during pregnancy further increased the likelihood of low birthweight (LBW, adjusted OR 3.9, 95% CI 1.6-9.3). Multivariate logistic regression analysis adjusted for maternal sociodemographical characteristics, mental illness, alcohol, tobacco and other substance use demonstrated gestational cannabis use to be independently associated with LBW (OR 2.3, 95% CI 1.1-5.2). CONCLUSION: Gestational cannabis use was independently associated with low birthweight, synergistically affected by tobacco smoking.

Describing the Challenges of Prehospital Rapid Sequence Intubation by Macintosh Blade Video Laryngoscopy Recordings.

STUDY OBJECTIVE: Structured review of video laryngoscopy recordings from physician team prehospital rapid sequence intubations (RSIs) may provide new insights into why prehospital intubations are difficult. The aim was to use laryngoscope video recordings to give information on timings, observed features of the airway, laryngoscopy technique, and laryngoscope performance. This was to both describe prehospital airways and to investigate which factors were associated with increased time taken to intubate. METHODS: Sydney Helicopter Emergency Medical Service (HEMS; the aeromedical wing of New South Wales Ambulance, Australia) has a database recording all intubations. The database comprises free-text case detail, airway dataset, scanned case sheet, and uploaded laryngoscope video. The teams of critical care paramedic and doctor use protocol-led intubations with a C-MAC Macintosh size four laryngoscope and intubation adjunct. First-pass intubation rate is approximately 97%. Available video recordings and their database entries were retrospectively analyzed for pre-specified qualitative and quantitative factors. RESULTS: Prehospital RSI video recordings were available for 385 cases from January 2018 through July 2020. Timings revealed a median of 58 seconds of apnea from laryngoscope entering mouth to ventilations. Median time to intubate (laryngoscope passing lips until tracheal tube inserted) was 35 seconds, interquartile range 28-46 seconds. Suction was required prior to intubation in 29% of prehospital RSIs. Fogging of the camera lens at time of laryngoscopy occurred in 28%. Logistic regression revealed longer time to intubate was associated with airway soiling, Cormack-Lehane Grade 2 or 3, multiple bougie passes, or change of bougie. CONCLUSION: Video recordings averaging 35 seconds for first-pass success prehospital RSI with an adjunct give bed-side "definitions of difficulty" of 30 seconds for no glottic view, 45 seconds for no bougie placement, and 60 seconds for no endotracheal tube placement. Awareness of apnea duration can help guide decision making for oxygenation. All emergency intubators need to be cognizant of the need for suctioning. Improving the management of bloodied airways and bougie usage may reduce laryngoscopy duration and be a focus for training. Video screen fogging and missed recordings from some patients may be something manufacturers can address in the future.

Rocuronium ≤1.5 mg/kg versus >1.5 mg/kg and inadequate paralysis in prehospital and retrieval intubation: A retrospective study.

OBJECTIVE: Greater Sydney Area Helicopter Emergency Medical Service encouraged an increased dose of rocuronium for rapid sequence intubations (RSIs) from 1.5 mg/kg to 2.0 mg/kg from the end of 2017 in response to a number of inadequately paralysed patients identified by our airway audit processes. Subsequent protocol change incorporated 2.0 mg/kg rocuronium. This retrospective observational study was undertaken to see if doses over 1.5 mg/kg rocuronium were associated with a reduction in the number of inadequately paralysed patients. METHODS: Retrospective review of patient prehospital notes and airway database records from 2017 to 2018 for all cases using rocuronium for RSI. Primary outcome of interest was physician notes describing skeletal muscle activity at laryngoscopy. Patients with tissued vascular access were excluded. Dose of rocuronium, estimated patient actual weight and grade of laryngoscopy were recorded. Comparisons were made between rocuronium doses ≤1.5 mg/kg and >1.5 mg/kg by estimated weight. RESULTS: From 211 patients receiving rocuronium ≤1.5 mg/kg, five cases were inadequately paralysed, compared with two cases from 384 patients receiving >1.5 mg/kg rocuronium. CONCLUSIONS: Although there were fewer inadequately paralysed patients with rocuronium doses >1.5 mg/kg, this did not reach statistical significance, presumably because of the low event rate. Further investigation into rocuronium dose for RSI is warranted.

The Association of Laryngeal Position on Videolaryngoscopy and Time Taken to Intubate Using Spatial Point Pattern Analysis of Prospectively Collected Quality Assurance Data.

BACKGROUND: During videolaryngoscopy (VL), the larynx appears within the defined area of the video screen, and its location can be measured as a point within this space. Spatial statistics offer methods to explore the relationship between location data and associated variables of interest. The aims of this study were to use spatial point pattern analysis to explore if the position of the larynx on VL is associated with longer times to intubate, increased risk of a needing >1 intubation attempt, or percentage of glottic opening. METHODS: Quality assurance data and clinical notes from all prehospital intubations using C-MAC Pocket Monitor with CMAC-4 blade (Karl Storz) from January 1, 2018, to July 31, 2020, were reviewed. We extracted 6 measurements corresponding to the time taken to obtain the initial and then best laryngeal view, time to manipulate a bougie, and time to place the endotracheal tube, as well a percentage of glottic opening and a number of intubation attempts. Larynx location was the middle of the base of glottis, in cm from the left and bottom on the C-MAC screen. Two plots were produced to summarize the base of glottis location and time to perform each time component of intubation. Next, a cross mark function and a maximum absolute deviation hypothesis test were performed to assess the null hypotheses that the spatial distributions were random. The association between glottis location and >1 intubation attempt was assessed by a spatial relative risk plot. RESULTS: Of 619 eligible intubations, 385 had a video for analysis. The following time variables had a nonrandom spatial distribution with a tendency for longer times when the larynx was off-center to the top or right of the screen: laryngoscope passing from teeth to glottis, glottis first view to best view of the larynx, time from bougie appearing to being placed in the cords, and overall time from teeth to endotracheal tube passing through cords. There was no increased relative risk for >1 intubation attempt. CONCLUSIONS: Spatial point pattern analysis identified a relationship between the position of the larynx during VL and prolonged intubation times. We did not find a relationship between larynx location and >1 attempt. Whether the location of the larynx on the screen is a marker for difficult VL or if optimizing the larynx position to the center of the screen improves intubation times would require further prospective studies.

Design of an individualised questionnaire to measure the impact of cancer on quality of life: The cancer dependent quality of life (CancerDQoL) questionnaire.

AIM: To design an individualised questionnaire to measure the impact of cancer and its treatments on quality of life (QoL). MATERIALS & METHODS: Design of the Cancer-Dependent Quality of Life (CancerDQoL) questionnaire was based on the Audit of Diabetes Dependent QoL (ADDQoL) questionnaire and related -DQoLs for other conditions. Item selection, face validity and content validity were established through clinician and patient ratings of the importance and relevance of 60 domains from the -DQoL Item Library, and semi-structured interviews with 25 English-speaking participants with a range of cancers attending a cancer centre in Zimbabwe (age range: 25-78 years; 16 women, 9 men). Ten interviews were subsequently conducted with UK English-speaking participants with a range of cancers attending Maggie's Centres in London and Dundee (age range: 40-76; 5 women, 5 men) to adapt the CancerDQoL for UK use. RESULTS: The first draft of the CancerDQoL contained 25 domain-specific items from the -DQoL Item Library plus four overview items. Zimbabwean participants indicated that cancer negatively impacted on all life domains included, except 'having children'. Weighted impact (impact ratings multiplied by importance) was most negative for 'sex life', 'depend on others' and 'physical capability'. The least negative weighted impact was found for 'having children', 'spiritual/religious life' and 'past medical/self-care'. UK interviews confirmed no new items were required. CONCLUSIONS: Face and content validity of the CancerDQoL is established for an adult sample of English-speaking cancer patients in Zimbabwe and confirmed in an adaptation following UK interviews.

Predictors of health-related quality of life following injury in childhood and adolescence: a pooled analysis.

BACKGROUND: Injury is a leading contributor to the global disease burden in children and places children at risk for adverse and lasting impacts on their health-related quality of life (HRQoL) and development. This study aimed to identify key predictors of HRQoL following injury in childhood and adolescence. METHODS: Data from 2259 injury survivors (<18 years when injured) were pooled from four longitudinal cohort studies (Australia, Canada, UK, USA) from the paediatric Validating Injury Burden Estimates Study (VIBES-Junior). Outcomes were the Paediatric Quality of Life Inventory (PedsQL) total, physical, psychosocial functioning scores at 1, 3-4, 6, 12, 24 months postinjury. RESULTS: Mean PedsQL total score increased with higher socioeconomic status and decreased with increasing age. It was lower for transport-related incidents, ≥1 comorbidities, intentional injuries, spinal cord injury, vertebral column fracture, moderate/severe traumatic brain injury and fracture of patella/tibia/fibula/ankle. Mean PedsQL physical score was lower for females, fracture of femur, fracture of pelvis and burns. Mean PedsQL psychosocial score was lower for asphyxiation/non-fatal submersion and muscle/tendon/dislocation injuries. CONCLUSIONS: Postinjury HRQoL was associated with survivors' socioeconomic status, intent, mechanism of injury and comorbidity status. Patterns of physical and psychosocial functioning postinjury differed according to sex and nature of injury sustained. The findings improve understanding of the long-term individual and societal impacts of injury in the early part of life and guide the prioritisation of prevention efforts, inform health and social service planning to help reduce injury burden, and help guide future Global Burden of Disease estimates.

Health-Related Quality of Life (HRQoL) Outcomes Following Injury in Childhood and Adolescence Using EuroQol (EQ-5D) Responses with Pooled Longitudinal Data.

BACKGROUND: Injury is a leading contributor to the global disease burden in children, affecting their health-related quality of life (HRQoL)-yet valid estimates of burden are absent. METHODS: This study pooled longitudinal data from five cohort studies of pediatric injury survivors (5-17 years) at baseline, 1-, 4-, 6-, 12-, and 24- months (n = 2334). HRQoL post-injury was measured using the 3-level EQ-5D utility score (EQ-5D) and five health states (mobility, self-care, activity, pain, anxiety and depression (anxiety)). RESULTS: Mean EQ-5D post-injury did not return to baseline level (0.95) by 24 months (0.88) and was lower for females over time (-0.04, 95%CI -0.05, -0.02). A decreased adjusted risk ratio over time (ARR) was observed for intentional injuries (pain: 0.85, 95%CI 0.73,0.98; anxiety: 0.62, 95%CI 0.49,0.78); spinal cord injuries (mobility: 0.61, 95%CI 0.45,0.83), self-care: 0.76, 95%CI 0.63,0.91, activity: 0.64, 95%CI 0.47,0.88); moderate/severe traumatic brain injury (activity: 0.83, 95%CI 0.71,0.96). ARRs were also low for certain fractures, with various health states affected. CONCLUSIONS: HRQoL outcomes over time for children and adolescents post-injury differed across key demographic and injury related attributes. HRQoL did not reach levels consistent with full health by 24 months with recovery plateauing from 6 to 24 months. Tailored interventions are required to respond to the varying post-injury recovery trajectories in this population.

Changes in quality of life (QoL) and other patient-reported outcome measures (PROMs) in living-donor and deceased-donor kidney transplant recipients and those awaiting transplantation in the UK ATTOM programme: a longitudinal cohort questionnaire survey with additional qualitative interviews.

OBJECTIVE: To examine quality of life (QoL) and other patient-reported outcome measures (PROMs) in kidney transplant recipients and those awaiting transplantation. DESIGN: Longitudinal cohort questionnaire surveys and qualitative semi-structured interviews using thematic analysis with a pragmatic approach. SETTING: Completion of generic and disease-specific PROMs at two time points, and telephone interviews with participants UK-wide. PARTICIPANTS: 101 incident deceased-donor (DD) and 94 incident living-donor (LD) kidney transplant recipients, together with 165 patients on the waiting list (WL) from 18 UK centres recruited to the Access to Transplantation and Transplant Outcome Measures (ATTOM) programme completed PROMs at recruitment (November 2011 to March 2013) and 1 year follow-up. Forty-one of the 165 patients on the WL received a DD transplant and 26 received a LD transplant during the study period, completing PROMs initially as patients on the WL, and again 1 year post-transplant. A subsample of 10 LD and 10 DD recipients participated in qualitative semi-structured interviews. RESULTS: LD recipients were younger, had more educational qualifications and more often received a transplant before dialysis. Controlling for these and other factors, cross-sectional analyses at 12 months post-transplant suggested better QoL, renal-dependent QoL and treatment satisfaction for LD than DD recipients. Patients on the WL reported worse outcomes compared with both transplant groups. However, longitudinal analyses (controlling for pre-transplant differences) showed that LD and DD recipients reported similarly improved health status and renal-dependent QoL (p<0.01) pre-transplant to post-transplant. Patients on the WL had worsened health status but no change in QoL. Qualitative analyses revealed transplant recipients' expectations influenced their recovery and satisfaction with transplant. CONCLUSIONS: While cross-sectional analyses suggested LD kidney transplantation leads to better QoL and treatment satisfaction, longitudinal assessment showed similar QoL improvements in PROMs for both transplant groups, with better outcomes than for those still wait-listed. Regardless of transplant type, clinicians need to be aware that managing expectations is important for facilitating patients' adjustment post-transplant.

Establishment of a sentinel surveillance network for sexually transmissible infections and blood borne viruses in Aboriginal primary care services across Australia: the ATLAS project.

BACKGROUND: Sexually transmissible infection (STI) and blood-borne virus (BBV) diagnoses data are a core component of the Australian National Notifiable Diseases Surveillance System (NNDSS). However, the NNDSS data alone is not enough to understand STI and BBV burden among priority population groups, like Aboriginal and Torres Strait Islander people, because it lacks testing, treatment and management data. Here, we describe the processes involved in establishing a STI and BBV sentinel surveillance network representative of Aboriginal Community-Controlled Health Services (ACCHS)-known as the ATLAS network-to augment the NNDSS and to help us understand the burden of disease due to STI and BBV among Aboriginal and Torres Strait Islander peoples. METHODS: Researchers invited participation from ACCHS in urban, regional and remote areas clustered in five clinical hubs across four Australian jurisdictions. Participation agreements were developed for each clinical hub and individual ACCHS. Deidentified electronic medical record (EMR) data relating to STI and BBV testing, treatment and management are collected passively from each ACCHS via the GRHANITEtm data extraction tool. These data are analysed centrally to inform 12 performance measures which are included in regular surveillance reports generated for each ACCHS and clinical hub. RESULTS: The ATLAS network currently includes 29 ACCHS. Regular reports are provided to ACCHS to assess clinical practice and drive continuous quality improvement initiatives internally. Data is also aggregated at the hub, jurisdictional and national level and will be used to inform clinical guidelines and to guide future research questions. The ATLAS infrastructure can be expanded to include other health services and potentially linked to other data sources using GRHANITE. CONCLUSIONS: The ATLAS network is an established national surveillance network specific to Aboriginal and Torres Strait Islander peoples. The data collected through the ATLAS network augments the NNDSS and will contribute to improved STI and BBV clinical care, guidelines and policy program-planning.