A system-wide approach to digital equity: the Digital Access Coordinator program in primary care.

INTRODUCTION: The transition to digital tools prompted by the pandemic made evident digital disparities. To address digital literacy gaps, we implemented a system-wide digital navigation program. METHODS: The Digital Access Coordinator (DAC) program consists of 12 multilingual navigators who support patients in enrolling and using the patient portal and digital tools. We implemented the program in our primary care network which consists of 1.25 million patients across 1211 clinicians. RESULTS: From May 2021 to November 2022, the DACs completed outreach to 16 045 patients. Of the 13 413 patients they reached, they successfully enrolled 8193 (61%) patients in the patient portal. Of those patients they enrolled, most patients were of Other race, Hispanic ethnicity, and were English-speaking (44%) and Spanish-speaking patients (44%). Using our embedded model, we increased enrollment across 7 clinics (mean increase: 21.3%, standard deviation: 9.2%). Additionally, we identified key approaches for implementing a digital navigation program. CONCLUSION: Organizations can support patient portal enrollment, a key part of digital health equity, by creating and prioritizing digital navigation programs.

Casemix and performance of Australian emergency departments: A comparison of major city, regional and remote locations.

OBJECTIVE: EDs are an essential service, and higher rates of presentations per population are seen in regional and remote areas compared to major cities. Australia-wide differences in utilisation and performance remain largely unknown. METHODS: This was a descriptive, retrospective epidemiological study analysing data collected via the National Non-Admitted Patient Emergency Department Care Database managed by the Australian Institute of Health and Welfare. Data from all reporting public hospitals in Australia for the period between 1 July 2018 and 30 June 2019 were analysed. Reporting EDs were geographically categorised using the 2016 Australian Statistical Geography Standard - Remoteness Area. RESULTS: ED presentations for the 293 reporting EDs were 8 352 192 (median 17 904, range 8-113 929), one-third (33.09%, 95% CI 33.06-33.12) were outside major cities. Remote ED presentations were less likely to arrive by ambulance (12.13% [12.01-12.26]; major cites 28.07% [28.03-28.10]; regional 22.55% [22.50-22.60]) but more likely by police/correctional services vehicle (major cities 0.59% [0.58-0.60]; regional 0.71% [0.70-0.72]; remote 1.71% [1.66-1.76]). Presentations to remote EDs were more likely to leave without being attended by a health professional (5.29% [5.21-5.38]; major cities 3.93% [3.92-3.95]; regional 3.53% [3.51-3.55]). A larger proportion of admitted patients stayed at least 8 h in remote (21.83% [21.46-22.20]) and regional (21.52% [21.41-21.62]) EDs compared to major cities (19.82% [19.76-19.88]). CONCLUSIONS: Our study highlights ED utilisation, casemix and performance by location. The differences observed, especially areas of inequity and need for interventions, reiterate that imperative regional and remote EDs are appropriately resourced to support the communities they serve.

Understanding the menopausal experiences of women with intellectual disabilities: A scoping review.

During the process of ageing, women experience important hormonal, endocrine and biological changes. Menopause is a natural phenomenon in female development, during which women's ovarian function shifts from a reproductive to a non-reproductive state. The experience of menopause is unique for every woman, including women with intellectual disabilities. Globally, the available literature on women with intellectual disabilities and menopause focuses on providing medical insights into onset and symptoms and little attention has been paid to documenting how menopause affects women themselves. This represents a significant gap in understanding how women understand this change in life and has been a key justification for the need for this research. This scoping review aims to consider published studies capturing the perceptions, experiences and attitudes of women with intellectual disabilities and their caregivers as they transition through the menopause.

Association of dietary flavan-3-ol intakes with plasma phenyl-γ-valerolactones: analysis from the TUDA cohort of healthy older adults.

BACKGROUND: Dietary polyphenols, including flavan-3-ols (F3O), are associated with better health outcomes. The relationship of plasma phenyl-γ-valerolactones (PVLs), the products of colonic bacterial metabolism of F3O, with dietary intakes is unclear. OBJECTIVES: To investigate whether plasma PVLs are associated with self-reported intakes of total F3O and procyanidins+(epi)catechins. DESIGN: We measured 9 PVLs by uHPLC-MS-MS in plasma from adults (>60y) in the Trinity-Ulster-Department of Agriculture (TUDA study (2008 to 2012; n=5186) and a follow-up subset (2014 to 2018) with corresponding dietary data (n=557). Dietary (poly)phenols collected by FFQ were analyzed using Phenol-Explorer. RESULTS: Mean (95% confidence interval [CI]) intakes were estimated as 2283 (2213, 2352) mg/d for total (poly)phenols, 674 (648, 701) for total F3O, and 152 (146, 158) for procyanidins+(epi)catechins. Two PVL metabolites were detected in plasma from the majority of participants, 5-(hydroxyphenyl)-γ-VL-sulfate (PVL1) and 5-(4'-hydroxyphenyl)-γ-VL-3'-glucuronide (PVL2). The 7 other PVLs were detectable only in 1-32% of samples. Self-reported intakes (mg/d) of F3O (r = 0.113, P = 0.017) and procyanidin+(epi)catechin (r = 0.122, P = 0.010) showed statistically significant correlations with the sum of PVL1 and PVL 2 (PVL1+2). With increasing intake quartiles (Q1-Q4), mean (95% CI) PVL1+2 increased; from 28.3 (20.8, 35.9) nmol/L in Q1 to 45.2 (37.2, 53.2) nmol/L in Q4; P = 0.025, for dietary F3O, and from 27.4 (19.1, 35.8) nmol/L in Q1 to 46.5 (38.2, 54.9) nmol/L in Q4; P = 0.020, for procyanidins+(epi)catechins. CONCLUSIONS: Of 9 PVL metabolites investigated, 2 were detected in most samples and were weakly associated with intakes of total F3O and procyanidins+(epi)catechins. Future controlled feeding studies are required to validate plasma PVLs as biomarkers of these dietary polyphenols.

The Legacy of Mental Distress Following Physical Illness in Childhood: Findings From the Australian Temperament Project.

OBJECTIVE: Childhood physical illnesses have been associated with heightened risk for mental health problems in adolescence and young adulthood; however, little is known about the natural history of this relationship. Here, we examine the nature of mental health adjustment to illness from diagnosis in childhood into adolescence and young adult life. METHODS: Data were drawn from a large population-based cohort. Parents reported whether their child had a physical illness at 5-6 and 7-8 years and whether they believed their child was so sick it was thought they might die. Depression and anxiety symptoms were reported by parents (for children 7-10 years) and self-reports (11-28 years). RESULTS: A total of 1,001 (56%) parents reported their child had a physical illness. Of these parents, 143 (8%) believed their child might die. Findings indicated there was some evidence of higher levels of depressive and anxious symptoms across late childhood and into early adolescence for those reporting a physical illness in childhood. A similar pattern was observed for those who were so sick it was thought they might die, although symptoms were elevated to a greater extent. CONCLUSION: Although physical illness in middle childhood is associated with higher levels of depressive and anxious symptoms, by early adolescence, these differences diminish, indicating a process of adaptation that persists into young adulthood. This suggests a potentially sensitive period of adjustment to illness for some, especially for children who it was feared might die. Additional psychosocial assessment and support may be warranted across the "acute" illness period.

Overcoming adversity: Building a remote interdisciplinary neurorehabilitation service during the COVID-19 pandemic.

Background: The COVID-19 pandemic necessitated rapid change in neurorehabilitation delivery at the Defence Medical Rehabilitation Centre (DMRC), with a reduction in inpatient capacity. Aims and method: An interdisciplinary remote working group developed a novel neurorehabilitation telerehabilitation (TR) model. The plan, do, study, act (PDSA) model was used to develop and monitor activity in the changing pandemic context and to identify clinical outputs, key themes and learning points. Results: Eight PDSA cycles were performed, including video outpatient clinics, multidisciplinary team meetings, virtual ward rounds and TR for patients at home. Ten patients and 21 staff members provided feedback. Qualitative themes emerged including information technology, consultation environment, access to clinical notes and record keeping, clinical considerations, consent, patient and staff feedback, and feasibility. Conclusion: COVID-19 accelerated the implementation of TR at DMRC, allowing maintenance of service during lockdown. TR was acceptable to patients but placed a significant burden on staff. Practical suggestions for establishing a TR service are provided alongside challenges and limitations.

Chemical explosion, COVID-19, and environmental justice: Insights from low-cost air quality sensors.

OBJECTIVES: To examine the impact of the Intercontinental Terminals Company (ITC) fire and COVID-19 on airborne particulate matter (PM) concentrations and the PM disproportionally affecting communities in Houston using low-cost sensors. METHODS: We compared measurements from a network of low-cost sensors with a separate network of monitors from the Environmental Protection Agency (EPA) in the Houston metropolitan area from Mar 18, 2019, to Dec 31, 2020. Further, we examined the associations between neighborhood-level sociodemographic status and air pollution patterns by linking the low-cost sensor data to EPA environmental justice screening and mapping systems. FINDINGS: We found increased PM levels during ITC fire and pre-COVID-19, and lower PM levels after the COVID-19 lockdown, comparable to observations from the regulatory monitors, with higher variations and a greater number of locations with high PM levels detected. In addition, the environmental justice analysis showed positive associations between higher PM levels and the percentage of minority, low-income population, and demographic index. IMPLICATION: Our study indicates that low-cost sensors provide pollutant measures with higher spatial variations and a better ability to identify hot spots and high peak concentrations. These advantages provide critical information for disaster response and environmental justice studies. SYNOPSIS: We used measurements from a low-cost sensor network for air pollution monitoring and environmental justice analysis to examine the impact of anthropogenic and natural disasters.

Elucidating heterogeneous iron biomineralization patterns in a denitrifying As(iii)-oxidizing bacterium: implications for arsenic immobilization.

Anaerobic nitrate-dependent iron(ii) oxidation is a process common to many bacterial species, which promotes the formation of Fe(iii) minerals that can influence the fate of soil and groundwater pollutants, such as arsenic. Herein, we investigated simultaneous nitrate-dependent Fe(ii) and As(iii) oxidation by Acidovorax sp. strain ST3 with the aim of studying the Fe biominerals formed, their As immobilization capabilities and the metabolic effect on cells. X-ray powder diffraction (XRD) and scanning transmission electron microscopy (STEM) nanodiffraction were applied for biomineral characterization in bulk and at the nanoscale, respectively. NanoSIMS (nanoscale secondary ion mass spectrometry) was used to map the intra and extracellular As and Fe distribution at the single-cell level and to trace metabolically active cells, by incorporation of a 13C-labeled substrate (acetate). Metabolic heterogeneity among bacterial cells was detected, with periplasmic Fe mineral encrustation deleterious to cell metabolism. Interestingly, Fe and As were not co-localized in all cells, indicating delocalized sites of As(iii) and Fe(ii) oxidation. The Fe(iii) minerals lepidocrocite and goethite were identified in XRD, although only lepidocrocite was identified via STEM nanodiffraction. Extracellular amorphous nanoparticles were formed earlier and retained more As(iii/v) than crystalline "flakes" of lepidocrocite, indicating that longer incubation periods promote the formation of more crystalline minerals with lower As retention capabilities. Thus, the addition of nitrate promotes Fe(ii) oxidation and formation of Fe(iii) biominerals by ST3 cells which retain As(iii/v), and although this process was metabolically detrimental to some cells, it warrants further examination as a viable mechanism for As removal in anoxic environments by biostimulation with nitrate.

Management of chronic urinary retention in glanular penile calciphylaxis.

Urinary retention in penile calciphylaxis is a rare phenomenon due to its association with end-stage renal failure. A 48 year-old male was noted to have a lesion with necrotic appearances overlying his urethral meatus with increasing bladder volumes. He is on haemodialysis for end-stage renal failure and was being treated for infected calciphylaxis ulcers on his thigh. The current literature provides little guidance on managing urinary retention in this cohort of patients. We recommend that ultrasound-guided aspiration of the bladder should be performed in patients with glanular penile calciphylaxis who develop urinary retention as it offers a high safety profile.

Acceptability of 11 fortified balanced energy-protein supplements for pregnant women in Nepal.

Evidence suggests that multiple micronutrient and balanced energy protein (BEP) supplementation during pregnancy can decrease the risk of stillbirth and small-for-gestational-age births and increase birth weight. We conducted a mixed-methods formative research study to identify the most acceptable among a range of 11 candidates fortified BEP supplements for use in pregnancy and lactation in a rural district in Nepal. Forty pregnant women aged 15-40 years participated in a test meal tasting of 11 different sweet and savoury candidate BEP supplements. Each participant rated the products on organoleptic properties using a 7-point hedonic scale (1 = Dislike it very much to 7 = Like it very much), ranked her 'top 3' most liked supplements, and subsequently discussed each product with peers in focus group discussions (FGDs). Five supplements (sweet lipid-based nutrient supplement (LNS), savoury LNS, sweet vanilla biscuits, vanilla instant drinks and seasoned pillows) achieved the maximum overall median hedonic score of 7, with sweet LNS and seasoned pillows ranking as the top 2. This was consistent with the assessments in FGDs. Women in the FGDs expressed dislike of the smell and taste of the cocoa drink, savoury masala bar, sweet mango bar and savoury curry biscuit, which was consistent with the hedonic scale scores. This study provides valuable insights into our understanding of women's acceptance of different BEP supplements during pregnancy in rural Nepal and has helped identify the two most accepted BEP supplements to be used in a two-month home trial to assess utilisation and compliance in this setting.

Rural emergency care facilities may be adapting to their context: A population-level study of resources and workforce.

OBJECTIVE: To provide a structured understanding of rural hospital-based emergency care facility workforce and resources. DESIGN: The resources of regional training hubs were used to survey eligible emergency care facilities in their surrounding region. SETTING: Rural emergency care facilities manage more than one third of Australia's emergency presentations. These emergency care facilities include emergency departments and less-resourced facilities in smaller towns. PARTICIPANTS: Hospital facilities located outside metropolitan areas that report emergency presentations to the Australian Institute of Health and Welfare. INTERVENTIONS: A survey tool was sent by email. MAIN OUTCOME MEASURES: Presence of human, diagnostic and other resources as reported on a questionnaire. RESULTS: A completed questionnaire was received from 195 emergency care facilities. Over 60% of Small hospitals had on-call doctors only. General practitioners/generalists and nurses with extended emergency skills were found in all hospital types. Emergency physicians were present across all remoteness areas, but more commonly seen in larger facilities. All Major/Large facilities and most Medium facilities reported having onsite pathology and radiology. Point of care testing and clinician radiography were more commonly reported in smaller facilities. Among Small hospitals, Very Remote hospitals were more likely than Inner Regional hospitals to have an onsite doctor in the emergency care facility and/or a high dependency unit. CONCLUSION: Smaller and more remote facilities appear to adapt by using different workforce structures and bedside investigations.

Compliance with and acceptability of two fortified balanced energy protein supplements among pregnant women in rural Nepal.

Some evidence suggests that balanced energy protein (BEP) supplements taken during pregnancy and lactation can have positive effects on birth outcomes such as small-for-gestational age and birthweight, but more evidence is needed on the long-term use and acceptability of such supplements. We conducted a mixed-methods formative research study to assess and compare compliance with and acceptability of two BEP supplements, a lipid-based peanut paste and a biscuit, to identify BEP supplements for subsequent inclusion in an efficacy trial. We conducted an 8-week feeding trial of daily supplementation among two groups of 40 pregnant women each in rural Nepal. Compliance data were collected and supplements distributed at the weekly visits. Sensory properties of the supplements were assessed using a 7-point Likert scale. In addition, in-depth interviews with women (n = 16), family members (n = 6) and health workers (n = 6) and focus group discussions (FGDs) (n = 4) were conducted to explore themes related to general use and intention of future use of the supplement. Overall self-reported compliance was high: medians of 91.1% in the lipid-based peanut paste group and 96.4% in the biscuit group. Both supplements were rated highly on overall likability (median score 6/7) and sensory properties. Qualitative findings showed that sustained use of the supplements was attributed to expected health benefits, favourable sensory attributes, and family support. The FGDs suggested providing the option to choose between more than one type/flavour of supplements to improve compliance. Sharing was mostly evident in the first week with higher sharing reported in the biscuit group.

The Human Tic Detector: An automatic approach to tic characterization using wearable sensors.

OBJECTIVE: Current rating scales for Tourette syndrome (TS) are limited by recollection bias or brief assessment periods. This proof-of-concept study aimed to develop a sensor-based paradigm to detect and classify tics. METHODS: We recorded both electromyogram and acceleration data from seventeen TS patients, either when voluntarily moving or experiencing tics and during the modified Rush Video Tic Rating Scale (mRVTRS). Spectral properties of voluntary and tic movements from the sensor that captured the dominant tic were calculated and used as features in a support vector machine (SVM) to detect and classify movements retrospectively. RESULTS: Across patients, the SVM had an accuracy, sensitivity, and specificity of 96.69 ± 4.84%, 98.24 ± 4.79%, and 96.03 ± 6.04%, respectively, when classifying movements in the test dataset. Furthermore, each patient's SVM was validated using data collected during the mRVTRS. Compared to the expert consensus, the tic detection accuracy was 85.63 ± 15.28% during the mRVTRS, while overall movement classification accuracy was 94.23 ± 5.97%. CONCLUSIONS: These results demonstrate that wearable sensors can capture physiological differences between tic and voluntary movements and are comparable to expert consensus. SIGNIFICANCE: Ultimately, wearables could individualize and improve care for people with TS, provide a robust and objective measure of tics, and allow data collection in real-world settings.

Exploring Innovations in Human Milk Analysis in the Neonatal Intensive Care Unit: A Survey of the United States.

Introduction: Human milk (HM) is the ideal enteral feeding for nearly all infants and offers unique benefits to the very low birthweight (VLBW) infant population. It is a challenge to meet the high nutrient requirements of VLBW infants due to the known variability of HM composition. Human milk analysis (HMA) assesses the composition of HM and allows for individualized fortification. Due to recent U.S. Food and Drug Administration (FDA) approval, it has relatively recent availability for clinical use in the US. Aim: To identify current practices of HMA and individualized fortification in neonatal intensive care units (NICUs) across the United States (US) and to inform future translational research efforts implementing this nutrition management method. Methods: An institutional review board (IRB) approved survey was created and collected data on the following subjects such as NICU demographics, feeding practices, HM usage, HM fortification practices, and HMA practices. It was distributed from 10/30-12/21/2020 via online pediatric nutrition groups and listservs selected to reach the intended audience of NICU dietitians and other clinical staff. Each response was assessed prior to inclusion, and descriptive analysis was performed. Results: About 225 survey responses were recorded during the survey period with 119 entries included in the analysis. This represented 36 states and Washington D.C., primarily from level III and IV NICUs. HMA was reported in 11.8% of responding NICUs. The most commonly owned technology for HMA is the Creamatocrit Plus TM (EKF Diagnostics), followed by the HM Analyzer by Miris (Uppsala, Sweden). In NICUs practicing HMA, 84.6% are doing so clinically. Discussion: Feeding guidelines and fortification of HM remain standard of care, and interest in HMA was common in this survey. Despite the interest, very few NICUs are performing HMA and individualized fortification. Barriers identified include determining who should receive individualized fortification and how often, collecting a representative sample, and the cost and personnel required. Conclusions: Human milk analysis and individualized fortification are emerging practices within NICUs in the US. Few are using it in the clinical setting with large variation in execution among respondents and many logistical concerns regarding implementation. Future research may be beneficial to evaluate how practices change as HMA and individualized fortification gain popularity and become more commonly used in the clinical setting.

Subcellular dynamics studies of iron reveal how tissue-specific distribution patterns are established in developing wheat grains.

Understanding the mechanisms of iron trafficking in plants is key to enhancing the nutritional quality of crops. Because it is difficult to image iron in transit, we currently have an incomplete picture of the route(s) of iron translocation in developing seeds and how the tissue-specific distribution is established. We have used a novel approach, combining iron-57 (57 Fe) isotope labelling and nanoscale secondary ion mass spectrometry (NanoSIMS), to visualize iron translocation between tissues and within cells in immature wheat grain, Triticum aestivum. This enabled us to track the main route of iron transport from maternal tissues to the embryo through the different cell types. Further evidence for this route was provided by genetically diverting iron into storage vacuoles, with confirmation provided by histological staining and transmission electron microscopy energy dispersive X-ray spectroscopy (TEM-EDS). Almost all iron in both control and transgenic grains was found in intracellular bodies, indicating symplastic rather than apoplastic transport. Furthermore, a new type of iron body, highly enriched in 57 Fe, was observed in aleurone cells and may represent iron being delivered to phytate globoids. Correlation of the 57 Fe enrichment profiles obtained by NanoSIMS with tissue-specific gene expression provides an updated model of iron homeostasis in cereal grains with relevance for future biofortification strategies.

Dissimilatory Fe(III) Reduction Controls on Arsenic Mobilization: A Combined Biogeochemical and NanoSIMS Imaging Approach.

Microbial metabolism plays a key role in controlling the fate of toxic groundwater contaminants, such as arsenic. Dissimilatory metal reduction catalyzed by subsurface bacteria can facilitate the mobilization of arsenic via the reductive dissolution of As(V)-bearing Fe(III) mineral assemblages. The mobility of liberated As(V) can then be amplified via reduction to the more soluble As(III) by As(V)-respiring bacteria. This investigation focused on the reductive dissolution of As(V) sorbed onto Fe(III)-(oxyhydr)oxide by model Fe(III)- and As(V)-reducing bacteria, to elucidate the mechanisms underpinning these processes at the single-cell scale. Axenic cultures of Shewanella sp. ANA-3 wild-type (WT) cells [able to respire both Fe(III) and As(V)] were grown using 13C-labeled lactate on an arsenical Fe(III)-(oxyhydr)oxide thin film, and after colonization, the distribution of Fe and As in the solid phase was assessed using nanoscale secondary ion mass spectrometry (NanoSIMS), complemented with aqueous geochemistry analyses. Parallel experiments were conducted using an arrA mutant, able to respire Fe(III) but not As(V). NanoSIMS imaging showed that most metabolically active cells were not in direct contact with the Fe(III) mineral. Flavins were released by both strains, suggesting that these cell-secreted electron shuttles mediated extracellular Fe(III)-(oxyhydr)oxide reduction, but did not facilitate extracellular As(V) reduction, demonstrated by the presence of flavins yet lack of As(III) in the supernatants of the arrA deletion mutant strain. 3D reconstructions of NanoSIMS depth-profiled single cells revealed that As and Fe were associated with the cell surface in the WT cells, whereas for the arrA mutant, only Fe was associated with the biomass. These data were consistent with Shewanella sp. ANA-3 respiring As(V) in a multistep process; first, the reductive dissolution of the Fe(III) mineral released As(V), and once in solution, As(V) was respired by the cells to As(III). As well as highlighting Fe(III) reduction as the primary release mechanism for arsenic, our data also identified unexpected cellular As(III) retention mechanisms that require further investigation.

Evidence of hydrogen trapping at second phase particles in zirconium alloys.

Zirconium alloys are used in safety-critical roles in the nuclear industry and their degradation due to ingress of hydrogen in service is a concern. In this work experimental evidence, supported by density functional theory modelling, shows that the α-Zr matrix surrounding second phase particles acts as a trapping site for hydrogen, which has not been previously reported in zirconium. This is unaccounted for in current models of hydrogen behaviour in Zr alloys and as such could impact development of these models. Zircaloy-2 and Zircaloy-4 samples were corroded at 350 °C in simulated pressurised water reactor coolant before being isotopically spiked with 2H2O in a second autoclave step. The distribution of 2H, Fe and Cr was characterised using nanoscale secondary ion mass spectrometry (NanoSIMS) and high-resolution energy dispersive X-ray spectroscopy. 2H- was found to be concentrated around second phase particles in the α-Zr lattice with peak hydrogen isotope ratios of 2H/1H = 0.018-0.082. DFT modelling confirms that the hydrogen thermodynamically favours sitting in the surrounding zirconium matrix rather than within the second phase particles. Knowledge of this trapping mechanism will inform the development of current understanding of zirconium alloy degradation through-life.

Home consumption of two fortified balanced energy protein supplements by pregnant women in Burkina Faso.

Balanced energy protein (BEP) supplementation for pregnant and lactating women in low- and middle-income countries is a promising strategy to improve birth outcomes and child growth. The objective of this study was to assess and compare the acceptability of new formulations of two fortified BEP supplements, a lipid-based peanut paste and a vanilla biscuit, among 80 pregnant women in rural Burkina Faso, prior to an efficacy trial. A 10-week individually randomized cross-over study was designed, in which women received a weekly supply of each supplement for 4 weeks, and a daily choice between the supplements in the last 2 weeks. Questionnaires to assess daily consumption and supplement acceptability (n = 80) and home observations (n = 20) were combined with focus group discussions (n = 6) and in-depth interviews with women (n = 80) and stakeholders (n = 24). Results showed that the two supplements were well accepted. Quantitative findings indicated high compliance (>99.6%) and high overall appreciation (Likert score >6 out of 7) of both supplements. The assessment of preferred choice in Weeks 9 and 10 indicated a slight preference for the vanilla biscuit. Qualitative findings indicated that perceived health benefits, support from household members and educational messages from health professionals were important drivers for acceptance and compliance. Sharing was not often reported but was identified during interviews as a possible risk. We recommend that future studies use a combination of methods to identify appropriate food supplements and context-specific factors that influence acceptability, compliance and subsequent impact of nutritious food supplements.

Where are children seen in Australian emergency departments? Implications for research efforts.

OBJECTIVE: With most paediatric emergency research in Australia conducted at tertiary EDs, it is important to understand how presentations differ between those at tertiary paediatric EDs and all other EDs. METHODS: Retrospective epidemiological study assessing paediatric case-mix and time-based performance metrics (aged 0-14 years) obtained from a national health service minimum dataset for the 2017-2018 financial year, comparing tertiary paediatric EDs and all other EDs. We defined a 'major tertiary paediatric hospital' as one which was accredited for training in both paediatric emergency medicine and paediatric intensive care. RESULTS: Of the 1 695 854 paediatric ED presentations, 23.8% were seen in nine major metropolitan tertiary paediatric hospitals. Reasons for presentations were more distinctive between cohorts among children aged 10-14 years, where psychiatric illness (5.2% vs 2.5%) and neurological illness (4.5% vs 2.5%) were more commonly seen in major tertiary paediatric EDs. Australian Indigenous children were significantly less likely to present to tertiary paediatric EDs (3.0%), compared with other EDs (9.7%) (odds ratio 0.27, 95% confidence interval 0.26-0.27). While median waiting times were longer in major tertiary paediatric EDs (28 min [interquartile range 11-65]) than in other EDs (20 min [interquartile range 8-48], P < 0.001), patients were also less likely to leave without being seen (5.5% in tertiary paediatric EDs vs 6.9% in other EDs; odds ratio 0.80, 95% confidence interval 0.78-0.81). CONCLUSIONS: The present study identified key areas of difference in paediatric presentations between tertiary paediatric EDs and other EDs. It is vital to broaden paediatric ED research beyond tertiary paediatric centres, to ensure relevance and generalisability.

Characteristics of Aboriginal and Torres Strait Islander peoples attending Australian emergency departments.

OBJECTIVE: Aboriginal and Torres Strait Islander patients are overrepresented in Australian EDs. The present study aimed to assess their characteristics in utilising ED services at a national level. METHODS: This exploratory, quantitative study used 2016-2017 de-identified data from the National Non-admitted Patient Emergency Department Care Database to assess the proportions (with 95% confidence interval) of Indigenous and non-Indigenous Australians across various aspects of ED presentations, including mode of arrival, triage scale, diagnosis information, episode end status and ED length of stay. Episode level ED data were compared by Indigenous status and geographical remoteness of EDs. RESULTS: Of 7.4 million presentations, 6.58% were Indigenous presentations, with over two-thirds occurring in regional and remote EDs. Indigenous patients were more likely than non-Indigenous patients to arrive to EDs by ambulance and police/correctional services vehicle across all remoteness areas. Additionally, they were more likely to present with respiratory system illness, illness of the skin/subcutaneous tissue/breast and mental/behavioural disorders. Indigenous Australians were more likely to leave EDs before being seen or care complete (odds ratio 1.73, 95% confidence interval 1.71-1.74), and this was observed for patients classified across all levels of triage scale. CONCLUSIONS: This is the first national study looking at the characteristics of and reasons for presenting to Australian EDs for Indigenous and non-Indigenous patients. Our findings provide important insight into the potential factors affecting Indigenous patient care, and an impetus for ongoing research and advocacy work to improve the quality of emergency care provided to Indigenous Australians.