Ethics guidelines use and Indigenous governance and participation in Aboriginal and Torres Strait Islander health research: a national survey.

OBJECTIVES: To assess the use of NHMRC Indigenous research guidelines by Australian researchers and the degree of Aboriginal and Torres Strait Islander governance and participation in Indigenous health research. DESIGN, SETTING, PARTICIPANTS: Cross-sectional survey of people engaged in Indigenous health research in Australia, comprising respondents to an open invitation (social media posts in general and Indigenous health research networks) and authors of primary Indigenous health research publications (2015-2019) directly invited by email. MAIN OUTCOME MEASURES: Reported use of NHMRC guidelines for Indigenous research; reported Indigenous governance and participation in Indigenous health research. RESULTS: Of 329 people who commenced the survey, 247 people (75%) provided responses to all questions, including 61 Indigenous researchers (25%) and 195 women (79%). The NHMRC guidelines were used "all the time" by 206 respondents (83%). Most respondents (205 of 247, 83%) reported that their research teams included Indigenous people, 139 reported dedicated Indigenous advisory boards (56%), 91 reported designated seats for Indigenous representatives on ethics committees (37%), and 43 reported Indigenous health research ethics committees (17%); each proportion was larger for respondents working in Indigenous community-controlled organisations than for those working elsewhere. More than half the respondents reported meaningful Indigenous participation during five of six research phases; the exception was data analysis (reported as apparent "none" or "some of the time" by 143 participants, 58%). CONCLUSIONS: Indigenous health research in Australia is largely informed by non-Indigenous world views, led by non-Indigenous people, and undertaken in non-Indigenous organisations. Re-orientation and investment are needed to give control of the framing, design, and conduct of Indigenous health research to Indigenous people.

Rodeo Trauma: Outcome Data from 10 Years of Injuries.

Introduction: There are few data addressing rodeo injury outcomes, though injury incidence has been well described. The purpose of this study was to describe rodeo-related injury patterns and outcomes. Methods: A 10-year retrospective case series was performed of patients injured in rodeo events and who were treated at an ACS-verified level I trauma center. Data regarding demographics, injury characteristics, and outcomes were summarized. Results: Seventy patients were identified. Half were injured by direct contact with rodeo stock and 34 by falls. Head injuries were most common, occurring in 38 (54.3%). Twenty injuries (28.6%) required surgery. Sixty-nine patients (98.6%) were discharged to home. There was one death. Conclusions: Head injuries were the most common injury among this cohort. Apart from one fatality, immediate outcomes after injury were good, with most patients dismissed home. Improved data collection at the time of admission may help to evaluate the success of current safety equipment use.

Octogenarian Motor Vehicle Collisions: Injury Patterns Matter.

INTRODUCTION: Motor vehicle collision (MVC) is the second most common mechanism of injury among octogenarians and is on the rise. These "oldest old" trauma patients have higher mortality rates than expected. This study examined potential factors influencing this increased mortality including comorbidities, medications, injury patterns, and hospital interventions. METHODS: A 10-year retrospective review was conducted of patients aged 80 and over who were injured in an MVC. Data collected included patient demographics, comorbidities, medication use prior to injury, collision details, injury severity and patterns, hospitalization details, outcomes, and discharge disposition. RESULTS: A total of 239 octogenarian patients were identified who were involved in an MVC. Overall mortality was 18.8%. An increased mortality was noted for specific injury patterns, patients injured in a rural setting, and those who were transfused, intubated, or admitted to the ICU. No correlation was found between mortality and medications or comorbidities. CONCLUSIONS: The high mortality rate for octogenarian patients involved in an MVC was related to injury severity, type of injury, and in-hospital complications, and not due to comorbidities and prior medications.

Comment: Sedation as part of secondary prophylaxis to prevent recurrent rheumatic fever in Aboriginal and Torres Strait Islander peoples: time for a reset?

Australia's national clinical practice guidelines recommend intramuscular (IM) penicillin every 28 days for persons diagnosed with an initial episode of acute rheumatic fever (ARF). This antibiotic coverage is initiated to reduce recurrent ARF episodes by preventing repeat infections with the causative bacterium, group A Streptococcus. Because disease has already occurred, this regimen is known as secondary prophylaxis (SP), done in order to prevent more episodes of ARF (known as recurrences). In 2020, eight authors shared with readers of Rural and Remote Health their experience of introducing off-label an oral, centrally acting, alpha agonist sedative to the prescribed SP regimen of IM penicillin for each of three Aboriginal children previously diagnosed with ARF. The living environments of the three children increased their risk for repeat group A Streptococcus infections and subsequent recurrences of ARF. We find the clinical case report perpetuates a troubling academic tone about this singular priority for SP. Injecting a child with IM penicillin appears to supersede all other objectives. Off-label sedation in remote settings is legitimised in order to succeed in this imperative. Those articles that peer-reviewed medical journals choose to publish privilege directions for priorities, policy and practice. In this commentary, we present alternative perspectives and initiatives for consideration.

Elderly trauma associated with high-risk recreational activity: A population-based study, United States, 2010 through 2016.

BACKGROUND: Understanding trends in prevalence and etiology is critical to public health strategies for prevention and management of injury related to high-risk recreation in elderly Americans. METHODS: The National Emergency Department Sample from 2010 through 2016 was queried for patients with a principal diagnosis of trauma (ICD-9 codes 800.0-959.9) and who were 55 years and older. High-risk recreation was determined from e-codes a priori. Primary outcome measures were mortality and total hospital charges. RESULTS: Of the 29,491,352 patient cohort, 458,599 (1.56%) engaged in high-risk activity, including those age 85 and older. High-risk cases were younger (median age 61 vs 70) and majority male (71.87% vs 39.24%). The most frequent activities were pedal cycling (45.81%), motorcycling (29.08%), and off-road vehicles (9.13%). Brain injuries (8.82% vs 3.88%), rib/sternal fractures (13.35% vs 3.53%), and cardiopulmonary injury (5.25% vs 0.57%) were more common among high-risk cases. Mortality (0.75% vs 0.40%) and total median hospital charges ($3,360 vs $2,312) were also higher for high-risk admissions, where the odds of mortality increased exponentially per year of age (odds ratio, 1.06; 99.5% CI, 1.05-1.08). High-risk recreation was associated with more than $1 billion in total hospital charges and more than 100 deaths among elderly Americans per year. CONCLUSION: Morbidity, mortality, and resource utilization due to high-risk recreation extend into the ninth decade of life. The patterns of injury described here offer opportunities for targeted injury prevention education to minimize risk among this growing segment of the United States population.

Communicable disease outbreaks: Surveillance and infrastructure.

The sixth article in a series on communicable disease outbreaks looks beyond the acute epidemic to the rationale for surveillance systems, mandatory notification and social determinants.

Communicable disease outbreaks: The bigger picture.

This fourth article in a series on communicable disease outbreaks introduces the larger legislative, executive and social framework within which health protection takes place.

Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study.

BACKGROUND: The implementation of evidence-based protocols for stroke management in the emergency department (ED) for the appropriate triage, administration of tissue plasminogen activator to eligible patients, management of fever, hyperglycaemia and swallowing, and prompt transfer to a stroke unit were evaluated in an Australian cluster-randomised trial (T3 trial) conducted at 26 emergency departments. There was no reduction in 90-day death or dependency nor improved processes of ED care. We conducted an a priori planned process influential factors that impacted upon protocol uptake. METHODS: Qualitative face-to-face interviews were conducted with purposively selected ED and stroke clinicians from two high- and two low-performing intervention sites about their views on factors that influenced protocol uptake. All Trial State Co-ordinators (n = 3) who supported the implementation at the 13 intervention sites were also interviewed. Data were analysed thematically using normalisation process theory as a sensitising framework to understand key findings, and compared and contrasted between interviewee groups. RESULTS: Twenty-five ED and stroke clinicians, and three Trial State Co-ordinators were interviewed. Three major themes represented key influences on evidence uptake: (i) Readiness to change: reflected strategies to mobilise and engage clinical teams to foster cognitive participation and collective action; (ii) Fidelity to the protocols: reflected that beliefs about the evidence underpinning the protocols impeded the development of a shared understanding about the applicability of the protocols in the ED context (coherence); and (iii) Boundaries of care: reflected that appraisal (reflexive monitoring) by ED and stroke teams about their respective boundaries of clinical practice impeded uptake of the protocols. CONCLUSIONS: Despite initial high 'buy-in' from clinicians, a theoretically informed and comprehensive implementation strategy was unable to overcome system and clinician level barriers. Initiatives to drive change and integrate protocols rested largely with senior nurses who had to overcome contextual factors that fell outside their control, including low medical engagement, beliefs about the supporting evidence and perceptions of professional boundaries. To maximise uptake of evidence and adherence to intervention fidelity in complex clinical settings such as ED cost-effective strategies are needed to overcome these barriers. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ( ACTRN12614000939695 ).

Predictors of retained hemothorax in trauma: Results of an Eastern Association for the Surgery of Trauma multi-institutional trial.

BACKGROUND: The natural history of traumatic hemothorax (HTX) remains unclear. We aimed to describe outcomes of HTX following tube thoracostomy drainage and to delineate factors that predict progression to a retained hemothorax (RH). We hypothesized that initial large-volume HTX predicts the development of an RH. METHODS: We conducted a prospective, observational, multi-institutional study of adult trauma patients diagnosed with an HTX identified on computed tomography (CT) scan with volumes calculated at time of diagnosis. All patients were managed with tube thoracostomy drainage within 24 hours of presentation. Retained hemothorax was defined as blood-density fluid identified on follow-up CT scan or need for additional intervention after initial tube thoracostomy placement for HTX. RESULTS: A total of 369 patients who presented with an HTX initially managed with tube thoracostomy drainage were enrolled from 17 trauma centers. Retained hemothorax was identified in 106 patients (28.7%). Patients with RH had a larger median (interquartile range) HTX volume on initial CT compared with no RH (191 [48-431] mL vs. 88 [35-245] mL, p = 0.013) and were more likely to be older with a higher burden of thoracic injury. After controlling for significant differences between groups, RH was independently associated with a larger HTX on presentation, with a 15% increase in risk of RH for each additional 100 mL of HTX on initial CT imaging (odds ratio, 1.15; 95% confidence interval, 1.08-1.21; p < 0.001). Patients with an RH also had higher rates of pneumonia and longer hospital length of stay than those with successful initial management. Retained hemothorax was also associated with worse functional outcomes at discharge and first outpatient follow-up. CONCLUSION: Larger initial HTX volumes are independently associated with RH, and unsuccessful initial management with tube thoracostomy is associated with worse patient outcomes. Future studies should use this experience to assess a range of options for reducing the risk of unsuccessful initial management. LEVEL OF EVIDENCE: Therapeutic/care management study, level III.

Communicable disease outbreaks: Contact tracing.

This third article in a series on communicable disease outbreaks focuses on contact tracing, fondly known as 'shoe-leather epidemiology'.

Communicable disease outbreaks: What is a case?

This second article in a series on communicable disease outbreaks focuses on case definitions, testing and early phases of a public health response.

Communicable disease outbreaks: Describing an epidemic.

This first article in a series on communicable disease outbreaks explains terms used by public health authorities during epidemics.

Incidence of Gunshot Wounds: Before and After Implementation of a Shall Issue Conceal Carry Law.

INTRODUCTION: This study examined the incidence of gunshot wounds before and after enacting a conceal carry (CC) law in a predominately rural state. METHODS: A retrospective review was conducted of all patients who were admitted with a gunshot injury to a Level I trauma center. Patient data collected included demographics, injury details, hospital course, and discharge destination. RESULTS: Among the 238 patients included, 44.6% (n = 107) were admitted during the pre-CC period and 55.4% (n = 131) in the post-CC period. No demographic differences were noted between the two periods except for an increase in uninsured patients from 43.0% vs 61.1% (p = 0.020). Compared to pre-CC patients, post-CC patients experienced a trend toward increased abdominal injury (11.2% vs 20.6%, p = 0.051) and increased vascular injuries (11.2% vs 22.1%, p = 0.026) while lower extremity injuries decreased significantly (38.3% vs 26.0%, p = 0.041). Positive focused assessment with sonography in trauma (FAST) exams (2.2% vs 16.8, p < 0.001), intensive care unit admission (26.2% vs 42.0%, p = 0.011) and need for ventilator support (11.2% vs 22.1%, p = 0.026) all increased during the post-CC period. In-hospital mortality more than doubled (8.4% vs 18.3%, p = 0.028) across the pre- and post-CC time periods. CONCLUSION: Implementation of a CC law was not associated with a decrease in the overall number of penetrating injuries or a decrease in mortality.

Syphilis testing performance in Aboriginal primary health care: exploring impact of continuous quality improvement over time.

Data from 110 primary healthcare clinics participating in two or more continuous quality improvement (CQI) cycles in preventive care, which included syphilis testing performance (STP) for Aboriginal and Torres Strait Islander people aged between 15 and 54 years, were used to examine whether the number of audit cycles including syphilis testing was associated over time with STP improvement at clinic level in this specific measure of public health importance. The number of cycles per clinic ranged from two to nine (mode 3). As shown by medical record audit at entry to CQI, only 42 (38%) clinics had tested or approached 50% or more of their eligible clients for syphilis in the prior 24 months. Using mixed effects logistic regression, it was found that the odds of a clinic's STP relative to its first cycle increased only modestly. Counterintuitively, clinics undertaking the most preventive health CQI cycles tended to have the lowest STP throughout. Participation in a general preventive care CQI tool was insufficient to achieve and sustain high rates of STP for Aboriginal and Torres Strait Islander people required for public health benefit. Improving STP requires dedicated effort and greater understanding of barriers to effective CQI within and beyond clinic control.

Communicable disease outbreaks: Ethics in an outbreak.

This fifth article in a series on communicable disease outbreaks explores ethical aspects of public health action, information disclosure and research in an epidemic.

Practice Variation in Vena Cava Filter Use Among Trauma Centers in the National Trauma Database.

BACKGROUND: Agreement regarding indications for vena cava filter (VCF) utilization in trauma patients has been in flux since the filter's introduction. As VCF technology and practice guidelines have evolved, the use of VCF in trauma patients has changed. This study examines variation in VCF placement among trauma centers. MATERIALS AND METHODS: A retrospective study was performed using data from the National Trauma Data Bank (2005-2014). Trauma centers were grouped according to whether they placed VCFs during the study period (VCF+/VCF-). A multivariable probit regression model was fit to predict the number of VCFs used among the VCF+ centers (the expected [E] number of VCF per center). The ratio of observed VCF placement (O) to expected VCFs (O:E) was computed and rank ordered to compare interfacility practice variation. RESULTS: In total, 65,482 VCFs were placed by 448 centers. Twenty centers (4.3%) placed no VCFs. The greatest predictors of VCF placement were deep vein thrombosis, spinal cord paralysis, and major procedure. The strongest negative predictor of VCF placement was admission during the year 2014. Among the VCF+ centers, O:E varied by nearly 500%. One hundred fifty centers had an O:E greater than one. One hundred sixty-nine centers had an O:E less than one. CONCLUSIONS: Substantial variation in practice is present in VCF placement. This variation cannot be explained only by the characteristics of the patients treated at these centers but could be also due to conflicting guidelines, changing evidence, decreasing reimbursement rates, or the culture of trauma centers.

Presumptive antibiotics in tube thoracostomy for traumatic hemopneumothorax: a prospective, Multicenter American Association for the Surgery of Trauma Study.

BACKGROUND: Thoracic injuries are common in trauma. Approximately one-third will develop a pneumothorax, hemothorax, or hemopneumothorax (HPTX), usually with concomitant rib fractures. Tube thoracostomy (TT) is the standard of care for these conditions, though TTs expose the patient to the risk of infectious complications. The controversy regarding antibiotic prophylaxis at the time of TT placement remains unresolved. This multicenter study sought to reconcile divergent evidence regarding the effectiveness of antibiotics given as prophylaxis with TT placement. METHODS: The primary outcome measures of in-hospital empyema and pneumonia were evaluated in this prospective, observational, and American Association for the Surgery of Trauma multicenter study. Patients were grouped according to treatment status (ABX and NoABX). A 1:1 nearest neighbor method matched the ABX patients with NoABX controls. Multilevel models with random effects for matched pairs and trauma centers were fit for binary and count outcomes using logistic and negative binomial regression models, respectively. RESULTS: TTs for HPTX were placed in 1887 patients among 23 trauma centers. The ABX and NoABX groups accounted for 14% and 86% of the patients, respectively. Cefazolin was the most frequent of 14 antibiotics prescribed. No difference in the incidence of pneumonia and empyema was observed between groups (2.2% vs 1.5%, p=0.75). Antibiotic treatment demonstrated a positive but non-significant association with risk of pneumonia (OR 1.61; 95% CI: 0.86~3.03; p=0.14) or empyema (OR 1.51; 95% CI: 0.42~5.42; p=0.53). CONCLUSION: There is no evidence to support the routine use of presumptive antibiotics for post-traumatic TT to decrease the incidence of pneumonia or empyema. More investigation is necessary to balance optimal patient outcomes and antibiotic stewardship. LEVEL OF EVIDENCE: II Prospective comparative study.