High-flow nasal oxygen for children's airway surgery to reduce hypoxaemic events: a randomised controlled trial.

BACKGROUND: Tubeless upper airway surgery in children is a complex procedure in which surgeons and anaesthetists share the same operating field. These procedures are often interrupted for rescue oxygen therapy. The efficacy of nasal high-flow oxygen to decrease the frequency of rescue interruptions in children undergoing upper airway surgery is unknown. METHODS: In this multicentre randomised trial conducted in five tertiary hospitals in Australia, children aged 0-16 years who required tubeless upper airway surgery were randomised (1:1) by a web-based randomisation tool to either nasal high-flow oxygen delivery or standard oxygen therapy (oxygen flows of up to 6 L/min). Randomisation was stratified by site and age (<1 year, 1-4 years, and 5-16 years). Subsequent tubeless upper airway surgery procedures in the same child could be included if there were more than 2 weeks between the procedures, and repeat surgical procedures meeting this condition were considered to be independent events. The oxygen therapy could not be masked, but the investigators remained blinded until outcome data were locked. The primary outcome was successful anaesthesia without interruption of the surgical procedure for rescue oxygenation. A rescue oxygenation event was defined as an interruption of the surgical procedure to deliver positive pressure ventilation using either bag mask technique, insertion of an endotracheal tube, or laryngeal mask to improve oxygenation. There were ten secondary outcomes, including the proportion of procedures with a hypoxaemic event (SpO2 <90%). Analyses were done on an intention-to-treat (ITT) basis. Safety was assessed in all enrolled participants. This trial is registered in the Australian New Zealand Clinical Trials Registry, ACTRN12618000949280, and is completed. FINDINGS: From Sept 4, 2018, to April 12, 2021, 581 procedures in 487 children were randomly assigned to high-flow oxygen (297 procedures) or standard care (284 procedures); after exclusions, 528 procedures (267 assigned to high-flow oxygen and 261 assigned to standard care) in 483 children (293 male and 190 female) were included in the ITT analysis. The primary outcome of successful anaesthesia without interruption for tubeless airway surgery was achieved in 236 (88%) of 267 procedures on high-flow oxygen and in 229 (88%) of 261 procedures on standard care (adjusted risk ratio [RR] 1·02, 95% CI 0·96-1·08, p=0·82). There were 51 (19%) procedures with a hypoxaemic event in the high-flow oxygen group and 57 (22%) in the standard care group (RR 0·86, 95% CI 0·58-1·24). Of the other prespecified secondary outcomes, none showed a significant difference between groups. Adverse events of epistaxis, laryngospasm, bronchospasm, hypoxaemia, bradycardia, cardiac arrest, hypotension, or death were similar in both study groups. INTERPRETATION: Nasal high-flow oxygen during tubeless upper airway surgery did not reduce the proportion of interruptions of the procedures for rescue oxygenation compared with standard care. There were no differences in adverse events between the intervention groups. These results suggest that both approaches, nasal high-flow or standard oxygen, are suitable alternatives to maintain oxygenation in children undergoing upper airway surgery. FUNDING: Thrasher Research Fund, the Australian and New Zealand College of Anaesthetists, the Society for Paediatric Anaesthesia in New Zealand and Australia.

Flexible bronchoscopy insufflated and high-flow nasal oxygen pilot trial (BUFFALO protocol pilot trial).

BACKGROUND: Hypoxaemia occurs in approximately 30% of children during anaesthesia for flexible bronchoscopy. High-flow nasal oxygen (HFNO) can prolong safe apnoea time and be used in children with abnormal airways. During flexible bronchoscopy, there is limited evidence if HFNO confers advantages over current standard practice in avoiding hypoxaemia. The aim is to investigate feasibility of HFNO use during anaesthesia for flexible bronchoscopy to reduce frequency of rescue oxygenation and hypoxaemia. METHODS: BUFFALO is a bi-centre, unmasked, randomised controlled, parallel group, protocol for a pilot trial comparing HFNO techniques to standard practice during anaesthesia. Children (n = 81) aged > 37 weeks to 16 years presenting for elective bronchoscopy who fulfil inclusion but not exclusion criteria will be randomised prior to the procedure to HFNO or standard care oxygenation post induction of anaesthesia. Maintenance of anaesthesia with HFNO requires total venous anaesthesia (TIVA) and with standard, either inhalational or TIVA at discretion of anaesthetist in charge of the patient. Outcomes will include the feasibility of recruitment and adherence to trial procedures, acceptability of the intervention of the protocol and completion rates of data collection methods. DISCUSSION: Findings of this trial will determine feasibility to plan for a larger multicentre randomised clinical trial and support the feasibility of the proposed study procedures. TRIAL REGISTRATION: BUFFALO trial was registered with Australia and New Zealand Clinical Trials Registry (TRN12621001635853) on 29 November 2021 and commenced recruitment in May 2022. https://www.anzctr.org.au/ . The primary manuscript will be submitted for publication in a peer-reviewed journal.

Exploring the relationship between loneliness and volunteering amongst Australian adults: a cross-sectional study.

BACKGROUND: Alleviating loneliness and fostering social connections and a sense of belonging are essential for individuals' well-being in the aftermath of the COVID-19 pandemic. Volunteering has emerged as a potential strategy to prevent or alleviate loneliness among adults. To gain insights into factors that can reduce or protect against loneliness, it is important to consider multi-dimensional measures of loneliness and motivations to volunteer. This study aimed to understand which variables predict Australian volunteers' social, family, and romantic loneliness. METHODS: From October 2021 to January 2022, a cross-sectional online survey was administered to a sample of Australian adults with volunteering experience. The survey collected demographic information and used validated measures to assess social, family, and romantic loneliness and volunteer motivation. Bivariate and multivariate analyses were conducted to examine the association between loneliness and motivations for volunteering. RESULTS: Of the 1723 individuals who accessed the survey link, 160 participants completed the survey. The average age of respondents was 59.87 years (SD 12.3). The majority were female (77.5%), married or partnered (70.6%), and had ten or more years of volunteering experience (62.1%). Overall, participants reported low to moderate levels of loneliness across social (M = 12.1; SD = 5.3), family (M = 11.3; SD = 6.7), and romantic (M = 14.8; SD = 8.3) dimensions. Social motivation for volunteering was negatively associated with social and romantic loneliness, while enhancement and protective motivations were positively associated with family and romantic loneliness. Age and rurality were not significantly associated with any dimension of loneliness. CONCLUSIONS: Loneliness is a multifaceted and intricate experience that impacts individuals socially and emotionally. This study's findings confirmed that having protective and enhancement motives to volunteer was associated with increased loneliness. Social motives to volunteer were associated with a tendency to have lower levels of loneliness, possibly due to the positive impact of building and maintaining social relationships through volunteering. Understanding these associations is necessary to ensure that volunteering activities align with each person's unique needs and motivations.

Transnasal Humidified Rapid Insufflation Ventilatory Exchange in children requiring emergent intubation (Kids THRIVE): a statistical analysis plan for a randomised controlled trial.

The placement of an endotracheal tube for children with acute or critical illness is a low-frequency and high-risk procedure, associated with high rates of first-attempt failure and adverse events, including hypoxaemia. To reduce the frequency of these adverse events, the provision of oxygen to the patient during the apnoeic phase of intubation has been proposed as a method to prolong the time available for the operator to insert the endotracheal tube, prior to the onset of hypoxaemia. However, there are limited data from randomised controlled trials to validate the efficacy of this technique in children. The technique known as transnasal humidified rapid insufflation ventilatory exchange (THRIVE) uses high oxygen flow rates (approximately 2 L/kg/min) delivered through nasal cannulae during apnoea. It has been shown to at least double the amount of time available for safe intubation in healthy children undergoing elective surgery. The technique and its application in real time have not previously been studied in acutely ill or injured children presenting to the emergency department or admitted to an intensive care unit. The Kids THRIVE trial is a multicentre, international, randomised controlled trial (RCT) in children less than 16 years old undergoing emergent intubation in either the intensive care unit or emergency department of participating hospitals. Participants will be randomised to receive either the THRIVE intervention or standard care (no apnoeic oxygenation) during their intubation. The primary objective of the trial is to determine if the use of THRIVE reduces the frequency of oxygen desaturation and increases the frequency of first-attempt success without hypoxaemia in emergent intubation of children compared with standard practice. The secondary objectives of the study are to assess the impact of the use of THRIVE on the rate of adverse events, length of mechanical ventilation and length of stay in intensive care. In this paper, we describe the detailed statistical analysis plan as an update of the previously published protocol.

The effect of a multi-faceted quality improvement program on paramedic intubation success in the critical care transport environment: a before-and-after study.

INTRODUCTION: Endotracheal intubation (ETI) is an infrequent but key component of prehospital and retrieval medicine. Common measures of quality of ETI are the first pass success rates (FPS) and ETI on the first attempt without occurrence of hypoxia or hypotension (DASH-1A). We present the results of a multi-faceted quality improvement program (QIP) on paramedic FPS and DASH-1A rates in a large regional critical care transport organization. METHODS: We conducted a retrospective database analysis, comparing FPS and DASH-1A rates before and after implementation of the QIP. We included all patients undergoing advanced airway management with a first strategy of ETI during the time period from January 2016 to December 2021. RESULTS: 484 patients met the inclusion criteria during the study period. Overall, the first pass intubation success (FPS) rate was 72% (350/484). There was an increase in FPS from the pre-intervention period (60%, 86/144) to the post-intervention period (86%, 148/173), p < 0.001. DASH-1A success rates improved from 45% (55/122) during the pre-intervention period to 55% (84/153) but this difference did not meet pre-defined statistical significance (p = 0.1). On univariate analysis, factors associated with improved FPS rates were the use of video-laryngoscope (VL), neuromuscular blockage, and intubation inside a healthcare facility. CONCLUSIONS: A multi-faceted advanced airway management QIP resulted in increased FPS intubation rates and a non-significant improvement in DASH-1A rates. A combination of modern equipment, targeted training, standardization and ongoing clinical governance is required to achieve and maintain safe intubation by paramedics in the prehospital and retrieval environment.

Research monitoring practices in critical care research: a survey of current state and attitudes.

BACKGROUND/AIMS: In 2016, international standards governing clinical research recommended that the approach to monitoring a research project should be undertaken based on risk, however it is unknown whether this approach has been adopted in Australia and New Zealand (ANZ) throughout critical care research. The aims of the project were to: 1) Gain an understanding of current research monitoring practices in academic-led clinical trials in the field of critical care research, 2) Describe the perceived barriers and enablers to undertaking research monitoring. METHODS: Electronic survey distributed to investigators, research co-ordinators and other research staff currently undertaking and supporting academic-led clinical trials in the field of critical care in ANZ. RESULTS: Of the 118 respondents, 70 were involved in the co-ordination of academic trials; the remaining results pertain to this sub-sample. Fifty-eight (83%) were working in research units associated with hospitals, 29 (41%) were experienced Research Coordinators and 19 (27%) Principal Investigators; 31 (44%) were primarily associated with paediatric research. Fifty-six (80%) develop monitoring plans with 33 (59%) of these undertaking a risk assessment; the most common barrier reported was lack of expertise. Nineteen (27%) indicated that centralised monitoring was used, noting that technology to support centralised monitoring (45/51; 88%) along with support from data managers and statisticians (45/52; 87%) were key enablers. Coronavirus disease-19 (COVID-19) impacted monitoring for 82% (45/55) by increasing remote (25/45; 56%) and reducing onsite (29/45; 64%) monitoring. CONCLUSIONS: Contrary to Good Clinical Practice guidance, risk assessments to inform monitoring plans are not being consistently performed due to lack of experience and guidance. There is an urgent need to enhance risk assessment methodologies and develop technological solutions for centralised statistical monitoring.

The Course of Posttraumatic Stress in Children: Examination of Symptom Trajectories and Predictive Factors Following Admission to Pediatric Intensive Care.

OBJECTIVES: This study investigated trauma symptom trajectories of children 2-16 years old following admission to pediatric intensive care and identified factors that predicted a child's trauma symptom trajectory. DESIGN: Prospective longitudinal design. SETTING: Two tertiary care PICUs in Brisbane, Qld, Australia. PATIENTS: Children 2-16 years old admitted to PICU for longer than 8 hours. MEASUREMENTS MAIN RESULTS: Maternal reported child posttraumatic stress symptoms (n = 272) on the Trauma Symptom Checklist for Young Children were used to assess posttraumatic stress symptoms up to 12 months post admission. Semiparametric group-based trajectory analyses were completed to identify patterns over time. Age, gender, length of stay, premorbid functioning, maternal perceived threat to life, and maternal acute distress were assessed as potential risk factors. Three likely trajectory groups were identified. The majority of children were resilient (83.8%); however, a significant minority experienced chronic symptoms (12.9%) or elevated stress symptoms which resolved quickly (3.3%). After controlling for other variables, maternal report of premorbid internalizing behavior significantly predicted both chronic (odds ratio, 6.3) and recovery (odds ratio, 38.0) trajectories. Maternal acute distress significantly predicted child chronic symptom trajectories (odds ratio, 5.2). CONCLUSIONS: Children with elevated trauma symptoms postintensive care need timely and effective intervention. The majority of children with high levels of acute symptoms will continue to have chronic, ongoing posttraumatic stress symptoms. In addition, acute maternal distress and preexisting internalizing child behavior predict ongoing psychologic distress after discharge from the PICU. Screening in the acute period post-PICU admission may identify children likely to experience ongoing chronic posttraumatic distress symptoms and enable targeted treatment of children at risk. This is the first study to examine symptom trajectories in children following pediatric intensive care admission and includes a sample of very young children.

High-flow oxygen for children's airway surgery: randomised controlled trial protocol (HAMSTER).

INTRODUCTION: Hypoxaemia during anaesthesia for tubeless upper airway surgery in children with abnormal airways is common due to the complexity of balancing adequate depth of anaesthesia with maintenance of spontaneous breathing and providing an uninterrupted field of view of the upper airway for the surgeon. High-flow nasal oxygenation (HIGH-FLOW) can prolong safe apnoea time and be used in children with abnormal airways but to date has not been compared with the alternative technique of low-flow nasal oxygenation (LOW-FLOW). The aim is to investigate if use of HIGH-FLOW can reduce the number of hypoxaemic events requiring rescue oxygenation compared with LOW-FLOW. METHODS AND ANALYSIS: High-flow oxygen for children's airway surgery: randomised controlled trial (HAMSTER) is a multicentre, unmasked, randomised controlled, parallel group, superiority trial comparing two oxygenation techniques during anaesthesia. Children (n=530) aged >37 weeks to 16 years presenting for elective tubeless upper airway surgery who fulfil inclusion but not exclusion criteria will be randomised prior to surgery to HIGH-FLOW or LOW-FLOW post induction of anaesthesia. Maintenance of anaesthesia with HIGH-FLOW requires Total IntraVenous Anaesthesia (TIVA) and with LOW-FLOW, either inhalational or TIVA at discretion of anaesthetist. The primary outcome is the incidence of hypoxaemic events requiring interruption of procedure for rescue oxygenation by positive pressure ventilation and the secondary outcome includes total hypoxaemia time, adverse cardiorespiratory events and unexpected paediatric intensive care admission admission. Hypoxaemia is defined as Sp02 <90%. Analysis will be conducted on an intention-to-treat basis. ETHICS AND DISSEMINATION: Ethical approval has been obtained by Children's Health Queensland Human Research Ethics Committee (HREC/18/QRCH/130). The trial commenced recruitment in 2018. The primary manuscript will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: The HAMSTER is registered with the Australia and New Zealand Clinical TrialsRegistry: ACTRN12618000949280.

A Discussion of the Use of Virtual Reality for Training Healthcare Practitioners to Recognize Child Protection Issues.

Background: Virtual reality technology is a rapidly developing tool which has been shown to have exciting prospects in the field of medical education (1). In a recent, subsequent study, Pan et al. consider the potential of the same technology in the realm of child protection training and safeguarding issues (2). To build upon the Pan et al. (2) study, a panel discussion was held at The Centre for Behavior Change Annual Conference 2018 to discuss the question "Can a virtual reality communication scenario be used to teach General Practitioners and trainees how to recognize and manage child protection issues?." Methodology: The above study comprised an immersive virtual reality consultation, in which the ability of 63 doctors to pick up covert safeguarding cues was tested in the context of a consultation with an adult patient, where the patient's child happened to be present as well. The study and its findings were discussed at the Centre for Behavior Change 4th Annual Conference, and this paper summarizes the opinions of both the panel and the audience. Viewpoint: Safeguarding is a challenging area of practice where we must listen to the child, and tackle difficult conversations with parents. Within medical training, role play is the gold standard for teaching how to communicate in difficult scenarios. Given the ethical questions surrounding children being asked to role play such abuse, the use of virtual reality characters could have a key role in upgrading current practices in medical education on safeguarding.

Innovation in Central Venous Access Device Security: A Pilot Randomized Controlled Trial in Pediatric Critical Care.

OBJECTIVES: Central venous access devices enable many treatments during critical illness; however, 25% of pediatric central venous access devices fail before completion of treatment due to infection, thrombosis, dislodgement, and occlusion. This is frequently attributed to inadequate securement and dressing of the device; however, high-quality research evaluating pediatric central venous access device securement innovation to prevent central venous access device failure is scarce. This study aimed to establish the feasibility of a definitive randomized control trial examining the effectiveness of current and new technologies to secure central venous access devices in pediatrics. DESIGN: Single-center, parallel group, superiority, pilot randomized control trial. SETTING: Anesthetic and intensive care departments of a tertiary pediatric hospital SUBJECTS:: One-hundred eighty pediatric patients with nontunneled central venous access device INTERVENTIONS:: Participants were randomized to receive central venous access device securement via standard care (bordered polyurethane dressing, with prolene sutures, chlorhexidine gluconate disc), tissue adhesive (Histoacryl, B Braun, Melsungen, Germany) in addition to standard care; or integrated dressing securement (SorbaView SHIELD [Centurion Medical Products, Franklin, MA], with prolene sutures and chlorhexidine gluconate disc). OUTCOMES: Primary: Feasibility (including effect size estimates, acceptability); central venous access device failure; central venous access device complications; secondary: individual central venous access device complications, skin damage, dressing performance, and product cost. MEASUREMENTS AND MAIN RESULTS: Feasibility criteria were achieved as recruitment occurred with acceptable eligibility, recruitment, missing data, and attrition rates, as well as good protocol adherence. Family members and staff-reported comparable levels of acceptability between study arms; however, tissue adhesive was reported as the most difficult to apply. Overall, 6% of central venous access devices failed, including 6% (3/54; incident rate, 13.2 per 1,000 catheter days) standard care, 2% (1/56; incident rate, 3.65 per 1,000 catheter days) integrated, and 8% (5/59; 25.0 per 1,000 catheter days) tissue adhesive. CONCLUSIONS: It is feasible to conduct an efficacy randomized control trial of the studied interventions. Further research is required to definitively identify clinical, cost-effective methods to prevent central venous access device failure by examining new dressing and securement technologies and techniques.

Transnasal Humidified Rapid Insufflation Ventilatory Exchange in children requiring emergent intubation (Kids THRIVE): a protocol for a randomised controlled trial.

INTRODUCTION: Emergency intubation of children with abnormal respiratory or cardiac physiology is a high-risk procedure and associated with a high incidence of adverse events including hypoxemia. Successful emergency intubation is dependent on inter-related patient and operator factors. Preoxygenation has been used to maximise oxygen reserves in the patient and to prolong the safe apnoeic time during the intubation phase. Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) prolongs the safe apnoeic window for a safe intubation during elective intubation. We designed a clinical trial to test the hypothesis that THRIVE reduces the frequency of adverse and hypoxemic events during emergency intubation in children and to test the hypothesis that this treatment is cost-effective compared with standard care. METHODS AND ANALYSIS: The Kids THRIVE trial is a multicentre randomised controlled trial performed in participating emergency departments and paediatric intensive care units. 960 infants and children aged 0-16 years requiring emergency intubation for all reasons will be enrolled and allocated to THRIVE or control in a 1:1 allocation with stratification by site, age (<1, 1-7 and >7 years) and operator (junior and senior). Children allocated to THRIVE will receive weight appropriate transnasal flow rates with 100% oxygen, whereas children in the control arm will not receive any transnasal oxygen insufflation. The primary outcomes are defined as follows: (1) hypoxemic event during the intubation phase defined as SpO2 <90% (patient-dependent variable) and (2) first intubation attempt success without hypoxemia (operator-dependent variable). Analyses will be conducted on an intention-to-treat basis. ETHICS AND DISSEMINATION: Ethics approval for the protocol and consent process has been obtained (HREC/16/QRCH/81). The trial has been actively recruiting since May 2017. The study findings will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: ACTRN12617000147381.

Search Smart for Your Health - A Statewide Health Literacy Campaign.

The Georgia Health Sciences Library Association (GHSLA) and the Georgia Alliance for Health Literacy (GAHL) partnered to educate residents about reliable health information online to raise health literacy awareness across the state of Georgia. The two groups received a gubernatorial declaration designating October as Health Literacy Month in Georgia. Information was posted online and demonstration workshops were held. The networking opportunities that resulted have allowed for additional partnerships and grant support to address the vital health literacy information needs of those with health disparities through clinician training and additional workshops.

A Study of Professional Awareness Using Immersive Virtual Reality: The Responses of General Practitioners to Child Safeguarding Concerns.

The art of picking up signs that a child may be suffering from abuse at home is one of those skills that cannot easily be taught, given its dependence on a range of non-cognitive abilities. It is also difficult to study, given the number of factors that may interfere with this skill in a real-life, professional setting. An immersive virtual reality environment provides a way round these difficulties. In this study, we recruited 64 general practitioners (GPs), with different levels of experience. Would this level of experience have any impact on general practitioners' ability to pick up child-safeguarding concerns? Would more experienced GPs find it easier to pick up subtle (rather than obvious) signs of child-safeguarding concerns? Our main measurement was the quality of the note left by the GP at the end of the virtual consultation: we had a panel of 10 (all experienced in safeguarding) rate the note according to the extent to which they were able to identify and take the necessary steps required in relation to the child safeguarding concerns. While the level of professional experience was not shown to make any difference to a GP's ability to pick up those concerns, the parent's level of aggressive behavior toward the child did. We also manipulated the level of cognitive load (reflected in a complex presentation of the patient's medical condition): while cognitive load did have some impact upon GPs in the "obvious cue" condition (parent behaving particularly aggressively), this effect fell short of significance. Furthermore, our results also suggest that GPs who are less stressed, less neurotic, more agreeable and extroverted tend to be better at raising potential child abuse issues in their notes. These results not only point at the considerable potential of virtual reality as a training tool, they also highlight fruitful avenues for further research, as well as potential strategies to support GP's in their dealing with highly sensitive, emotionally charged situations.

Particle and bioaerosol characteristics in a paediatric intensive care unit.

The paediatric intensive care unit (PICU) provides care to critically ill neonates, infants and children. These patients are vulnerable and susceptible to the environment surrounding them, yet there is little information available on indoor air quality and factors affecting it within a PICU. To address this gap in knowledge we conducted continuous indoor and outdoor airborne particle concentration measurements over a two-week period at the Royal Children's Hospital PICU in Brisbane, Australia, and we also collected 82 bioaerosol samples to test for the presence of bacterial and viral pathogens. Our results showed that both 24-hour average indoor particle mass (PM10) (0.6-2.2µgm-3, median: 0.9µgm-3) and submicrometer particle number (PN) (0.1-2.8×103pcm-3, median: 0.67×103pcm-3) concentrations were significantly lower (p<0.01) than the outdoor concentrations (6.7-10.2µgm-3, median: 8.0µgm-3 for PM10 and 12.1-22.2×103pcm-3, median: 16.4×103pcm-3 for PN). In general, we found that indoor particle concentrations in the PICU were mainly affected by indoor particle sources, with outdoor particles providing a negligible background. We identified strong indoor particle sources in the PICU, which occasionally increased indoor PN and PM10 concentrations from 0.1×103 to 100×103pcm-3, and from 2µgm-3 to 70µgm-3, respectively. The most substantial indoor particle sources were nebulization therapy, tracheal suction and cleaning activities. The average PM10 and PN emission rates of nebulization therapy ranged from 1.29 to 7.41mgmin-1 and from 1.20 to 3.96pmin-1×1011, respectively. Based on multipoint measurement data, it was found that particles generated at each location could be quickly transported to other locations, even when originating from isolated single-bed rooms. The most commonly isolated bacterial genera from both primary and broth cultures were skin commensals while viruses were rarely identified. Based on the findings from the study, we developed a set of practical recommendations for PICU design, as well as for medical and cleaning staff to mitigate aerosol generation and transmission to minimize infection risk to PICU patients.

Drug Therapy for Gender Transitions and Health Screenings in Transgender Older Adults.

Transgender medicine is a relatively new field in health care, with only a small amount of evidence-based literature available for reference. This is especially true for the older adult population, for whom most information must be extrapolated from younger adults. Be it a newly transitioned older adult or a transgendered individual who has been undergoing hormonal therapy for many years, it is important that healthcare professionals be aware of the significant effects that transgender pharmacotherapy can have on older adults. Healthcare providers must also recommend appropriate preventative screenings to transgendered persons.

Central venous Access device SeCurement And Dressing Effectiveness (CASCADE) in paediatrics: protocol for pilot randomised controlled trials.

INTRODUCTION: Paediatric central venous access devices (CVADs) are associated with a 25% incidence of failure. Securement and dressing are strategies used to reduce failure and complication; however, innovative technologies have not been evaluated for their effectiveness across device types. The primary aim of this research is to evaluate the feasibility of launching a full-scale randomised controlled efficacy trial across three CVAD types regarding CVAD securement and dressing, using predefined feasibility criteria. METHODS AND ANALYSIS: Three feasibility randomised, controlled trials are to be undertaken at the Royal Children's Hospital and the Lady Cilento Children's Hospital, Brisbane, Australia. CVAD securement and dressing interventions under examination compare current practice with sutureless securement devices, integrated securement dressings and tissue adhesive. In total, 328 paediatric patients requiring a peripherally inserted central catheter (n=100); non-tunnelled CVAD (n=180) and tunnelled CVAD (n=48) to be inserted will be recruited and randomly allocated to CVAD securement and dressing products. Primary outcomes will be study feasibility measured by eligibility, recruitment, retention, attrition, missing data, parent/staff satisfaction and effect size. CVAD failure and complication (catheter-associated bloodstream infection, local infection, venous thrombosis, occlusion, dislodgement and breakage) will be compared between groups. ETHICS AND DISSEMINATION: Ethical approval to conduct the research has been obtained. All dissemination will be undertaken using the CONSORT Statement recommendations. Additionally, the results will be sent to the relevant organisations which lead CVAD focused clinical practice guidelines development. TRIAL REGISTRATION NUMBERS: ACTRN12614001327673; ACTRN12615000977572; ACTRN12614000280606.

Residency curriculum improves breastfeeding care.

OBJECTIVES: Multiple studies have revealed inadequacies in breastfeeding education during residency, and results of recent studies have confirmed that attitudes of practicing pediatricians toward breastfeeding are deteriorating. In this we study evaluated whether a residency curriculum improved physician knowledge, practice patterns, and confidence in providing breastfeeding care and whether implementation of this curriculum was associated with increased breastfeeding rates in patients. SUBJECTS AND METHODS: A prospective cohort of 417 residents was enrolled in a controlled trial of a novel curriculum developed by the American Academy of Pediatrics in conjunction with experts from the American College of Obstetricians and Gynecologists, American Academy of Family Physicians, and Association of Pediatric Program Directors. Six intervention residency programs implemented the curriculum, whereas 7 control programs did not. Residents completed pretests and posttests before and after implementation. Breastfeeding rates were derived from randomly selected medical charts in hospitals and clinics at which residents trained. RESULTS: Trained residents were more likely to show improvements in knowledge (odds ratio [OR]: 2.8 [95% confidence interval (CI): 1.5-5.0]), practice patterns related to breastfeeding (OR: 2.2 [95% CI: 1.3-3.7]), and confidence (OR: 2.4 [95% CI: 1.4-4.1]) than residents at control sites. Infants at the institutions in which the curriculum was implemented were more likely to breastfeed exclusively 6 months after intervention (OR: 4.1 [95% CI: 1.8-9.7]). CONCLUSIONS: A targeted breastfeeding curriculum for residents in pediatrics, family medicine, and obstetrics and gynecology improves knowledge, practice patterns, and confidence in breastfeeding management in residents and increases exclusive breastfeeding in their patients. Implementation of this curriculum may similarly benefit other institutions.