Enhancing clinician participation in quality improvement training: implementation and impact of an evidence-based initiative to maximise antenatal clinician participation in training regarding women's alcohol consumption during pregnancy.

BACKGROUND: There are significant challenges in ensuring sufficient clinician participation in quality improvement training. Clinician capability has been identified as a barrier to the delivery of evidence-based care. Clinician training is an effective strategy to address this barrier, however, there are significant challenges in ensuring adequate clinician participation in training. This study aimed to assess the extent of participation by antenatal clinicians in evidence-based training to address alcohol consumption during pregnancy, and to assess differences in participation by profession. METHODS: A 7-month training initiative based on six evidence-based principles was implemented in a maternity service in New South Wales, Australia. Descriptive statistics described participation in training (% attending: any training; six evidence-based principles of training; all principles). Regression analyses examined differences by profession. RESULTS: Almost all antenatal clinicians participated in some training (182/186; 98%); 69% participated in ≥1 h of training (µ = 88.2mins, SD:56.56). The proportion of clinicians participating in training that satisfied each of the six principles ranged from 35% (training from peers and experts) to 82% (training was educational and instructional). Only 7% participated in training that satisfied all principles. A significantly higher proportion of midwifery compared to medical clinicians participated in training satisfying five of the six training principles. CONCLUSIONS: A training initiative based on evidence-based principles resulted in almost all clinicians receiving some training and 69% participating in at least 1 h of training. Variability between professions suggests training needs to be tailored to such groups. Further research is required to determine possible associations with care delivery outcomes. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, No. ACTRN12617000882325 (date registered: 16/06/2017).

Worldwide surveillance of self-reported sitting time: a scoping review.

BACKGROUND: Prolonged sitting time is a risk factor for chronic disease, yet recent global surveillance is not well described. The aims were to clarify: (i) the countries that have collected country-level data on self-reported sitting time; (ii) the single-item tools used to collect these data; and (iii) the duration of sitting time reported across low- to high-income countries. METHODS: Country-level data collected within the last 10 years using single-item self-report were included. The six-stage methodology: (1) reviewing Global Observatory for Physical Activity! Country Cards; (2-4) country-specific searches of PubMed, the Demographic and Health Survey website and Google; (5) analysing the Eurobarometer 88.4; and (6) country-specific searches for World Health Organization STEPwise reports. RESULTS: A total of 7641 records were identified and screened for eligibility. Sixty-two countries (29%) reported sitting time representing 47% of the global adult population. The majority of data were from high-income (61%) and middle income (29%) countries. The tools used were the International Physical Activity Questionnaire (IPAQ; n = 34), a modified IPAQ (n = 1) or the Global Physical Activity Questionnaire (GPAQ; n = 27). The median of mean daily sitting times was 4.7 (IQR: 3.5-5.1) hours across all countries. Higher-income countries recorded a longer duration of sitting time than lower-income countries (4.9 vs 2.7 h). CONCLUSIONS: This study provides an updated collation of countries collecting self-reported sitting time data. The daily sitting time findings should be interpreted cautiously. Current surveillance of sitting time is limited by a lack of coverage. Measures of population sitting time that are valid, feasible and sensitive to change should be embedded within global surveillance systems, to help guide future policy, research and practice. TRIAL REGISTRATION: Not applicable.

Utility of Urine Cultures in Predicting Blood Culture Susceptibilities in Patients with Bacteremic Urinary Tract Infection.

In a review of 428 patients with bacteremic urinary tract infections, urine culture susceptibility results accurately predicted blood culture results when the same organism was isolated from both cultures. Early targeted therapy using urine culture results can potentially reduce broad-spectrum antibiotic exposure and its associated adverse effects and the length of hospitalization.

Effect of preoperative biliary drainage on cholestasis-associated inflammatory and fibrotic gene signatures in perihilar cholangiocarcinoma.

Preoperative biliary drainage (PBD) is used routinely in the evaluation of patients with potentially resectable perihilar cholangiocarcinoma to relieve cholestasis and improve the liver's resilience to surgery. Little preclinical or translatational data are, however, currently available to guide the use of PBD in this patient group. The effect of PBD on hepatic gene expression profiles was therefore studied by microarray analysis. Drainage affects inflammatory and fibrotic gene signatures.

Back pain, mental health and substance use are associated in adolescents.

BACKGROUND: During adolescence, prevalence of pain and health risk factors such as smoking, alcohol use and poor mental health all rise sharply. The aim of this study was to describe the relationship between back pain and health risk factors in adolescents. METHODS: Cross-sectional data from the Healthy Schools Healthy Futures study, and the Australian Child Wellbeing Project was used, mean age: 14-15 years. Children were stratified according to back pain frequency. Within each strata, the proportion of children that reported drinking alcohol or smoking or that experienced feelings of anxiety or depression was reported. Test-for-trend analyses assessed whether increasing frequency of pain was associated with health risk factors. RESULTS: Data was collected from ~2500 and 3900 children. Larger proportions of children smoked or drank alcohol within each strata of increasing pain frequency. The trend with anxiety and depression was less clear, although there was a marked difference between the children that reported no pain, and pain more frequently. CONCLUSION: Two large, independent samples show adolescents that experience back pain more frequently are also more likely to smoke, drink alcohol and report feelings of anxiety and depression. Pain appears to be part of the picture of general health risk in adolescents.

Economic evaluations of public health implementation-interventions: a systematic review and guideline for practice.

OBJECTIVES: Implementation interventions applied in public health are about using proven strategies to influence the uptake of evidence-based prevention and health promotion initiatives. The decision to invest in implementation has an opportunity cost, which can be overlooked. The purpose of this study was to assess the extent to which economic evaluations have been applied to implementation interventions in public health. STUDY DESIGN: We conducted a systematic review of empirical studies examining the costs and consequences, cost-effectiveness or cost-benefit of strategies directed towards enhancing the implementation of public health interventions and policies in developed countries. METHODS: The following databases were searched for English language publications reporting both effect measures and costs, from 1990 to current: MEDLINE, Embase, PsycINFO, CINAHL, EconLit, EPPI-Centre database of health promotion research, Cost-Effectiveness Analysis Registry, NHS Economic Evaluation Database, Informit and Scopus. RESULTS: The search strategy returned 3229 records after duplicate removal, from which we included 14 economic evaluations. All the included evaluations were conducted and published after 2000. Twelve of the 14 evaluations were based on controlled trials and two reported hypothetical modelled scenarios. The methodologic rigour and compliance with reporting guidelines for economic evaluations was highly varied and not related to the publication date. CONCLUSIONS: Our findings offer the first insight into the application and methodologic rigour of economic evaluations of implementation strategies supporting public health policies and interventions. To usefully inform public health policy and investment decisions, there needs to be greater application of economic evaluation to understand the cost-effectiveness of alternative implementation efforts. This review highlights the great paucity and mixed quality of the evidence on this topic and offers guidance by way of a checklist to improve the quality and reporting of future evaluations.

Impact of Defaulting to Single-Lumen Peripherally Inserted Central Catheters on Patient Outcomes: An Interrupted Time Series Study.

Defaulting to single-lumen peripherally inserted central catheters (PICCs) ordered from non-critical care units resulted in a sustained reduction in PICC-related complications. This system of care is transferrable to other institutions, with potential for improved patient safety and efficiency in outpatient parenteral antimicrobial therapy clinics.

Telephone-based weight loss support for patients with knee osteoarthritis: a pragmatic randomised controlled trial.

OBJECTIVE: To determine the effectiveness of telephone-based weight loss support in reducing the intensity of knee pain in patients with knee osteoarthritis, who are overweight or obese, compared to usual care. DESIGN: We conducted a parallel randomised controlled trial (RCT), embedded within a cohort multiple RCT of patients on a waiting list for outpatient orthopaedic consultation at a tertiary referral hospital in NSW, Australia. Patients with knee osteoarthritis, classified as overweight or obese [body mass index (BMI) between ≥27 kg/m2 and <40 kg/m2] were randomly allocated to receive referral to an existing non-disease specific government funded 6-month telephone-based weight management and healthy lifestyle service or usual care. The primary outcome was knee pain intensity measured using an 11-point numerical rating scale (NRS) over 6-month follow-up. A number of secondary outcomes, including self-reported weight were measured. Data analysis was by intention-to-treat according to a pre-published analysis plan. RESULTS: Between May 19 and June 30 2015, 120 patients were randomly assigned to the intervention (59 analysed, one post-randomisation exclusion) or usual care (60 analysed). We found no statistically significant between group differences in pain intensity [area under the curve (AUC), mean difference 5.4, 95%CI: -13.7 to 24.5, P = 0.58] or weight change at 6 months (self-reported; mean difference -0.4, 95%CI: -2.6 to 1.8, P = 0.74). CONCLUSIONS: Among patients with knee osteoarthritis who are overweight, telephone-based weight loss support, provided using an existing 6-month weight management and healthy lifestyle service did not reduce knee pain intensity or weight, compared with usual care. TRIAL REGISTRATION NUMBER: ACTRN12615000490572.

Factors associated with the implementation of a vegetable and fruit program in a population of Australian elementary schools.

Implementation of vegetable and fruit programs in schools is less than optimal. This study aimed to identify, using a theoretical framework, factors associated with implementation of a school vegetable and fruit program; that provides a time in class for children to consume a piece of vegetable or fruit they have brought from home. Three hundred and three randomly selected school principals across the state of New South Wales, Australia responded to a 25-min telephone survey. Principals were asked if their school had implemented a vegetable and fruit program, and which of 12 factors from Damschroder's consolidated framework for implementation research had facilitated or impeded implementation. Multiple logistic regression models examined the association between such factors and program implementation. Seventy-eight percent of schools had a vegetable and fruit program. Schools were significantly more likely to implement the program if the principal believed that: the program was effective (OR = 2.97; P < 0.02); they had sufficient resources to implement the program (OR = 4.22; P < 0.0001); the program would not be difficult to implement (OR = 10.16; P< 0.0001) and that the program was as important as other school priorities (OR = 2.45; P < 0.02). Realizing the intended benefits of vegetable and fruit programs requires widespread implementation by schools. Consideration of principal beliefs about the program effectiveness, resources, difficultly and relative importance in program implementation strategies appear key to increasing program implementation.

Validation of the EORTC QLQ-BIL21 questionnaire for measuring quality of life in patients with cholangiocarcinoma and cancer of the gallbladder.

BACKGROUND: There is no specific quality of life (QoL) measurement tool to quantify QoL in patients with biliary tract cancer. Quality of life measurement is an increasingly crucial trial end point and is now being incorporated into clinical practice. METHODS: This International Multicentre Phase IV Validation Study assessed the QLQ-BIL21 module in 172 patients with cholangiocarcinoma and 91 patients with cancer of the gallbladder. Patients completed the questionnaire at baseline pretherapy and subsequently at 2 months. Following this, the psychometric properties of reliability, validity, scale structure and responsiveness to change were analysed. RESULTS: Analysis of the QLQ-BIL21 scales showed appropriate reliability with Cronbach's α-coefficients >0.70 for all scales overall. Intraclass correlations exceeded 0.80 for all scales. Convergent validity >0.40 was demonstrated for all items within scales, and discriminant validity was confirmed with values <0.70 for all scales compared with each other. Scale scores changed in accordance with Karnofsky performance status and in response to clinical change. CONCLUSIONS: The QLQ-BIL21 is a valid tool for the assessment of QoL in patients with cholangiocarcinoma and cancer of the gallbladder.

Effects of a 'school-based' physical activity intervention on adiposity in adolescents from economically disadvantaged communities: secondary outcomes of the 'Physical Activity 4 Everyone' RCT.

BACKGROUND/OBJECTIVES: Obesity prevention during adolescence is a health priority. The 'Physical Activity 4 Everyone' (PA4E1) study tested a multi-component physical activity intervention in 10 secondary schools from socio-economically disadvantaged communities. This paper aimed to report the secondary outcomes of the study; to determine whether the intervention impacted on adiposity outcomes (weight, body mass index (BMI), BMI z-score), and whether any effect was moderated by sex, baseline BMI and baseline physical activity level, at 12 and 24 months. SUBJECTS/METHODS: A cluster randomised controlled trial was conducted in New South Wales, Australia. The school-based intervention included seven physical activity strategies targeting the following: curriculum (strategies to maximise physical activity in physical education, student physical activity plans, an enhanced school sport programme); school environment (physical activity during school breaks, modification of school policy); and parents and the community (parent engagement, links with community physical activity providers). Students' weight (kg), BMI and BMI z-score, were collected at baseline (Grade 7), 12 and 24 months. Linear Mixed Models were used to assess between-group mean difference from baseline to 12 and 24 months. Exploratory sub-analyses were undertaken according to three moderators of energy balance. RESULTS: A total of 1150 students (mean age=12 years) provided outcome data at baseline, 1051 (91%) at 12 months and 985 (86%) at 24 months. At 12 months, there were group-by-time effects for weight (mean difference=-0.90 kg (95% confidence interval (CI)=-1.50, -0.30), P<0.01) and BMI (-0.28 kg m-2 (-0.50, -0.06), P=0.01) in favour of the intervention group, but not for BMI z-score (-0.05 (-0.11; 0.01), P=0.13). These findings were consistent for weight (-0.62 kg (-1.21, 0.03), P=0.01) and BMI (-0.28 kg m-2 (-0.49, -0.06), P=0.01) at 24 months, with group-by-time effects also found for BMI z-score (-0.08 (-0.14; -0.02), P=0.02) favouring the intervention group. CONCLUSION: The PA4E1 school-based intervention achieved moderate reductions in adiposity among adolescents from socio-economically disadvantaged communities. Multi-component interventions that increase adolescents' engagement in moderate-to-vigorous physical activity (MVPA) may assist in preventing unhealthy weight gain.

Sending repeat cultures: is there a role in the management of bacteremic episodes? (SCRIBE study).

BACKGROUND: In the management of bacteremia, positive repeat blood cultures (persistent bacteremia) are associated with increased mortality. However, blood cultures are costly and it is likely unnecessary to repeat them for many patients. We assessed predictors of persistent bacteremia that should prompt repeat blood cultures. METHODS: We conducted a retrospective cohort study of bacteremias at an academic hospital from April 2010 to June 2014. We examined variables associated with patients undergoing repeat blood cultures, and with repeat cultures being positive. A nested case control analysis was performed on a subset of patients with repeat cultures. RESULTS: Among 1801 index bacteremias, repeat cultures were drawn for 701 patients (38.9 %), and 118 persistent bacteremias (6.6 %) were detected. Endovascular source (adjusted odds ratio [aOR], 7.66; 95 % confidence interval [CI], 2.30-25.48), epidural source (aOR, 26.99; 95 % CI, 1.91-391.08), and Staphylococcus aureus bacteremia (aOR, 4.49; 95 % CI, 1.88-10.73) were independently associated with persistent bacteremia. Escherichia coli (5.1 %, P = 0.006), viridans group (1.7 %, P = 0.035) and ß-hemolytic streptococci (0 %, P = 0.028) were associated with a lower likelihood of persistent bacteremia. Patients with persistent bacteremia were less likely to have achieved source control within 48 h of the index event (29.7 % vs 52.5 %, P < .001), but after variable reduction, source control was not retained in the final multivariable model. CONCLUSIONS: Patients with S. aureus bacteremia or endovascular infection are at risk of persistent bacteremia. Achieving source control within 48 h of the index bacteremia may help clear the infection. Repeat cultures after 48 h are low yield for most Gram-negative and streptococcal bacteremias.

The impact of alcohol management practices on sports club membership and revenue.

Issue addressed: The aim of this study was to assess the impact of an alcohol management intervention on community sporting club revenue (total annual income) and membership (number of club players, teams and spectators).Methods: The study employed a cluster randomised controlled trial design that allocated clubs either an alcohol accreditation intervention or a control condition. Club representatives completed a scripted telephone survey at baseline and again ~3 years following. Demographic information about clubs was collected along with information about club income.Results: Number of players and senior teams were not significantly different between treatment groups following the intervention. The intervention group, however, showed a significantly higher mean number of spectators. Estimates of annual club income between groups at follow-up showed no significant difference in revenue.Conclusions: This study found no evidence to suggest that efforts to reduce alcohol-related harm in community sporting clubs will compromise club revenue and membership.So what?: These findings suggest that implementation of an intervention to improve alcohol management of sporting clubs may not have the unintended consequence of harming club viability.

Survival after resection of perihilar cholangiocarcinoma-development and external validation of a prognostic nomogram.

BACKGROUND: The objective of this study was to derive and validate a prognostic nomogram to predict disease-specific survival (DSS) after a curative intent resection of perihilar cholangiocarcinoma (PHC). PATIENTS AND METHODS: A nomogram was developed from 173 patients treated at Memorial Sloan Kettering Cancer Center (MSKCC), New York, USA. The nomogram was externally validated in 133 patients treated at the Academic Medical Center (AMC), Amsterdam, The Netherlands. Prognostic accuracy was assessed with concordance estimates and calibration, and compared with the American Joint Committee on Cancer (AJCC) staging system. The nomogram will be available as web-based calculator at mskcc.org/nomograms. RESULTS: For all 306 patients, the median overall survival (OS) was 40 months and the median DSS 41 months. Median follow-up for patients alive at last follow-up was 48 months. Lymph node involvement, resection margin status, and tumor differentiation were independent prognostic factors in the derivation cohort (MSKCC). A nomogram with these prognostic factors had a concordance index of 0.73 compared with 0.66 for the AJCC staging system. In the validation cohort (AMC), the concordance index was 0.72, compared with 0.60 for the AJCC staging system. Calibration was good in the derivation cohort; in the validation cohort patients had a better median DSS than predicted by the model. CONCLUSIONS: The proposed nomogram to predict DSS after curative intent resection of PHC had a better prognostic accuracy than the AJCC staging system. Calibration was suboptimal because DSS differed between the two institutions. The nomogram can inform patients and physicians, guide shared decision making for adjuvant therapy, and stratify patients in future randomized, controlled trials.

Using personas to tailor educational messages to the preferences of coronary heart disease patients.

PURPOSE: Although tailoring health education messages to individual characteristics of patients has shown promising results, most patient education materials still take a one-size-fits-all approach. The aim of this study was to develop a method for tailoring health education messages to patients' preferences for various message features, using the concept of personas. This is a preliminary study focused on education for coronary heart disease (CHD) patients. METHODS: This study used a three-step approach. First, we created personas by (i) performing k-means cluster analysis on data from an online survey that assessed the preferences of 213 CHD patients for various message features and, (ii) creating a vivid description of the preferences per patient cluster in an iterative process with the research team. Second, we developed adaptation rules to tailor existing educational messages to the resulting personas. Third, we conducted a pilot validation by adapting nine existing educational messages to each of the personas. These messages and the resulting personas were then presented to a separate group of 38 CHD patients who visited the cardiology outpatient clinic. They were first asked to choose their most preferred, second most preferred, and least preferred persona. Subsequently, they were asked to rate three of the adapted messages; one for every of the persona choices. RESULTS: We created five personas that pertained to five patient clusters. Personas varied mainly on preferences for medical or lay language, current or future temporal perspective, and including or excluding explicit health risks. Fifty-five different adaptation rules were developed, primarily describing adaptations to the message's perspective, level of detail, sentence structure, and terminology. Most participants in the validation study could identify with one of the five personas, although some of them found it hard to choose. On average, 68.5% of all participants rated the messages that matched their most preferred persona more positively than, or in the same way as, the messages that matched their least preferred persona. CONCLUSIONS: The persona-based method developed in this study can be used to create a manageable set of patient-centered tailored messages, while additionally using the developed personas to assess patients' preferences.

Adoption of obesity prevention policies and practices by Australian primary schools: 2006 to 2013.

Despite significant investment in many countries, the extent of schools' adoption of obesity prevention policies and practices has not been widely reported. The aims of this article are to describe Australian schools' adoption of healthy eating and physical activity policies and practices over an 8-year period and to determine if their adoption varies according to schools' size, geographic or socio-economic location. Between 2006 and 2013, a representative randomly selected cohort of primary schools (n = 476) in New South Wales, Australia, participated in four telephone interviews. Repeated measures logistic regression analyses using a Generalised Estimating Equation (GEE) framework were undertaken to assess change over time. The prevalence of all four of the healthy eating practices and one physical activity practice significantly increased, while the prevalence of one physical activity practice significantly decreased. The adoption of practices did not differ by school characteristics. Government investment can equitably enhance school adoption of some obesity prevention policies and practices on a jurisdiction-wide basis. Additional and/or different implementation strategies may be required to facilitate greater adoption of physical activity practices. Ongoing monitoring of school adoption of school policies and practices is needed to ensure the intended benefits of government investment are achieved.

Surgical accuracy in identifying the elbow rotation axis on fluoroscopic images.

PURPOSE: To assess the accuracy of surgeons in identifying elbow rotation axis (RA) on fluoroscopic images and to measure the interobserver variability. METHODS: Five healthy subjects underwent 3-dimensional computed tomography (CT) analysis of their nondominant elbow. Real-time rotation software enabled surgeons to approximate the elbow RA on CT-reconstructed fluoroscopy, which was repeated twice with different starting positions to increase the number of observations. The surgeons used anatomical landmarks of choice. Analysis of variance (ANOVA) was used to determine structural error differences between surgeons, and intraclass correlation coefficients (ICCs) were used to determine the corresponding interobserver variability. RESULTS: Eight subspecialty-trained trauma surgeons (P.K., N.W.L.S., V.M.d.J., P.J., G.M.K., R.W.P., T.S., B.A.v.D.) participated and attempted to identify the RA on reconstructed fluoroscopy. A total of 15 RA definitions on 5 elbows were recorded per surgeon. The surgeons had a mean rotational error of 5° (range, < 1°-13°) and mean translational error of 1 mm (range, < 1-8 mm), compared with the true elbow RA as measured by the 3-dimensional CT analysis. The ANOVA showed structural differences between surgeons in rotational and translational errors, indicating that some surgeons consistently had more accurately identified the elbow RA than others. The ICC was 0.12 for rotational error and 0.10 for translational error, indicating a large interobserver variability. CONCLUSIONS: We show in this in vivo study that identification of the elbow RA on fluoroscopy is associated with substantial rotational errors and large inconsistencies among surgeons. Implementation of standardized anatomical landmarks is required to improve surgeons' accuracy. These landmarks should preferably take into account both the coronal and the sagittal planes, using the orientation of the capitellum and trochlea as well as the posterior distal humeral cortex. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Loss of elongation factor P disrupts bacterial outer membrane integrity.

Elongation factor P (EF-P) is posttranslationally modified at a conserved lysyl residue by the coordinated action of two enzymes, PoxA and YjeK. We have previously established the importance of this modification in Salmonella stress resistance. Here we report that, like poxA and yjeK mutants, Salmonella strains lacking EF-P display increased susceptibility to hypoosmotic conditions, antibiotics, and detergents and enhanced resistance to the compound S-nitrosoglutathione. The susceptibility phenotypes are largely explained by the enhanced membrane permeability of the efp mutant, which exhibits increased uptake of the hydrophobic dye 1-N-phenylnaphthylamine (NPN). Analysis of the membrane proteomes of wild-type and efp mutant Salmonella strains reveals few changes, including the prominent overexpression of a single porin, KdgM, in the efp mutant outer membrane. Removal of KdgM in the efp mutant background ameliorates the detergent, antibiotic, and osmosensitivity phenotypes and restores wild-type permeability to NPN. Our data support a role for EF-P in the translational regulation of a limited number of proteins that, when perturbed, renders the cell susceptible to stress by the adventitious overexpression of an outer membrane porin.