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Remote research studies are an invaluable tool for reaching populations in geographical regions with limited access to large medical centers or universities. To expand the remote study toolkit, we have previously developed homeRNA, which allows for at-home self-collection and stabilization of blood and demonstrated the feasibility of using homeRNA in high temperature climates. Here, we expand upon this work through a systematic study exploring the effects of high temperature on RNA integrity through in-lab and field experiments. Compared to the frozen controls (overall mean RIN of 8.2, n = 8), samples kept at 37°C for 2, 4, and 8 days had mean RINs of 7.6, 5.9, and 5.2 ( n = 3), respectively, indicating that typical shipping conditions (∼2 days) yield samples suitable for downstream RNA sequencing. Shorter time intervals (6 hours) resulted in minimal RNA degradation (median RIN of 6.4, n = 3) even at higher temperatures (50°C) compared to the frozen control (mean RIN of 7.8, n = 3). Additionally, we shipped homeRNA-stabilized blood from a single donor to 14 different states and back during the summer with continuous temperature probes (7.1 median RIN, n = 42). Samples from all locations were analyzed with 3' mRNA-seq to assess differences in gene counts, with the transcriptomic data suggesting that there was no preferential degradation of transcripts as a result of different shipping times, temperatures, and regions. Overall, our data support that homeRNA can be used in elevated temperature conditions, enabling decentralized sample collection for telemedicine, global health, and clinical research.

Introduction: Emergency clinical research has played an important role in improving outcomes for acutely ill patients. This is due in part to regulatory measures that allow Exception From Informed Consent (EFIC) trials. The Food and Drug Administration (FDA) requires sponsor-investigators to engage in community consultation and public disclosure activities prior to initiating an Exception From Informed Consent trial. Various approaches to community consultation and public disclosure have been described and adapted to local contexts and Institutional Review Board (IRB) interpretations. The COVID-19 pandemic has precluded the ability to engage local communities through direct, in-person public venues, requiring research teams to find alternative ways to inform communities about emergency research., Methods: The PreVent and PreVent 2 studies were two Exception From Informed Consent trials of emergency endotracheal intubation, conducted in one geographic location for the PreVent Study and in two geographic locations for the PreVent 2 Study. During the period of the two studies, there was a substantial shift in the methodological approach spanning across the periods before and after the pandemic from telephone, to in-person, to virtual settings., Results: During the 10 years of implementation of Exception From Informed Consent activities for the two PreVent trials, there was overall favorable public support for the concept of Exception From Informed Consent trials and for the importance of emergency clinical research. Community concerns were few and also did not differ much by method of contact. Attendance was higher with the implementation of virtual technology to reach members of the community, and overall feedback was more positive compared with telephone contacts or in-person events. However, the proportion of survey responses received after completion of the remote, live event was substantially lower, with a greater proportion of respondents having higher education levels. This suggests less active engagement after completion of the synchronous activity and potentially higher selection bias among respondents. Importantly, we found that engagement with local community leaders was a key component to develop appropriate plans to connect with the public., Conclusion: The PreVent experience illustrated operational advantages and disadvantages to community consultation conducted primarily by telephone, in-person events, or online activities. Approaches to enhance community acceptance included partnering with community leaders to optimize the communication strategies and trust building with the involvement of Institutional Review Board representatives during community meetings. Researchers might need to pivot from in-person planning to virtual techniques while maintaining the ability to engage with the public with two-way communication approaches. Due to less active engagement, and potential for selection bias in the responders, further research is needed to address the costs and benefits of virtual community consultation and public disclosure activities compared to in-person events., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Rationale: Restoration of blood flow after out-of-hospital cardiac arrest (OHCA) is associated with inflammation that causes cellular injury. The extent of this reperfusion injury (RI) is associated with the duration of ischemia and adequacy of resuscitation. Remote ischemic conditioning (RIC) consists of repeated application of non-lethal ischemia then reperfusion to a limb distal to the heart by inflating a blood pressure (BP) cuff. Trials in animal models in cardiac arrest and in humans with acute infarction show RIC reduces RI., Objective: We sought to demonstrate the feasibility and safety of RIC in patients resuscitated from OHCA and transported to hospital., Methods: This study was conducted under exception from informed consent (EFIC) for emergency research. Eligible subjects were randomized with masked allocation to control (standard care) versus intervention (standard care and RIC). Included were adults with non-traumatic OHCA. The primary outcome was attrition, the proportion of patients enrolled and not on allocated therapy for the study duration. Key secondary outcomes were survival to discharge, neurologic status at discharge, hospital-free survival, and adverse events. Results were summarized descriptively as recommended for pilot studies., Results: N = 30 patients were enrolled (n = 14 control, n = 16 intervention). Mean age of enrolled patients was 52.5 ± 16.2 years. Eight (27%) were female gender and 7 (23%) had a shockable first recorded rhythm. 100% of enrolled patients completed their allocated study intervention (i.e., 0% attrition). The RIC group had 7 (44%) survival to discharge and median Rankin score of 6 (IQR 1, 6) at discharge as compared to the standard care group which had 6 (43%) survival to discharge and median Rankin score of 6 (IQR 1.5, 6) at discharge. A single patient (6%) in the intervention group had transient occlusion of their upper extremity intravenous line, which immediately resolved on repositioning of the blood pressure cuff., Conclusion: Application of RIC to patients resuscitated from CA and transported to an ED is feasible and safe. An adequately powered trial is required to assess whether RIC is effective at decreasing morbidity and mortality after CA., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Racism contributes to health inequities faced by people of colour and marginalised groups. Despite widespread recognition of the impacts of racism, mitigating strategies and legislation have been largely unsuccessful. Research into racism in healthcare has mostly examined personal experiences of healthcare workers and patients, assuming that the definitions of racism and race are similarly understood by all. However, ethnicity and race are often conflated, and racism seen as primarily interpersonal and ahistorical., Purpose: This paper explores hospital employee understandings of racism, its impacts and how to reduce it., Methods: Forty-nine staff within one Australian hospital participated in individual qualitative interviews regarding the definition, impact, and ways of reducing racism. Interviews were analysed with a reflexive thematic analytic approach using a Postcolonial framework., Results: Participants described racism as being experienced by marginalised groups of people in Australia. They identified that racism has detrimental effects on health and wellbeing. Not all were clear regarding what constituted racism: it was not described as an ideology created to justify colonial distribution of power and resources. Some thought that racism was individual prejudice while others noted it was also structural in nature. Participants commonly defined race as involving physical or cultural differences, suggesting that discredited historical and colonial concepts of race continue in Australian society. While many felt that education was the best way to reduce racism and its impacts, some participants noted that being educated did not necessarily change racist behaviour., Conclusions: The lack of accurate understanding of the concept of race and racism likely contributes to the relatively poor effect of current strategies to combat racism. As an initial part of deeper systemic anti-racist reform, this research supports calls for anti-racist education to clarify the definition of racism as an ideology., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Respiratory infections are common in children, and there is a need for user-friendly collection methods. Here, we performed the first human subjects study using the CandyCollect device, a lollipop-inspired saliva collection device .We showed that the CandyCollect device can be used to collect salivary bacteria from healthy adults using Streptococcus mutans and Staphylococcus aureus as proof-of-concept commensal bacteria. We enrolled healthy adults in a nationwide (USA) remote study in which participants were sent study packages containing CandyCollect devices and traditional commercially available oral swabs and spit tubes. Participants sampled themselves at home, completed usability and user preference surveys, and mailed the samples back to our laboratory for analysis by qPCR. Our results showed that for participants in which a given bacterium ( S. mutans or S. aureus ) was detected in one or both of the commercially available methods (oral swab and/or spit tubes), CandyCollect devices had a 100% concordance with the positive result ( n = 14 participants). Furthermore, the CandyCollect device was ranked the highest preference sampling method among the three sampling methods by 26 participants surveyed (combining survey results across two enrollment groups). We also showed that the CandyCollect device has a shelf life of up to 1 year at room temperature, a storage period that is convenient for clinics or patients to keep the CandyCollect device and use it any time. Taken together, we have demonstrated that the CandyCollect is a user-friendly saliva collection tool that has the potential to be incorporated into diagnostic assays in clinic visits and telemedicine.

Settler colonisation continues to cause much damage across the globe. It has particularly impacted negatively on Indigenous peoples' health and wellbeing causing great inequity. Health professional education is a critical vehicle to assist in addressing this; however, non-Indigenous educators often feel unprepared and lack skill in this regard. In this qualitative study, 20 non-Indigenous nursing, physiotherapy and occupational therapy educators in Australia were interviewed about their experiences and perspectives of teaching Indigenous health. Findings from the inductive thematic analysis suggest educators require skill development to: identify their discomfort in teaching cultural safety; contextualise the sources of this discomfort and; reflect on how this understanding can improve their teaching. Additionally, educators require professional training to become practitioners of cultural humility and to be facilitators and colearners (rather than experts) of the Aboriginal-led curriculum. Of relevance to this is educator training in how to decentre non-Indigenous needs and perspectives. Educators can also renew their teaching practices by understanding what a dominant settler paradigm is, identifying if this is problematically present in their teaching and knowing how to remedy this. Crucial to improved cultural safety teaching is institutional support, which includes Indigenous leadership, institutional commitment, relevant policies, and well-designed professional development., (© 2022 The Authors. Nursing Inquiry published by John Wiley & Sons Ltd.)

Background: Using critical discourse analysis, this study examined the portrayal of Aboriginal and Torres Strait Islander people in Australian Government policies regarding alcohol and other drug (AOD) use., Methods: We used critical discourse analysis, informed by an Indigenous Research Paradigm, to analyse texts and contexts of six key Australian Government AOD drug policies; two Aboriginal AOD data documents, two reporting documents and two AOD strategy documents., Results: The social practice analysis found issues of power imbalance relating to the socio-political situation the documents were created in. Textual analysis identified: culture being performative or functional in documents; cultural unsafety in construction of targets and outcomes, and; the decentring of Aboriginal peoples in the framing of the documents. The discourse analysis identified that the documents often wrote about Aboriginal peoples rather than writing documents with or by Aboriginal peoples. This typically: absented complexities of consultation occurring within a complex power imbalanced cultural interface; did not support an Aboriginal paradigm; centred Gubba people in power and; promoted a paternalistic view of 'helping' Aboriginal people., Conclusions: There is an urgent need to move from policy relating to Aboriginal affairs that relies on a deficit discourse, to more effective AOD policy that improves power balance in policy development, is written with or by Aboriginal people, is inclusive of Aboriginal epistemologies and ontologies, and represents a paradigm-shift to a strength-based approach., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier B.V.)

Streptococcus pyogenes is a major human-specific bacterial pathogen and a common cause of a wide range of symptoms from mild infection such as pharyngitis (commonly called strep throat) to life-threatening invasive infection and post-infectious sequelae. Traditional methods for diagnosis include collecting a sample using a pharyngeal swab, which can cause discomfort and even discourage adults and children from seeking proper testing and treatment in the clinic. Saliva samples are an alternative to pharyngeal swabs. To improve the testing experience for strep throat, we developed a novel lollipop-inspired sampling platform (called CandyCollect) to capture bacteria in saliva. The device can be used in clinics or in the home and shipped back to a lab for analysis, integrating with telemedicine. CandyCollect is designed to capture bacteria on an oxygen plasma treated polystyrene surface embedded with flavoring substances to enhance the experience for children and inform the required time to complete the sampling process. In addition, the open channel structure prevents the tongue from scraping and removing the captured bacteria. The flavoring substances did not affect bacterial capture and the device has a shelf life of at least 2 months (with experiments ongoing to extend the shelf life). We performed a usability study with 17 participants who provided feedback on the device design and the dissolving time of the candy. This technology and advanced processing techniques, including polymerase chain reaction (PCR), will enable user-friendly and effective diagnosis of streptococcal pharyngitis.

Expanding whole blood sample collection for transcriptome analysis beyond traditional phlebotomy clinics will open new frontiers for remote immune research and telemedicine. Determining the stability of RNA in blood samples exposed to high ambient temperatures (>30°C) is necessary for deploying home-sampling in settings with elevated temperatures (e.g., studying physiological response to natural disasters that occur in warm locations or in the summer). Recently, we have developed home RNA, a technology that allows for self-blood sampling and RNA stabilization remotely. home RNA consists of a lancet-based blood collection device, the Tasso-SST™ which collects up to 0.5 ml of blood from the upper arm, and a custom-built stabilization transfer tube containing RNA later™ . In this study, we investigated the robustness of our home RNA kit in high temperature settings via two small pilot studies in Doha, Qatar (no. participants = 8), and the Western and South Central USA during the summer of 2021, which included a heatwave of unusually high temperatures in some locations (no. participants = 11). Samples collected from participants in Doha were subjected to rapid external temperature fluctuations from being moved to and from air-conditioned areas and extreme heat environments (up to 41°C external temperature during brief temperature spikes). In the USA pilot study, regions varied in outdoor temperature highs (between 25°C and 43.4°C). All samples that returned a RNA integrity number (RIN) value from the Doha, Qatar group had a RIN ≥7.0, a typical integrity threshold for downstream transcriptomics analysis. RIN values for the Western and South Central USA samples ( n  = 12 samples) ranged from 6.9-8.7 with 9 out of 12 samples reporting RINs ≥7.0. Overall, our pilot data suggest that home RNA can be used in some regions that experience elevated temperatures, opening up new geographical frontiers in disseminated transcriptome analysis for applications critical to telemedicine, global health, and expanded clinical research. Further studies, including our ongoing work in Qatar, USA, and Thailand, will continue to test the robustness of home RNA., Competing Interests: The authors acknowledge the following potential conflicts of interest: ABT: ownership in Stacks to the Future, LLC. ST: ownership in Stacks to the Future, LLC, Salus Discovery, LLC, and Tasso, Inc. EB: ownership in Stacks to the Future, LLC, Salus Discovery, LLC, and Tasso, Inc., and employment by Tasso, Inc. Technologies from Stacks to the Future, LLC and Salus Discovery, LLC are not included in this publication. The blood collection device used in this publication is from Tasso, Inc.; the terms of this arrangement have been reviewed and approved by the University of Washington in accordance with its policies governing outside work and financial conflicts of interest in research., (© 2022 Brown, Haack, Kennedy, Adams, Stolarczuk, Takezawa, Berthier, Thongpang, Lim, Chaussabel, Garand and Theberge.)

Purpose: To determine whether a brief leadership curriculum including high-fidelity simulation can improve leadership skills among resident physicians., Method: This was a double-blind, randomized controlled trial among obstetrics-gynecology and emergency medicine (EM) residents across 5 academic medical centers from different geographic areas of the United States, 2015-2017. Participants were assigned to 1 of 3 study arms: the Leadership Education Advanced During Simulation (LEADS) curriculum, a shortened Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) curriculum, or as active controls (no leadership curriculum). Active controls were recruited from a separate site and not randomized to limit any unintentional introduction of materials from leadership curricula. The LEADS curriculum was developed in partnership with the Council on Resident Education in Obstetrics and Gynecology and Council of Residency Directors in Emergency Medicine as a novel way to provide a leadership toolkit. Both LEADS and the abbreviated TeamSTEPPS were designed as six 10-minute interactive web-based modules.The primary outcome of interest was the leadership performance score from the validated Clinical Teamwork Scale instrument measured during standardized high-fidelity simulation scenarios. Secondary outcomes were 9 key components of leadership from the detailed leadership evaluation measured on 5-point Likert scales. Both outcomes were rated by a blinded clinical video reviewer., Results: One hundred ten obstetrics-gynecology and EM residents participated in this 2-year trial. Participants in both LEADS and TeamSTEPPS had statistically significant improvement in leadership scores from "average" to "good" ranges both immediately and at the 6-month follow-up, while controls remained unchanged in the "average" category throughout the study. There were no differences between LEADS and TeamSTEPPS curricula with respect to the primary outcome., Conclusions: Residents who participated in a brief structured leadership training intervention had improved leadership skills that were maintained at 6-month follow-up., (Copyright © 2021 by the Association of American Medical Colleges.)

Objectives: Health inequities exist for racial groups as a result of political, societal, historical and economic injustices, such as colonisation and racism. To address this, health professions have applied various health education pedagogies to equip learners to contribute better to cultural safety. The aim of this realist review was to provide an overview of cultural safety programs that evaluate transition of learning to practice to generate program theory as to what strategies best translate cultural safety theory to practice for nurses and midwives., Design: A systematic review following realist review publication standards., Data Sources: Nine papers were selected from six databases, from inception to January 2020. Any article that evaluated nurses and midwives practice change following participation in cultural safety education programs was included., Review Methods: A realist review was undertaken to refine cultural safety education program theory. This involved an initial broad search of literature, research team consultation, systematic literature search with refinement of the inclusion criteria. For each included article the context, mechanism and outcomes were extracted and analysed., Results: Three program theories resulted. Firstly, system and structural leadership to drive the change process, including adoption of policy and accreditation standards and involvement of the community impacted by health inequity. Second critical pedagogy to reveal institutional and individual racist behaviours and third, nurse and midwife commitment to cultural safety., Conclusion: Change in practice to achieve cultural safety is complex, requiring a multi-system approach. Cultural safety education programs adopting critical pedagogy is necessary for critical consciousness building by nurses and midwives to have impact. However, this is only one part of this interdependent change process. Involvement of those communities experiencing culturally unsafe practice is also necessary for program effectiveness. Further research is required to examine the effectiveness of coordinated multi-system approaches, alongside, nurse and midwife commitment for cultural safety., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Current archaeological research on cultigens emphasizes the protracted and intimate human interactions with wild species that defined paths to domestication and, with certain plants, profoundly impacted humanity. Tobacco arguably has had more impact on global patterns in history than any other psychoactive substance, but how deep its cultural ties extend has been widely debated. Excavations at the Wishbone site, directed at the hearth-side activities of the early inhabitants of North America's desert west, have uncovered evidence for human tobacco use approximately 12,300 years ago, 9,000 years earlier than previously documented. Here we detail the preservation context of the site, discuss its cultural affiliation and suggest ways that the tobacco may have been used. The find has implications for our understanding of deep-time human use of intoxicants and its sociocultural intersection with food crop domestication., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

In this latest contribution to the 'When I say … ' series, Vass and Adams explore the pervasive impact of colonisation as an under-recognised and poorly addressed context of medical education., (© 2021 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Gene expression analysis ( e.g. , targeted gene panels and transcriptomics) from whole blood can elucidate mechanisms of the immune function and aid in the discovery of biomarkers. Conventional venipuncture offers only a small snapshot of our broad immune landscape as immune responses may occur outside of the time and location parameters available for conventional venipuncture. A self-operated method that enables flexible sampling of liquid whole blood coupled with immediate stabilization of cellular RNA is instrumental in facilitating capture and preservation of acute or transient immune fluxes. To this end, we developed home RNA, a kit for self-collection of peripheral blood (∼0.5 mL) and immediate stabilization of cellular RNA, using the Tasso-SST blood collection device with a specially designed stabilizer tube containing RNA later . To assess the feasibility of home RNA for self-collection and stabilization of whole blood RNA, we conducted a pilot study ( n = 47 participants) in which we sent home RNA to participants aged 21-69, located across 10 US states (94% successful blood collections, n = 61/65). Among participants who successfully collected blood, 93% reported no or minimal pain/discomfort using the kit ( n = 39/42), and 79% reported very easy/somewhat easy stabilization protocol ( n = 33/42). Total RNA yield from the stabilized samples ranged between 0.20 and 5.99 μg (mean = 1.51 μg), and all but one RNA integrity number values were above 7.0 (mean = 8.1), indicating limited RNA degradation. The results from this study demonstrate the self-collection and RNA stabilization of whole blood with home RNA by participants themselves in their own home.

Culture is an important social and emotional wellbeing factor for Aboriginal peoples in Australia, particularly regarding recovery from colonization. However, little is understood about how culture and wellbeing interact for young urban Aboriginal people. This study used Yarning methods to explore experiences and perceptions of culture and wellbeing for young urban Aboriginal people in Narrm, Australia. Findings indicate that culture is experienced as connection, and that perceived connection or disconnection has an essential influence on the wellbeing of young people. Through sharing young people stories, a range of factors, including colonization, relationships, cultural knowledge, community support, and agency, were identified as affecting perceptions of connectedness, and therefore on wellbeing. Youth were able to develop strategies to increase connection and provided illuminating advice and suggestions for improving connection for future generations. This study thus contributes to efforts to improved understanding of Aboriginal perspectives about social and emotional wellbeing and culture.

In April 2020 a Group of Eight Taskforce was convened, consisting of over 100 researchers, to provide independent, research-based recommendations to the Commonwealth Government on a "Roadmap to Recovery" from COVID-19. The report covered issues ranging from pandemic control and relaxation of social distancing measures, to well-being and special considerations for vulnerable populations. Our work focused on the critical needs of Aboriginal and Torres Strait Islander communities; this paper presents an overview of our recommendations to the Roadmap report. In addressing the global challenges posed by pandemics for citizens around the world, Indigenous people are recognised as highly vulnerable. At the time of writing Australia's First Nations Peoples have been largely spared from COVID-19 in comparison to other Indigenous populations globally. Our recommendations emphasise self-determination and equitable needs-based funding to support Indigenous communities to recover from COVID-19, addressing persistent overcrowded housing, and a focus on workforce, especially for regional and remote communities. These latter two issues have been highlighted as major issues of risk for Indigenous communities in Australia It remains to be seen how governments across Australia take up these recommendations to support Indigenous peoples' health and healing journey through yet another, potentially catastrophic, health crisis., Competing Interests: The authors declare no conflict of interest., (© 2020 Australian Social Policy Association.)

Introduction: General practitioners (GPs) and family medicine clinicians should respond to Indigenous peoples' health needs. However, medical graduates feel underprepared for this work. The foundational elements of racism, white privilege and cultural self-reflexivity remain conspicuously absent from medical education in general practice programmes, despite inclusion in curriculum frameworks. This study explored the perception and experiences of Australian GP educators in teaching this content., Methods: We undertook a qualitative study that gathered data through semi-structured interviews with GP educators (n = 12) at a medical school in Victoria, Australia. We utilised the Reflection learning domain of the Aboriginal and Torres Strait Islander Health Curriculum Framework to shape interview questions on racism, white privilege and cultural self-reflexivity. Data were analysed from constructivist and Critical Indigenous Theory paradigms to formulate key themes., Results: General practitioner educators were challenged by Reflection content, struggled to articulate a refined pedagogy for provision of anti-racist, self-reflexive learning and felt poorly qualified to teach Indigenous health, articulating preference for delegation of teaching to Indigenous peoples. They simultaneously stated the importance of inclusion of Reflection teaching in general practice, alongside expressing beliefs that appeared to devalue its perceived relevance. Students were perceived as being either disinterested or incapable of Reflection learning, or conversely, more engaged than previous generations with these topics., Discussion: The results call into question how skilled are GP educators to teach elements of Indigenous health education such as racism, white privilege and cultural self-reflexivity. Unskilled educators can reinforce colonialism in curricula, including through minimisation of content. Stronger anti-racist pedagogy is urgently required in medical education. Vital to this is active research on educator preparedness, evidence-based teaching models and accountable curriculum accreditation., (© 2020 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

In recent decades Indigenous health curriculum frameworks have been developed, however, few studies about their implementation exist. This study aimed to employ critical theory and action research to understand how an Indigenous health curriculum framework could be applied and associated learning and teaching iteratively improved. Three action research cycles where conducted from 2017 to 2019. Student reaction (satisfaction and engagement) was collected via survey 2017-2019. Student learning was collated 2018-2019 via self-perception survey (knowledge, attitude, confidence, commitment); multi-choice questions (knowledge) and; content analysis of apply and analyse activities (skill). The teaching team met annually to reflect on findings and plan enhancements to learning and teaching. Over 2017-2019 there was a pattern of improved student reaction and learning. Connecting this research to Faculty level committees led to widening success and improved sustainability of the practice. The online unit and workshop delivery were scalable, overcame a barrier of educator skill and confidence to teach this area, allowed for quality content control and provided data for analysis. Interestingly, learning gained from this unit matched that described as occurring from student placements in health settings with high numbers of Indigenous people. Student learning occurred across the Framework three levels (novice, intermediate and entry to practice) suggesting that the taxonomy of the Framework does not necessarily align with the reality of learning and teaching. Vertical implementation of the five learning domains would benefit from alignment with training evaluation models and validated assessment to understand learning that has occurred rather than the teaching that has been taught. In this study health profession accreditation bodies had driven the imperative for an Indigenous health program and curriculum. Research on Indigenous health learning and teaching relating to behaviour and results in workplaces is needed., Competing Interests: Declaration of competing interest None declared., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: To examine key factors influencing the prioritisation of food and nutrition in Aboriginal and Torres Strait Islander health policy during 1996-2015., Design: A qualitative policy analysis case study was undertaken, combining document analysis with thematic analysis of key informant interviews., Setting: Australia., Participants: Key actors involved in Aboriginal and Torres Strait Islander health policy between 1996 and 2015 (n 38)., Results: Prioritisation of food and nutrition in policy reduced over time. Several factors which may have impeded the prioritisation of nutrition were identified. These included lack of cohesion among the community of nutritionists, Aboriginal and Torres Strait Islander leaders and civil society actors advocating for nutrition; the absence of an institutional home for nutrition policy; and lack of consensus and a compelling policy narrative about how priority nutrition issues should be addressed. Political factors including ideology, dismantling of public health nutrition governance structures and missing the opportunities presented by 'policy windows' were also viewed as barriers to nutrition policy change. Finally, the complexity and multifaceted nature of nutrition as a policy problem and perceived lack of evidence-based solutions may also have constrained its prioritisation in Aboriginal and Torres Strait Islander health policy., Conclusions: Future advocacy should focus on embedding nutrition within holistic approaches to health and building a collective voice through advocacy coalitions with Aboriginal and Torres Strait Islander leadership. Strategic communication and seizing political opportunities may be as important as evidence for raising the priority of Aboriginal and Torres Strait Islander health issues.

Delivery of culturally safe healthcare is critical to ensuring access to high-quality care for indigenous people. A key component of this is for Aboriginal and Torres Strait Islander people to be participants in the health workforce. The proportion of indigenous people in the health workforce should at least equate to the proportion in the population served. We describe the development and implementation of a successful affirmative action employment policy at Monash Health, one of Australia's largest Academic Health Centres, and provide perspective on its adoption., (© 2019 Royal Australasian College of Physicians.)

Background: Globally, an estimated 370 million Indigenous peoples reside in more than 70 countries with these people commonly experiencing health care access inequity. Purpose: This systematic review aimed to examine the impact of Indigenous health care curriculum on entry-level health professional learners in preparation to deliver equitable health care. Methods: Seventeen articles were identified and analyzed for: context; study design; study measures, teaching and learning delivery mode, content and duration; positive and negative learner reactions; learning gained and article quality was assessed using the Medical Education Research Study Quality Instrument. Results: Most included studies described face-to-face delivery along with blended learning combining a placement in an Indigenous setting, stand-alone placements and digital learning. Descriptions of learning gained covered five domains: remembering, understanding, self-knowledge, perspective and application relating mostly to cultural awareness. Factors contributing to positive learner reactions included attitude, environment, educator skill, pedagogy and opportunities. Factors contributing to negative learner reactions included attitude and environment. Conclusions: There is a need to further explore how health professional graduates are prepared to work in Indigenous health and the appropriate measures to do this. There is opportunity to learn more about Indigenous health teaching and learning across learning domains, in mainstream clinical placements and in digital learning.

Background: Pheochromocytoma and paraganglioma (PHEO/PGL) are rare neuroendocrine tumors which may cause potentially life-threatening complications, with about a third of cases found to harbor specific gene mutations. Thus, early diagnosis, treatment, and meticulous monitoring are of utmost importance. Because of low incidence of succinate dehydrogenase complex subunit A ( SDHA )-related metastatic PHEO/PGL, currently there exists insufficient clinical information, especially with regards to its diagnostic and treatment characteristics. Methods: Ten patients with SDHA -related metastatic PHEO/PGL were followed-up prospectively and/or retrospectively between January 2010-July 2018. They underwent biochemical tests ( n = 10), 123 I-MIBG ( n = 9) scintigraphy, and multiple whole-body positron emission tomography/computed tomography (PET/CT) scans with 68 Ga-DOTATATE ( n = 10), 18 F-FDG ( n = 10), and 18 F-FDOPA ( n = 6). Results: Our findings suggest that these tumors can occur early and at extra-adrenal locations, behave aggressively, and have a tendency to develop metastatic disease within a short period of time. None of our patients had a family history of PHEO/PGL, making them appear sporadic. Nine out of 10 patients showed abnormal PHEO/PGL-specific biochemical markers with predominantly noradrenergic and/or dopaminergic phenotype, suggesting their utility in diagnosing and monitoring the disease. Per patient detection rates of 68 Ga-DOTATATE ( n = 10/10), 18 F-FDG ( n = 10/10), 18 F-FDOPA ( n = 5/6) PET/CT, and 123 I-MIBG ( n = 7/9) scintigraphy were 100, 100, 83.33, and 77.77%, respectively. Five out of 7 123 I-MIBG positive patients had minimal 123 I-MIBG avidity or detected very few lesions compared to widespread metastatic disease on 18 F-FDG PET/CT, implying that diagnosis and treatment with 123/131 I-MIBG is not a good option. 68 Ga-DOTATATE PET/CT was found to be superior or equal to 18 F-FDG PET/CT in 7 out of 10 patients and hence, is recommended for evaluation and follow-up of these patients. All 7 out of 7 patients who received conventional therapies (chemotherapy, somatostatin analog therapy, radiation therapy, 131 I-MIBG, peptide receptor radionuclide therapy) in addition to surgery showed disease progression. Conclusion: In our cohort of patients, SDHA -related metastatic PHEO/PGL followed a disease-course similar to that of SDHB -related metastatic PHEO/PGL, showing highly aggressive behavior, similar imaging and biochemical phenotypes, and suboptimal response to conventional therapies. Therefore, we recommend careful surveillance of the affected patients and a search for effective therapies.

Background: Mechanical thrombectomy has revolutionised the treatment of acute ischaemic stroke due to large vessel occlusion. It is well recognised that patients are more likely to benefit when reperfusion happens quickly, however, there is uncertainty as to how best to deliver this service., Objectives: To compare outcomes of patients in Northern -Ireland who underwent thrombectomy via direct admission to the single endovascular centre (mothership [MS]) with those transferred from primary stroke centres (drip-and-ship [DS])., Methods: Analysis was conducted on the records of all patients who underwent thrombectomy from January 2014 to December 2017 inclusive. The primary outcome measure was 3 months functional independence (modified Rankin Score [mRS] 0-2). Secondary outcome measures were full recovery (mRS 0) at 3 months, symptomatic intracranial haemorrhage (sICH) rates and mortality rates., Results: Two hundred fourteen patients underwent thrombectomy (MS 124, DS 90). Patients in the MS group were older (median 73 vs. 70 years, p = 0.026), but there was no significant difference in baseline National Institutes of Health Stroke Scale (median 15 MS vs. 16.5 DS, p = 0.162) or thrombolysis rates (41.9% MS vs. 54.4% DS, p = 0.070) between the groups. Time from stroke onset to arrival at thrombectomy centre was shorter in the MS group (median 71 vs. 218 min, p < 0.001) but door to groin puncture time was shorter in the DS group (median 30 vs. 60 min, p < 0.001). There was no significant difference in 3 months functional independence (51.6% MS vs. 62.2% DS, p = 0.123), or in the secondary outcome measures of full recovery (21.8% MS vs. 12.2% DS, p = 0.071), sICH (MS 0.8%, DS 4.4%, p = 0.082) and mortality (MS 24.2%, DS 20.0%, p = 0.468)., Conclusions: Our analysis showed similar outcomes after thrombectomy in the MS and DS groups. For patients potentially eligible for thrombectomy, rapid access to the endovascular centre is essential to optimise both the number of patients treated and the outcomes achieved., (© 2019 S. Karger AG, Basel.)

Objective To provide an overview of previous reviews of programs that aimed to improve nutritional status or diet-related health outcomes for Aboriginal and Torres Strait Islander peoples, in order to determine what programs are effective and why. Methods A systematic search of databases and relevant websites was undertaken to identify reviews of nutrition interventions for Aboriginal and Torres Strait Islander Australians. Pairs of reviewers undertook study selection and data extraction and performed quality assessment using a validated tool. Results Twelve papers reporting 11 reviews were identified. Two reviews were rated high quality, three were rated medium and six were rated low quality. The reviews demonstrated that a positive effect on nutrition and chronic disease indicators can be a result of: 1) incorporating nutrition and breastfeeding advice into maternal and child health care services; and 2) multifaceted community nutrition programs. The evidence suggests that the most important factor determining the success of Aboriginal and Torres Strait Islander food and nutrition programs is community involvement in (and, ideally, control of) program development and implementation. Conclusions Community-directed food and nutrition programs, especially those with multiple components that address the underlying causes of nutrition issues, can be effective in improving nutrition-related outcomes. What is known about the topic? More effective action is urgently required in order to reduce the unacceptable health inequalities between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians. Food insecurity and nutrition-related chronic conditions are responsible for a large proportion of the ill health experienced by Australia's First Peoples. What does this paper add? This narrative overview of 11 reviews published between 2005 and 2015 provides a synthesis of the current evidence for improving Aboriginal and Torres Strait Islander nutrition across the lifespan. The findings suggest that community-based and community-controlled programs, especially those with multiple components that address the underlying causes of nutrition issues, have the greatest potential to improve nutrition-related health outcomes. What are the implications for practitioners? Food and nutrition programs that are initiated and designed by local Aboriginal and Torres Strait Islander people are most likely to be effective. Nutrition and breastfeeding education and advice should be consistently incorporated into maternal and child healthcare services. Nutrition issues should be addressed through multifaceted approaches that address improving individual knowledge and skills, as well as strategies that increase access to nutritious food and provide a healthy food environment.

Patients harboring germline mutations in the succinate dehydrogenase complex subunit B (SDHB) gene present with pheochromocytomas and paragangliomas (PPGL) that are more likely malignant and clinically aggressive. The combination chemotherapy cyclophosphamide, vincristine, and dacarbazine (CVD) was retrospectively evaluated in patients with SDHB-associated metastatic PPGL.Query Twelve metastatic PPGL patients harboring SDHB mutations/polymorphisms with undetectable SDHB immunostaining were treated with CVD. CVD therapy consisted of 750 mg/m 2 cyclophosphamide with 1.4 mg/m 2 vincristine on day 1 and 600 mg/m 2 dacarbazine on days 1 and 2, every 21-28 days. Treatment outcome was determined by RECIST criteria as well as determination of response duration and progression-free and overall survivals. A median of 20.5 cycles (range 4-41) was administered. All patients had tumor reduction (12-100% by RECIST). Complete response was seen in two patients, while partial response was observed in 8. The median number of cycles to response was 5.5. Median duration of response was 478 days, with progression-free and overall survivals of 930 and 1190 days, respectively. Serial [ 18 F]-fluorodeoxyglucose positron emission tomography and computed tomography imaging demonstrated continued incremental reduction in maximal standardized uptake values (SUV max ) values in 26/30 lesions. During treatment administration, the median SUV decreased from > 25 to < 6, indicating the efficacy of chemotherapy over a prolonged period of time. Prolonged therapy results in continued incremental tumor reduction, and is consistent with persistent drug sensitivity. CVD chemotherapy is recommended to be considered part of the initial management in patients with metastatic SDHB-related PPGL.

The aim of the present systematic review was to investigate whether placements in Aboriginal health affect the self-perceived skill in working in Aboriginal health settings and career aspirations of health students, and in particular, aspects of the placement that had the greatest impact. The Embase, Cinahl, ProQuest, Scopus, Informit, Ovid MEDLINE, PsychINFO, and PubMed databases were searched in April/May 2016. Placements of at least 1 week duration in an Aboriginal health setting involving Australian students of medical, nursing, dentistry, or allied health disciplines, with outcomes relating to changes in students' knowledge, attitudes, and/or career aspirations, were included. The search retrieved 1351 papers. Fourteen studies were eligible for inclusion in this review. Narrative synthesis found that work placements in Aboriginal health increased understanding and awareness of Aboriginal culture, promoted deeper understanding of Aboriginal health determinant complexity, increased awareness of everyday racism toward Aboriginal Australians, and enhanced desire to work in Aboriginal health. There is a need for improved teaching and learning scholarship to understand whether placements improve students' skill working with Aboriginal people in health care or increase the likelihood of future employment in these settings., (© 2018 John Wiley & Sons Australia, Ltd.)

Objective: To examine the extent and nature of coverage of Aboriginal and Torres Strait Islander nutrition issues in major Australian newspapers over two decades., Methods: Content and framing analysis of Australian newspaper articles published between 1996 and 2015 that included the terms 'Aboriginal or Indigenous' and 'nutrition or diet' in the headline and/or lead paragraph. Analysis focused on the nature of coverage, trends over time, stakeholder representation and how coverage related to policy., Results: A total of 79 articles were included. Coverage of nutrition fluctuated over time, with peaks in 1998 and 2008. The majority of articles focused on remote Aboriginal communities. Both individual and structural representations of nutrition were used and dietary quality and food insecurity were the most commonly reported nutrition issues. Few articles employed positive representations of Aboriginal peoples. Six policy functions of articles were identified: highlighting problems; reporting government announcements; promoting programs; advocating solutions; critiquing government; and defending policy., Conclusion: The coverage of Aboriginal and Torres Strait Islander nutrition in newspapers does not reflect the diversity and strengths of Australia's First Peoples. Implications for public health: This study highlights the role of the media in policy advocacy; however, advocates should ensure that they do not perpetuate negative representations of Aboriginal and Torres Strait Islander peoples., (© 2018 The Authors.)

Purpose: To evaluate and compare diagnostic performance of 68 Ga-DOTA(0)-Tyr(3)-octreotate ( 68 Ga-DOTATATE) with 18 F-fluoro-2-deoxy-D-glucose ( 18 F-FDG) positron emission tomography-computed tomography (PET/CT) and anatomic imaging using computed tomography and/or magnetic resonance (CT/MR) imaging in detection of SDHx-related pheochromocytomas and paragangliomas (PPGLs) in pediatric patients., Methods: Nine pediatric patients (5:4, girls:boys; 14.6 ± 2.0 years) with an SDHx-related mutation (SDHB:SDHA:SDHD, n = 7:1:1) were included in this retrospective study. At the time of initial diagnosis, 7/9 patients had metastatic disease. They underwent CT/MR imaging along with PET/CT using 68 Ga-DOTATATE (n = 9), 18 F-FDG (n = 8), and positron emission tomography-magnetic resonance imaging (PET/MR) using 18 F-FDG (n = 1). In this manuscript, 18 F-FDG PET/CT refers to both 18 F-FDG PET/CT and 18 F-FDG PET/MR. The per-lesion, per-region, and per-patient detection rates were compared and calculated for each of the imaging modalities. A composite of all functional and anatomic imaging studies served as the imaging comparator., Results: Eight out of nine patients were positive for PPGLs on the imaging studies that demonstrated 107 lesions in 22 anatomic regions on the imaging comparator. The per-lesion detection rates for 68 Ga-DOTATATE PET/CT, 18 F-FDG PET/CT, and CT/MR imaging were 93.5% (95%CI, 87.0% to 97.3%); 79.4% (95%CI, 70.5% to 86.6%); and 73.8% (95%CI, 64.5% to 81.9%), respectively. The per-lesion detection rate for 68 Ga-DOTATATE PET/CT was significantly higher than that of 18 F-FDG PET/CT (p = 0.001) or CT/MR imaging (p < 0.001). In all of the anatomic regions except abdomen, the per-lesion detection rates for 68 Ga-DOTATATE PET/CT was found to be equal or superior to 18 F-FDG PET/CT, and CT/MR imaging. The per-region detection rate was 100% (95%CI, 84.6% to 100%) for 68 Ga-DOTATATE PET/CT and 90.9% (95%CI, 70.8% to 98.9%) for both 18 F-FDG PET/CT and CT/MR imaging. The per-patient detection rates for 68 Ga-DOTATATE PET/CT, 18 FDG PET/CT, and CT/MR imaging were all 100% (95%CI, 63.1% to 100%)., Conclusion: Our preliminary study demonstrates the superiority of 68 Ga-DOTATATE PET/CT in localization of SDHx-related PPGLs in pediatric population compared to 18 F-FDG PET/CT and CT/MR imaging with the exception of abdominal (excluding adrenal and liver) lesions, and suggests that it might be considered as a first-line imaging modality in pediatric patients with SDHx-related PPGLs.

Context: MYC-associated factor X (MAX) has been recently described as a new susceptibility pheochromocytoma (PHEO) gene with a total of ~40 reported cases. At present, no study has specifically described the functional imaging phenotype of MAX-related PHEO., Objective, Patients, and Design: The objective of the present study was to present our experience with contrast-enhanced computed tomography (CT) and 18F-fluorodihydroxyphenylalanine (18F-FDOPA) positron emission tomography (PET)/CT in six consecutive patients (four at the initial diagnosis and two at the follow-up evaluation) with rare, but clinically important, MAX-related PHEOs. In five patients, 18F-FDOPA was also compared with other radiopharmaceutical agents., Results: The patients had five different mutations in the MAX gene that caused disruption of Max/Myc interaction and/or abolished interaction with DNA based on in silico analyses. All but one patient developed bilateral PHEOs during their lifetime. In all cases, 18F-FDOPA PET/CT accurately visualized PHEOs that were often multiple within the same gland or bilaterally and detected more adrenal and extra-adrenal lesions than did CT (per-lesion sensitivity, 90.9% vs 52.4% for CT/magnetic resonance imaging). The two PHEOs missed on 18F-FDOPA PET/CT were <1 cm, corresponding to nodular adrenomedullary hyperplasia. 68Ga-DOTA,Tyr3-octreotate PET/CT detected fewer lesions than did 18F-FDOPA PET/CT in one of three patients, and 18F-fluorodeoxyglucose PET/CT was only faintly positive in two of four patients with underestimation of extra-adrenal lesions in one patient., Conclusions: MAX-related PHEOs exhibit a marked 18F-FDOPA uptake, a finding that illustrates the common well-differentiated chromaffin pattern of PHEOs associated with activation of kinase signaling pathways. 18F-FDOPA PET/CT should be considered as the first-line functional imaging modality for diagnostic or follow-up evaluations for these patients.

Background: The 2007 United Nations Declaration on the Rights of Indigenous Peoples states that Indigenous peoples have the right to self-determination for social and cultural development. This fundamental right has been impeded worldwide through colonisation where many Indigenous peoples have had to adapt to ensure continuation of cultural knowledge and practice. In South East Australia colonisation was particularly brutal interrupting a 65,000 year-old oral culture and archives have increasing importance for cultural revival., Aim: The aim of this research was to collate archival material on South East Australian Aboriginal women's birthing knowledge and practice., Methods: Archivist research methods were employed involving a search for artefacts and compiling materials from these into a new collection. This process involved understanding the context of the artefact creation. Collaborative yarning methods were used to reflect on materials and their meaning., Findings: Artefacts found included materials written by non-Aboriginal men and women, materials written by Aboriginal women, oral histories, media reports and culturally significant sites. Material described practices that connected birth to country and the community of the women and their babies. Practices included active labour techniques, pain management, labour supports, songs for labour, ceremony and the role of Aboriginal midwives. Case studies of continuing cultural practice and revival were identified., Conclusion: Inclusion of Aboriginal women's birthing practices and knowledge is crucial for reconciliation and self-determination. Challenging the colonisation of birthing, through the inclusion of Aboriginal knowledge and practice is imperative, as health practices inclusive of cultural knowledge are known to be more effective., (Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Objectives: . To estimate the prevalence of risk factors for metabolic syndrome in adults who are community kitchen-users in a district in Lima., Materials and Methods: . An observational, cross-sectional study was carried out with 20 to 59-year-old users of community kitchens selected from a two-stage cluster sampling. The metabolic syndrome was measured according to the International Diabetes Federation (IDF). Risk factors proposed by the WHO and the IDF were assessed, as well as the diet needs and intake average and its components at lunch., Results: . The global prevalence of metabolic syndrome was 40.1%: women exhibited a 30.4% prevalence and men 24%. Prevalence of the metabolic syndrome components were, abdominal obesity 51.6%, low C-HDL 42.2%, hypertriglyceridemia 35.3%, obesity 43.3%, overweight 35.8%, arterial hypertension 21.0%, and hyperglycemia 14.1%. A sedentary lifestyle is present in 86.1% of participants., Conclusions: . Excess weight, abdominal obesity, and high cholesterol were the most prevalent risk factors in women. The metabolic syndrome component with the highest prevalence in community kitchen users in a district of Lima is abdominal obesity.

Purpose: Succinate dehydrogenase subunit B (SDHB) gene mutations are associated with an aggressive clinical disease course of pheochromocytoma/paraganglioma (PHEO/PGL). Limited information is available concerning PHEO/PGL penetrance among SDHB mutation carriers with regards to primary tumor location, specific mutation type, and gender. We assessed PHEO/PGL penetrance in SDHB mutation carriers and described the clinical presentation and disease course., Methods: Asymptomatic relatives (N = 611) of 103 index patients were tested for SDHB mutations. Mutation carriers (N = 328) were offered PHEO/PGL screening, of which 241 participated and were included in penetrance analysis. For additional disease outcome analysis, the 103 index patients and 40 screened individuals who developed PHEO/PGL were included. Clinical data were collected between October 2004 and June 2016., Results: Forty (16.60%) of the 241 screened individuals developed PHEO/PGL during the study. The penetrance estimate in this population was 49.80% (95% CI 29-74.9) at 85 years. A significantly higher age-related penetrance of disease was observed in males compared to females, with 50% penetrance achieved at age 74 vs. not reached. Age-related penetrance analysis demonstrated 4 mutations (Ile127Ser, IVS1+1G>T, Exon 1 deletion, Arg90X) presenting with a slower rate of disease development (50% penetrance ages, respectively: not achieved, 70, 63, 61 years) compared to Arg46X and Val140Phe mutations (50% penetrance at 38 years)., Conclusions: Here, we found a higher estimated penetrance compared to several other studies, and a striking difference in age-related penetrance between male and female SDHB mutation carriers with no association between mutation and gender or tumor location.

Pheochromocytoma/paraganglioma (PPGL) syndromes associated with polycythemia have previously been described in association with mutations in the von Hippel-Lindau gene. Recently, mutations in the prolyl hydroxylase gene ( PHD ) 1 and 2 and in the hypoxia-inducible factor 2 α ( HIF2A ) were also found to be associated with multiple and recurrent PPGL. Such patients also presented with PPGL and polycythemia, and later on, some presented with duodenal somatostatinoma. In additional patients presenting with PPGL and polycythemia, no further mutations have been discovered. Because the functional imaging signature of patients with PPGL-polycythemia syndromes is still unknown, and because these tumors (in most patients) are multiple, recurrent, and metastatic, the goal of our study was to assess the optimal imaging approach using 4 different PET radiopharmaceuticals and CT/MRI in these patients. Methods: Fourteen patients (10 women, 4 men) with confirmed PPGL and polycythemia prospectively underwent 68 Ga-DOTATATE (13 patients), 18 F-FDG (13 patients), 18 F-fluorodihydroxyphenylalanine ( 18 F-FDOPA) (14 patients), 18 F-fluorodopamine ( 18 F-FDA) (11 patients), and CT/MRI (14 patients). Detection rates of PPGL lesions were compared between all imaging studies and stratified between the underlying mutations. Results: 18 F-FDOPA and 18 F-FDA PET/CT showed similar combined lesion-based detection rates of 98.7% (95% confidence interval [CI], 92.7%-99.8%) and 98.3% (95% CI, 90.9%-99.7%), respectively. The detection rates for 68 Ga-DOTATATE (35.3%; 95% CI, 25.0%-47.2%), 18 F-FDG (42.3; 95% CI, 29.9%-55.8%), and CT/MRI (60.3%; 95% CI, 48.8%-70.7%) were significantly lower ( P < 0.01), irrespective of the mutation status. Conclusion: 18 F-FDOPA and 18 F-FDA are superior to 18 F-FDG, 68 Ga-DOTATATE, and CT/MRI and should be the radiopharmaceuticals of choice in this rare group of patients., (© 2017 by the Society of Nuclear Medicine and Molecular Imaging.)

Background: Australia's Aboriginal and Torres Strait Islander peoples (hereafter referred to as "Aboriginal people") have the longest continuing culture in the world, living sustainably for at least 65,000 years on the Australian continent. In relatively recent times, colonization processes have resulted in Aboriginal people experiencing unacceptable health inequalities compared with other Australians. One disease introduced due to colonization is diabetes, the second leading cause of death for Aboriginal peoples., Objectives: The objective of this study was to describe the construction and utilization of the website "How's Your Sugar, " a website for Aboriginal people with type 2 diabetes (herein after referred to as diabetes). The questions for the evaluation were as follows: how was the website constructed; did target groups utilize the website; and did engagement with the website improve diabetes management., Methods: A mixed-method study design was employed. A content analysis of project documents provided information about the website construction. Data from Google analytics provided information about website utilization. To describe patterns of website sessions, percentages and numbers were calculated. A voluntary survey provided more information on website utilization and diabetes self-management. Percentage, numbers, and 95% CIs were calculated for each variable. A chi-square test was performed for Aboriginal status, age, gender, and Aboriginal diabetic status using Australian population estimates and Aboriginal diabetes rates., Results: The website development drew on Aboriginal health, social marketing, interactive health promotion frameworks, as well as evidence for diabetes self-management. The website build involved a multidisciplinary team and participation of Aboriginal diabetics, Aboriginal diabetic family members, and Aboriginal health workers. This participation allowed for inclusion of Aboriginal ways of knowing and being. The highest number of website sessions came from Australia, 98.15% (47,717/48,617) and within Australia, Victoria 50.97% (24,323/47,717). There were 129 survey respondents, and the distribution had more female, 82.9% (107/129, 95% CI 76-88), Aboriginal, 21.7% (28/129, 95% CI 16-30), and Aboriginal diabetic, 48% (13/27, 95% CI 31-66) respondents than expected with P<.001 for these three groups. Most common reasons for visits were university assignment research, 40.6% (41/101), and health workers looking for information, 20.8% (21/101). The sample size was too small to calculate diabetes self-management change., Conclusions: Inclusion of Aboriginal ways of knowing and being alongside other theoretical and evidence models in Web design is possible. Aboriginal people do utilize Web-based health promotion, and further understanding about reaching to this population would be of use. Provision of an education resource would likely have enhanced educational engagement. Web-based technologies are rapidly evolving, and these can potentially measure behavior change in engaging ways that also have benefits for the participant. A challenge for designers is inclusivity of cultural diversity for self-determination., (©Karen Adams, Anna Liebzeit, Jennifer Browne, Petah Atkinson. Originally published in JMIR Diabetes (http://diabetes.jmir.org), 04.04.2017.)

Objective: To develop preliminary treat-to-target (T2T) recommendations for psoriasis and psoriatic arthritis (PsA) for Canadian daily practice., Methods: A task force composed of expert Canadian dermatologists and rheumatologists performed a needs assessment among Canadian clinicians treating these diseases as well as an extensive literature search on the outcome measures used in clinical trials and practice., Results: Based on results from the needs assessment and literature search, the task force established 5 overarching principles and developed 8 preliminary T2T recommendations., Conclusion: The proposed recommendations should improve management of psoriasis and PsA in Canadian daily practice. However, these recommendations must be further validated in a real-world observational study to ensure that their use leads to better longterm outcomes.

Aboriginal health policy in Australia represents a unique policy subsystem comprising a diverse network of Aboriginal-specific and "mainstream" organisations, often with competing interests. This paper describes the network structure of organisations attempting to influence national Aboriginal health policy and examines how the different subgroups within the network approached the policy discourse. Public submissions made as part of a policy development process for the National Aboriginal and Torres Strait Islander Health Plan were analysed using a novel combination of network analysis and qualitative framing analysis. Other organisational actors in the network in each submission were identified, and relationships between them determined; these were used to generate a network map depicting the ties between actors. A qualitative framing analysis was undertaken, using inductive coding of the policy discourses in the submissions. The frames were overlaid with the network map to identify the relationship between the structure of the network and the way in which organisations framed Aboriginal health problems. Aboriginal organisations were central to the network and strongly connected with each other. The network consisted of several densely connected subgroups, whose central nodes were closely connected to one another. Each subgroup deployed a particular policy frame, with a frame of "system dysfunction" also adopted by all but one subgroup. Analysis of submissions revealed that many of the stakeholders in Aboriginal health policy actors are connected to one another. These connections help to drive the policy discourse. The combination of network and framing analysis illuminates competing interests within a network, and can assist advocacy organisations to identify which network members are most influential., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Worldwide, the syndromes of paraganglioma (PGL), somatostatinoma (SOM) and early childhood polycythemia are described in only a few patients with somatic mutations in the hypoxia-inducible factor 2 alpha (HIF2A). This study provides detailed information about the clinical aspects and course of 7 patients with this syndrome and brings into perspective these experiences with the pertinent literature. Six females and one male presented at a median age of 28 years (range 11-46). Two were found to have HIF2A somatic mosaicism. No relatives were affected. All patients were diagnosed with polycythemia before age 8 and before PGL/SOM developed. PGLs were found at a median age of 17 years (range 8-38) and SOMs at 29 years (range 22-38). PGLs were multiple, recurrent and metastatic in 100, 100 and 29% of all cases, and SOMs in 40, 40 and 60%, respectively. All PGLs were primarily norepinephrine-producing. All patients had abnormal ophthalmologic findings and those with SOMs had gallbladder disease. Computed tomography (CT) and magnetic resonance imaging revealed cystic lesions at multiple sites and hemangiomas in 4 patients (57%), previously thought to be pathognomonic for von Hippel-Lindau disease. The most accurate radiopharmaceutical to detect PGL appeared to be [ 18 F]-fluorodihydroxyphenylalanine ([ 18 F]-FDOPA). Therefore, [ 18 F]-FDOPA PET/CT, not [ 68 Ga]-(DOTA)-[Tyr3]-octreotate ([ 68 Ga]-DOTATATE) PET/CT is recommended for tumor localization and aftercare in this syndrome. The long-term prognosis of the syndrome is unknown. However, to date no deaths occurred after 6 years follow-up. Physicians should be aware of this unique syndrome and its diagnostic and therapeutic challenges., Competing Interests: Declaration of interest The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported., (© 2016 Society for Endocrinology.)

Purpose: Pheochromocytomas/paragangliomas (PPGLs) and their metastases are tumors that predominantly express somatostatin receptor 2 (SSR2). (68)Ga-DOTA(0)-Tyr(3)-octreotate ((68)Ga-DOTATATE) is a PET radiopharmaceutical with both high and selective affinity for SSRs. The purpose of this study was to evaluate the utility of (68)Ga-DOTATATE in comparison with other specific and nonspecific radiopharmaceuticals recommended in the current guidelines for the localization of metastatic sporadic PPGL by PET/CT., Methods: This prospective study included 22 patients (15 men, 7 women; aged 50.0 ± 13.9 years) with confirmed metastatic PPGL, a negative family history for PPGL, and negative genetic testing, who underwent (68)Ga-DOTATATE, (18)F-fluoro-2-deoxy-D-glucose ((18)F-FDG) PET/CT, and CT/MRI. Only 12 patients underwent an additional (18)F-fluorodihydroxyphenylalanine ((18)F-FDOPA) PET/CT scan and only 11 patients underwent an additional (18)F-fluorodopamine ((18)F-FDA) PET/CT scan. The rates of detection of metastatic lesions were compared among all the imaging studies. A composite of all functional and anatomical imaging studies served as the imaging comparator., Results: (68)Ga-DOTATATE PET/CT showed a lesion-based detection rate of 97.6 % (95 % confidence interval, CI, 95.8 - 98.7 %). (18)F-FDG PET/CT, (18)F-FDOPA PET/CT, (18)F-FDA PET/CT, and CT/MRI showed detection rates of 49.2 % (CI 44.5 - 53.6 %; p < 0.01), 74.8 % (CI 69.0 - 79.9 %); p < 0.01), 77.7 % (CI 71.5 - 82.8 %; p < 0.01), and 81.6 % (CI 77.8 - 84.8 %; p < 0.01), respectively., Conclusion: The results of this study demonstrate the superiority of (68)Ga-DOTATATE PET/CT in the localization of sporadic metastatic PPGLs compared to all other functional and anatomical imaging modalities, and suggest modification of future guidelines towards this new imaging modality.

Objective: Pharmacological treatment is mandatory in patients with hormonally functional phaeochromocytoma and paraganglioma (PHAEO/PGL). We evaluated if patients initially diagnosed with hormonally functional PHAEO/PGL by various medical subspecialties received proper adrenoceptor blockade, and analysed factors predicting the prescription of adequate treatment., Methods: In a retrospective cohort study, we reviewed data from patients initially diagnosed with hormonally functional PHAEO/PGL outside the National Institutes of Health and Cedars-Sinai Medical Center, who were referred to these institutions between January 2001 and April 2015. Logistic regression was used to assess factors associated with proper adrenoceptor blockade., Results: A total of 381 patients were included. Adequate pharmacological treatment was prescribed to 69·3%, of which 93·1% received α-adrenoceptor blockers. Regarding patients who were inappropriately treated, 53% did not receive any medication. Independent predictors of the prescription of a proper blockade were the diagnosis by endocrinologists [odds ratio (OR) 4·14; 95% confidence interval (CI), 2·51-6·85; P < 0·001], the presence of high blood pressure (OR 5·94; 95% CI, 3·11-11·33; P < 0·001) and the evidence of metastasis (OR 5·96; 95% CI, 1·93-18·46; P = 0·002)., Conclusions: Although most patients received adequate pharmacological treatment, almost one-third were either not treated or received inappropriate medications. The diagnosis by endocrinologists, the presence of high blood pressure and the evidence of metastatic disease were identified as independent predictors of a proper blockade. These results highlight the need to educate physicians about the importance of starting adequate adrenoceptor blockade in all patients with hormonally functional PHAEO/PGL., (© 2016 John Wiley & Sons Ltd.)

Objective: Overall about 10 to 20% of pheochromocytomas/paragangliomas (PHEOs/PGLs) are metastatic, with higher metastatic potential observed in succinate dehydrogenase subunit B/fumarate hydratase (SDHB/FH)-related tumors. Due to the improved availability of biochemical and genetic testing and the frequent use of anatomical/functional imaging, there is currently a higher detection rate of metastatic PHEO/PGL., Methods: A retrospective analysis of 132 patients (27 children, 105 adults) with metastatic PHEO/PGL diagnosed and treated from 2000 to 2014 was conducted., Results: Seventy-seven (58%) males and 55 (42%) females were included; 39 (30%) have died, with no sex preference. Seventy-three (55%) patients had SDHB mutations; 59 (45%) patients had apparently sporadic tumors (AST). SDHB patients had an average age at primary tumor diagnosis of 31 ± 16 years compared to 40 ± 15 years in AST patients (P<.001). The average metastatic interval (MI) decreased with increasing age in both SDHB and AST patients (P = .013 for both). Only 16% of all primary tumors were smaller than 4.5 cm. Eleven percent of patients had biochemically silent disease, more with SDHB. Of SDHB patients, 23% had metastatic tumors at first diagnosis, compared to 15% of AST patients. Five- and 10-year survival rates were significantly better for metastatic AST than SDHB patients (P = .01). Overall survival was significantly different between children and adults (P = .037); this was mostly attributed to the SDHB patients, in whom children had statistically significantly longer survival than adults (P = .006). The deceased patients all died due to the PHEO/PGL and mainly had noradrenergic phenotypes., Conclusion: In children, metastatic PHEOs/PGLs are mainly due to SDHB mutations; in adults they are equally distributed between in SDHB mutations and AST, with better 5- and 10-year survival rates for ASTs. In SDHB patients, children survive longer than adults. Primary metastatic tumors, most presenting as noradrenergic PGLs, are larger than 4.5 cm in >80% of patients. The frequency of metastatic tumors from primary AST increases with age, including a decreased MI compared to SDHB tumors. These results support several recommendations that are summarized in the Discussion.

Unlabelled: Pheochromocytomas/paragangliomas overexpress somatostatin receptors, and recent studies have already shown excellent results in the localization of sympathetic succinate dehydrogenase complex, subunit B, mutation-related metastatic pheochromocytomas/paragangliomas using (68)Ga-DOTATATE PET/CT. Therefore, the goal of our study was to assess the clinical utility of this functional imaging modality in parasympathetic head and neck paragangliomas (HNPGLs) compared with anatomic imaging with CT/MRI and other functional imaging modalities, including (18)F-fluorohydroyphenylalanine ((18)F-FDOPA) PET/CT, currently the gold standard in the functional imaging of HNPGLs., Methods: (68)Ga-DOTATATE PET/CT was prospectively performed in 20 patients with HNPGLs. All patients also underwent (18)F-FDOPA PET/CT, (18)F-FDG PET/CT, and CT/MRI, with 18 patients also undergoing (18)F-fluorodopamine ((18)F-FDA) PET/CT. (18)F-FDOPA PET/CT and CT/MRI served as the imaging comparators., Results: Thirty-eight lesions in 20 patients were detected, with (18)F-FDOPA PET/CT identifying 37 of 38 and CT/MRI identifying 23 of 38 lesions (P < 0.01). All 38 and an additional 7 lesions (P = 0.016) were detected on (68)Ga-DOTATATE PET/CT. Significantly fewer lesions were identified by (18)F-FDG PET/CT (24/38, P < 0.01) and (18)F-FDA PET/CT (10/34, P < 0.01)., Conclusion: (68)Ga-DOTATATE PET/CT identified more lesions than other imaging modalities. With the results of the present study, and the increasing availability and use of DOTA analogs in the therapy of neuroendocrine tumors, we expect that (68)Ga-DOTATATE PET/CT will become the preferred functional imaging modality for HNPGLs in the near future., (© 2016 by the Society of Nuclear Medicine and Molecular Imaging, Inc.)

Of graduating obstetrics and gynecology residents, 40% apply for fellowship training and this percentage is likely to increase. The fellowship interview process creates a substantial financial burden on candidates as well as significant challenges in scheduling the multiple interviews for residents, residency programs, and fellowship programs. Coverage with relatively short lead time is needed for some resident rotations, multiple residents may request time off during overlapping time periods, and applicants may not be able to interview based on conflicting interview dates or the inability to find coverage from other residents for their clinical responsibilities. To address these issues, we propose that each subspecialty fellowship within obstetrics and gynecology be allocated a specified and limited time period to schedule their interviews with minimal overlap between subspecialties. Furthermore, programs in close geographic areas should attempt to coordinate their interview dates. This will allow residents to plan their residency rotation schedules far in advance to minimize the impact on rotations that are less amenable to time away from their associated clinical duties, and decrease the numbers of residents needing time off for interviews during any one time period. In addition, a series of formal discussions should take place between subspecialties related to these issues as well as within subspecialties to facilitate coordination., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Patients with succinate dehydrogenase subunit B(SDHB) mutation-related pheochromocytoma/paraganglioma (PHEO/PGL) are at a higher risk for metastatic disease than other hereditary PHEOs/PGLs. Current therapeutic approaches are limited, but the best outcomes are based on the early and proper detection of as many lesions as possible. Because PHEOs/PGLs overexpress somatostatin receptor 2 (SSTR2), the goal of our study was to assess the clinical utility of [(68)Ga]-DOTA(0)-Tyr(3)-octreotate ([(68)Ga]-DOTATATE) positron emission tomography/computed tomography (PET/CT) and to evaluate its diagnostic utility in comparison with the currently recommended functional imaging modalities [(18)F]-fluorodopamine ([(18)F]-FDA), [(18)F]-fluorodihydroxyphenylalanine ([(18)F]-FDOPA), [(18)F]-fluoro-2-deoxy-d-glucose ([(18)F]- FDG) PET/CT as well as CT/MRI., Experimental Design: [(68)Ga]-DOTATATE PET/CT was prospectively performed in 17 patients with SDHB-related metastatic PHEOs/PGLs. All patients also underwent [(18)F]-FDG PET/CT and CT/MRI, with 16 of the 17 patients also receiving [(18)F]-FDOPA and [(18)F]-FDA PET/CT scans. Detection rates of metastatic lesions were compared between all these functional imaging studies. A composite synthesis of all used functional and anatomical imaging studies served as the imaging comparator., Results: [(68)Ga]-DOTATATE PET/CT demonstrated a lesion-based detection rate of 98.6% [95% confidence interval (CI), 96.5%-99.5%], [(18)F]-FDG, [(18)F]-FDOPA, [(18)F]-FDA PET/CT, and CT/MRI showed detection rates of 85.8% (CI, 81.3%-89.4%; P < 0.01), 61.4% (CI, 55.6%-66.9%; P < 0.01), 51.9% (CI, 46.1%-57.7%; P < 0.01), and 84.8% (CI, 80.0%-88.5%; P < 0.01), respectively., Conclusions: [(68)Ga]-DOTATATE PET/CT showed a significantly superior detection rate to all other functional and anatomical imaging modalities and may represent the preferred future imaging modality in the evaluation of SDHB-related metastatic PHEO/PGL., (©2015 American Association for Cancer Research.)

Pheochromocytomas and paragangliomas are chromaffin cell tumors arising from neuroendocrine cells. At least 1/3 of paragangliomas are related to germline mutations in 1 of 17 genes. Although these tumors can occur throughout the body, cardiac paragangliomas are very rare, accounting for <0.3% of mediastinal tumors. The purpose of this study was to determine the clinical characteristics of patients with cardiac paragangliomas, particularly focusing on their genetic backgrounds. A retrospective chart analysis of 15 patients with cardiac paragangliomas was performed to determine clinical presentation, genetic background, diagnostic workup, and outcomes. The average age at diagnosis was 41.9 years. Typical symptoms of paraganglioma (e.g., hypertension, sweating, palpitations, headache) were reported at initial presentation in 13 patients (86.7%); the remaining 2, as well as 4 symptomatic patients, initially presented with cardiac-specific symptoms (e.g., chest pain, dyspnea). Genetic testing was done in 13 patients (86.7%); 10 (76.9%) were positive for mutations in succinate dehydrogenase (SDHx) subunits B, C, or D. Thirteen patients (86.7%) underwent surgery to remove the paraganglioma with no intraoperative morbidity or mortality; 1 additional patient underwent surgical resection but experienced intraoperative complications after removal of the tumor due to co-morbidities and did not survive. SDHx mutations are known to be associated with mediastinal locations and malignant behavior of paragangliomas. In this report, the investigators extend the locations of predominantly SDHx-related paragangliomas to cardiac tumors. In conclusion, cardiac paragangliomas are frequently associated with underlying SDHx germline mutations, suggesting a need for genetic testing of all patients with this rare tumor., (Published by Elsevier Inc.)

Objective: The Canadian Rheumatology Association (CRA) and the Spondyloarthritis Research Consortium of Canada (SPARCC) have collaborated to update the recommendations for the management of spondyloarthritis (SpA)., Methods: A working group was assembled and consisted of the SPARCC executive committee, rheumatologist leaders from SPARCC collaborating sites, Canadian rheumatologists from across the country with an interest in SpA (both academic and community), a rheumatology trainee with an interest in SpA, an epidemiologist/health services researcher, a member of the CRA executive, a member of the CRA therapeutics committee, and a patient representative from the Canadian Spondylitis Association. An extensive review was conducted of literature published from 2007 to 2014 involving the management of SpA. The working group created draft recommendations using multiple rounds of Web-based surveys and an in-person conference., Results: Recommendations for the management of SpA were created. Part II: Specific Management Recommendations addresses management with nonpharmacologic methods, nonsteroidal anti-inflammatories and analgesics, disease-modifying antirheumatic drugs, antibiotics, tumor necrosis factor inhibitors, other biologic agents, and surgery. Also included are 10 modifications for application to juvenile SpA., Conclusion: These recommendations were developed based on current literature and applied to a Canadian healthcare context. It is hoped that implementation of these recommendations will promote best practices in the treatment of SpA.