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Digital technology is now pervasive, however, not all groups have uniformly benefitted from technological changes and some groups have been left behind or digitally excluded. Comprehensive data from the 2017 Current Population Survey shows that older people and persons with disabilities still lag behind in computer and internet access. Furthermore unique ethical, privacy and safety implications exist for the use of technology for older persons and people with disabilities and careful reflection is required to incorporate these aspects, which are not always part of a traditional software lifecycle. In this paper we present the Inclusion4EU project that aims to co-design a new framework, guidelines and checklists for inclusive software design and development with end-users from excluded categories, academics with expertise in human-computer interaction and industry practitioners from software engineering.

BACKGROUND: Despite many Australians supporting organ donation, national posthumous organ donation rates have not increased as expected over the last three decades. Little is known about the barriers to organ donation for patients in intensive care that meet the criteria for organ donation. OBJECTIVE(S): The aim of this study was to describe the characteristics of patients identified as potentially suitable for organ donation and to explore the variables associated with the success, or failure, of solid organ donation within the context of an Australian public hospital intensive care unit (ICU). METHOD(S): A retrospective audit examined electronic records of 280 potential organ donors aged 18-80 years, admitted into the ICU between 1 July 2012 and 30 June 2016. Data extracted from three separate electronic hospital databases were amalgamated for analysis. RESULT(S): Of the 280 potential organ donors identified, conversations with families of 182 (65%) patients resulted in their agreement to organ donation. Consent to organ donation was most often provided by the patient's spouse (65, 35.7%); however, only 63.7% (n = 116) were successful organ donors. The remaining 36.3% (n = 66) of patients did not donate organs for medical reasons. Compared with those who did not donate, the typical organ donor was significantly younger (M 49.9 years, p = 0.020), Australian-born (p = 0.031), and had a shorter length of ICU stay (M 64.9 h, p = 0.002). The most frequently donated organs were kidneys (103, 88.8%), lungs (59, 50.9%), and livers (52, 44.8%). CONCLUSION(S): This study provided insights into patient, family, and organisational factors contributing to the success of organ donation outcomes in the ICU. Two factors that adversely impacted donation outcomes were the following: (1) the family did not consent to organ donation on behalf of the patient and (2) consent was provided, but donation did not proceed for medical reasons. Although the focus on the consenting process has

BACKGROUND: Despite many Australians supporting organ donation, national posthumous organ donation rates have not increased as expected over the last three decades. Little is known about the barriers to organ donation for patients in intensive care that meet the criteria for organ donation. OBJECTIVE(S): The aim of this study was to describe the characteristics of patients identified as potentially suitable for organ donation and to explore the variables associated with the success, or failure, of solid organ donation within the context of an Australian public hospital intensive care unit (ICU). METHOD(S): A retrospective audit examined electronic records of 280 potential organ donors aged 18-80 years, admitted into the ICU between 1 July 2012 and 30 June 2016. Data extracted from three separate electronic hospital databases were amalgamated for analysis. RESULT(S): Of the 280 potential organ donors identified, conversations with families of 182 (65%) patients resulted in their agreement to organ donation. Consent to organ donation was most often provided by the patient's spouse (65, 35.7%); however, only 63.7% (n = 116) were successful organ donors. The remaining 36.3% (n = 66) of patients did not donate organs for medical reasons. Compared with those who did not donate, the typical organ donor was significantly younger (M 49.9 years, p = 0.020), Australian-born (p = 0.031), and had a shorter length of ICU stay (M 64.9 h, p = 0.002). The most frequently donated organs were kidneys (103, 88.8%), lungs (59, 50.9%), and livers (52, 44.8%). CONCLUSION(S): This study provided insights into patient, family, and organisational factors contributing to the success of organ donation outcomes in the ICU. Two factors that adversely impacted donation outcomes were the following: (1) the family did not consent to organ donation on behalf of the patient and (2) consent was provided, but donation did not proceed for medical reasons. Although the focus on the consenting process has

Background and objectives: Hypernatremia can be community or hospital-acquired, and there may be specific factors unique to the hospital environment, such as intravenous fluid treatment, which contribute to hypernatremia. The aim of this study was to determine the factors associated with the progression from moderate to severe hospital-acquired hypernatremia among patients admitted under general medicine. Material(s) and Method(s): In this retrospective, single-center cohort study (2012 to 2017), we used ICD-10 coding and medical records to identify adult patients who developed moderate hypernatremia and followed them for progression to severe hypernatremia. We profiled the serum biochemistry and the volume and composition of prescribed intravenous fluids. We applied logistic regression to determine the factors associated with the progression to severe hypernatremia, using the patients with moderate hypernatremia as reference. Result(s): Of the 180 medical inpatients (median age of 81 years) with moderate hospital-acquired hypernatremia, 9.4% progressed to severe hypernatremia. Normal saline comprised 76% of intravenous fluid volume administered prior to onset of moderate hypernatremia. After the onset, 38% of fluid volume prescribed remained normal saline. The factors independently associated with progression to severe hypernatremia included chronic kidney disease stage (odds ratio 2.38, 95% CI: 1.26-4.50, P = 0.008) and serum creatinine increase (per 10 micromol/L, OR 1.29, 95% CI: 1.07-1.57, P = 0.009). Conclusion(s): Patients with chronic kidney disease and acute kidney injury may have an increased risk of severe hospital-acquired hypernatremia.

OBJECTIVE: To identify the attitudes of Australian and New Zealand geriatricians to legalisation of voluntary assisted dying. METHOD(S): An anonymous, voluntary, online survey of Australian and New Zealand Society for Geriatric Medicine (ANZSGM) members. RESULT(S): A total of 226 members completed the survey equating to a 20% response rate. About 24% of respondents supported legalisation of voluntary assisted dying, whilst 53% opposed. If voluntary assisted dying was legalised, 12% would be willing to prescribe to an appropriate patient, and 61% would be willing to refer them onto a third party. Risk to vulnerable patients was the most important concern identified. CONCLUSION(S): Support for voluntary assisted dying among surveyed ANZSGM members is low, but varies according to patient circumstances. Key areas of concern highlighted were risk to vulnerable patients, estimating prognosis, and capacity assessments. Further training is required for doctors on discussing voluntary assisted dying options, estimating prognosis, and capacity assessments prior to implementation.Copyright © 2019 AJA Inc.

Treatment of hyperkalemia with intravenous insulin-dextrose is associated with a risk of hypoglycemia. We aimed to determine the factors associated with hypoglycemia (glucose<3.9 mmol/L, or<70 mg/dL) and the critical time window with the highest incidence. In a retrospective cohort study in a tertiary hospital network, we included 421 adult patients with a serum potassium>=6.0 mmol/L who received insulin-dextrose treatment. The mean age was 70 years with 62% male predominance. The prevalence of diabetes was 60%, and 70% had chronic kidney disease (eGFR<60 ml/min/1.73 m2). The incidence of hypoglycemia was 21%. In a multivariable logistic regression model, the factors independently associated with hypoglycemia were: body mass index (per 5 kg/m2, OR 0.85, 95% CI: 0.69-0.99, P=0.04), eGFR<60 mL/min/1.73 m2 (OR 2.47, 95% CI: 1.32-4.63, P=0.005), diabetes (OR 0.57, 95% CI 0.33-0.98, P=0.043), pre-treatment blood glucose (OR 0.84, 95% CI: 0.77-0.91, P<0.001), and treatment in the emergency department compared to other locations (OR 2.53, 95% CI: 1.49-4.31, P=0.001). Hypoglycemia occurred most frequently between 60 and 150 min, with a peak at 90 min. Understanding the factors associated with hypoglycemia and the critical window of risk is essential for the development of preventive strategies.

OBJECTIVE: To investigate whether certain patient, acute care, or primary care factors are associated with medication initiation and discontinuation in the community after stroke or TIA. METHOD(S): This is a retrospective cohort study using prospective data on adult patients with first-ever acute stroke/TIA from the Australian Stroke Clinical Registry (April 2010 to June 2014), linked with nationwide medication dispensing and Medicare claims data. Medication users were those with >=1 dispensing in the year postdischarge. Discontinuation was assessed among medication users and defined as having no medication supply for >=90 days in the year postdischarge. Multivariable competing risks regression, accounting for death during the observation period, was conducted to investigate factors associated with time to medication discontinuation. RESULT(S): Among 17,980 registry patients with stroke/TIA, 91.4% were linked to administrative datasets. Of these, 9,817 adults with first-ever stroke/TIA were included (45.4% female, 47.6% aged >=75 years, and 11.4% intracerebral hemorrhage). While most patients received secondary prevention medications (79.3% antihypertensive, 81.8% antithrombotic, and 82.7% lipid-lowering medication), between one-fifth and one-third discontinued treatment over the subsequent year postdischarge (20.9% antihypertensive, 34.1% antithrombotic, and 28.5% lipid-lowering medications). Prescription at hospital discharge (sub-hazard ratio [SHR] 0.70; 95% confidence interval [CI] 0.62-0.79), quarterly contact with a primary care physician (SHR 0.62; 95% CI 0.57-0.67), and prescription by a specialist physician (SHR 0.87; 95% CI 0.77-0.98) were all inversely associated with antihypertensive discontinuation. CONCLUSION(S): Patterns of use of secondary prevention medications after stroke/TIA are not optimal, with many survivors discontinuing treatment within 1 year postdischarge. Improving postdischarge care for patients with stroke/TIA is needed to minimize unwa

Background and objectives: Hypernatremia can be community or hospital-acquired, and there may be specific factors unique to the hospital environment, such as intravenous fluid treatment, which contribute to hypernatremia. The aim of this study was to determine the factors associated with the progression from moderate to severe hospital-acquired hypernatremia among patients admitted under general medicine. Material(s) and Method(s): In this retrospective, single-center cohort study (2012 to 2017), we used ICD-10 coding and medical records to identify adult patients who developed moderate hypernatremia and followed them for progression to severe hypernatremia. We profiled the serum biochemistry and the volume and composition of prescribed intravenous fluids. We applied logistic regression to determine the factors associated with the progression to severe hypernatremia, using the patients with moderate hypernatremia as reference. Result(s): Of the 180 medical inpatients (median age of 81 years) with moderate hospital-acquired hypernatremia, 9.4% progressed to severe hypernatremia. Normal saline comprised 76% of intravenous fluid volume administered prior to onset of moderate hypernatremia. After the onset, 38% of fluid volume prescribed remained normal saline. The factors independently associated with progression to severe hypernatremia included chronic kidney disease stage (odds ratio 2.38, 95% CI: 1.26-4.50, P = 0.008) and serum creatinine increase (per 10 micromol/L, OR 1.29, 95% CI: 1.07-1.57, P = 0.009). Conclusion(s): Patients with chronic kidney disease and acute kidney injury may have an increased risk of severe hospital-acquired hypernatremia.

OBJECTIVE: To identify the attitudes of Australian and New Zealand geriatricians to legalisation of voluntary assisted dying. METHOD(S): An anonymous, voluntary, online survey of Australian and New Zealand Society for Geriatric Medicine (ANZSGM) members. RESULT(S): A total of 226 members completed the survey equating to a 20% response rate. About 24% of respondents supported legalisation of voluntary assisted dying, whilst 53% opposed. If voluntary assisted dying was legalised, 12% would be willing to prescribe to an appropriate patient, and 61% would be willing to refer them onto a third party. Risk to vulnerable patients was the most important concern identified. CONCLUSION(S): Support for voluntary assisted dying among surveyed ANZSGM members is low, but varies according to patient circumstances. Key areas of concern highlighted were risk to vulnerable patients, estimating prognosis, and capacity assessments. Further training is required for doctors on discussing voluntary assisted dying options, estimating prognosis, and capacity assessments prior to implementation.Copyright © 2019 AJA Inc.

BACKGROUND: Although codes of conduct, guidelines and standards call for healthcare practitioners to protect patients' dignity, there are widespread concerns about a lack of attention to the dignity of older people who need assistance with toileting, incontinence or bladder or bowel care in health or social care settings that provide long-term care. Incontinence and care dependence threatens patient dignity. The aim of this research was to explore, describe and explain the concept of dignity as it relates to continence care for older people requiring long-term care. METHOD(S): The first four steps of Rodgers evolutionary method of concept analysis were followed. First, a comprehensive and systematic search of databases and key guidelines about continence care was undertaken to identify empirical research about dignity and continence care in older people in facilities that provide permanent residential or inpatient care of older people for day-to-day living. Data were extracted on the authors, date, sample, country of origin, and key definitions, attributes, contexts and consequences from each included record. Findings were inductively analysed and grouped according to whether they were the key attributes and antecedents of dignity in relation to continence care or the consequences of undignified continence care. RESULT(S): Of 625 articles identified, 18 were included in the final analysis. Fifty individual attributes were identified that were categorised in 6 domains (respect, empathy, trust, privacy, autonomy and communication). A further 15 were identified that related to the environment (6 physical and 9 social). Key consequences of undignified continence care were also identified and categorised into 3 levels of impact (resident/family member, staff or organisation). CONCLUSION(S): This research resulted in a conceptual understanding of dignity that can be used as a value or guiding principle in an ethic of care for older people who need assistance with toiletin

Treatment of hyperkalemia with intravenous insulin-dextrose is associated with a risk of hypoglycemia. We aimed to determine the factors associated with hypoglycemia (glucose<3.9 mmol/L, or<70 mg/dL) and the critical time window with the highest incidence. In a retrospective cohort study in a tertiary hospital network, we included 421 adult patients with a serum potassium>=6.0 mmol/L who received insulin-dextrose treatment. The mean age was 70 years with 62% male predominance. The prevalence of diabetes was 60%, and 70% had chronic kidney disease (eGFR<60 ml/min/1.73 m2). The incidence of hypoglycemia was 21%. In a multivariable logistic regression model, the factors independently associated with hypoglycemia were: body mass index (per 5 kg/m2, OR 0.85, 95% CI: 0.69-0.99, P=0.04), eGFR<60 mL/min/1.73 m2 (OR 2.47, 95% CI: 1.32-4.63, P=0.005), diabetes (OR 0.57, 95% CI 0.33-0.98, P=0.043), pre-treatment blood glucose (OR 0.84, 95% CI: 0.77-0.91, P<0.001), and treatment in the emergency department compared to other locations (OR 2.53, 95% CI: 1.49-4.31, P=0.001). Hypoglycemia occurred most frequently between 60 and 150 min, with a peak at 90 min. Understanding the factors associated with hypoglycemia and the critical window of risk is essential for the development of preventive strategies.

The distribution of mental illness information is a crucial element of mental health promotion initiatives. We assessed the receipt and perceived helpfulness of such information in Australia. Data from the Australian National Survey of Mental Health and Wellbeing indicated that, during the year prior to the survey, 33.7% of Australians received mental illness information; of these, 51.2% found it helpful. Among people with a mental disorder, 46.1% received information; of these, 67.4% found it helpful. Non-English speakers and the socially disadvantaged were less likely to receive mental illness information. Older and less educated respondents were less likely to both receive mental illness information and find it helpful. Mental health service users were more likely to receive mental illness information perceived as helpful than those who had not accessed such services. Better targeted information interventions are required to ensure those most likely to benefit receive mental illness-related information.

BACKGROUND: There is little published data on brain imaging and intracranial haemorrhage after hospital inpatient falls. Imaging protocols for inpatient falls have been adopted from head injury guidelines developed from data in patients presenting to the Emergency Department. We sought to describe the use of brain computed tomography (CT) following inpatient falls, and determine the incidence and potential risk factors for intracranial haemorrhage. METHOD(S): We identified inpatient falls in acute medical wards at Monash Health, a large hospital network in the southeast region of Melbourne in Australia, from the incident reporting system during a 32month period. We examined the post-fall medical assessment form, neurological observation chart and the diagnostic imaging system for details of the fall and brain CT findings. We used survival analysis to evaluate the timeliness of brain imaging and determined potential risk factors for intracranial haemorrhage by logistic regression. RESULT(S): From 934 falls in 789 medical inpatients, 191 brain CT scans were performed. The median age of patients was 77years. Only 55% of falls were from standing height and 24% experienced a head strike. Less than 10% of patients received an urgent scan within one hour, and timeliness of imaging was influenced by anticoagulation status rather than guideline determination of urgency. The overall incidence of intracranial haemorrhage was 0.9%. The factors associated with intracranial haemorrhage were head strike, anticoagulation, loss of consciousness or amnesia, drop in Glasgow Coma Scale and advanced chronic kidney disease. CONCLUSION(S): The incidence of intracranial haemorrhage was low as most inpatient falls were at low risk for head injury. Research is needed to determine if guidelines specific for hospital inpatients may reduce unnecessary scans without compromising case detection, and improve timeliness of urgent scans.

BACKGROUND: Early hospital readmissions are a challenging and costly experience for both patients and the healthcare service. Reducing hospital readmission rates is a priority for health services globally and this is evident with the establishment of multiple outpatient services to promote early follow-up and to initiate secondary preventative care measures. One such intervention has been the introduction of a pharmacist-led, Hospital Outreach Medication Review (HOMR) service. However, the demand for the service has meant reaching this target has become an increasingly ambitious goal within allocated resources. OBJECTIVE(S): To validate a risk-stratification tool to identify low-risk patients in whom a telephone medication review would be a safe and effective alternative to a home-based review. METHOD(S): A risk tool was derived and applied to a retrospective sample to act as the parent cohort. A prospective cohort was stratified into low and high-risk based on this tool, and received either a telephone or a traditional home medication review respectively. RESULT(S): 235 patients were included in final analysis (n=113 prospective, n=122 baseline controls). High-risk patients were more likely to be readmitted at 60 and 90 days in the baseline cohort (9/38 vs 7/84, p=0.04 and 11/38 vs 9/84, p=0.02 respectively), with a trend towards increased readmissions at 30 days (5/38 vs 3/84, p=0.11). Logistic regression identified the risk tool as an independent predictor of hospital readmission (IRR 1.18, p=0.04), whereas age and Charlson comorbidity were not (p=0.80 and 0.31 respectively). There was no significant difference between the new model (incorporating phone reviews) and the parent cohort (p=0.25). CONCLUSION(S): Our risk score was able to identify those at highest risk of hospital readmission at 60 and 90 days. Utilising this risk score, a telephone HOMR for low-risk patients was a safe and efficient alternative to a traditional home review.Copyright © 2018 Elsevier

Background: Island flaps are more mobile than local flaps in-continuity and rely on the laxity of the adjacent tissues. We present a new island flap design, called the inverted love-heart flap, used to reconstruct cutaneous defects of the limbs. Method(s): A retrospective chart review of patients who underwent inverted love-heart flap reconstruction post excision of a cutaneous malignancy during July 2017 to July 2019 was performed. Result(s): Seventeen patients underwent 18 inverted love-heart flap reconstructions postexcision of a cutaneous malignancies during the study period. There were no reported cases of partial or total flap necrosis. Conclusion(s): The inverted love-heart flap offers a reliable reconstruction for cutaneous defects. It has the advantage of a primary donor site closure, minimal patient morbidity and avoids the need for skin grafting and postoperative immobilization.

BACKGROUND: Navigating treatment pathways remains a challenge for populations with complex needs due to bottlenecks, service gaps and access barriers. The application of novel methods may be required to identify and remedy such problems. OBJECTIVE(S): To demonstrate a novel approach to identifying persistent service gaps, generating potential solutions and prioritizing action. DESIGN: Co-creation and multi-criteria decision analysis in the context of a larger, mixed methods study. SETTING AND PARTICIPANTS: Community-dwelling sample of older women living alone (OWLA), residing in Melbourne, Australia (n = 13-37). Convenience sample of (n = 11) representatives from providers and patient organizations. INTERVENTIONS: Novel interventions co-created to support health, well-being and independence for OWLA and bridge missing links in pathways to care. MAIN OUTCOME MEASURES: Performance criteria, criterion weights , performance ratings, summary scores and ranks reflecting the relative value of interventions to OWLA. RESULT(S): The co-creation process generated a list of ten interventions. Both OWLA and stakeholders considered a broad range of criteria when evaluating the relative merits of these ten interventions and a "Do Nothing" alternative. Combining criterion weights with performance ratings yielded a consistent set of high priority interventions, with "Handy Help," "Volunteer Drivers" and "Exercise Buddies" most highly ranked by both OWLA and stakeholder samples. DISCUSSION AND CONCLUSION(S): The present study described and demonstrated the use of multi-criteria decision analysis to prioritize a set of novel interventions generated via a co-creation process. Application of this approach can add community voice to the policy debate and begin to bridge the gap in service provision for underserved populations.Copyright © 2019 The Authors Health Expectations published by John Wiley & Sons Ltd.

BACKGROUND: This study describes the temporal changes in risk profiles and outcomes among patients with aortic stenosis (AS) undergoing surgical aortic valve replacement (SAVR) in Australia between 2002 and 2015. METHOD(S): Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons database, we identified first-recorded SAVR for AS over 14 years. Patients' surgical risk profiles, procedures, 30-day and 12-month outcomes were summarized before and after the introduction of transcatheter aortic valve implantation in Australia, in 2008. We applied multivariable regression models to investigate the changes over time on risk-adjusted 30-day mortality, re-hospitalization and 12-month mortality. RESULT(S): We identify a total of 18147 patients with AS who underwent SAVR; mostly men (64%) with a mean age of 72years. The proportion of major cardiac surgeries devoted to SAVR increased from 14% in 2002 to 20% in 2015. More SAVRs were performed electively (80% in 2002 versus 86% in 2015), and the recipients were at lower surgical risk (mean multi-risk score 3.9% in 2002 versus 3.0% in 2015). The use of bioprosthetic aortic valves increased over time (67% in 2002 to 88% in 2015). We found no significant changes in 30-day mortality, a significant decrease in 30-day readmission and minor fluctuations in 12-month mortality over the study period. CONCLUSION(S): SAVR comprises an increasingly larger proportion of all adult cardiac surgeries in Australia. There has been a greater use of bioprosthetic aortic valves, a fall in 30-day readmission but no significant changes in mortality.Copyright © 2019 Royal Australasian College of Surgeons.

OBJECTIVE: To identify discharge medications, especially psychotropic medications that are associated with falls, amongst older adults within 6 months following hospitalisation. METHOD(S): Negative binomial regression was used to examine relationships between discharge medications and falls in older post-hospitalised adults. Multiple regression that considered falls risk factors at discharge was performed. RESULT(S): Data for 267 participants showed that discharge medications were not independently associated with falls postdischarge after adjustment for other falls risk factors. Male gender (adjusted incidence rate ratio [95% confidence interval, CI]) 2.15 [1.36-3.40]), higher depression scores (1.14 [1.05-1.25]) and co-morbidity of neurological disease other than stroke (5.98 [3.08-11.60]) were independently associated with an increased rate of falls. Higher depression scores (1.20 [1.11-1.31]) and co-morbidity of cancer (1.97 [1.20-3.25]) were independently associated with an increased rate of injurious falls in the 6 months postdischarge. CONCLUSION(S): Falls prevention strategies, other than hospital discharge medication management in the postdischarge older adults, warrant investigation.Copyright © 2019 AJA Inc.

OBJECTIVE: The aims of this study were to describe patterns and dose of rehabilitation received following stroke and to investigate their relationship with outcomes. DESIGN: This was a prospective observational cohort study. SETTING: A total of seven public hospitals and all subsequent rehabilitation services in Queensland, Australia, participated in the study. SUBJECTS: Participants were consecutive patients surviving acute stroke between July 2016 and January 2017. METHOD(S): We tracked rehabilitation for six months following stroke and obtained 90- to 180-day outcomes from the Australian Stroke Clinical Registry. MEASURES: Dose of rehabilitation - time in therapy by physiotherapy, occupational therapy and speech pathology; modified Rankin Scale (mRS)- premorbid, acute care discharge and 90- to 180-day follow-up. RESULT(S): We recruited 504 patients, of whom 337 (median age = 73years, 41% female) received 643 episodes of rehabilitation in 83 different services. Initial rehabilitation was predominantly inpatient (260/337, 77%) versus community-based (77/337, 21%). Therapy time was greater within inpatient services (median = 29 hours) compared to community-based (6 hours) or transition care (16 hours). Median (Quartile 1, Quartile 3) six-month cumulative therapy time was 73 hours (40, 130) when rehabilitation commenced in stroke units and continued in inpatient rehabilitation units; 43 hours (23, 78) when commenced in inpatient rehabilitation units; and 5 hours (2, 9) with only community rehabilitation. In 317 of 504 (63%) with follow-up data, improvement in mRS was most likely with inpatient rehabilitation (OR = 3.6, 95% CI = 1.7-7.7), lower with community rehabilitation (OR = 1.6, 95% CI = 0.7-3.8) compared to no rehabilitation, after adjustment for baseline factors. CONCLUSION(S): Amount of therapy varied widely between rehabilitation pathways. Amount of therapy and chance of improvement in function were highest with inpatient rehabilitation.

BACKGROUND: Culturally competent health care service delivery can improve health outcomes, increasing the efficiency of clinical staff, and greater patient satisfaction. We aimed to explore the experience of patients with limited English proficiency and professional interpreters in an acute hospital setting. METHOD(S): In-depth interviews explored the experiences of four culturally and linguistically diverse communities with regards to their recent hospitalisation and access to interpreters. We also conducted focus group with professional interpreters working. Data were analysed using an inductive thematic approach with constant comparison. RESULT(S): Individual interviews were conducted with 12 patients from Greek, Chinese, Dari and Vietnamese backgrounds. Focus groups were conducted with 11 professional interpreters. Key themes emerged highlighting challenges to the delivery of health care due distress and lack of advocacy in patients. Interpreters struggled due to a reliance on family to act as interpreters and hospital staff proficiency in working with them. CONCLUSION(S): In an era of growing ethnic diversity this study confirms the complexity of providing a therapeutic relationships in contemporary health practice. This can be enhanced by training towards the effective use of professional interpreters in a hospital setting. Such efforts should be multidisciplinary and collective in order to ensure patients don't fall through the gaps with regards to the provision of culturally competent care.

BACKGROUND: The treatment of choice for early stage non-small cell lung cancer (NSCLC) is surgical resection. Little is known about the short- and long-term outcomes among very elderly patients. We sought to determine predictors of short- and long-term survival among octogenarians undergoing curative-intent resection for NSCLC in Victoria, Australia. METHOD(S): We retrospectively reviewed data from all patients aged >=80 years who underwent curative-intent resection for NSCLC over 12years (January 2005-December 2016) across five tertiary centres. We examined effect of age, stage of disease, extent of surgery and lung function on short- and long-term survival. RESULT(S): Two hundred patients aged >=80 years underwent curative-intent resections. Mortality at 30 and 120days was 2.9% and 5.9%, respectively. Increased early mortality was observed among those >=83years, at 30days (6.8% versus 0.8%, P = 0.044) and 120days (12.2% versus 2.3%, P = 0.0096). Early mortality was highest among patients >=83years requiring lobectomy, compared to sub-lobar resection at 120days (17% versus 3.8%, P = 0.019). Long-term survival was predicted by age and stage of disease. Among patients with Stage I disease aged <83years, lobectomy was associated with superior 5-year survival, compared to sub-lobar resection (83% versus 61%, P = 0.02). CONCLUSION(S): In carefully selected elderly patients undergoing curative-intent resection of early stage NSCLC, both short- and long-term outcomes appear consistent with younger historical cohorts. Early mortality was associated with lobectomy in those with advanced age. Older patients undergoing lobectomy appeared to be at highest risk for early mortality, while younger patients with Stage I disease undergoing at least lobectomy appear to have the best long-term survival.Copyright © 2018 Royal Australasian College of Surgeons.

The role of cytarabine-based induction and autologous stem cell transplantation (ASCT) in front-line treatment of younger patients with mantle cell lymphoma (MCL) is well established, however the utility of intensive approaches in older patients remains unclear. This retrospective study compared first line treatment outcomes in patients aged 60 years or more, treated at six tertiary centres between 2000-2015. 70 patients included had a median age of 69 (60-91) and most (94%) demonstrated advanced stage disease. Treatment regimens included: R-CHOP-like (n=39), alternating R-CHOP/R-DHAC (n=10), R-HyperCVAD/R-MA (n=7), R-CHOP/Cytarabine (Nordic Protocol) (n=10) and other (n=4). 16 patients underwent an ASCT. The median follow-up for surviving patients was 37 months. Compared to R-CHOP-like therapies, cytarabine-based regimens were associated with an improved overall response rate (ORR) of 70% vs 33% (p<0.001) and overall survival (OS) (HR 0.541, [0.292-1.001], p=0.05). No difference in efficacy between different cytarabine-based regimens was detected, but R-HyperCVAD/R-MA was associated with increased hospitalisation and transfusion requirements. Patients undergoing ASCT demonstrated an improved median OS (HR 0.108 [0.015-0.796], p=0.029) but were significantly younger. These results reaffirm the use of cytarabine in MCL for selected patients aged over 60. Such regimens should be strongly considered for this population in frontline therapy.

OBJECTIVE: The aim of this systematic review was to identify, evaluate, and synthesize the evidence from studies that have investigated the effect of nonsurgical, nonpharmacological, pelvic floor muscle interventions on any type of pelvic floor dysfunction or health-related quality of life in patients after any type of treatment for gynecological cancer. METHOD(S): Six electronic databases (Cochrane Library 2018, CINAHL 1982-2018, MEDLINE 1950-2018, EMBASE 1980-2018, PsycINFO 1806-2018, and EMCARE 1995-2018) were systematically searched in June 2018. Reference lists of identified articles were hand searched. Randomized controlled trials (RCTs), cohort studies, and case series were included if they investigated the effects of conservative treatments, including pelvic floor muscle training or dilator training, on bladder, bowel, or sexual function in patients who had received treatment for gynecological cancer. Risk of bias was assessed using the Physiotherapy Evidence Database scale for RCTs and the Newcastle-Ottawa scale for cohort studies. RESULT(S): Five RCTs and 2 retrospective cohort studies were included (n = 886). The results provided moderate-level evidence that pelvic floor muscle training with counseling and yoga or core exercises were beneficial for sexual function (standardized mean difference = -0.96, 95% CI = -1.22 to -0.70, I2 = 0%) and health-related quality of life (standardized mean difference = 0.63, 95% CI = 0.38 to 0.88, I2 = 0%) in survivors of cervical cancer and very low-level evidence that dilator therapy reduced vaginal complications in survivors of cervical and uterine cancer (odds ratio = 0.37, 95% CI = 0.17 to 0.80, I2 = 54%). There were insufficient data for meta-analysis of bladder or bowel function. CONCLUSION(S): Conservative pelvic floor muscle interventions may be beneficial for improving sexual function and health-related quality of life in survivors of gynecological cancer. Given the levels of evidence reported in this review, fur

OBJECTIVE: To determine whether multifactorial falls prevention interventions are effective in preventing falls, fall injuries, emergency department (ED) re-presentations and hospital admissions in older adults presenting to the ED with a fall. DESIGN: Systematic review and meta-analyses of randomised controlled trials (RCTs). DATA SOURCES: Four health-related electronic databases (Ovid MEDLINE, CINAHL, EMBASE, PEDro and The Cochrane Central Register of Controlled Trials) were searched (inception to June 2018). STUDY SELECTION: RCTs of multifactorial falls prevention interventions targeting community-dwelling older adults ( >= 60 years) presenting to the ED with a fall with quantitative data on at least one review outcome. DATA EXTRACTION: Two independent reviewers determined inclusion, assessed study quality and undertook data extraction, discrepancies resolved by a third. DATA SYNTHESIS: 12 studies involving 3986 participants, from six countries, were eligible for inclusion. Studies were of variable methodological quality. Multifactorial interventions were heterogeneous, though the majority included education, referral to healthcare services, home modifications, exercise and medication changes. Meta-analyses demonstrated no reduction in falls (rate ratio = 0.78; 95% CI: 0.58 to 1.05), number of fallers (risk ratio = 1.02; 95% CI: 0.88 to 1.18), rate of fractured neck of femur (risk ratio = 0.82; 95% CI: 0.53 to 1.25), fall-related ED presentations (rate ratio = 0.99; 95% CI: 0.84 to 1.16) or hospitalisations (rate ratio = 1.14; 95% CI: 0.69 to 1.89) with multifactorial falls prevention programmes. CONCLUSION(S): There is insufficient evidence to support the use of multifactorial interventions to prevent falls or hospital utilisation in older people presenting to ED following a fall. Further research targeting this population group is required.Copyright © Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.

The distribution of mental illness information is a crucial element of mental health promotion initiatives. We assessed the receipt and perceived helpfulness of such information in Australia. Data from the Australian National Survey of Mental Health and Wellbeing indicated that, during the year prior to the survey, 33.7% of Australians received mental illness information; of these, 51.2% found it helpful. Among people with a mental disorder, 46.1% received information; of these, 67.4% found it helpful. Non-English speakers and the socially disadvantaged were less likely to receive mental illness information. Older and less educated respondents were less likely to both receive mental illness information and find it helpful. Mental health service users were more likely to receive mental illness information perceived as helpful than those who had not accessed such services. Better targeted information interventions are required to ensure those most likely to benefit receive mental illness-related information.

BACKGROUND: Indeterminate fine-needle aspiration cytology (FNAC) imposes challenges in the management of thyroid nodules. This study aimed to examine whether preoperative anti-thyroid antibodies (Abs) and TSH are indicators of thyroid malignancy and aggressive behavior in patients with indeterminate FNAC. METHOD(S): This was a retrospective study of thyroidectomy patients from 2008 to 2016. We analyzed Abs and TSH levels, FNAC, and histopathology. Serum antibody levels were categorized as 'Undetectable', 'In-range' if detectable but within normal range, and 'Elevated' if above upper limit of normal. 'Detectable' levels referred to 'In-range' and 'Elevated' combined. RESULT(S): There were 531 patients included. Of 402 patients with preoperative FNAC, 104 (25.9%) had indeterminate cytology (Bethesda III-V). Of these, 39 (37.5%) were malignant and 65 (62.5%) benign on histopathology. In the setting of indeterminate FNAC, an increased risk of malignancy was associated with 'Elevated' thyroglobulin antibodies (TgAb) (OR 7.25, 95% CI 1.13-77.15, P=0.01) and 'Elevated' thyroid peroxidase antibodies (TPOAb) (OR 6.79, 95% CI 1.23-45.88, P=0.008). Similarly, while still 'In-range', TSH>=1 mIU/L was associated with an increased risk of malignancy (OR 3.23, 95% CI 1.14-9.33, P=0.01). In all patients with malignancy, the mean tumor size was 8 mm larger in those with TSH>=1 mIU/L (P=0.03); furthermore, in PTC patients, 'Detectable' TgAb conferred a 4xrisk of lymph node metastasis (95% CI 1.03-13.77, P=0.02). CONCLUSION(S): In this cohort, in indeterminate FNAC patients, Abs and TSH were associated with an increased risk of malignancy. Additionally, TgAb and TSH were potential markers of aggressive biology. As such, they may be diagnostic and prognostic adjuncts.

BACKGROUND: There is little published data on brain imaging and intracranial haemorrhage after hospital inpatient falls. Imaging protocols for inpatient falls have been adopted from head injury guidelines developed from data in patients presenting to the Emergency Department. We sought to describe the use of brain computed tomography (CT) following inpatient falls, and determine the incidence and potential risk factors for intracranial haemorrhage. METHOD(S): We identified inpatient falls in acute medical wards at Monash Health, a large hospital network in the southeast region of Melbourne in Australia, from the incident reporting system during a 32month period. We examined the post-fall medical assessment form, neurological observation chart and the diagnostic imaging system for details of the fall and brain CT findings. We used survival analysis to evaluate the timeliness of brain imaging and determined potential risk factors for intracranial haemorrhage by logistic regression. RESULT(S): From 934 falls in 789 medical inpatients, 191 brain CT scans were performed. The median age of patients was 77years. Only 55% of falls were from standing height and 24% experienced a head strike. Less than 10% of patients received an urgent scan within one hour, and timeliness of imaging was influenced by anticoagulation status rather than guideline determination of urgency. The overall incidence of intracranial haemorrhage was 0.9%. The factors associated with intracranial haemorrhage were head strike, anticoagulation, loss of consciousness or amnesia, drop in Glasgow Coma Scale and advanced chronic kidney disease. CONCLUSION(S): The incidence of intracranial haemorrhage was low as most inpatient falls were at low risk for head injury. Research is needed to determine if guidelines specific for hospital inpatients may reduce unnecessary scans without compromising case detection, and improve timeliness of urgent scans.

Background: Island flaps are more mobile than local flaps in-continuity and rely on the laxity of the adjacent tissues. We present a new island flap design, called the inverted love-heart flap, used to reconstruct cutaneous defects of the limbs. Method(s): A retrospective chart review of patients who underwent inverted love-heart flap reconstruction post excision of a cutaneous malignancy during July 2017 to July 2019 was performed. Result(s): Seventeen patients underwent 18 inverted love-heart flap reconstructions postexcision of a cutaneous malignancies during the study period. There were no reported cases of partial or total flap necrosis. Conclusion(s): The inverted love-heart flap offers a reliable reconstruction for cutaneous defects. It has the advantage of a primary donor site closure, minimal patient morbidity and avoids the need for skin grafting and postoperative immobilization.

BACKGROUND: Early hospital readmissions are a challenging and costly experience for both patients and the healthcare service. Reducing hospital readmission rates is a priority for health services globally and this is evident with the establishment of multiple outpatient services to promote early follow-up and to initiate secondary preventative care measures. One such intervention has been the introduction of a pharmacist-led, Hospital Outreach Medication Review (HOMR) service. However, the demand for the service has meant reaching this target has become an increasingly ambitious goal within allocated resources. OBJECTIVE(S): To validate a risk-stratification tool to identify low-risk patients in whom a telephone medication review would be a safe and effective alternative to a home-based review. METHOD(S): A risk tool was derived and applied to a retrospective sample to act as the parent cohort. A prospective cohort was stratified into low and high-risk based on this tool, and received either a telephone or a traditional home medication review respectively. RESULT(S): 235 patients were included in final analysis (n=113 prospective, n=122 baseline controls). High-risk patients were more likely to be readmitted at 60 and 90 days in the baseline cohort (9/38 vs 7/84, p=0.04 and 11/38 vs 9/84, p=0.02 respectively), with a trend towards increased readmissions at 30 days (5/38 vs 3/84, p=0.11). Logistic regression identified the risk tool as an independent predictor of hospital readmission (IRR 1.18, p=0.04), whereas age and Charlson comorbidity were not (p=0.80 and 0.31 respectively). There was no significant difference between the new model (incorporating phone reviews) and the parent cohort (p=0.25). CONCLUSION(S): Our risk score was able to identify those at highest risk of hospital readmission at 60 and 90 days. Utilising this risk score, a telephone HOMR for low-risk patients was a safe and efficient alternative to a traditional home review.Copyright © 2018 Elsevier

Objective A pilot study to: (1) describe the ability of emergency physicians to provide primary consults at an Australian, major metropolitan, adult emergency department (ED) during the COVID-19 pandemic when compared with historical performance; and (2) to identify the effect of system and process factors on productivity. Methods A retrospective cross-sectional description of shifts worked between 1 and 29 February 2020, while physicians were carrying out their usual supervision, flow and problem-solving duties, as well as undertaking additional COVID-19 preparation, was documented. Effect of supervisory load, years of Australian registration and departmental flow factors were evaluated. Descriptive statistical methods were used and regression analyses were performed. Results A total of 188 shifts were analysed. Productivity was 4.07 patients per 9.5-h shift (95% CI 3.56-4.58) or 0.43 patients per h, representing a 48.5% reduction from previously published data (P<0.0001). Working in a shift outside of the resuscitation area or working a day shift was associated with a reduction in individual patient load. There was a 2.2% (95% CI: 1.1-3.4, P<0.001) decrease in productivity with each year after obtaining Australian medical registration. There was a 10.6% (95% CI: 5.4-15.6, P<0.001) decrease in productivity for each junior physician supervised. Bed access had no statistically significant effect on productivity. Conclusions Emergency physicians undertake multiple duties. Their ability to manage their own patients varies depending on multiple ED operational factors, particularly their supervisory load. COVID-19 preparations reduced their ability to see their own patients by half. What is known about the topic? An understanding of emergency physician productivity is essential in planning clinical operations. Medical productivity, however, is challenging to define, and is controversial to measure. Although baseline data exist, few studies examine the effect of patient f

OBJECTIVES: The onset of many illnesses is confounded with age and sex. Increasing age is a risk factor for the development of many illnesses, and sexual dimorphism influences brain anatomy, function, and cognition. Here, we examine frequency-specific connectivity in resting-state networks in a large sample (n = 406) of healthy aged adults. METHOD(S): We quantify frequency-specific connectivity in three resting-state networks known to be implicated in age-related decline: the default mode, dorsal attention, and salience networks, using multiband functional magnetic resonance imaging. Frequency-specific connectivity was quantified in four bands: low (0.015-0.027 Hz), moderately low (0.027-0.073 Hz), moderately high (0.073-0.198 Hz), and high (0.198-0.5 Hz) frequency bands, using mean intensity and spatial extent. Differences in connectivity between the sexes in each of the three networks were examined. RESULT(S): Each network showed the largest intensity and spatial extent at low frequencies and smallest extent at high frequencies. Males showed greater connectivity than females in the salience network. Females showed greater connectivity than males in the default mode network. DISCUSSION: Results in this healthy aged cohort are compatible with those obtained in young samples, suggesting that frequency-specific connectivity, and differences between the sexes, are maintained into older age. Our results indicate that sex should be considered as an influencing factor in studies of resting-state connectivity.Copyright © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

BACKGROUND: Weight loss increases fracture risk in older adults. We aimed to determine associations of 2-year body composition trajectories with subsequent falls and fractures in older men. METHOD(S): We measured appendicular lean mass (ALM) and total fat mass (FM) by dual-energy X-ray absorptiometry at baseline and Year 2 in 1,326 community-dwelling men aged >=70 and older. Body composition trajectories were determined from residuals of a linear regression of change in ALM on change in FM (higher values indicate maintenance of ALM over FM), and a categorical variable for change in ALM and FM (did not lose [>=-5% change] versus lost [<-5% change]). Bone mineral density (BMD), hand grip strength, and gait speed were assessed at Years 2 and 5. After Year 2, incident fractures (confirmed by radiographical reports) and falls were recorded for 6.8 years. RESULT(S): Compared with men who did not lose ALM or FM, men who did not lose ALM but lost FM, and men who lost both ALM and FM, had reduced falls (-24% and -34%, respectively; both p < .05). Men who lost ALM but did not lose FM had increased falls (incidence rate ratio = 1.73; 95% CI 1.37-2.18). ALM/FM change residuals were associated with improved lumbar spine BMD (B = 0.007; 95% CI 0.002-0.012 g/cm2 per SD increase) and gait speed (0.015; 0.001-0.029 m/s), and reduced hip fractures (hazard ratio = 0.68; 95% CI 0.47-0.99). CONCLUSION(S): Fracture risk may be increased in older men who lose higher ALM relative to FM. Weight loss interventions for obese older men should target maintenance of lean mass.Copyright © The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Background: SAEFVIC is the Victorian surveillance system for adverse events following immunisation (AEFI). It enhances passive surveillance by also providing clinical support and education to vaccinees and immunisation providers. This report summarises surveillance, clinical and vaccine pharmacovigilance activities of SAEFVIC in 2018. Method(s): A retrospective observational cohort study of AEFI reports received by SAEFVIC in 2018, compared with previous years since 2008. Data were categorised by vaccinee demographics of age, sex, pregnancy and Indigenous status, vaccines administered and AEFI reactions reported. Age cohorts were defined as infant (0-12 months); young child (1-4 years); school-aged (5-17 years); adult (18-64 years); and older person (65+ years). Proportional reporting ratios were calculated for signal investigation of serious adverse neurological events with all vaccines and with influenza vaccines. Clinical support services and educational activities are described. Result(s): SAEFVIC received 1730 AEFI reports (26.8 per 100,000 population), with 9.3% considered serious. Nineteen percent (n = 329) attended clinical review. Annual AEFI reporting trends increased for infants, children and older persons, but were stable for school-aged and adult cohorts. Females comprised 55% of all reports and over 80% of reports among adults. There were 17 reports of AEFI in pregnant women and 12 (0.7%) in persons identifying as Indigenous Australians. A possible signal regarding serious adverse neurological events (SANE) was detected, but was not supported by signal validation testing. A clinical investigation is ongoing. Two deaths were reported coincident to immunisation with no evidence of causal association. Conclusion(s): SAEFVIC continues to provide robust AEFI surveillance supporting vaccine safety monitoring in Victoria and Australia, with new signal detection and validation methodologies strengthening capabilities.Copyright © Commonwealth of Australia CC BY

OBJECTIVE: The objective of this systematic review was to examine the effects of different balance exercise interventions compared with non-balance exercise controls on balance task performance in older adults. DESIGN: Systematic review. DATA SOURCES: Medline, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Scopus and Cochrane Database of Systematic Reviews were searched until July 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Systematic reviews and meta-analyses of randomised trials of balance exercise interventions for older adults were identified for extraction of eligible randomised trials. Eligibility criteria for inclusion of randomised trials in meta-analyses were comparison of a balance exercise intervention with a control group that did not perform balance exercises, report of at least one end-intervention balance outcome measurement that was consistent with the five subgroups of balance exercise identified, and full-text article available in English. RESULT(S): Ninety-five trials were included in meta-analyses and 80 in meta-regressions. For four balance exercise types (control centre of mass, multidimensional, mobility and reaching), significant effects for balance exercise interventions were found in meta-analyses (standardised mean difference (SMD) 0.31-0.50), however with considerable heterogeneity in observed effects (I2: 50.4%-80.6%). Risk of bias assessments (Physiotherapy Evidence Database score and funnel plots) did not explain heterogeneity. One significant relationship identified in the meta-regressions of SMD and balance exercise frequency, time and duration explained 2.1% of variance for the control centre of mass subgroup. CONCLUSION(S): Limitations to this study included the variability in design of balance interventions, incomplete reporting of data and statistical heterogeneity. The design of balance exercise programmes provides inadequate explanation of the observed benefits of these interventions.Copyright © Article

AIMS AND OBJECTIVES: To examine the relationship between resuscitation status and (i) patient characteristics; (ii) transfer characteristics; and (iii) patient outcomes following an emergency inter-hospital transfer from a subacute to an acute care hospital. BACKGROUND: Patients who experience emergency inter-hospital transfers from subacute to acute care hospitals have high rates of acute care readmission (81%) and in-hospital mortality (15%). DESIGN: This prospective, exploratory cohort study was a subanalysis of data from a larger case-time-control study in five Health Services in Victoria, Australia. There were 603 transfers in 557 patients between August 2015 and October 2016. The study was conducted in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology guidelines. METHOD(S): Data were extracted by medical record audit. Three resuscitation categories (full resuscitation; limitation of medical treatment (LOMT) orders; or not-for-cardiopulmonary resuscitation (CPR) orders) were compared using chi-square or Kruskal-Wallis tests. Stratified multivariable proportional hazard Cox regression models were used to account for health service clustering effect. FINDINGS: Resuscitation status was 63.5% full resuscitation; 23.1% LOMT order; and 13.4% not-for-CPR. Compared to patients for full resuscitation, patients with not-for-CPR or LOMT orders were more likely to have rapid response team calls during acute care readmission or to die during hospitalisation. Patients who were not-for-CPR were less likely to be readmitted to acute care and more likely to return to subacute care. CONCLUSION(S): Two-thirds of patients in subacute care who experienced an emergency inter-hospital transfer were for full resuscitation. Although the proportion of patients with LOMT and not-for-CPR orders increased after transfer, there were deficiencies in the documentation of resuscitation status and planning for clinical deterioration for subacute care patie

BACKGROUND: Navigating treatment pathways remains a challenge for populations with complex needs due to bottlenecks, service gaps and access barriers. The application of novel methods may be required to identify and remedy such problems. OBJECTIVE(S): To demonstrate a novel approach to identifying persistent service gaps, generating potential solutions and prioritizing action. DESIGN: Co-creation and multi-criteria decision analysis in the context of a larger, mixed methods study. SETTING AND PARTICIPANTS: Community-dwelling sample of older women living alone (OWLA), residing in Melbourne, Australia (n = 13-37). Convenience sample of (n = 11) representatives from providers and patient organizations. INTERVENTIONS: Novel interventions co-created to support health, well-being and independence for OWLA and bridge missing links in pathways to care. MAIN OUTCOME MEASURES: Performance criteria, criterion weights , performance ratings, summary scores and ranks reflecting the relative value of interventions to OWLA. RESULT(S): The co-creation process generated a list of ten interventions. Both OWLA and stakeholders considered a broad range of criteria when evaluating the relative merits of these ten interventions and a "Do Nothing" alternative. Combining criterion weights with performance ratings yielded a consistent set of high priority interventions, with "Handy Help," "Volunteer Drivers" and "Exercise Buddies" most highly ranked by both OWLA and stakeholder samples. DISCUSSION AND CONCLUSION(S): The present study described and demonstrated the use of multi-criteria decision analysis to prioritize a set of novel interventions generated via a co-creation process. Application of this approach can add community voice to the policy debate and begin to bridge the gap in service provision for underserved populations.Copyright © 2019 The Authors Health Expectations published by John Wiley & Sons Ltd.

BACKGROUND: This study describes the temporal changes in risk profiles and outcomes among patients with aortic stenosis (AS) undergoing surgical aortic valve replacement (SAVR) in Australia between 2002 and 2015. METHOD(S): Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons database, we identified first-recorded SAVR for AS over 14 years. Patients' surgical risk profiles, procedures, 30-day and 12-month outcomes were summarized before and after the introduction of transcatheter aortic valve implantation in Australia, in 2008. We applied multivariable regression models to investigate the changes over time on risk-adjusted 30-day mortality, re-hospitalization and 12-month mortality. RESULT(S): We identify a total of 18147 patients with AS who underwent SAVR; mostly men (64%) with a mean age of 72years. The proportion of major cardiac surgeries devoted to SAVR increased from 14% in 2002 to 20% in 2015. More SAVRs were performed electively (80% in 2002 versus 86% in 2015), and the recipients were at lower surgical risk (mean multi-risk score 3.9% in 2002 versus 3.0% in 2015). The use of bioprosthetic aortic valves increased over time (67% in 2002 to 88% in 2015). We found no significant changes in 30-day mortality, a significant decrease in 30-day readmission and minor fluctuations in 12-month mortality over the study period. CONCLUSION(S): SAVR comprises an increasingly larger proportion of all adult cardiac surgeries in Australia. There has been a greater use of bioprosthetic aortic valves, a fall in 30-day readmission but no significant changes in mortality.Copyright © 2019 Royal Australasian College of Surgeons.

OBJECTIVE: To identify discharge medications, especially psychotropic medications that are associated with falls, amongst older adults within 6 months following hospitalisation. METHOD(S): Negative binomial regression was used to examine relationships between discharge medications and falls in older post-hospitalised adults. Multiple regression that considered falls risk factors at discharge was performed. RESULT(S): Data for 267 participants showed that discharge medications were not independently associated with falls postdischarge after adjustment for other falls risk factors. Male gender (adjusted incidence rate ratio [95% confidence interval, CI]) 2.15 [1.36-3.40]), higher depression scores (1.14 [1.05-1.25]) and co-morbidity of neurological disease other than stroke (5.98 [3.08-11.60]) were independently associated with an increased rate of falls. Higher depression scores (1.20 [1.11-1.31]) and co-morbidity of cancer (1.97 [1.20-3.25]) were independently associated with an increased rate of injurious falls in the 6 months postdischarge. CONCLUSION(S): Falls prevention strategies, other than hospital discharge medication management in the postdischarge older adults, warrant investigation.Copyright © 2019 AJA Inc.

OBJECTIVE: The aims of this study were to describe patterns and dose of rehabilitation received following stroke and to investigate their relationship with outcomes. DESIGN: This was a prospective observational cohort study. SETTING: A total of seven public hospitals and all subsequent rehabilitation services in Queensland, Australia, participated in the study. SUBJECTS: Participants were consecutive patients surviving acute stroke between July 2016 and January 2017. METHOD(S): We tracked rehabilitation for six months following stroke and obtained 90- to 180-day outcomes from the Australian Stroke Clinical Registry. MEASURES: Dose of rehabilitation - time in therapy by physiotherapy, occupational therapy and speech pathology; modified Rankin Scale (mRS)- premorbid, acute care discharge and 90- to 180-day follow-up. RESULT(S): We recruited 504 patients, of whom 337 (median age = 73years, 41% female) received 643 episodes of rehabilitation in 83 different services. Initial rehabilitation was predominantly inpatient (260/337, 77%) versus community-based (77/337, 21%). Therapy time was greater within inpatient services (median = 29 hours) compared to community-based (6 hours) or transition care (16 hours). Median (Quartile 1, Quartile 3) six-month cumulative therapy time was 73 hours (40, 130) when rehabilitation commenced in stroke units and continued in inpatient rehabilitation units; 43 hours (23, 78) when commenced in inpatient rehabilitation units; and 5 hours (2, 9) with only community rehabilitation. In 317 of 504 (63%) with follow-up data, improvement in mRS was most likely with inpatient rehabilitation (OR = 3.6, 95% CI = 1.7-7.7), lower with community rehabilitation (OR = 1.6, 95% CI = 0.7-3.8) compared to no rehabilitation, after adjustment for baseline factors. CONCLUSION(S): Amount of therapy varied widely between rehabilitation pathways. Amount of therapy and chance of improvement in function were highest with inpatient rehabilitation.

BACKGROUND: Culturally competent health care service delivery can improve health outcomes, increasing the efficiency of clinical staff, and greater patient satisfaction. We aimed to explore the experience of patients with limited English proficiency and professional interpreters in an acute hospital setting. METHOD(S): In-depth interviews explored the experiences of four culturally and linguistically diverse communities with regards to their recent hospitalisation and access to interpreters. We also conducted focus group with professional interpreters working. Data were analysed using an inductive thematic approach with constant comparison. RESULT(S): Individual interviews were conducted with 12 patients from Greek, Chinese, Dari and Vietnamese backgrounds. Focus groups were conducted with 11 professional interpreters. Key themes emerged highlighting challenges to the delivery of health care due distress and lack of advocacy in patients. Interpreters struggled due to a reliance on family to act as interpreters and hospital staff proficiency in working with them. CONCLUSION(S): In an era of growing ethnic diversity this study confirms the complexity of providing a therapeutic relationships in contemporary health practice. This can be enhanced by training towards the effective use of professional interpreters in a hospital setting. Such efforts should be multidisciplinary and collective in order to ensure patients don't fall through the gaps with regards to the provision of culturally competent care.

BACKGROUND: The treatment of choice for early stage non-small cell lung cancer (NSCLC) is surgical resection. Little is known about the short- and long-term outcomes among very elderly patients. We sought to determine predictors of short- and long-term survival among octogenarians undergoing curative-intent resection for NSCLC in Victoria, Australia. METHOD(S): We retrospectively reviewed data from all patients aged >=80 years who underwent curative-intent resection for NSCLC over 12years (January 2005-December 2016) across five tertiary centres. We examined effect of age, stage of disease, extent of surgery and lung function on short- and long-term survival. RESULT(S): Two hundred patients aged >=80 years underwent curative-intent resections. Mortality at 30 and 120days was 2.9% and 5.9%, respectively. Increased early mortality was observed among those >=83years, at 30days (6.8% versus 0.8%, P = 0.044) and 120days (12.2% versus 2.3%, P = 0.0096). Early mortality was highest among patients >=83years requiring lobectomy, compared to sub-lobar resection at 120days (17% versus 3.8%, P = 0.019). Long-term survival was predicted by age and stage of disease. Among patients with Stage I disease aged <83years, lobectomy was associated with superior 5-year survival, compared to sub-lobar resection (83% versus 61%, P = 0.02). CONCLUSION(S): In carefully selected elderly patients undergoing curative-intent resection of early stage NSCLC, both short- and long-term outcomes appear consistent with younger historical cohorts. Early mortality was associated with lobectomy in those with advanced age. Older patients undergoing lobectomy appeared to be at highest risk for early mortality, while younger patients with Stage I disease undergoing at least lobectomy appear to have the best long-term survival.Copyright © 2018 Royal Australasian College of Surgeons.

OBJECTIVE: The aim of this systematic review was to identify, evaluate, and synthesize the evidence from studies that have investigated the effect of nonsurgical, nonpharmacological, pelvic floor muscle interventions on any type of pelvic floor dysfunction or health-related quality of life in patients after any type of treatment for gynecological cancer. METHOD(S): Six electronic databases (Cochrane Library 2018, CINAHL 1982-2018, MEDLINE 1950-2018, EMBASE 1980-2018, PsycINFO 1806-2018, and EMCARE 1995-2018) were systematically searched in June 2018. Reference lists of identified articles were hand searched. Randomized controlled trials (RCTs), cohort studies, and case series were included if they investigated the effects of conservative treatments, including pelvic floor muscle training or dilator training, on bladder, bowel, or sexual function in patients who had received treatment for gynecological cancer. Risk of bias was assessed using the Physiotherapy Evidence Database scale for RCTs and the Newcastle-Ottawa scale for cohort studies. RESULT(S): Five RCTs and 2 retrospective cohort studies were included (n = 886). The results provided moderate-level evidence that pelvic floor muscle training with counseling and yoga or core exercises were beneficial for sexual function (standardized mean difference = -0.96, 95% CI = -1.22 to -0.70, I2 = 0%) and health-related quality of life (standardized mean difference = 0.63, 95% CI = 0.38 to 0.88, I2 = 0%) in survivors of cervical cancer and very low-level evidence that dilator therapy reduced vaginal complications in survivors of cervical and uterine cancer (odds ratio = 0.37, 95% CI = 0.17 to 0.80, I2 = 54%). There were insufficient data for meta-analysis of bladder or bowel function. CONCLUSION(S): Conservative pelvic floor muscle interventions may be beneficial for improving sexual function and health-related quality of life in survivors of gynecological cancer. Given the levels of evidence reported in this review, fur

The role of cytarabine-based induction and autologous stem cell transplantation (ASCT) in front-line treatment of younger patients with mantle cell lymphoma (MCL) is well established, however the utility of intensive approaches in older patients remains unclear. This retrospective study compared first line treatment outcomes in patients aged 60 years or more, treated at six tertiary centres between 2000-2015. 70 patients included had a median age of 69 (60-91) and most (94%) demonstrated advanced stage disease. Treatment regimens included: R-CHOP-like (n=39), alternating R-CHOP/R-DHAC (n=10), R-HyperCVAD/R-MA (n=7), R-CHOP/Cytarabine (Nordic Protocol) (n=10) and other (n=4). 16 patients underwent an ASCT. The median follow-up for surviving patients was 37 months. Compared to R-CHOP-like therapies, cytarabine-based regimens were associated with an improved overall response rate (ORR) of 70% vs 33% (p<0.001) and overall survival (OS) (HR 0.541, [0.292-1.001], p=0.05). No difference in efficacy between different cytarabine-based regimens was detected, but R-HyperCVAD/R-MA was associated with increased hospitalisation and transfusion requirements. Patients undergoing ASCT demonstrated an improved median OS (HR 0.108 [0.015-0.796], p=0.029) but were significantly younger. These results reaffirm the use of cytarabine in MCL for selected patients aged over 60. Such regimens should be strongly considered for this population in frontline therapy.

OBJECTIVE: To determine whether multifactorial falls prevention interventions are effective in preventing falls, fall injuries, emergency department (ED) re-presentations and hospital admissions in older adults presenting to the ED with a fall. DESIGN: Systematic review and meta-analyses of randomised controlled trials (RCTs). DATA SOURCES: Four health-related electronic databases (Ovid MEDLINE, CINAHL, EMBASE, PEDro and The Cochrane Central Register of Controlled Trials) were searched (inception to June 2018). STUDY SELECTION: RCTs of multifactorial falls prevention interventions targeting community-dwelling older adults ( >= 60 years) presenting to the ED with a fall with quantitative data on at least one review outcome. DATA EXTRACTION: Two independent reviewers determined inclusion, assessed study quality and undertook data extraction, discrepancies resolved by a third. DATA SYNTHESIS: 12 studies involving 3986 participants, from six countries, were eligible for inclusion. Studies were of variable methodological quality. Multifactorial interventions were heterogeneous, though the majority included education, referral to healthcare services, home modifications, exercise and medication changes. Meta-analyses demonstrated no reduction in falls (rate ratio = 0.78; 95% CI: 0.58 to 1.05), number of fallers (risk ratio = 1.02; 95% CI: 0.88 to 1.18), rate of fractured neck of femur (risk ratio = 0.82; 95% CI: 0.53 to 1.25), fall-related ED presentations (rate ratio = 0.99; 95% CI: 0.84 to 1.16) or hospitalisations (rate ratio = 1.14; 95% CI: 0.69 to 1.89) with multifactorial falls prevention programmes. CONCLUSION(S): There is insufficient evidence to support the use of multifactorial interventions to prevent falls or hospital utilisation in older people presenting to ED following a fall. Further research targeting this population group is required.Copyright © Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.

BACKGROUND: Indeterminate fine-needle aspiration cytology (FNAC) imposes challenges in the management of thyroid nodules. This study aimed to examine whether preoperative anti-thyroid antibodies (Abs) and TSH are indicators of thyroid malignancy and aggressive behavior in patients with indeterminate FNAC. METHOD(S): This was a retrospective study of thyroidectomy patients from 2008 to 2016. We analyzed Abs and TSH levels, FNAC, and histopathology. Serum antibody levels were categorized as 'Undetectable', 'In-range' if detectable but within normal range, and 'Elevated' if above upper limit of normal. 'Detectable' levels referred to 'In-range' and 'Elevated' combined. RESULT(S): There were 531 patients included. Of 402 patients with preoperative FNAC, 104 (25.9%) had indeterminate cytology (Bethesda III-V). Of these, 39 (37.5%) were malignant and 65 (62.5%) benign on histopathology. In the setting of indeterminate FNAC, an increased risk of malignancy was associated with 'Elevated' thyroglobulin antibodies (TgAb) (OR 7.25, 95% CI 1.13-77.15, P=0.01) and 'Elevated' thyroid peroxidase antibodies (TPOAb) (OR 6.79, 95% CI 1.23-45.88, P=0.008). Similarly, while still 'In-range', TSH>=1 mIU/L was associated with an increased risk of malignancy (OR 3.23, 95% CI 1.14-9.33, P=0.01). In all patients with malignancy, the mean tumor size was 8 mm larger in those with TSH>=1 mIU/L (P=0.03); furthermore, in PTC patients, 'Detectable' TgAb conferred a 4xrisk of lymph node metastasis (95% CI 1.03-13.77, P=0.02). CONCLUSION(S): In this cohort, in indeterminate FNAC patients, Abs and TSH were associated with an increased risk of malignancy. Additionally, TgAb and TSH were potential markers of aggressive biology. As such, they may be diagnostic and prognostic adjuncts.

OBJECTIVES: The onset of many illnesses is confounded with age and sex. Increasing age is a risk factor for the development of many illnesses, and sexual dimorphism influences brain anatomy, function, and cognition. Here, we examine frequency-specific connectivity in resting-state networks in a large sample (n = 406) of healthy aged adults. METHOD(S): We quantify frequency-specific connectivity in three resting-state networks known to be implicated in age-related decline: the default mode, dorsal attention, and salience networks, using multiband functional magnetic resonance imaging. Frequency-specific connectivity was quantified in four bands: low (0.015-0.027 Hz), moderately low (0.027-0.073 Hz), moderately high (0.073-0.198 Hz), and high (0.198-0.5 Hz) frequency bands, using mean intensity and spatial extent. Differences in connectivity between the sexes in each of the three networks were examined. RESULT(S): Each network showed the largest intensity and spatial extent at low frequencies and smallest extent at high frequencies. Males showed greater connectivity than females in the salience network. Females showed greater connectivity than males in the default mode network. DISCUSSION: Results in this healthy aged cohort are compatible with those obtained in young samples, suggesting that frequency-specific connectivity, and differences between the sexes, are maintained into older age. Our results indicate that sex should be considered as an influencing factor in studies of resting-state connectivity.Copyright © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.