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Polycystic ovary syndrome (PCOS) is a heterogeneous disorder and many women are dissatisfied with their healthcare under the current fragmented health services. Here, we review existing literature on PCOS healthcare services and qualitatively evaluate an integrated PCOS service based on experiences of women with PCOS. Limited prior PCOS-dedicated services have been studied and their quantitative and efficacy-focused evaluations are summarized. Here, we also provide a broader PCOS service evaluation via semistructured interviews and surveys, with thematic analysis based on a predetermined evaluation framework. Fifteen women completed interviews and surveys. Overall the integrated, evidence-based PCOS service was well-received and women were generally satisfied with appropriateness, effectiveness, and reported positive health impact resulting from the service. Integrated care, tailored treatments, education, lifestyle support, and laser therapy were highly valued. Patients reported improvements on symptoms, understanding and confidence in managing PCOS, and emotional well-being. Elements of efficiency in the initial stages, awareness and communication, and the need for service expansion and tensions between evidence-based treatments and patient preferences were also captured to guide improvement. Further research into models of care is recommended to meet the needs of women with PCOS.

Given the pace of technological advancement and government mandates for healthcare and system transformation, there is an imperative for change. Health systems are highly complex in their design, networks and interacting components, and experience demonstrates that change is very challenging to enact, sustain and scale. Policy-makers, academics and clinicians all need better insight into the nature of this complexity and an understanding of the evidence-base that can support healthcare improvement (HCI), or quality improvement, interventions and make them more effective in driving change. The evidence base demonstrates the vital role of clinical engagement and leadership in HCI, and it is imperative that clinicians engage to improve front-line healthcare. The literature on HCI is vast, applies different and inconsistent terminology and encompasses often loosely defined and overlapping concepts. An increasingly broad range of disciplines has contributed to the available evidence base, but often discipline-specific perspectives frame these contributions. Available literature can also be overly driven by the generation of theoretical concepts and the advancement of academic understanding. It does not necessarily primarily provide focussed and pragmatic insights to guide and inform frontline practice. We aim to address these issues by summarising theories, frameworks, models and success factors for improvement in complex health systems to assist clinicians and others to engage and lead change. We integrate the field of HCI into the learning health system highlighting the key role of the clinician. We seek to inform stakeholders; clinicians and managers to guide the planning, enacting, sustaining and scaling of HCI.

ObjectivesWe draw on institutional theory to explore the roles and actions of innovation teams and how this influences their behaviour and capabilities as ‘institutional entrepreneurs (IEs)’, in particular the extent to which they are both ‘willing’ and ‘able’ to facilitate transformational change in healthcare through service redesign.DesignA longitudinal qualitative study that applied a ‘researcher in residence’ as an ethnographic approach.SettingThe development and implementation of two innovation projects within a single public hospital setting in an Australian state jurisdiction.ParticipantsTwo innovation teams, with members including senior research fellows, PhD scholars and front-line clinicians (19 participants and 47 interviews).ResultsDespite being from the same hospital, the two innovation teams occupied contrasting subject positions with one facilitating transformational improvements in service delivery, while the other sought more conservative improvements. Cast as ‘IEs’ we show how one team took steps to build legitimacy for their interventions enabling spread and scale in improvements and how, in the other case, failure to build legitimacy resulted in unintended consequences which undermined the sustainability of the improvements achieved.ConclusionsAdopting an institutional approach provided insight into the ‘willingness’ and ‘ability’ to facilitate transformational change in healthcare through service redesign. The manner in which innovation teams operate from different subject positions influences the structural and normative legitimacy afforded to their activities. Specifically, we observed that those with the most power (organisational or professional) to bring about transformational change can be the least willing to do so in ways which challenge current practice. Those most willing to challenge the status quo (more peripheral organisation members or professionals) can be least able to deliver transformation. Better understanding of these insights can inform healthcare leaders in supporting innovation team efforts, considering their subject position.

OBJECTIVE To determine if a structured transition program for young adults with type 1 diabetes improves clinic attendance, glycemic control, diabetes-related distress, quality of life, and satisfaction with care. RESEARCH DESIGN AND METHODS In this multicenter randomized controlled trial, young adults (17–20 years) with type 1 diabetes were randomly assigned to a transition program with a transition coordinator or to standard care. The intervention lasted 18 months (6 in pediatric and 12 in adult care). The primary outcome was the proportion of participants who failed to attend at least one adult diabetes clinic visit during the 12-month follow-up after completion of the intervention. RESULTS We randomized 205 participants, 104 to the transition program and 101 to standard care. Clinic attendance was improved in the transition program (mean [SD] number of visits 4.1 [1.1] vs. 3.6 [1.2], P = 0.002), and there was greater satisfaction with care (mean [SD] score 29.0 [2.7] vs. 27.9 [3.4], P = 0.032) and less diabetes-related distress (mean [SD] score 1.9 [0.8] vs. 2.1 [0.8], P = 0.049) reported than in standard care. There was a trend toward improvement in mean HbA1c (8.33% [68 mmol/mol] vs. 8.80% [73 mmol/mol], P = 0.057). During the 12-month follow-up, there was no difference in those failing to attend at least one clinic visit (P = 0.846), and the mean change in HbA1c did not differ between the groups (P = 0.073). At completion of follow-up, the groups did not differ with respect to satisfaction with care or diabetes-related distress and quality of life. CONCLUSIONS Transition support during this 18-month intervention was associated with increased clinic attendance, improved satisfaction with care, and decreased diabetes-related distress, but these benefits were not sustained 12 months after completion of the intervention.

Aim and objectives To determine the factors influencing nurses' decisions and capacity to reduce sedentary behaviour in hospital inpatients in sub-acute hospital settings. Background Sedentary behaviour in hospital inpatients is a complex issue that can be resistant to resolution. There is little research investigating factors influencing nurses' promotion of reduced levels of sedentary behaviour in sub-acute hospital settings. Design An explanatory sequential design was employed, comprising quantitative and qualitative phases. Methods An online survey was conducted with a convenience sample of 138 nurses from five Australian states. Logistic regression modelling identified demographic and behavioural characteristics of nurses who often encouraged patients to reduce their sedentary behaviour. In-depth interviews were conducted with 11 ward nurses and nurse managers, with the content subjected to thematic analysis. STROBE and GRAMMS checklists were employed. Results Nurses recognised their role in promoting reduced sedentary behaviour but faced a range of personal and organisational barriers in achieving this outcome for patients. Few nurses were aware of national physical activity and sedentary behaviour guidelines. Five themes emerged from interviews (nursing role, care challenges, expectations of advocates, teamwork and improving the experience). Overall, many nurses experienced a lack of agency in promoting reduced sedentary behaviour and cognitive dissonance in feeling unable to undertake this role. Conclusions The results of this study are significant in confirming that reducing sedentary behaviour in hospital inpatients is influenced by a range of complex and multi-level factors. There is a fundamental need for organisational and clinical leadership in building a culture and climate in which staff feel empowered to promote reduced sedentary behaviour in their patients. Relevance to clinical practice The results of this study highlight the importance of taking action to reduce sedentary behaviour in sub-acute hospital settings. A co-design approach to developing interventions in local health services is warranted.

Background: For stroke centers performing endovascular procedures, ensuring documentation of post procedure assessments - site and pulse - is not only important for patient safety but also for program certification. Not being able to demonstrate the appropriate documentation during certification site visits can lead to survey findings and action plans that must be created and managed. Use of tools in an EMR can assist the nurse with documentation compliance for these important assessments. Methods: The electronic medical record (EMR) build was mirrored after an already established process for post IV thrombolytic monitoring. When the thrombolytic order set is initiated and the IV thrombolytic medication is documented on the medication administration record, tasks “fire” to the nurse tasklist related to post thrombolytic monitoring for the 24 hour post IV monitoring period. The nurse can select the task on the tasklist and it takes the nurse to the appropriate place to document as well as at the appropriate time to document. Use of this process helped to drive compliance with post IV thrombolytic monitoring documentation. In order to achieve compliance for post procedure assessments documentation, this same process was requested by nursing. To achieve this, the EMR was designed to “fire” tasks to the nurse tasklist when the post thrombectomy order set is initiated and the time hemostasis is achieved is documented; these tasks cover the post thrombectomy monitoring for the required 24 hours. Part of these tasks include post procedure assessments. Results: From May 2019 to October 2019 the average monthly compliance for post procedure assessments was 77.6%. In November 2019, the appropriate tasking function was implemented in the EMR and education related to the new process was provided. From December 2019 to May 2020 average monthly compliance has been 91.1% with a monthly compliance rate greater than 90% since February 2020. Conclusions: Use of the nurse tasklist in an electronic medical can assist the nurse with documentation of post procedure assessments and achieve documentation compliance.

Anxiety in older age is a worldwide problem and co-associated with other mental health problems, physical health conditions, disability, reduced quality of life and increased healthcare utilisation. Yet the symptoms of anxiety are often unrecognised in older people, challenging early diagnosis and increasing the risk of older people developing more chronic and disabling illness. This article reports on research led by mental health nurses and a primary care nurse that supported primary care practitioners to undertake a routine assessment of anxiety in older people in Australia. The Geriatric Anxiety Inventory-Short Form was incorporated into the annual, in-depth 75 years and older, health assessment that is undertaken in primary care settings and funded by Australia's Medicare. An initial feasibility study demonstrated good acceptance levels of the routine assessment by the primary care practitioners. These findings suggest fertile ground for the everyday use of the routine assessment in primary care settings in Australia, with transferability internationally in low-, middle- and high-income global communities. Mental health nurses can play a key role in supporting primary care nurses to recognise and respond to anxiety in older people. Illness prevention and health promotion activities are low cost and have the potential to make a difference worldwide to the health of people across the lifespan.

Background Patients with diabetes and advanced chronic kidney disease face a high health care burden. As part of a patient-oriented research initiative to identify ways to better support patients' diabetes care, we explored their health care experience and solutions for patient-centred diabetes care. Methods We engaged 2 patients with advanced kidney disease and diabetes to join our multidisciplinary team as full research partners. They were involved in our design and conduct of the study, the analysis of the results and knowledge translation. We conducted qualitative interviews (1:1 semistructured interviews and focus groups) with patients with a history of both diabetes (type 1 or 2) and advanced kidney disease including those using dialysis. We identified overarching themes using individual and team analysis and conducted interviews until data saturation was reached. Results Twelve participants were interviewed between October 2017 and February 2018. Six people were interviewed in 2 separate focus groups (consisting of 4 and 2 participants) and 6 participated in 1:1 interviews with our team. Participants described being burdened by medical appointments, strict conflicting diets, costly diabetes therapies and fragmented, siloed health care. They indicated that self-management support, education and coordinated diabetes care might better support their diabetes care. Interpretation Patients with complex medical comorbidities face many challenges traversing a health care system organized around single diseases. Researchers and policy-makers should study and develop patient-centred diabetes care strategies to better support these high-risk patients.

Background: Weight and lifestyle management is advocated as the first-line treatment for polycystic ovary syndrome (PCOS) by evidence-based guidelines. Current literature describes both systems- and individual-related challenges that general practitioners (GPs) face when attempting to implement guideline recommendations for lifestyle management into clinical practice for the general population. The GPs&rsquo, perspective in relation to weight and lifestyle advice for PCOS has not been captured. Methods: Fifteen GPs were recruited to take part in semi-structured interviews. NVIVO software was used for qualitative analysis. Results: We report that GPs unanimously acknowledge the importance of weight and lifestyle management in PCOS. Practice was influenced by both systems-related and individual-related facilitators and barriers. Individual-related barriers include perceived lack of patient motivation for weight loss, time pressures, lack of financial reimbursement, and weight management being professionally unrewarding. System-related barriers include costs of accessing allied health professionals and unavailability of allied health professionals in certain locations. Individual-related facilitators include motivated patient subgroups such as those trying to get pregnant and specific communication techniques such as motivational interviewing. System-related facilitators include the GP&rsquo, s role in chronic disease management. Conclusions: This study contributes to the understanding of barriers and facilitators that could be addressed to optimize weight and lifestyle management in women with PCOS in primary care.

Summary Objective Eating disorders are prevalent among adolescents with type 1 diabetes (T1D). We examined the clinical utility of the Diabetes Eating Problem Survey‐Revised (DEPS‐R), a brief self‐report questionnaire developed for patients with T1D, to identify at‐risk adolescents. We aimed to determine whether a positive DEPS‐R screen was predictive of a formal diagnosis of an eating disorder as per the DSM‐V. In addition, we assessed whether other variables including psychosocial characteristics and diabetes conflict were associated with an abnormal DEPS‐R screen. Methods Cross‐sectional study of 116 T1D adolescents aged 12‐17 years. All participants completed the DEPS‐R screening; both participants and parents completed a questionnaire addressing psychosocial characteristics/conflict around diabetes management. Clinical variables were obtained from participant charts. Differences were examined between positive and negative DEPS‐R groups. Adolescents who screened positive were offered a referral to a specialized eating disorder team for further assessment. Results From 116 participants (mean age ± SD = 14.6 years ± 1.56), 21% (24/116) scored positive for DEPS‐R More females than males had abnormal DEPS‐R (75% vs 25%, P = 0.001). Those with positive DEPS‐R score had higher HbA1c% (mean = 9.3 ± 1.3 vs 8.3 ± 1.2, P = 0.001). Positive DEPS‐R group had higher conflict score for diabetes management in both parents’ and children's assessments (both ps child‐reported conflict (OR = 1.78, 95%CI: 1.02‐3.11, P = 0.044) were predictors of an abnormal DEPS‐R score. Conclusion The DEPS‐R score is a useful clinical tool for identifying T1D adolescents at risk for disordered eating behaviour, but has a low positive predictive value (PPV) for identifying adolescents who meet diagnostic criteria for an eating disorder. Female gender, suboptimal diabetes control and increased conflict in diabetes management are associated with an abnormal DEPS‐R score.

BackgroundTo address guideline-practice gaps and improve management of patients with both diabetes and chronic kidney disease (CKD), we involved patients, health professionals and patient advocacy groups in the co-design and implementation of an integrated diabetes-kidney service.ObjectiveIn this study, we explored the experiences of patients and health-care providers, within this integrated diabetes and kidney service.Methods5 focus groups and 2 semi-structured interviews were conducted amongst attending patients, referring primary health professionals, and attending specialist health professionals. Maximal variation sampling was used for both patients and referring primary health professionals to ensure an equal representation of males and females, and patients of different CKD stages. All discussions were audiotaped and transcribed verbatim, before being thematically analysed independently by 2 researchers.ResultsThe mean age (SD) for specialist health professionals, primary care professionals and patients who participated was 45 (11), 44 (15) and 68 (5) years with men being 50%, 80% and 76% of the participants respectively. Key strengths of the diabetes and kidney service were noted to be better integration of care and a perception of improved health and management of health. Whilst some aspects of access such as time between referral and initial appointment and having fewer appointments improved, other aspects such as in-clinic waiting times and parking remained problematic. Specialist health professionals noted that health professional education could be improved. Patient self-management was also noted by to be an issue with some patients requesting more information and some health professionals expressing difficulty in empowering some patients.ConclusionsHealth professionals and patients reported that a co-designed integrated diabetes kidney service improved integration of care and improved health and management of health. However, some aspects of the process of care, health professional education and patient self-management remained challenging.

Background Cultural beliefs, practices and experiences significantly influence pregnancy preparation. Limited in-depth information exists regarding how women from migrant and refugee backgrounds (migrant women) prepare for pregnancy. This study explored pregnancy planning, preconception lifestyles, awareness, experiences and healthcare needs of migrant women in Australia. Methods Semi-structured interviews and focus groups were conducted with 25 women recruited through a diverse community in Melbourne, Australia (November 2017-February 2018). Discussions explored pregnancy planning, preconception health awareness, experiences and information needs. Qualitative data was analysed iteratively, through content and thematic analysis. Findings Four themes were identified: pregnancy planning experiences and perspectives, preconception health awareness and behaviours, social and cultural influences on pregnancy planning, and health information needs. Women had limited understanding of the concept or importance of preconception health, limited access to preconception health information and most women with children had experienced at least one unplanned pregnancy. Cultural mores constrained community discussion of preconception health in the context of sexual and reproductive health. Social factors emerged as predominant preconception concerns. Women reported wanting more information on preconception health through multiple, broad-reaching avenues, paired with timely, sensitive healthcare engagement. Conclusion Information for women addressing preconception health and pregnancy planning is limited. Our study demonstrates additional cultural and social nuances that need to be understood when working with migrant women. Discomfort raising reproductive and preconception health discussions with healthcare providers was a reported concern. Integration of culturally-sensitive preconception care within routine client assessments warrants exploration. Emphasis of the importance of preconception care for all women is needed.

OBJECTIVE To test the feasibility of general practice nurse (GPN)-led screening for clinically significant symptoms of anxiety (CSSA) in older people and to estimate the prevalence of CSSA. METHODS General practice nurse-led screening for CSSA was undertaken in eight general practices by integrating the five-item Geriatric Anxiety Inventory-Short Form (GAI-SF) into the annual 75 years and older health assessment (75+ HA). Prevalence rates were calculated, and field notes were analysed. RESULTS Over 30 months, 736 patients were screened for CSSA, with a detected prevalence rate of 20.1%. The application of the GAI-SF into the 75+ HA was feasible and readily accepted by patients. CONCLUSIONS The five-item GAI-SF is an age-appropriate screening tool for CSSA in general practice settings. Further research is warranted, particularly in relation to the development and implementation of evidence-informed, general practice-based interventions for CSSA that can be effectively delivered to meet the needs of older people.

Background Multidisciplinary teams (MDTs) are an integral component in the delivery of health care. This is particularly evident in the delivery of cancer care, where multidisciplinary teams are internationally recognized as the preferred method for service delivery. The use of health information systems and technology are key enabling factors for building the capacity of MDTs to engage in improvement and implementation projects but there is scant research on how MDTs make use of technology and information systems or the kinds of systems needed for them to undertake improvement and implementation research. This paper reports findings on how seven MDTs in cancer care utilized technological and information systems and the barriers and enabling factors that impacted on their uptake. Methods Seven multidisciplinary teams from two large metropolitan hospitals participated in the study. Qualitative methods including structured observations and semi structured interviews that explored how teams engaged in research and improvement activities were utilized. Participants were also observed and interviewed in relation to their use of data and health information systems. Findings were subject to content analysis and key themes were identified. Interviews were transcribed and de-identified and key themes were subsequently discussed with participants to allow for member checking and further clarification of findings. Results A total of 43 MDT meetings across seven tumor streams were observed. Of these, observation notes from 13 meetings contained direct references to emerging technologies and health information systems. Findings from 15 semi-structured interviews were also analyzed in relation to how MDTs used technology in weekly meetings, and the perceived impact of technology. Three broad themes emerged: (1) methods for data collection and use by MDTs, (2) the impact of technology on the MDT meeting environment, and (3) the impact of technology and information systems on clinical decision making. Conclusion The study demonstrates that real time data collection and imaging may improve patient centered care coordination. However, ICTs can be used sub-optimally by teams. We therefore urge additional research to identify the enabling factors that support better collection and use of outcome data from ICT. Electronic supplementary material The online version of this article (10.1186/s12913-018-3242-3) contains supplementary material, which is available to authorized users.

Mastectomy rates have increased, coinciding with more advanced reconstruction options. Deep inferior epigastric perforator (DIEP) flaps decrease abdominal donor site morbidity, but require considerable technical expertise. Preoperative computed tomography angiography (CTA) can accurately demonstrate DIEA anatomy and perforator courses, facilitating preoperative planning and flap design, allowing for more targeted intraoperative microdissection. Patients who undergo CTA before DIEP flap have better clinical outcomes with shorter operative times and hospital length of stay, which can decrease overall associated health care costs. Future directions include selected imaging of the thoracic anatomy and recipient vasculature, allowing for additional preoperative planning and customization.

Continuing medical education (CME) is challenging and often has limited impact on clinician behavior or patient outcomes. This study examined the impact of an online Qstream education program on senior clinicians to determine its utility for increasing clinician knowledge about the latest guidelines regarding genetic assessment and consideration of genetic testing for women with particular types of ovarian, fallopian tube and primary peritoneal cancer. Participants were recruited into a pilot study that involved responding to case-based scenarios at spaced and repeated intervals. At the completion of the program, semi-structured interviews were conducted to ascertain the impact on their knowledge and referral behavior. Findings from interviews were subject to thematic analysis that involved the identification of categories and themes. Twenty-one participants commenced the program, seventeen completed and twelve participated in semi-structured interviews. Thematic analysis yielded several themes including knowledge change, curriculum and format and changes in referral patterns. A majority of participants (n = 10) agreed the program had helped update their knowledge about referring women, and eight agreed they would now change their referral patterns. The use of QStream as an approach to CME has significant advantages when working with busy clinicians. QStream has a well accepted format and most participants indicated it is very appropriate for disseminating updates to clinical guidelines and protocols. It is important to supplement CME programs with other implementation techniques, such as audit and feedback as multifaceted approaches are more likely to result in behavior change.

A 32-year-old woman named A.C. was diagnosed five years ago with stage IIIB nodular sclerosing Hodgkin lymphoma (HL). Following initial chemotherapy, she had refractory disease as evidenced by hypermetabolic activity on positron-emission tomography (PET) scan. A.C. was treated with a short course of salvage chemotherapy, stem cell collection, and autologous HSCT about 11 months after initial diagnosis. Her post-transplantation course was complicated by pneumonia and interstitial lung disease secondary to chemotherapy that rapidly improved with high-dose steroids .

The Audit of Disability Research in Australia (hereafter the Audit) identified research about people with disabilities, including psychosocial disability, and their families and carers living in Australia. The Audit covered both scientific and grey literature published in Australia between the years 2000–2013. Because the National Disability Research and Development Agenda (Disability Policy and Research Working Group, 2011) identified four cohorts that experience particular disadvantage, including Aboriginal and Torres Strait Islander people, women with disabilities, those from culturally and linguistically diverse backgrounds and those living in rural and remote Australia, the Audit included a search based on geography. This paper reports on studies identified in the Audit that address disability and mental illness in the rural and remote context. In the literature unclear and overlapping definitions of mental illness and psychosocial disability were considerable challenges for the reviewers and these d...

Aim To use systematic methods to explore the psychosocial facilitators and challenges of insulin pump therapy among people with type 1 diabetes. Background Insulin pump therapy is now widely accepted in the management of type 1 diabetes. Given the increasing use of insulin pumps it is timely to review the evidence relating to the psychosocial impacts of this therapy which have not been addressed in previous reviews. Design An integrative review of the literature (January 2005 – February 2017). Data sources A systematic search of electronic databases: CINAHL, Cochrane, Medline, PsycINFO and Scopus. Review methods Empirical literature reporting psychosocial facilitators and challenges of insulin pump therapy were eligible for inclusion. A constant comparative method was used to guide the review. Quality appraisal was performed using the Mixed Methods Appraisal Tool Version 2011. Results Thirty-five potential articles identified from titles and abstracts were reviewed. Of these, 13 articles were included in the final review. Psychosocial facilitators of insulin pump therapy included the flexibility and freedom it provided for living with diabetes, enhancing social situations and daily management. In contrast challenges included the demands of pump therapy, self-consciousness in wearing the pump and fear of hypoglycaemia and pump failure. Conclusion Findings can be used by health professionals to inform people embarking on insulin pump therapy and prepare them with regard to expectations of the treatment. Further research is required to explore the role of diabetes health professional in providing psychosocial support to people with type 1 diabetes on insulin pump therapy. This article is protected by copyright. All rights reserved.

The subserous space is a large, anatomically continuous potential space that interconnects the chest, abdomen, and pelvis. The subserous space is formed from areolar and adipose tissue, and contains branches of the vascular, lymphatic, and nervous systems. As such, it provides one large continuous space in which many disease processes can spread between the chest, abdomen, and the pelvis.

Objective. To assess a comprehensive, intensive lifestyle intervention in combination with metformin extended release (MXR) or placebo on body mass index (BMI) and risk factors for type 2 diabetes and cardiovascular disease in obese adolescents.Study Design. Sixty-nineobese adolescents (mean BMI 32.5) received a comprehensive lifestyle intervention with structured dietary, physical activity, and behavioral components for 24 months. Subjects were randomized to 1 of 4 groups: MXR (33) 2,000 mg daily or placebo, with either moderate or vigorous intensity exercise for the first 3 months. Subsequently the exercise intervention was the same for all 4 groups.Results.Anthropometry measurements did not differ with initial exercise intensity at any time. At 3 months % body fat decreased in all 4 groups (P<0.006). BMI and % body fat decreased in the MXR groups, but not the placebo groups, at 6 (−0.88, −3.16) and 12 months (−0.56, −2.34) (P<0.05). Insulin resistance, fasting blood glucose, and leptin improved in all groups at 6 and 12 months. A high subject attrition rate (58%) occurred by 24 months.Conclusion. A comprehensive, intensive lifestyle intervention combined with MXR led to a decline in BMI and % body fat at 1 year independent of initial exercise intensity. This trial is registered with ClinicalTrials.govNCT00934570.

Optimal treatment of thyroid cancer is highly dependent on accurate staging of the extent of disease at presentation. Preoperative ultrasonography (US) is the most sensitive method for detecting metastatic lymph nodes and is recommended as part of the standard preoperative workup. Missed findings on preoperative scans may lead to understaging and inadequate surgical management, which subsequently predispose these patients to residual disease postoperatively and a higher risk for recurrence, possibly requiring repeat surgery. Traditionally, thyroid US for pre- and postoperative staging has been performed by radiologists. However, there is a growing trend away from radiologist-performed US in favor of surgeon-performed US. Recent surgical and endocrinology literature has shown that, when compared with surgeon-performed US, radiologist-performed preoperative staging US is less accurate and is inadequate for presurgical planning, with higher local recurrence rates. This review highlights the importance of accurate preoperative US for patients with differentiated thyroid cancer, with specific attention to deficiencies that exist in general radiology department thyroid US reports. We present a standardized approach to neck US reporting that incorporates the newly updated 2015 recommendations from the American Thyroid Association and also addresses the pertinent questions for thyroid surgeons. By ensuring comprehensive preoperative assessment and improving thyroid US reporting, we seek to improve patient access to optimized care. ©RSNA, 2016.

Background Adverse events are a significant quality and safety issue in the hospital setting due to their direct impact on patients. Additionally, such events are often handled by junior doctors due to their direct involvement with patients. As such, it is important for health care organizations to prioritize education and training for junior doctors on identifying adverse events and handling them when they occur. The Cancer Cup Challenge is an educational program focuses on quality improvement and adverse event awareness targeting for junior oncology doctors across three international sites. Methods A mixed methodology was used to develop and evaluate the program. The Qstream spaced learning platform was used to disseminate information to participants, as it has been demonstrated to impact on both knowledge and behavior. Eight short case based scenarios with expert feedback were developed by a multidisciplinary advisory committee containing representatives from the international sites. At the conclusion of the course impact on participant knowledge was evaluated using analysis of the metrics collected by the Qstream platform. Additionally, an online survey and semi-structured interviews were used to evaluate engagement and perceived value by participants. Results A total of 35 junior doctors registered to undertake the Qstream program, with 31 (88.57 %) successfully completing it. Analysis of the Qstream metrics revealed 76.57 % of cases were answered correctly on first attempt. The post-program survey received 17 responses, with 76.47 % indicating cases for the course were interesting and 82.35 % feeling cases were relevant. Finally, 14 participants consented to participate in semi-structured interviews about the program, with feedback towards the course being generally very positive. Conclusions Our study demonstrates that an online game is well accepted by junior doctors as a method to increase their quality improvement awareness. Developing effective and sustainable training for doctors is important to ensure positive patient outcomes are maintained in the hospital setting. This is particularly important for junior doctors as they are working closely with patients and learning skills and behaviors, which will influence their practice throughout their careers.

The placenta has a fundamental role in fetal health and functions as an important bridge to normal fetal development throughout pregnancy. A complete fetal ultrasound (US) survey should include full assessment of the placenta for any possible abnormalities. Placental diseases range from abnormal morphology, size, location, extent, and degree of placentation, to abruption and the presence of rare placental neoplasms of benign or malignant nature. Some of these conditions are associated with other diseases including aneuploidies, and their discovery should alert the radiologist to perform a very thorough fetal US examination. At times, a fetal karyotype may be needed to provide additional information. Timely detection of placental abnormalities can alert the clinician regarding the need to make important management decisions to reduce fetal and maternal morbidity and mortality. Familiarity with the normal and abnormal imaging appearance of the placenta is therefore necessary for the radiologist. Ultrasound with Doppler is the initial imaging modality of choice for placental assessment. Magnetic resonance imaging serves as a problem-solving examination in instances where the US findings are equivocal or where additional information is needed. Computed tomography has a limited role in the evaluation of placental disease because of its relatively limited tissue characterization and in particular because of the resultant direct radiation exposure of the fetus. However, in specific instances, particularly after trauma, computed tomography can provide invaluable information for patient management.

The objective of this study was to evaluate the reliability and accuracy of electrical cardiometry (EC) for the noninvasive determination of cardiac output (CO) in obese children and adolescents. We compared these results with those obtained by transthoracic echocardiography. Sixty-four participants underwent simultaneous measurement of CO. Cardiac output was measured by EC using the ICON(®) device. Simultaneously CO was determined by using transthoracic Doppler echocardiography from parasternal long-axis and apical view. The median age was 12.52 years (range 7.9-17.6 years) and 36 (56 %) were female. A strongly significant correlation was found between the COEC and COEcho measurements (p 0.0001, r = 0.91). Significant correlations were also found between CO and age (r = 0.37, p = 0.002), weight (r = 0.57, p 0.0001), height (0.60, p 0.0001) and BMI (r = 0.42, p = 0.001). The mean difference between the two methods (COEC - COEcho) was 0.015 l min(-1). According to the Bland and Altman method, the upper and lower limits of agreement, defined as mean difference ±2 SD, were +1.21 and -0.91 l min(-1), respectively. Compared to the transthoracic Doppler echocardiography, Electrical Cardiometry provides accurate and reliable CO measurements in obese children and adolescents.

A rising conciousness within both the medical community and in the public has been created by the current levels of radiation exposure from increased use of computed tomography. The concern has prompted the need for more data collection and analysis of hospital and imaging center exam doses. This has spurred the American College of Radiology (ACR) to develop the Dose Index Registry (DIR), which will allow participating insitutions to compare the radiation dose from their CT exams to aggregate national CT dose data based on exam type and body part. We outline the steps involved in the process of enrolling in the DIR, the technical requirements, the challenges we encountered, and our solutions to those challenges. A sample of the quaterly report released by the ACR is presented and discussed. Enrolling in the ACR dose registry is a team effort with participation from IT, a site physicist, and a site radiologist. Participation in this registry is a great starting point to initiate a QA process for monitoring CT dose if none has been established at an institution. The ACR has developed an excellent platform for gathering, analyzing, and reporting CT dose data. Even so, each insititutions will have its own unique issues in joining the project.

High-quality computed tomography (CT) exams are critical to maximizing radiologist’s interpretive ability. Exam quality in part depends on proper contrast administration. We examined injector data from consecutive abdominal and pelvic CT exams to analyze variation in contrast administration. Discrepancies between intended IV contrast dose and flow rate with the actual administered contrast dose and measured flow rate were common. In particular, delivered contrast dose discrepancies of at least 10% occurred in 13% of exams while discrepancies in flow rate of at least 10% occurred in 42% of exams. Injector logs are useful for assessing and tracking this type of variability which may confound contrast administration optimization and standardization efforts.

In the United States, increasing numbers of White women are mothering children of color. Little is known about their psychosocial experiences of racially socializing non-White children within a culture that transmits socially constructed meanings about race. Such messages influence employment and quality and access to health care. Thirteen White mothers of non-White children (school age to adulthood) residing in the U.S. were interviewed. Their psychosocial experiences and racial socialization practices were explored. Through an analysis of transcribed interviews and interview notes, seven themes emerged: (1) Looking Like a Family and Looking Alike; (2) Mothering as Vulnerability; (3) Teen Daughters’ Perceptions of Black Men as Undesirable and Frightening; (4) Exposing Children to Culture; (5) Children and Mothers’ Experiences as “Other”; (6) Hostility from Black Women; and (7) Not Talking About Race. Study's limitations and future research are discussed.

ACCESSIBLE SUMMARY: • There are many challenges associated with rural mental health practice. • There are few education programmes that orientate nursing and allied health clinicians to rural practice. • The authors developed and evaluated an online orientation programme for clinicians commencing work in mental health in rural New South Wales. • The online programme focussed on the survival skills and support structures that may contribute to their retention in rural areas. The aim of this study was to develop and evaluate an online, interprofessional education programme for clinicians commencing work in rural mental health services in New South Wales, Australia. Twenty-eight participants, including nurses, psychologists, social workers and occupational therapists, completed a 24-week education programme (Introduction to Rural Mental Health Practice programme) that orientated clinicians to working in rural settings. The online programme included an orientation to online learning and clinical skills such as risk assessment, therapeutic communication and de-escalation skills applied in rural settings. Twenty-four participants provided pre- and post-evaluation responses that were matched and analysed using paired t-tests to identify any significant differences in mean scores across the domains of interest. Fifty per cent (n= 13) of participants had a background in nursing and 49% were allied health clinicians (psychologists, social workers and occupational therapists). Statistically significant improvements (P Language: en

Objective The aim of the present study was to identify key enabling factors for engaging multidisciplinary teams (MDTs) in cancer care across the spectrum of translational research and quality improvement (QI) projects. Methods The study was conducted in two large Sydney metropolitan hospitals. Qualitative methods, including structured observations of MDT meetings and semi-structured interviews with MDT leaders and champions, were used to identify how teams interact with and generate research and implementation initiatives. Enabling factors for and barriers to the engagement of MDTs in translational research and QI were identified. Results Four key enabling factors emerged from the analysis of data generated from observing 43 MDT meetings and 18 semi-structured interviews: (1) access to high-quality data around individual and team performance; (2) research-active team leaders; (3) having experts, such as implementation scientists, embedded into teams; and (4) having dedicated research or QI-focused meetings. Barriers included a lack of time, administrative support, research expertise and access to real-time data. Conclusions The identification of enabling factors for and barriers to translational research and QI provides evidence for how multidisciplinary cancer care teams may best be engaged in research and QI that aims to improve service and care outcomes. What is known about the topic? MDTs are key to the delivery of cancer care in Australia, but there is scant research into how teams can best be engaged in translating research from basic science through to implementation science and QI. What does this paper add? This paper provides new evidence from an immersive study of cancer care MDTs in two large metropolitan hospitals in Sydney (NSW, Australia), regarding the key enabling factors for and barriers to successful engagement in translational research and QI in cancer care. What are the implications for practitioners? Cancer care professionals in MDTs are presented with an opportunity to embed translational research and QI into cancer care. MDTs can operate as an ideal vehicle to look beyond individual patient outcomes to broader trends and population health outcomes.

Background Collaborative research networks are often touted as a solution for enhancing the translation of knowledge, but questions remain about how to evaluate their impact on health service delivery. This pragmatic scoping study explored the enabling factors for developing and supporting a collaborative imaging network in a metropolitan university in Australia. Methods An advisory group was established to provide governance and to identify key informants and participants. Focus group discussions (n = 2) and semi-structured interviews (n = 22) were facilitated with representatives from a broad range of disciplines. In addition, a survey, a review of relevant websites (n = 15) and a broad review of the literature were undertaken to elicit information on collaborative research networks and perceived needs and factors that would support their involvement in a multi-disciplinary collaborative research network. Findings were de-identified and broad themes were identified. Results Participants identified human factors as having priority for developing and sustaining a collaborative research network. In particular, leadership, a shared vision and a communication plan that includes social media were identified as crucial for sustaining an imaging network in health research. It is important to develop metrics that map relationships between network members and the role that communication tools can contribute to this process. Conclusions This study confirms that human factors remain significant across a range of collaborative endeavours. The use of focus group discussions, interviews, and literature and website reviews means we can now strongly recommend the primacy of human factors. More work is needed to identify how the network operates and what specific indicators or metrics help build the capacity of clinicians and scientists to participate in translational research.

Background This study aimed to explore barriers to and enablers for future implementation of a draft clinical pathway for anxiety and depression in cancer patients in the Australian context. Methods Health professionals reviewed a draft clinical pathway and participated in qualitative interviews about the delivery of psychosocial care in their setting, individual components of the draft pathway, and barriers and enablers for its future implementation. Results Five interrelated themes were identified: ownership; resources and responsibility; education and training; patient reluctance; and integration with health services beyond oncology. Conclusions The five themes were perceived as both barriers and enablers and provide a basis for an implementation plan that includes strategies to overcome barriers. The next steps are to design and deliver the clinical pathway with specific implementation strategies that address team ownership, endorsement by leaders, education and training modules designed for health professionals and patients and identify ways to integrate the pathway into existing cancer services. Sydney Catalyst Translational Cancer Research Centre, Pilot and seed funding grant, P&S2012_CIA_Butow

Background Though recent data suggest that multidisciplinary outpatient interventions can have a positive effect on childhood obesity, it is still unclear which program components are most beneficial and how they affect quality of life (QoL). The aim of this study was to determine if a 1-year multidisciplinary, family-centered outpatient intervention based on social cognitive theory would be effective in (i) preventing further increases in BMI and BMI z-score, and (ii) improving QoL in obese children and adolescents. Methods Obese children and adolescents 8–17 years of age and their families participated in this 1-year longitudinal pilot intervention study. The intervention consisted of fifteen 90-minute educational sessions led by a dietitian, exercise specialist, and social worker. Anthropometric measures, body composition, and QoL (Pediatric Quality of Life Inventory 4.0), were assessed at baseline, 3 months, and 12 months. Laboratory values were measured at baseline and 12 months. The primary outcome measures were change in BMI and BMI z-score, secondary outcome measures included change in QoL and body composition. A paired sample t-test was used to assess within-group differences and 95% confidence intervals were reported for the mean differences. Results 42 obese children and adolescents (21 girls) completed the 1-year intervention (mean age 12.8 ± 3.14 years). Mean baseline BMI was 31.96 ± 5.94 kg/m2 and BMI z-score was +2.19 ± 0.34. Baseline QoL (self-assessments and parental assessments) was impaired: mean baseline scores were 74.5 ± 16.5 and 63.7 ± 19.4 for physical functioning and 69.0 ± 14.9 and 64.0 ± 18.3 for emotional functioning, respectively. At 12 months, BMI z-score had decreased (−0.07 ± 0.11, 95% CI: −0.11 to −0.04). BMI (0.80 ± 1.57 kg/m2, 95% CI 0.31 to 1.29) and fat-free mass (4.02 ± 6.27 kg, 95% CI 1.90 to 6.14) increased, but % body fat and waist circumference did not. Both the parent-reported physical (11.3 ± 19.2, 95% CI 4.7 to 17.9) and emotional (7.7 ± 15.7, 95% CI 2.3 to 13.0) functioning QoL scores and the children's self-reported physical (5.3 ± 17.1, 95% CI 0.5 to 11.1) and emotional (7.9 ± 14.3, 95% CI 3.2 to 12.7) functioning scores significantly improved. Conclusions Following a 1-year intervention, the participants’ BMI z-scores and QoL improved, while other adiposity-related measures of body composition remained unchanged. Trial registration UMIN Clinical Trials Registry UMIN000015622. Electronic supplementary material The online version of this article (doi:10.1186/s12887-014-0296-1) contains supplementary material, which is available to authorized users.

BackgroundThe Opioid Treatment Accreditation Course (OTAC) is a mandatory accreditation requirement in New South Wales, Australia, and aims to prepare medical practitioners for the provision of safe and effective Opioid Substitution Treatment to people with opioid dependence. The course has a strong focus on safe prescribing practices and the course design includes a Professional Practice Forum that is engaging for participants and effective at imparting complex ideas and concepts that do not place additional time constraints on already time-poor health professionals. ObjectiveThe study aimed to use participatory action research methods to develop and evaluate an online Professional Practice Forum that is a key component of the OTAC teaching and learning experience. MethodsThree evaluation cycles were implemented with three cohorts of participants (N=40) to inform the design and review of the updated OTAC course. Overall, the study relied on participatory action research methods to enhance a sense of online community and to revise the Professional Practice Forum component of the course. Findings from survey feedback and an examination of Web metrics were used to monitor participant learning and were subsequently subject to thematic analysis in order to identify key themes. ResultsThe use of participatory action techniques in the redesign of the OTAC course was a successful means of engaging with participants and resulted in four revisions based on feedback from facilitators and participants. The Professional Practice Forum was rated highly and received positive feedback from both moderators and participants. ConclusionsThe use of interactive forums in online learning in an educational module for adult learners can prove extremely valuable as a means for participants to share their expertise and improve their learning outcomes. In particular, the use of sticky and welcome threads were significant features that enhanced interactions between participants and facilitators and resulted in increased quantity and quality of postings. These findings can help inform future researchers on how to develop peer engagement modules that are amenable to assessment and that build an online sense of community.

The rate of cesarean deliveries continues to rise, while the rate of vaginal delivery after cesarean birth continues to decline. Many women now tend to undergo multiple cesarean deliveries, and therefore the associated chronic maternal morbidities are of growing concern. Accurate diagnosis of these conditions is crucial in maternal and fetal well-being. Many of these complications are diagnosed by imaging, and radiologists should be aware of the type and imaging appearances of these conditions.

Older legacy bariatric surgical procedures, including jejunocolic bypass, jejunoileal bypass, vertical banded gastroplasty, and biliopancreatic diversion, are no longer performed. Biliopancreatic diversion with duodenal switch is still performed in select centers. Although the legacy procedures are no longer performed, there are still patients who have undergone these surgeries in the past who are currently either under continuous surveillance or are being evaluated for surgical conversion or revision because of complications or weight regain. The purpose of this article is to describe the evolutionary development of various bariatric surgical techniques and the associated surgical anatomy. Because these procedures are no longer performed, only limited imaging of legacy bariatric surgeries is available for radiologic demonstration.Although earlier bariatric surgical techniques are no longer favored, there are still patients who underwent these procedures who require imaging evaluation for clinical follow-up or surgical revision. Understanding the radiologic-surgical anatomy of these older bariatric procedures can help in the prompt and appropriate management of these patients.

Publication bias is the preferential publication of research with positive results, and is a threat to the validity of medical literature. Preliminary evidence suggests that research in blood and marrow transplantation (BMT) lacks publication bias. We evaluated publication bias at an international conference, the 2006 Center for International Blood and Marrow Transplant Research (CIBMTR)/American Society for Blood and Marrow Transplantation (ASBMT) “tandem” meeting. All abstracts were categorized by type of research, funding status, number of centers, sample size, and direction of the results. Publication status was then determined for the abstracts by searching PubMed. Of 501 abstracts, 217 (43%) were later published as complete manuscripts. Abstracts with positive results were more likely to be published than those with negative or unstated results (P = .001). Furthermore, positive studies were published in journals with a mean impact factor of 6.92, whereas journals in which negative/unstated studies were published had an impact factor of only 4.30 (P = .02). We conclude that publication bias exists in the BMT literature. Full publication of research, regardless of direction of results, should be encouraged and the BMT community should be aware of the existence of publication bias.

Background Childhood obesity is a serious health concern affecting over 155 million children in developed countries worldwide. Childhood obesity is associated with significantly increased risk for development of type 2 diabetes, cardiovascular disease and psychosocial functioning problems (i.e., depression and decreased quality of life). The two major strategies for management of obesity and associated metabolic abnormalities are lifestyle modification and pharmacologic therapy. This paper will provide the background rationale and methods of the REACH childhood obesity treatment program. Methods/design The REACH study is a 2-year multidisciplinary, family-based, childhood obesity treatment program. Seventy-two obese adolescents (aged 10-16 years) and their parents are being recruited to participate in this randomized placebo controlled trial. Participants are randomized to receive either metformin or placebo, and are then randomized to a moderate or a vigorous intensity supervised exercise program for the first 12-weeks. After the 12-week exercise program, participants engage in weekly exercise sessions with an exercise facilitator at a local community center. Participants engage in treatment sessions with a dietitian and social worker monthly for the first year, and then every three months for the second year. The primary outcome measure is change in body mass index and the secondary outcome measures are changes in body composition, risk factors for type 2 diabetes and cardiovascular disease, changes in diet, physical activity, and psychosocial well-being (e.g., quality of life). It is hypothesized that participants who take metformin and engage in vigorous intensity exercise will show the greatest improvements in body mass index. In addition, it is hypothesized that participants who adhere to the REACH program will show improvements in body composition, physical activity, diet, psychosocial functioning and risk factor profiles for type 2 diabetes and cardiovascular disease. These improvements are expected to be maintained over the 2-year program. Discussion The findings from this study will advance the knowledge regarding the long-term efficacy and sustainability of interventions for childhood obesity. Trial Registration ClinicalTrials.gov number NCT00934570

Objective: It is well established that people who work with clients who are dependent on substances need to be well equipped to deal with challenging and complex situations. Our research explores the experience of alcohol and other drug workers (AODW) in order to identify how successful Australia's teaching institutions are at preparing AODWs to meet this challenge. Design: Interviews were conducted to ascertain the perceived gaps in existing training programs and the perceived training needs of AODW. Using a qualitative research approach in-depth interviews were conducted with more than 20 counsellors working in six AODW rehabilitation centres in regional New South Wales. Results: There was a perception among all workers that their training had been inadequate and that the preparation for employment in AODW settings had not meet the felt needs of grass-roots workers leaving them to learn through experience. Conclusion: Considering the recommendations of both national and state policies on AODWs in Australia there is an urgent need to develop courses relevant to the needs of workers as suggested by respondents to this research.

Background: Transition from pediatric to adult diabetes care is a high risk period during which there is an increased rate of disengagement from care. Suboptimal transition has been associated with higher risks for acute and chronic diabetes-related complications. The period of emerging adulthood challenges current systems of healthcare delivery as many young adults with type 1 diabetes (T1D) default from diabetes care and are at risk for diabetes complications which are undetected and therefore untreated. Despite the importance of minimizing loss to follow-up there are no randomized control trials evaluating models of transition from pediatric to adult diabetes care.Methods/Design: This is a multicentre randomized controlled trial. A minimum of 188 subjects with T1D aged between 17 and 20 years will be evaluated. Eligible subjects will be recruited from three pediatric care centres and randomly assigned in a 1:1 ratio to a structured transition program that will span 18 months or to receive standard diabetes care. The structured transition program is a multidisciplinary, complex intervention aiming to provide additional support in the transition period. A Transition Coordinator will provide transition support and will provide the link between pediatric and adult diabetes care. The Transition Coordinator is central to the intervention to facilitate ongoing contact with the medical system as well as education and clinical support where appropriate. Subjects will be seen in the pediatric care setting for 6 months and will then be transferred to the adult care setting where they will be seen for one year. There will then be a one-year follow-up period for outcome assessment. The primary outcome is the proportion of subjects who fail to attend at least one outpatient adult diabetes specialist visit during the second year after transition to adult diabetes care. Secondary outcome measures include A1C frequency measurement and levels, diabetes related emergency room visits and hospital admissions, frequency of complication screening, and subject perception and satisfaction with care.Discussion: This trial will determine if the support of a Transition Coordinator improves health outcomes for this at-risk population of young adults.Trial registration: Trial Registration Number: NCT01351857. © 2013 Spaic et al.; licensee BioMed Central Ltd.