Mannitol for acute traumatic brain injury.

BACKGROUND: Mannitol is sometimes dramatically effective in reversing acute brain swelling, but its effectiveness in the on-going management of severe head injury remains open to question. There is evidence that, in prolonged dosage, mannitol may pass from the blood into the brain, where it might cause reverse osmotic shifts that increase intracranial pressure. OBJECTIVES: To assess the effects of different mannitol therapy regimens, of mannitol compared to other intracranial pressure (ICP) lowering agents, and to quantify the effectiveness of mannitol administration given at other stages following acute traumatic brain injury. SEARCH STRATEGY: The review drew on the search strategy for the Injuries Group as a whole. We checked reference lists of trials and review articles, and contacted authors of trials. SELECTION CRITERIA: Randomised trials of mannitol, in patients with acute traumatic brain injury of any severity. The comparison group could be placebo-controlled, no drug, different dose, or different drug. Trials where the intervention was started more than eight weeks after injury, and cross-over trials were excluded. DATA COLLECTION AND ANALYSIS: The reviewers independently rated quality of allocation concealment and extracted the data. Relative risks (RR) and 95% confidence intervals (CI) were calculated for each trial on an intention to treat basis. MAIN RESULTS: Overall there were few eligible trials. In the pre-operative management of patients with acute intracranial haemorrhage the administration of high-dose mannitol resulted in reduced mortality (RR=0.55; 95%CI 0.36, 0.84) and reduced death and severe disability (RR=0.58; 95%CI 0.45, 0.74) when compared with conventional-dose mannitol. One trial compared ICP-directed therapy to 'standard care' (RR for death= 0.83; 95%CI 0.47,1.46). One trial compared mannitol to pentobarbital (RR for death = 0.85; 95% CI 0.52, 1.38). No trials compared mannitol to other ICP-lowering agents. One trial tested the effectiveness of pre-hospital administration of mannitol against placebo (RR for death=1.75; 95% CI 0.48, 6.38). REVIEWER'S CONCLUSIONS: High-dose mannitol appears to be preferable to conventional-dose mannitol in the pre-operative management of patients with acute intracranial haematomas. However, there is little evidence about the use of mannitol as a continuous infusion in patients with raised intracranial pressure in patients who do not have an operable intracranial haematoma. Mannitol therapy for raised ICP may have a beneficial effect on mortality when compared to pentobarbital treatment. ICP-directed treatment shows a small beneficial effect compared to treatment directed by neurological signs and physiological indicators. There are insufficient data on the effectiveness of pre-hospital administration of mannitol to preclude either a harmful or a beneficial effect on mortality

Determinants of access to chronic illness care: a mixed-methods evaluation of a national multifaceted chronic disease package for Indigenous Australians

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ OBJECTIVES: Indigenous Australians have a disproportionately high burden of chronic illness, and relatively poor access to healthcare. This paper examines how a national multicomponent programme aimed at improving prevention and management of chronic disease among Australian Indigenous people addressed various dimensions of access.DESIGN: Data from a place-based, mixed-methods formative evaluation were analysed against a framework that defines supply and demand-side dimensions to access. The evaluation included 24 geographically bounded 'sentinel sites' that included a range of primary care service organisations. It drew on administrative data on service utilisation, focus group and interview data on community members' and service providers' perceptions of chronic illness care between 2010 and 2013.SETTING: Urban, regional and remote areas of Australia that have relatively large Indigenous populations.PARTICIPANTS: 670 community members participated in focus groups; 374 practitioners and representatives of regional primary care support organisations participated in in-depth interviews.RESULTS: The programme largely addressed supply-side dimensions of access with less focus or impact on demand-side dimensions. Application of the access framework highlighted the complex inter-relationships between dimensions of access. Key ongoing challenges are achieving population coverage through a national programme, reaching high-need groups and ensuring provision of ongoing care.CONCLUSIONS: Strategies to improve access to chronic illness care for this population need to be tailored to local circumstances and address the range of dimensions of access on both the demand and supply sides. These findings highlight the importance of flexibility in national programme guidelines to support locally determined strategies

A case control study of breast cancer risk and exposure to injectable progestogen contraceptives

No Abstract

The response to COVID-19 among drug retail outlets in Indonesia: A cross-sectional survey of knowledge, attitudes, and practices

Background: Pharmacists have been at the frontline of the COVID-19 response in Indonesia, providing medicines, advice, and referral services often in areas with limited healthcare access. This study aimed to explore their knowledge, attitudes, and practices during the pandemic, so that we can be better prepared for future emergencies. / Methods: A cross-sectional online survey of community pharmacists and pharmacy technicians in Indonesia was conducted between July and August 2020. The dataset was analysed descriptively, and logistic regression was used to explore willingness to participate in COVID-19 interventions. / Findings: 4716 respondents participated in the survey. Two-thirds (66·7%) reported knowing only “a little” about COVID-19 and around a quarter (26·6%) said they had not received any COVID-19 guidelines. Almost all were concerned about being infected (97·2%) and regularly took steps to protect themselves and their clients (87·2%). Stock-outs of Personal Protective Equipment (PPE) and other products (32·3%) was the main reason for not taking any precautions. Around a third (37·7%) mentioned having dispensed antibiotics to clients suspected of having COVID-19. To support COVID-19 response efforts, most respondents were willing to provide verbal advice to clients (97·8%), distribute leaflets to clients (97·7%), and participate in surveillance activities (88·8%). Older respondents, those identifying as male, and those working in smaller outlets were more willing to provide information leaflets. Those working in smaller outlets were also more willing to engage in outbreak surveillance. / Interpretation: Drug retail outlets continue to operate at the frontline of disease outbreaks and pandemics around the world. These providers have an important role to play by helping to reduce the burden on facilities and providing advice and treatment. To fulfil this role, drug retail outlets require regular access to accurate guidelines and steady supplies of PPE. Calls for drug retail outlet staff to plat in response efforts including the provision of information to clients and surveillance could ease escalating pressures on the health system during future outbreaks. / Funding: This study was funded by a grant from the Department of Foreign Affairs and Trade, Australia, under the Stronger Health Systems for Health Security Scheme

Qualitative perspectives on the sustainability of sexual health continuous quality improvement in clinics serving remote Aboriginal communities in Australia

OBJECTIVES:To examine barriers and facilitators to sustaining a sexual health continuous quality improvement (CQI) programme in clinics serving remote Aboriginal communities in Australia. DESIGN:Qualitative study. SETTING:Primary health care services serving remote Aboriginal communities in the Northern Territory, Australia. PARTICIPANTS:Seven of the 11 regional sexual health coordinators responsible for supporting the Northern Territory Government Remote Sexual Health Program. METHODS:Semi-structured in-depth interviews conducted in person or by telephone; data were analysed using an inductive and deductive thematic approach. RESULTS:Despite uniform availability of CQI tools and activities, sexual health CQI implementation varied across the Northern Territory. Participant narratives identified five factors enhancing the uptake and sustainability of sexual health CQI. At clinic level, these included adaptation of existing CQI tools for use in specific clinic contexts and risk environments (eg, a syphilis outbreak), local ownership of CQI processes and management support for CQI. At a regional level, factors included the positive framing of CQI as a tool to identify and act on areas for improvement, and regional facilitation of clinic level CQI activities. Three barriers were identified, including the significant workload associated with acute and chronic care in Aboriginal primary care services, high staff turnover and lack of Aboriginal staff. Considerations affecting the future sustainability of sexual health CQI included the need to reduce the burden on clinics from multiple CQI programmes, the contribution of regional sexual health coordinators and support structures, and access to and use of high-quality information systems. CONCLUSIONS:This study contributes to the growing evidence on how CQI approaches may improve sexual health in remote Australian Aboriginal communities. Enhancing sustainability of sexual health CQI in this context will require ongoing regional facilitation, efforts to build local ownership of CQI processes and management of competing demands on health service staff.Praveena Gunaratnam, Gill Schierhout, Jenny Brands, Lisa Maher, Ross Bailie, James Ward, Rebecca Guy, Alice Rumbold, Nathan Ryder, Christopher K Fairley, Basil Donovan, Liz Moore, John Kaldor, Stephen Bel

The influence of contextual factors on healthcare quality improvement initiatives:a realist review

Background Recognising the influence of context and the context-sensitive nature of quality improvement (QI) interventions is crucial to implementing effective improvements and successfully replicating them in new settings, yet context is still poorly understood. To address this challenge, it is necessary to capture generalisable knowledge, first to understand which aspects of context are most important to QI and why, and secondly, to explore how these factors can be managed to support healthcare improvement, in terms of implementing successful improvement initiatives, achieving sustainability and scaling interventions. The research question was how and why does context influence quality improvement initiatives in healthcare? Methods A realist review explored the contextual conditions that influence healthcare improvement. Realist methodology integrates theoretical understanding and stakeholder input with empirical research findings. The review aimed to identify and understand the role of context during the improvement cycle, i.e. planning, implementation, sustainability and transferability; and distil new knowledge to inform the design and development of context-sensitive QI initiatives. We developed a preliminary theory of the influence of context to arrive at a conceptual and theoretical framework. Results Thirty-five studies were included in the review, demonstrating the interaction of key contextual factors across healthcare system levels during the improvement cycle. An evidence-based explanatory theoretical model is proposed to illustrate the interaction between contextual factors, system levels (macro, meso, micro) and the stages of the improvement journey. Findings indicate that the consideration of these contextual factors would enhance the design and delivery of improvement initiatives, across a range of improvement settings. Conclusions This is the first realist review of context in QI and contributes to a deeper understanding of how context influences quality improvement initiatives. The distillation of key contextual factors offers the potential to inform the design and development of context-sensitive interventions to enhance improvement initiatives and address the challenge of spread and sustainability. Future research should explore the application of our conceptual model to enhance improvement-planning processes