Culturally appropriate psychotherapy and its retention: An example from Far North Queensland (Australia)

BACKGROUND

Culturally appropriate mental health care is essential in remote Australia. However, while associated with the development of an effective therapeutic alliance, current literature insufficiently reports the retention and psychotherapy outcomes of Indigenous adults. We aimed to describe the characteristics and retention of clients attending the Far North Mental Health and Wellbeing Service (FNS).

METHODS

We conducted a retrospective cross-sectional study on clients who received one or more psychotherapy consultations between 1st July 2019 and 31st December 2020. Population, entrance, and treatment characteristics were described, with retention compared between the major cultural groups. Entrance characteristics comprised referral pathway and reason for presentation and were investigated as alternative predictors of client retention.

FINDINGS

There were 186 non-Indigenous (68.3 % female) and 174 Indigenous (62.6 % female) clients, with a median number of 3.0 consultations (IQR 2.0-5.3). Indigenous status did not significantly predict retention. Referral pathway significantly predicted the number of consultations (Wald X2(6) = 17.67, p = .0071) and immediate discontinuation (Wald X2(6) = 12.94, p = .044), with self-referred clients having the highest retention. Initial presentation reason significantly predicted the number of consultations (Wald X2(5) = 13.83, p = .017), with clients with potential health hazards related to socioeconomic and psychosocial circumstances having the lowest retention. Significantly more Indigenous clients presented for this reason (20.1 % vs 4.3 %).

INTERPRETATION

Comparable retention of Indigenous clients suggests cultural appropriateness of the psychotherapy being delivered by the FNS. Services might use the described therapeutic approach as a guide for culturally appropriate care.

Air Medical Retrieval of Central Australian Women in Labor: A Retrospective Observational Study

OBJECTIVE

The aim of this study was to describe the characteristics and outcomes of remote-dwelling pregnant women with threatened labor referred for air medical retrieval to a regional birthing center as well as factors associated with birth within 48 hours.

METHODS

This was a retrospective observational study of all pregnant women in the remote Central Australian region referred to the Medical Retrieval Consultation and Coordination Centre for labor > 23 weeks' gestation between February 12, 2018, and February 12, 2020. Univariate and multivariate statistical analyses were performed.

RESULTS

There were 116 women referred for retrieval for labor. There were no births during transport, and less than half of the cases resulted in birth within 48 hours of retrieval. Tocolysis was frequently used. Predictors of birth within 48 hours were cervical dilatation ≥ 5 cm, preterm gestational age, and ruptured membranes in the univariate analysis. Nearly one third of this cohort required intervention or had complications during birth.

CONCLUSION

Birth during transport for threatened labor did not occur in this cohort, and more than half of the retrievals did not result in birth within 48 hours; however, the high risk of birth complications may offset any benefit of avoiding air medical transport from remote regions. Retrieval clinicians should consider urgent transfer in cases of ruptured membranes, cervical dilatation of 5 cm or more, or gestational age less than 37 weeks.

Western Australia remote aeromedical substance use disorders outcomes

INTRODUCTION

Substance use disorders (SUDs) cause significant harm to regional Australians, who are more likely to misuse alcohol and other drugs (AODs) and encounter difficulty in accessing treatment services. The primary aims of this study were to describe the demographics of patients aeromedically retrieved from regional locations and compare hospital outcomes with a metropolitan-based cohort.

AIMS

Retrospective case-controlled cohort study. Participants were aeromedically retrieved within Western Australia for SUDs between 1 July 2014 and 30 June 2019. Retrieved patients were case-matched based on age and hospital discharge diagnosis. Descriptive statistics and χ2 analysis were used to summarise the findings.

RESULTS

One hundred thirty-six (91.3%) aeromedical retrievals were found, with the majority being male (n = 95; 69.9%). These were case-matched to 427 metropolitan patients, the majority male (n = 321; 75.2%). Retrieved patients were more likely (all P < 0.05) Indigenous (odds ratio [OR], 9.35 [95% confidence interval (CI), 5.96-14.85]), unemployed (OR, 2.9 [95% CI, 1.41-6.80]), referred to a tertiary hospital (OR, 2.18 [95% CI, 1.24-3.86]) and to stay longer in hospital (OR, 1.08 [95% CI, 1.02-1.14]).

DISCUSSION

Findings highlight that unmarried and/or unemployed males were overrepresented in the retrieval group, with over half identifying as Indigenous. Regional variation in retrievals was noted, while amphetamine-type stimulants featured prominently in the retrieval cohort, who experienced longer hospital stays and more restrictive treatment.

CONCLUSIONS

Comparing clinical outcomes for retrieved regional patients experiencing SUDs, service design and delivery should focus on offering culturally safe care for Indigenous people, catering for regional health care catchment areas, while ideally adopting collaborative and integrated approaches between AODs and mental health services.

A novel COVID-19 program, delivering vaccines throughout rural and remote Australia

Background

The Royal Flying Doctor Service of Australia (RFDS) established a unique SARS-CoV-2 vaccination program for vaccinating Australians that live in rural and remote areas. This paper describes the preparation and response phases of the RFDS response.

Methods

This study includes vaccinations conducted by the RFDS from 01 January 2021 until 31 December 2021 when vaccines were mandatory for work and social activities. Prior to each clinic, we conducted community consultation to determine site requirements, patient characteristics, expected vaccination numbers, and community transmission rates.

Findings

Ninety-five organizations requested support. The majority (n = 60; 63.2%) came from Aboriginal Community Controlled Health Organizations. Following consultation, 360 communities were approved for support. Actual vaccinations exceeded expectations (n = 70,827 vs. 49,407), with a concordance correlation coefficient of 0.88 (95% CI, 0.83, 0.93). Areas that reported healthcare workforce shortages during the preparation phase had the highest population proportion difference between expected and actual vaccinations. Areas that reported high vaccine hesitancy during the preparation phase had fewer than expected vaccines. There was a noticeable increase in vaccination rates in line with community outbreaks and positive polymerase chain reaction cases [r (41) = 0.35, p = 0.021]. Engagement with community leaders prior to clinic deployment was essential to provide a tailored response based on community expectations.

The Royal Flying Doctor Service Initiation of Helicopter Video Simulation Orientation Training for Air Medical Crews in Western Australia: A Pilot Study

OBJECTIVE

In May 2022, the Royal Flying Doctor Service Western Operations in Western Australia pioneered the introduction of the first organizational helicopter emergency service with 2 Eurocopter EC145 helicopters. This article describes the pilot study undertaken, assessing the implementation and flight crew confidence outcomes of the supplementation of video simulation training to standard clinical training for helicopter air medical retrieval.

METHODS

Survey assessments using a 5-point Likert scale provided anonymous demographic data with summarized results of the means and standard deviations. Nonparametric tests were used to compare responses between the control and experimental groups from pretraining to postintervention to postpractical.

RESULTS

The findings showed an increase in confidence rates after a classroom session and further increases after a practical session in the control group. The intervention group showed a small rise in overall confidence levels after being shown video simulations following the completion of their classroom session before commencing their practical session. This study established that regardless of the airframe, clinical staff, often with significant experience in air medical retrieval and critical care medicine, do not automatically have confidence in performing critical care procedures in a new aircraft type to which they have not previously been oriented. The results display a statistically significant increase in confidence levels in procedural performance after the classroom session compared with the pretraining questionnaire, with a subtle further rise when video simulations are included in the classroom session. When a classroom session is subsequently supplemented with a practical simulation session, confidence levels continue to rise.

CONCLUSION

Implementing a comprehensive educational strategy including classroom and practical elements for clinical staff in their orientation to new aircraft improves their confidence in performing critical care procedures if required in flight. The addition of in-flight prerecorded videos demonstrating these critical care procedures is a useful adjunct to simulation training for flight crew in air medical retrieval, and further analytical studies may indeed show a statistically significant improvement in staff confidence.

Aeromedical retrieval services characteristics globally: a scoping review

BACKGROUND

Aeromedical emergency retrieval services play an important role in supporting patients with critical and often life-threatening clinical conditions. Aeromedical retrieval services help to provide fast access to definitive care for critically ill patients in under-served regions. Typically, fixed-wing aeromedical retrieval becomes the most viable transport option compared with rotary-wing aircraft when distances away from centres of definitive care extend beyond 200 kms. To our knowledge, there are no studies that have investigated fixed-wing aeromedical services in the member countries of the organisation for economic cooperation and development (OECD). A description of the global characteristics of aeromedical services will inform international collaboration to optimise clinical outcomes for patients.

AIM

In this scoping review, we aimed to describe the features of government- and not-for-profit organisation-owned fixed-wing aeromedical retrieval services in some of the member countries of the OECD.

METHODS

We followed scoping review methodology based on the grey literature search strategy identified in earlier studies. This mostly involved internet-based searches of the websites of fixed-wing aeromedical emergency retrieval services affiliated with the OECD member countries.

RESULTS

We identified 460 potentially relevant records after searching Google Scholar (n = 24) and Google search engines (n = 436). After removing ineligible and duplicate information, this scoping review identified 86 government-and not-for-profit-operated fixed-wing aeromedical retrieval services as existing in 17 OECD countries. Concentrations of the services were greatest in the USA followed by Australia, Canada, and the UK. The most prevalent business models used across the identified OECD member countries comprised the government, not-for-profit, and hybrid models. Three-quarters of the not-for-profit and two-fifths of the hybrid business models were in the USA compared to other countries studied. The government or state-funded business model was most common in Australia (11/24, 46%), Canada (4/24, 17%), and the UK (4/24, 17%). The frequently used service delivery models adopted for patients of all ages included primary/secondary retrievals, secondary retrievals only, and service specialisation models. Of these service models, primary/secondary retrieval involving the transportation of adults and children from community clinics and primary health care facilities to centres of definitive care comprised the core tasks performed by most of the aeromedical retrieval services studied. The service specialisation model provided an extra layer of specialist health care dedicated to the transportation of neonates and paediatrics. At least eight aeromedical retrieval services catered solely for children from birth to 16 years of age. One aeromedical service, the royal flying doctor service in Australia also provided primary health care and telehealth services in addition to primary retrieval and interhospital transfer of patients. The doctor and registered nurse/paramedic (Franco-German model) and the nurse and/or paramedic (Anglo-American model) configurations were the most common staffing models used across the aeromedical services studied.

CONCLUSIONS

The development and composition of fixed-wing aeromedical emergency retrieval services operated by not-for-profit organisations and governments in the OECD countries showed diversity in terms of governance arrangements, services provided, and staffing models used. We do not fully understand the impact of these differences on the quality of service provision, including equitable service access, highlighting a need for further research.

Digitizing clinical trials

Clinical trials are a fundamental tool used to evaluate the efficacy and safety of new drugs and medical devices and other health system interventions. The traditional clinical trials system acts as a quality funnel for the development and implementation of new drugs, devices and health system interventions. The concept of a "digital clinical trial" involves leveraging digital technology to improve participant access, engagement, trial-related measurements, and/or interventions, enable concealed randomized intervention allocation, and has the potential to transform clinical trials and to lower their cost. In April 2019, the US National Institutes of Health (NIH) and the National Science Foundation (NSF) held a workshop bringing together experts in clinical trials, digital technology, and digital analytics to discuss strategies to implement the use of digital technologies in clinical trials while considering potential challenges. This position paper builds on this workshop to describe the current state of the art for digital clinical trials including (1) defining and outlining the composition and elements of digital trials; (2) describing recruitment and retention using digital technology; (3) outlining data collection elements including mobile health, wearable technologies, application programming interfaces (APIs), digital transmission of data, and consideration of regulatory oversight and guidance for data security, privacy, and remotely provided informed consent; (4) elucidating digital analytics and data science approaches leveraging artificial intelligence and machine learning algorithms; and (5) setting future priorities and strategies that should be addressed to successfully harness digital methods and the myriad benefits of such technologies for clinical research.

Granulocytic myeloid-derived suppressor cells (GR-MDSC) accumulate in cord blood of preterm infants and remain elevated during the neonatal period

Preterm delivery is the leading cause of perinatal morbidity and mortality. Among the most important complications in preterm infants are peri- or postnatal infections. Myeloid-derived suppressor cells (MDSC) are myeloid cells with suppressive activity on other immune cells. Emerging evidence suggests that granulocytic MDSC (GR-MDSC) play a pivotal role in mediating maternal-fetal tolerance. The role of MDSC for postnatal immune-regulation in neonates is incompletely understood. Until the present time, nothing was known about expression of MDSC in preterm infants. In the present pilot study, we quantified GR-MDSC counts in cord blood and peripheral blood of preterm infants born between 23 + 0 and 36 + 6 weeks of gestation (WOG) during the first 3 months of life and analysed the effect of perinatal infections. We show that GR-MDSC are increased in cord blood independent of gestational age and remain elevated in peripheral blood of preterm infants during the neonatal period. After day 28 they drop to nearly adult levels. In case of perinatal or postnatal infection, GR-MDSC accumulate further and correlate with inflammatory markers C-reactive protein (CRP) and white blood cell counts (WBC). Our results point towards a role of GR-MDSC for immune-regulation in preterm infants and render them as a potential target for cell-based therapy of infections in these patients.

Neutrophilic myeloid-derived suppressor cells in cord blood modulate innate and adaptive immune responses

Neonates show an impaired anti-microbial host defence, but the underlying immune mechanisms are not understood fully. Myeloid-derived suppressor cells (MDSCs) represent an innate immune cell subset characterized by their capacity to suppress T cell immunity. In this study we demonstrate that a distinct MDSC subset with a neutrophilic/granulocytic phenotype (Gr-MDSCs) is highly increased in cord blood compared to peripheral blood of children and adults. Functionally, cord blood isolated Gr-MDSCs suppressed T cell proliferation efficiently as well as T helper type 1 (Th1), Th2 and Th17 cytokine secretion. Beyond T cells, cord blood Gr-MDSCs controlled natural killer (NK) cell cytotoxicity in a cell contact-dependent manner. These studies establish neutrophilic Gr-MDSCs as a novel immunosuppressive cell subset that controls innate (NK) and adaptive (T cell) immune responses in neonates. Increased MDSC activity in cord blood might serve as key fetomaternal immunosuppressive mechanism impairing neonatal host defence. Gr-MDSCs in cord blood might therefore represent a therapeutic target in neonatal infections.

Phagocytosis and postphagocytic reaction of cord blood and adult blood monocyte after infection with green fluorescent protein-labeled Escherichia coli and group B Streptococci

BACKGROUND

Neonatal sepsis is characterized by an excessive inflammatory response induced by immune cells (monocytes). We investigated the initial stage of monocyte-pathogen interaction, i.e. bacterial ingestion and degradation at the single-cell level, by comparing a new flow cytometric procedure with culture methods. We also examined the hypothesis that, in terms of phagocytosis-induced cell death (PICD), phenotype, or cytokine production, cord blood monocytes (CBMO) differ from monocytes derived from adults (peripheral blood monocytes, PBMO).

METHODS

Phagocytosis and intracellular degradation were assessed by means of flow cytometry and bacterial cultures of green fluorescent protein-labeled group B Streptococci (GBS) and Escherichia coli. The production of reactive oxygen species (ROS) was measured through luminol-enhanced chemiluminescence. Apoptosis, phenotype, and cytokine production were assessed through flow cytometry.

RESULTS

Flow cytometry and bacterial cultures showed no difference between phagocytosis and degradation of GBS and E. coli by PBMO and CBMO. A high correlation between both methods was observed. No difference in ROS production was evident. In comparison with PBMO, CBMO apoptosis was lower after exposure to GBS and E. coli. Similarities were found between nonapoptotic monocytes and pro-inflammatory monocytes.

CONCLUSIONS

PICD is lower in CBMO during the early stages of monocyte-pathogen interaction. Our results emphasize that monocyte apoptosis has a potential role in tailoring the immune response in neonatal sepsis.

Influence of antidepressant pharmacotherapy on behavioral treatment adherence and smoking cessation outcome in a combined treatment involving fluoxetine

The authors examined whether serum fluoxetine levels influence behavioral treatment adherence and smoking cessation outcome. Nondepressed smokers (N = 989) from 16 centers were randomized on a double-blind basis to receive either fluoxetine (30 or 60 mg) or placebo plus 9 sessions of behavioral smoking cessation treatment. Fluoxetine and norfluoxetine blood levels were assayed 1 week after the quit date. Logistic regression was used to predict treatment completion and cessation outcome, controlling for gender, age, treatment site, and degree of nicotine dependence. Higher steady-state fluoxetine blood levels (fluoxetine + norfluoxetine) predicted less likelihood of dropping out, chi2(1, N = 820) = 3.9, p < .05, and more likelihood of being abstinent, chi2(1, N = 513) = 18.1, p < .001. Attaining a higher fluoxetine blood level improved the likelihood of completing behavioral treatment and increased the probability of achieving abstinence.

Rumination and cigarette smoking: a bad combination for depressive outcomes?

Ruminative coping has been shown to heighten the risk and severity of depression. The authors hypothesized that ruminators who smoke would experience greater depressive symptoms than ruminators who do not. The rationale is that, by heightening attentional focus, nicotine may increase ruminators' ability to focus on negative thoughts, augmenting depressed mood. Participants (N = 145) self-reported smoking status, rumination, and current and lifetime depressive symptoms, including depressed mood. Results showed that rumination accounted for a larger amount of variance in current and past depressed mood and severity of lifetime depressive symptoms among smokers than nonsmokers. Noncorrelational, experimental research should directly test whether nicotine worsens depressed mood among ruminative smokers. Such evidence would be surprising because it would contradict the assumption that nicotine dispels negative moods.

Influence of antidepressant pharmacotherapy on behavioral treatment adherence and smoking cessation outcome in a combined treatment involving fluoxetine

The authors examined whether serum fluoxetine levels influence behavioral treatment adherence and smoking cessation outcome. Nondepressed smokers (N = 989) from 16 centers were randomized on a double-blind basis to receive either fluoxetine (30 or 60 mg) or placebo plus 9 sessions of behavioral smoking cessation treatment. Fluoxetine and norfluoxetine blood levels were assayed 1 week after the quit date. Logistic regression was used to predict treatment completion and cessation outcome, controlling for gender, age, treatment site, and degree of nicotine dependence. Higher steady-state fluoxetine blood levels (fluoxetine + norfluoxetine) predicted less likelihood of dropping out, chi2(1, N = 820) = 3.9, p < .05, and more likelihood of being abstinent, chi2(1, N = 513) = 18.1, p < .001. Attaining a higher fluoxetine blood level improved the likelihood of completing behavioral treatment and increased the probability of achieving abstinence.

Rumination and cigarette smoking: a bad combination for depressive outcomes?

Ruminative coping has been shown to heighten the risk and severity of depression. The authors hypothesized that ruminators who smoke would experience greater depressive symptoms than ruminators who do not. The rationale is that, by heightening attentional focus, nicotine may increase ruminators' ability to focus on negative thoughts, augmenting depressed mood. Participants (N = 145) self-reported smoking status, rumination, and current and lifetime depressive symptoms, including depressed mood. Results showed that rumination accounted for a larger amount of variance in current and past depressed mood and severity of lifetime depressive symptoms among smokers than nonsmokers. Noncorrelational, experimental research should directly test whether nicotine worsens depressed mood among ruminative smokers. Such evidence would be surprising because it would contradict the assumption that nicotine dispels negative moods.

Influences of gender and weight gain on short-term relapse to smoking in a cessation trial

Few researchers have studied whether weight gain has an impact on short-term relapse to smoking. The authors of this study investigated predictors of relapse among 989 participants (60% women) in a randomized, double-blind, 10-week multicenter trial to determine the effect of fluoxetine (30 or 60 mg) versus placebo in combination with behavioral counseling for smoking cessation. Medication compliance and smoking status were biochemically verified. At Visit 2, participants were asked to set a quit date within the subsequent 2 visits. A proportional hazards regression model was used to predict risk of relapse within the first 3 months of quitting. Weight gain predicted relapse, but for men only. Female gender also predicted relapse. The results led the authors to question whether postcessation weight gain interventions should be restricted to women smokers.

Influences of gender and weight gain on short-term relapse to smoking in a cessation trial

Few researchers have studied whether weight gain has an impact on short-term relapse to smoking. The authors of this study investigated predictors of relapse among 989 participants (60% women) in a randomized, double-blind, 10-week multicenter trial to determine the effect of fluoxetine (30 or 60 mg) versus placebo in combination with behavioral counseling for smoking cessation. Medication compliance and smoking status were biochemically verified. At Visit 2, participants were asked to set a quit date within the subsequent 2 visits. A proportional hazards regression model was used to predict risk of relapse within the first 3 months of quitting. Weight gain predicted relapse, but for men only. Female gender also predicted relapse. The results led the authors to question whether postcessation weight gain interventions should be restricted to women smokers.

Antidepressant pharmacotherapy helps some cigarette smokers more than others

Adult smokers (N = 253) without clinically significant depression were randomized on a double-blind basis to receive fluoxetine (30 or 60 mg daily) or a placebo for 10 weeks in combination with cognitive-behavioral therapy (CBT). It was predicted that fluoxetine would selectively benefit smokers with higher baseline depression, nicotine dependence, and weight concern and lower self-efficacy about quitting smoking. Among those who completed the prescribed treatment regimen, baseline depression scores moderated the treatment response. Logistic regression analyses showed that 1 and 3 months after the quit date, fluoxetine increased the likelihood of abstinence, as compared with placebo, among smokers with minor depression but not among those with little or no depression. Results suggests that, as an adjunct to CBT, fluoxetine enhances cessation by selectively benefiting medication-compliant smokers who display even subclinical levels of depression.

Antidepressant pharmacotherapy helps some cigarette smokers more than others

Adult smokers (N = 253) without clinically significant depression were randomized on a double-blind basis to receive fluoxetine (30 or 60 mg daily) or a placebo for 10 weeks in combination with cognitive-behavioral therapy (CBT). It was predicted that fluoxetine would selectively benefit smokers with higher baseline depression, nicotine dependence, and weight concern and lower self-efficacy about quitting smoking. Among those who completed the prescribed treatment regimen, baseline depression scores moderated the treatment response. Logistic regression analyses showed that 1 and 3 months after the quit date, fluoxetine increased the likelihood of abstinence, as compared with placebo, among smokers with minor depression but not among those with little or no depression. Results suggests that, as an adjunct to CBT, fluoxetine enhances cessation by selectively benefiting medication-compliant smokers who display even subclinical levels of depression.