Lessons learnt from the COVID-19 pandemic in selected countries to inform strengthening of public health systems: a qualitative study

INTRODUCTION

The COVID-19 pandemic has prompted governments internationally to consider strengthening their public health systems. To support the work of Ireland's Public Health Reform Expert Advisory Group, the Health Information and Quality Authority, an independent governmental agency, was asked to describe the lessons learnt regarding the public health response to COVID-19 internationally and the applicability of this response for future pandemic preparedness.

METHODS

Semi-structured interviews with key public health representatives from nine countries were conducted. Interviews were conducted in March and April 2022 remotely via Zoom and were recorded. Notes were taken by two researchers, and a thematic analysis undertaken.

RESULTS

Lessons learnt from the COVID-19 pandemic related to three main themes: 1) setting policy; 2) delivering public health interventions; and 3) providing effective communication. Real-time surveillance, evidence synthesis, and cross-sectoral collaboration were reported as essential for policy setting; it was noted that having these functions established prior to the pandemic would lead to a more efficient implementation in a health emergency. Delivering public health interventions such as testing, contact tracing, and vaccination were key to limiting and or mitigating the spread of the SARS-CoV-2 virus. However, a number of challenges were highlighted such as staff capacity and burnout, delays in vaccination procurement, and reduced delivery of regular healthcare services. Clear, consistent, and regular communication of the scientific evidence was key to engaging citizens with mitigation strategies. However, these communication strategies had to compete with an infodemic of information being circulated, particularly through social media.

CONCLUSIONS

Overall, functions relating to policy setting, public health interventions, and communication are key to pandemic response. Ideally, these should be established in the preparedness phase so that they can be rapidly scaled-up during a pandemic.

Screening for Autism Spectrum Condition Through Inner City Homeless Services in the Republic of Ireland

Homeless service users were screened for autism spectrum disorder through one of Ireland's leading not for profit service providers. Keyworkers acted as proxy informants; their caseloads were screened using the DSM-5-Autistic Traits in the Homeless Interview (DATHI). Client current and historical health and behaviour data was collated. A representative sample of 106 eligible keyworkers caseloads were screened, identifying 3% "present" and 9% "possibly present" for autistic traits with the DATHI. These findings suggest a high estimate of autism prevalence and support emerging evidence that, people with autism are overrepresented in the homeless population, compared to housed populations. Autism may be a risk factor for entry into homelessness and a challenge to exiting homeless and engaging with relevant services.

Applicability of OECD TG 201, 202, 203 for the aquatic toxicity testing and assessment of 2D Graphene material nanoforms to meet regulatory needs

Tests using algae and/or cyanobacteria, invertebrates (crustaceans) and fish form the basic elements of an ecotoxicological assessment in a number of regulations, in particular for classification of a substance as hazardous or not to the aquatic environment according to the Globally Harmonised System of Classification and Labelling of Chemicals (GHS-CLP) (GHS, 2022) and the REACH regulation (Registration, Evaluation, Authorisation and Restriction of Chemicals, EC, 2006). Standardised test guidelines (TGs) of the Organisation for Economic Co-operation and Development (OECD) are available to address the regulatory relevant endpoints of growth inhibition in algae and cyanobacteria (TG 201), acute toxicity to invertebrates (TG 202), and acute toxicity in fish (TG 203). Applying these existing OECD TGs for testing two dimensional (2D) graphene nanoforms may require more attention, additional considerations and/or adaptations of the protocols, because graphene materials are often problematic to test due to their unique attributes. In this review a critical analysis of all existing studies and approaches to testing used has been performed in order to comment on the current state of the science on testing and the overall ecotoxicity of 2D graphene materials. Focusing on the specific tests and available guidance's, a complete evaluation of aquatic toxicity testing for hazard classification of 2D graphene materials, as well as the use of alternative tests in an integrated approach to testing and assessment, has been made. This information is essential to ensure future assessments generate meaningful data that will fulfil regulatory requirements for the safe use of this "wonder" material.

Aspects of Wellbeing for Indigenous Youth in CANZUS Countries: A Systematic Review

Indigenous children and young people (hereafter youth) across CANZUS nations embody a rich diversity of cultures and traditions. Despite the immense challenges facing these youth, many harness cultural and personal strengths to protect and promote their wellbeing. To support this for all youth, it is critical to understand what contributes to their wellbeing. This review aims to identify components contributing to wellbeing for Indigenous youth in CANZUS nations. Five databases were searched from inception to August 2022. Papers were eligible if they: focused on Indigenous youth in CANZUS nations; included views of youth or proxies; and focused on at least one aspect of wellbeing. We identified 105 articles for inclusion (Canada n = 42, Australia n = 27, Aotearoa New Zealand n = 8, USA n = 28) and our analysis revealed a range of thematic areas within each nation that impact wellbeing for Indigenous youth. Findings highlight the unique challenges facing Indigenous youth, as well as their immense capacity to harness cultural and personal strengths to navigate into an uncertain future. The commonalities of Indigenous youth wellbeing across these nations provide valuable insights into how information and approaches can be shared across borders to the benefit of all Indigenous youth and future generations.

High level review of configuration and reform of Public Health systems in selected countries

Background

The impact of the COVID-19 pandemic has prompted governments internationally to consider reform and strengthening of their Public Health systems. To support this work in Ireland, we undertook a review Public Health systems internationally (research question [RQ] 1), and identified lessons learned from the COVID-19 pandemic (RQ2).

Methods

Data relating to Public Health systems (RQ1), and lessons learned (RQ2) for a select group of 12 countries were identified from organisations’ websites, an electronic database and grey literature search and representatives from key national-level organisations. Data for RQ1 were extracted, mapped to the 12 Essential Public Health functions (EPHFs) at national, regional and local levels, and verified by participating representatives. For RQ2, thematic analysis of semi-structured interviews with participating representatives was undertaken and.

Results

Typically, across all included countries, there is national strategic oversight of all EPHFs and, for certain functions, there is regional and local level implementation. Lessons learned from the COVID-19 pandemic broadly related to the themes of legislation and decision making; data collection, surveillance, evidence synthesis and collaboration; public health interventions; public participation, public messaging and communication; continuation of healthcare services; and workforce capacity and resilience.

Conclusions

When structuring Public Health systems, there is a need to identify which functions, and or which elements of a function, should be delivered at a national, regional or local level to ensure a sustainable and comprehensive Public Health system. Appropriate IT infrastructure, strong communication and an established evidence synthesis function are key to timely and informed decision making. Ideally, these functions should be established during periods of relative stability to permit a faster response during a pandemic or emergency situation.

640 Improving Junior Doctors’ Knowledge and Confidence in Assessment, Management and Referral of Burns Patients in the Emergency Department, Royal Oldham Hospital

Aim

There are currently no online trust guidelines for adult burn injuries. We aim to improve ED trainee knowledge and confidence in managing burns patients by delivering focused teaching and developing accessible online resources.

Method

A survey circulated to junior doctors assessed their confidence in managing minor and major burns injuries. Focused teaching on burns depth, management of burns wounds and when to refer was delivered to ED trainees after completion of the survey. Online tools and resources for assessment, management and referral of burns were developed using NICE and British Burns Association Guidelines. Resources were circulated to trainees and a survey repeated to assess confidence.

Results

Initial surveys demonstrated 71% felt confident in assessing minor burns and 46% for major burns. When managing minor burns 68% of juniors felt confident and 43% for major burns. Only 25% were aware of referral criteria to a burns centre for major burns and 32% for minor burns. Following focused teaching sessions, clinician confidence in assessment and management of all burns improved to 100%. Awareness of referral criteria rose to 85-92% for all burn injuries. Qualitative feedback was positive amongst different levels of health care professionals for the new resources.

Conclusions

Burns injuries are common, yet confidence is low amongst junior doctors in their management. This was compounded by a lack of local guidance. Focused teaching and implementation of accessible online departmental guidance has improved clinician confidence and helped ensure that patients presenting with burns are managed by confident clinicians according to national guidelines.

Wellbeing of Indigenous Peoples in Canada, Aotearoa (New Zealand) and the United States: A Systematic Review

Despite the health improvements afforded to non-Indigenous peoples in Canada, Aotearoa (New Zealand) and the United States, the Indigenous peoples in these countries continue to endure disproportionately high rates of mortality and morbidity. Indigenous peoples' concepts and understanding of health and wellbeing are holistic; however, due to their diverse social, political, cultural, environmental and economic contexts within and across countries, wellbeing is not experienced uniformly across all Indigenous populations. We aim to identify aspects of wellbeing important to the Indigenous people in Canada, Aotearoa and the United States. We searched CINAHL, Embase, PsycINFO and PubMed databases for papers that included key Indigenous and wellbeing search terms from database inception to April 2020. Papers that included a focus on Indigenous adults residing in Canada, Aotearoa and the United States, and that included empirical qualitative data that described at least one aspect of wellbeing were eligible. Data were analysed using the stages of thematic development recommended by Thomas and Harden for thematic synthesis of qualitative research. Our search resulted in 2669 papers being screened for eligibility. Following full-text screening, 100 papers were deemed eligible for inclusion (Aotearoa (New Zealand) n = 16, Canada n = 43, United States n = 41). Themes varied across countries; however, identity, connection, balance and self-determination were common aspects of wellbeing. Having this broader understanding of wellbeing across these cultures can inform decisions made about public health actions and resources.

341 The Diagnosis and Management of Appendicitis During the COVID-19 Pandemic: The Pennine Acute Trust Experience

Introduction

Appendicitis management has evolved recently with more reliance on Computed Topography (CT) and laparoscopic surgery being commonplace. In this project we looked at how the Coronavirus pandemic (COVID-19) had impacted the diagnosis, management and outcomes of patients with appendicitis in our unit.

Method

A retrospective review of patients diagnosed with appendicitis from 1^st March – 30^th April in 2019 and 2020. Data was collected on diagnosis, management and outcomes.

Results

In 2020, 91 patients were identified (mean 33, range 6-85, F:M 1:1.4). In 2019, 107 patients were identified (mean 32, range 7-69, M:F 1:1.1). There was no significant difference in patients’ symptom duration (p = 0.21), White Cell Count (p = 0.20) or C-Reactive Protein (p = 0.10). More CTs were performed in 2020 (56/91, 61.5%) than in 2019 (40/107, 37.4%). Less patients underwent appendicectomy in 2020 (75/91, 82.4%) than in 2019 (104/107, 97.2%). Open appendicectomies were performed in 64% (48/75) of those operated in 2020 compared with 12.2% (13/104) in 2019. There was no difference in hospital length of stay or re-admissions rates.

Conclusions

The diagnosis and management of appendicitis changed considerably at our trust during COVID-19 with more reliance on CT diagnosis and less use of laparoscopy. Despite this, outcomes remained unchanged.

Association of chain of survival factors with out of hospital cardiac arrest survival in a region with low average population-density: a retrospective population-based cohort study

Background

Out of hospital cardiac arrest (OHCA) has an average global survival rate to discharge of 8%. Chain of survival factors are heavily time-dependant and optimization can increase survival. Regions with low population density encounter challeges in providing optimal OHCA care. Nova Scotia's average population density is 17.4 persons per square kilometer in compasiron to Toronto with 4334.4 person per square kilometer. OHCAs have been described well in large urban centers globally, however the characterization of OHCA chain of survival in low density populations is sparse.

Purpose

To describe chain of survival factors and identify characteristics of survivors and non-survivors among those treated by paramedics in a low average density provincial population.

Methods

This was a retrospective cohort study of OHCAs responded to by paramedics. All OHCA responses with a cardiac etiology in Nova Scotia, Canada were included. Exclusion criteria were non-cardiac cause arrests, those with “do not resuscitate” (DNR) directives and expected deaths. The paramedic electronic patient care record was reviewed for demographic, bystander, out of hospital treatment and operational characteristics. Primary outcome was survival to hospital discharge. Descriptive statistics were calculated to describe differences between survivorship using Prism 8.0 (San Diego, CA) with alpha=0.05 applying unpaired, Mann-Whitney tests.

Results

Of 1517 OHCA, 463 were excluded leaving 1054 OHCA. Of these, 478 (45.3%) were treated by paramedics and included in this analysis. Most were men (67.2%; n=274) with a mean age 66.8 (±16.4). A total of 7.1% (n=75) survived to discharge with 76% of survivors (n=58) discharged home. Survivors were more likely to present with ventricular fibrillation than non-survivors (42.7% vs. 19.6%). Survivors compared to non-survivors had significantly shorter paramedic response time (8.1 vs. 10.7 min, P<0.001), paramedic time on scene (35.7 vs. 45.4 min, P=0.002), estimated time to paramedic defibrillation (13.2 vs 19.4 min, P<0.001), and estimated time to return of spontaneous circulation (ROSC) (22.9 vs 31.9min, P<0.001).

Conclusion

Links in the chain of survival are associated with survival from OHCA. OHCA survival is lower in the less densely populated province of Nova Scotia compared to studies in urban Canadian centers and worldwide. Our study is limited by the retrospective nature of data collection and lack of access to neurological outcomes. Even among survivors, EMS response is delayed compared to more densely populated centers. In Nova Scotia, longer paramedic response times are associated with decreased survival.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Maritime Heart Center

Prediction of contrast induced acute kidney injury using novel biomarkers following contrast coronary angiography

BACKGROUND/INTRODUCTION

Chronic kidney disease (CKD) is a risk factor for contrast induced acute kidney injury (CI-AKI). Contrast angiography in CKD patients is a common procedure. Creatinine is a delayed marker of CI-AKI and delays diagnosis which results in significant morbidity and mortality.

AIM

Early diagnosis of CI-AKI requires validated novel biomarkers.

DESIGN

A prospective observation study of 301 consecutive CKD patients undergoing coronary angiography was performed.

METHODS

Samples for plasma neutrophil gelatinase-associated lipocalin (NGAL), serum liver fatty acid-binding protein (L-FABP), serum kidney injury marker 1, serum interleukin 18 and serum creatinine were taken at 0, 1, 2, 4, 6 and 48 h post-contrast. Urinary NGAL and urinary cystatin C were collected at 0, 6 and 48 h. Incidence of major adverse clinical events (MACE) was recorded at 1 year. CI-AKI was defined as an absolute delta rise in creatinine of ≥26.5 µmol/l or a 50% relative rise from baseline at 48 h following contrast.

RESULTS

CI-AKI occurred in 28 (9.3%) patients. Plasma NGAL was most predictive of CI-AKI at 6 h. L-FABP performed best at 4 h. A combination of Mehran score > 10, 4 h L-FABP and 6 h NGAL improved specificity to 96.7%. MACE was statistically higher at 1 year in CI-AKI patients (25.0 vs. 6.2% in non-CI-AKI patients).

DISCUSSION/CONCLUSION

Mehran risk score, 4 h serum L-FAPB and 6 h plasma NGAL performed best at early CI-AKI prediction. CI-AKI patients were four times more likely to develop MACE and had a trebling of mortality risk at 1 year.

Heart-type fatty acid-binding protein (H-FABP) and highly sensitive troponin T (hsTnT) as markers of myocardial injury and cardiovascular events in elective percutaneous coronary intervention (PCI)

BACKGROUND/INTRODUCTION

Type 4a myocardial infarction (MI) occurs when myocardial injury is combined with either symptoms suggestive of myocardial ischaemia, new left bundle branch block, angiographic loss of patency of a major artery or imaging suggestive of new loss of myocardium. Myocardial injury is defined as a rise of >5 x 99th upper reference limit (URL) of 14 ng/l (i.e. >70 ng/l) for highly sensitive troponin T (hsTnT) at 6 h if hsTnT was normal at baseline or >20% rise from 0 to 6 h if hsTnT was >14 ng/l at baseline.

AIM

To assess the prognostic value of biomarkers of myocardial injury following elective percutaneous coronary intervention (PCI).

DESIGN

A cohort of 209 patients were included of whom 144 (68.9%) were male, mean age was 68.8 years, 28 (13.4%) were smokers, 31 (14.8%) were diabetic, 199 (95.2%) had hypercholesterolaemia and 138 (66.0%) had hypertension.

METHODS

We evaluated hsTnT, heart-type fatty acid-binding protein (H-FABP), troponin I (TnI), creatine kinase MB type (CKMB), myoglobin, glycogen phosphorylase BB (GPBB) and carbonic anhydrase III (CA III) at 0, 4, 6 and 24 h following elective PCI. Patients were followed up at 1 year to assess for major adverse clinical events (MACE).

RESULTS

Myocardial injury was observed in 37 (17.7%) patients. Median hsTnT/H-FABP at 4 h were most predictive. MACE was noted in 6 (2.9%) patients, 3 had type 4a MI post PCI, P = 0.036.

DISCUSSION/CONCLUSIONS

Median 4 h hsTnT/H-FABP were most predictive of myocardial injury following PCI. H-FABP and hsTnT were predictive of MACE.

Hidradenitis Suppurativa and Crohn's Disease: A Case Series

Hidradenitis Suppurativa (HS) is characterized by chronic recurrent abscesses, nodules and draining sinus tracts with scar formation. Cutaneous Crohn's Disease (CD) may also present similarly. We wished to identify and describe an Irish cohort with combined HS and CD, with a view to a better recognition of clinical manifestations and understanding of the pathophysiology underlying these two overlapping conditions. Cases were identified using the HIPE Code at Tallaght Hospital from 1990-2014 and retrospective review was performed. Seven patients with both HS and CD were identified, 5(71%) female. The median age of diagnosis with both conditions was 37 years. In all cases, CD had preceded the diagnosis of HS. All patients smoked. Six had an increased BMI and 43% had additional autoimmune conditions. All patients required treatment with a TNF-alpha inhibitor for HS with 5 of 6 subjects having reduced frequency of flare ups and clinically less active HS on follow up.

Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study

BACKGROUND

International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries.

METHODS

Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated.

FINDINGS

Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations.

INTERPRETATION

We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems.

FUNDING

The Lowitja Institute.

Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study

BACKGROUND

International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries.

METHODS

Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated.

FINDINGS

Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations.

INTERPRETATION

We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems.

FUNDING

The Lowitja Institute.

A Randomized Controlled Trial of a Mobile Health Intervention to Promote Self-Management After Lung Transplantation

Lung transplant recipients are encouraged to perform self-management behaviors, including (i) monitoring health indicators, (ii) adhering to their regimen, and (iii) reporting abnormal health indicators to the transplant coordinator, yet performance is suboptimal. When hospital discharge was imminent, this two-group trial randomized 201 recipients to use either the mobile health (mHealth) intervention (n = 99) or usual care (n = 102), to compare efficacy for promoting self-management behaviors (primary outcomes) and self-care agency, rehospitalization, and mortality (secondary outcomes) at home during the first year after transplantation. The mHealth intervention group performed self-monitoring (odds ratio [OR] 5.11, 95% confidence interval [CI] 2.95-8.87, p < 0.001), adhered to medical regimen (OR 1.64, 95% CI 1.01-2.66, p = 0.046), and reported abnormal health indicators (OR 8.9, 95% CI 3.60-21.99, p < 0.001) more frequently than the usual care group. However, the two groups did not differ in rehospitalization (OR 0.78, 95% CI 0.36-1.66, p = 0.51) or mortality (hazard ratio 1.71, 0.68-4.28, p = 0.25). The positive impact of the mHealth intervention on self-management behaviors suggests that the intervention holds promise and warrants further testing.

Randomised Trial Comparing Two Four-Layer Bandage Systems in the Management of Chronic Leg Ulceration

Objective:

To compare a new four-layer bandage system (Profore) with the original 4LB in the closure of chronic leg ulceration.

Design:

Prospective randomised stratified parallel-groups open trial.

Methods:

Patients newly presenting to community leg ulcer services with chronic leg ulceration were screened for inclusion in this trial. Patients with arterial disease (ankle brachial pressure index <0.8) and causes of ulceration other than venous disease were excluded. In patients with bilateral ulceration, the limb with the larger area of ulceration was studied. The ulcer was dressed with a simple low-adherent dressing and all bandages were changed weekly unless required more frequently. Patients were randomised to receive either the original four-layer bandage or the newer system (Profore).

Results:

In all 233 patients were randomised, of whom 232 attended at least one follow-up visit (115 original, 117 Profore). At 12 weeks complete healing of the ulcerated limb, analysed by ‘intention-to-treat’ was 60% using the original 4LB compared with 72% using Profore. The difference of 11.8% (95% confidence interval (CI) −0.3% to 23.9%) had largely disappeared after 24 weeks, with 73% healed using the original 4LB and 76% using Profore, a difference of 3.0% (95% CI −8.2% to 14.2%). After 24 weeks of treatment the Kaplan-Meier estimate of complete healing was 82% using the original system and 84% using the Profore system. Overall, there was a higher healing rate for patients on Profore (hazard ratio = 1.18, 95% CI 0.87 to 1.59), but this did not achieve statistical significance ( p = 0.28).

Conclusion:

Ulcer healing using the newer Profore system is as good as with the original four-layer system.

Community Leg Ulcer Clinics: Effect on Quality of Life

Objective:

To investigate changes in the quality of life of patients with leg ulcers being treated in community leg ulcer clinics.

Design:

Patients were interviewed using a standard questionnaire, and then reinterviewed after 12 weeks of compression bandaging to observe changes.

Setting:

Community ulcer clinics held in health centres within Riverside Health District.

Patients:

All new patients presenting to community leg ulcer clinics up to 6 months from the start of a clinic and treated with four-layer compression bandaging.

Main outcome measures:

Changes in quality of life, interference in daily activities caused by leg ulceration and general health after 12 weeks of treatment.

Results:

Treatment over 12 weeks resulted in a mean reduction in anxiety (2.79 v 1.73, p < 0.001), depression (2.61 v 1.89, p < 0.001), hostility (1.59 v 1.00, p < 0.001) and cognition (1.29 v 0.87, p = 0.015). Pain significantly improved following treatment (χ2 trend = 103.7, 1d.f., p < 0.001). Changes in depression and hostility were related to complete ulcer healing.

Conclusions:

There were clear changes in quality of life following 12 weeks in a community leg ulcer clinic, which were related to the healing of the ulcer. Systems of care that offer rapid healing and improve patients' well-being must be considered when planning an effective leg ulcer service.

Novel Biomarkers of Acute Kidney Injury After Contrast Coronary Angiography

Acute kidney injury (AKI), defined as a rise in serum creatinine of greater than 25% from baseline measured at 48 hours after renal insult, may follow iodinated contrast coronary angiography. Termed contrast-induced nephropathy, it can result in considerable morbidity and mortality. Measurement of serum creatinine as a functional biomarker of glomerular filtration rate is widely used for detection of AKI, but it lacks sensitivity for the early diagnosis of AKI (typically rising 24 hours after functional loss) and, as a solely functional marker of glomerular filtration rate, is unable to differentiate among the various causes of AKI. These intrinsic limitations to creatinine measurement and the recognition that improved clinical outcomes are linked to a more timely diagnosis of AKI, has led investigators to search for novel biomarkers of "early" kidney injury. Several studies have investigated the utility of renal injury biomarkers in a variety of clinical settings including angiography/percutaneous coronary intervention, coronary artery bypass graft surgery, sepsis in intensive care patients, and pediatric cardiac surgery. In this article, we discuss the use of iodinated contrast for coronary procedures and the risk factors for contrast-induced nephropathy, followed by a review the potential diagnostic utility of several novel biomarkers of early AKI in the clinical settings of coronary angiography/percutaneous coronary intervention. In particular, we discuss neutrophil gelatinase associated lipocalin in depth. If validated, such biomarkers would facilitate earlier AKI diagnosis and improve clinical outcomes.