Metropolitan Centers Research Articles

Exploring patient ideas, concerns, and expectations in surgeon-patient consultations

ObjectivesThis study explores patient perspectives (ideas, concerns, and expectations) in surgeon-patient consultations. MethodsWe examined 54 video-recorded consultations using applied conversation analysis. Consultations took place from 2012 to 2017 in an Australian metropolitan hospital clinic centre and involved seven surgeons across six specialties. ResultsPatient perspectives emerged in less than one third of consultations. We describe the initiation of and response to potential perspectives sequences, demonstrating how patients and surgeons co-construct these sequences when they do occur. ConclusionsFindings suggest a need for greater attention to supporting patient agency through explicit pursuit of patient perspectives. The implications extend to the Calgary-Cambridge Guide, suggesting that it may benefit from a focus on active pursuit and appropriate responsiveness to patient perspectives. Practice implicationsThis study highlights the need for surgeons to actively engage with the patient perspective offered in consultations, emphasising the importance of respect for the patient’s knowledge and expectations to improve patient satisfaction and healthcare outcomes.

Organ donation after extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest in a metropolitan cardiac arrest centre in Milan, Italy

IntroductionExtracorporeal cardiopulmonary resuscitation (ECPR) may improve survival in refractory out-of-hospital cardiac arrest (OHCA) but also expand the donor pool as these patients often become eligible for organ donation. Our aim is to describe the impact of organ donation in OHCA patients treated with ECPR in a high-volume cardiac arrest centre. MethodsRate of organ donation (primary outcome), organs harvested, a composite of patient survival with favourable neurological outcome or donation of ≥1 solid organ (ECPR benefit), and the potential total number of individuals benefiting from ECPR (survivors with favourable neurological outcome and potential recipients of one solid organ) were analysed among all-rhythms refractory OHCA patients treated with ECPR between January 2013–November 2022 at San Raffaele Hospital in Milan, Italy. ResultsAmong 307 adults with refractory OHCA treated with ECPR (95% witnessed, 66% shockable, low-flow 70 [IQR 58–81] minutes), 256 (83%) died during hospital stay, 33% from brain death. Donation of at least one solid organ occurred in 58 (19%) patients, 53 (17%) after determination of brain death and 5 (1.6%) after determination of circulatory death, contributing a total of 167 solid organs (3.0 [IQR 2.5–4.0] organs/donor). Overall, 196 individuals (29 survivors with favourable neurological outcome and 167 potential recipients of 1 solid organ) possibly benefited from ECPR. ECPR benefit composite outcome was achieved in 87 (28%) patients. Solid organ donation decreased from 19% to 16% in patients with low-flow <60 min and to 11% with low-flow <60 min and initial shockable rhythm. ConclusionsWhen ECPR fails in patients with refractory OHCA, organ donation after brain or circulatory death can help a significant number of patients awaiting transplantation, enhancing the overall benefit of ECPR. ECPR selection criteria may affect the number of potential organ donors.

Incidence and Predictors of Readmissions to Non-Index Hospitals After Transcatheter Aortic Valve Implantation in the Contemporary Era in New South Wales, Australia

In Australia, transcatheter aortic valve implantation (TAVI) is only performed in a limited number of specialised metropolitan centres, many of which are private hospitals, making it likely that TAVI patients who require readmission will present to another (non-index) hospital. It is important to understand the impact of non-index readmission on patient outcomes and healthcare resource utilisation. We analysed linked hospital and death records for residents of New South Wales, Australia, aged ≥18 years, who had an emergency readmission within 90 days following a TAVI procedure in 2013-2022. Mixed-effect, multi-level logistic regression models were used to evaluate predictors of non-index readmission, and associations between non-index readmission and readmission length of stay, 90-day mortality, and 1-year mortality. Of 4,198 patients (mean age, 82.7 years; 40.6% female) discharged alive following TAVI, 933 (22.2%) were readmitted within 90 days of discharge. Over three-quarters (76.0%) of those readmitted returned to a non-index hospital, with no significant difference in readmission principal diagnosis between index hospital and non-index hospital readmissions. Among readmitted patients, independent predictors of non-index readmission included: residence in regional or remote areas, lower socio-economic status, having a pre-procedure transfer, and a private index hospital. Readmission length of stay (median, 4 days), 90-day mortality (adjusted odds ratio [OR] 1.04, 95% confidence interval [CI] 0.56-1.96) and 1-year mortality (adjusted OR 1.01, 95% CI 0.64-1.58) were similar between index and non-index readmissions. Non-index readmission following TAVI was highly prevalent but not associated with increased mortality or healthcare utilisation. Our results are reassuring for TAVI patients in regional and remote areas with limited access to return to index TAVI hospitals.

Engaging Young People in Occupations Served by Vocational Education: Case Study From Healthcare

Purpose: Globally, countries with both developed and developing economies are struggling to secure sufficient participation in vocational education to generate the range and quantum of skills required for their communities and realising national social and economic goals. In an era of high aspiration, vocational education and the occupations it serves are increasingly seen as being a less than desirable outcome by young people and their parents. Hence, there is a need to identify means by which to inform and engage young people in considering vocational education and the occupations it serves. The case study discussed in this paper is contextualised within the Australian state of Queensland, which, like many other countries is struggling to have a workforce sufficient to meet communities' healthcare needs as its population both grows and ages. Methods: The study data were collected from 1) interviews with healthcare-related stakeholders including health industry representatives, teachers or practitioners, and healthcare providers, 2) focus groups with senior secondary students, and 3) surveys with these participant groups. It provides a descriptive analysis of efforts to secure greater participation by young people in allied health roles, and, in particular, young Australian Indigenous people. Findings: The study participants included those from regional and metropolitan centres and from state and independent schools, and in all of which the focus on engagement was central. Findings indicated that engagement was necessary to advise young people about these occupations, the effective preparation for them, and likely retention in the workforce. Conclusion: This study highlights the need for intentional strategies to engage young people, their parents/guardians and with those efforts likely needing to be organised and enacted at the local level. This requires collaboration and engagement from education, industry, and local communities. Essentially, a systemic approach is required, specifying roles for government, employers, educational systems, and teachers and parents who engage directly with young people. In all, engagement, advice and opportunities locally are all emphasised in the study reported here.

The proliferation of international schools: implications for educational stratification

ABSTRACT This article applies positional conflict theory to investigate how the proliferation of international schools can create a new layer of educational stratification and deepen inequality of opportunity. Data from five international schools in metropolitan centres across southern China were collected through interviews, school visits, and a survey. The findings demonstrate how international schooling can enable local middle-class students to accumulate distinctive forms of positional advantages that are geared towards global higher education and careers in the global economy. The implications are threefold: (1) demonstrating how international schools can exacerbate educational divides, (2) revealing the nature of advantages created by international schooling, and (3) illuminating how international schooling can reposition students in a global class structure while potentially creating barriers within local/national contexts. The article concludes by calling for more critical attention to the ongoing expansion of international schools.

Assessing the Viability of Smaller Municipalities: The Alberta Model

A confluence of economic and social trends has created significant challenges for smaller municipalities in jurisdictions across the advanced industrial societies. Population stagnation or decline and the concentration of major industries in metropolitan centres have weakened the economies of smaller communities and frequently triggered fiscal crises. This leads to serious challenges not only for the local communities but for other levels of government. Responses to this challenge from provincial and national governments have followed a variety of paths. In some cases, governments have opted for major reorganization. This may entail a shift to regional forms of government or support for amalgamations or annexations by larger, financially stronger municipalities. In Canada, Manitoba and New Brunswick provide two recent examples of provincial governments that have chosen sweeping changes to their systems of local government. Alberta, by contrast, has elected a case-by case approach to municipal reorganization. The Ministry of Municipal Affairs has developed a process for viability reviews of municipalities facing serious fiscal challenges. This approach reflects the stronger economic state of most municipalities in the province; at this point, there is no need for a sweeping reorganization of municipal government. To date, 24 municipalities have undergone a viability review and 14 have elected to dissolve. In doing so, they become hamlets in the surrounding County or Municipal District. This process has worked well for Alberta, but challenges remain. Dissolution does not solve all of the problems that communities are facing; the problems that led to dissolution remain and become the responsibility of the absorbing entity. And more municipalities are likely to experience the difficulties that have led others to dissolve. Monitoring the health of local communities and providing support to both struggling municipalities and the counties and districts that may assume responsibility for them will be needed to ensure the sustainability of Alberta’s existing municipal framework.

The impact of pre-treatment smoking status on survival after chemoradiotherapy for locally advanced non-small-cell lung cancer

IntroductionSmoking is a risk factor for the development of lung cancer and reduces life expectancy within the general population. Retrospective studies suggest that non-smokers have better outcomes after treatment for lung cancer. We used a prospective database to investigate relationships between pre-treatment smoking status and survival for a cohort of patients with stage III non-small-cell lung cancer (NSCLC) treated with curative-intent concurrent chemoradiotherapy (CRT). MethodsAll patients treated with CRT for stage III NSCLC at a major metropolitan cancer centre were prospectively registered to a database. A detailed smoking history was routinely obtained at baseline. Kaplan-Meier statistics were used to assess overall survival and progression-free survival in never versus former versus current smokers. ResultsMedian overall survival for 265 eligible patients was 2.21 years (95 % Confidence Interval 1.78, 2.84). It was 5.5 years (95 % CI 2.1, not reached) for 25 never-smokers versus 1.9 years (95 % CI 1.5, 2.7) for 182 former smokers and 2.2 years (95 % CI 1.3, 2.7) for 58 current smokers. Hazard ratio for death was 2.43 (95 % CI 1.32–4.50) for former smokers and 2.75 (95 % CI 1.40, 5.40) for current smokers, p = 0.006. Actionable tumour mutations (EGFR, ALK, ROS1) were present in more never smokers (14/25) than former (9/182) or current (3/58) smokers. TKI use was also higher in never smokers but this was not significantly associated with superior survival (Hazard ratio 0.71, 95 % CI 0.41, 1.26). ConclusionsNever smokers have substantially better overall survival than former or current smokers after undergoing CRT for NSCLC.

Varanasi—The Making of a Smart Heritage City

One of the oldest cities in the world, Varanasi is home to more than one religion. It is an acclaimed centre of spirituality for Hindus and Buddhists while being equally sacred for Jains and Sikhs. The city is located along the river Ganga, which many believe is a celestial incarnation to grant salvation. Varanasi is a million-plus-population city; an increasingly important provincial metropolitan centre enshrined with the values of commerce, religion, ritual and tradition; and caught between the confluence and contestations of traditions and modernity. Since 2016, Varanasi has been incorporated under India’s Smart Cities Mission (SCM) to develop the city into a smart city with a strong focus on heritage and tourism. The present article is an attempt to trace the journey of the city that has developed as a palimpsest over centuries; it deliberates the contemporary urban landscape and maps out recent urban and infrastructure developments of the city and its concerns. This article also argues that Varanasi has focused on locally specific everyday urbanisms with heritage and culture and pivoted to making itself a Smart Heritage City.

조기발병 치매환자의 사회참여 활성화를 위한 캘리그래피 중심 집단미술치료 사례연구

Objectives The purpose of this study was to analyze how group art therapy using calligraphy impacts the social engagement activation of early onset dementia patients.&#x0D; Methods The group therapy was conducted for six early-onset dementia patients who were registered at the S Metropolitan Center for Dementia. The program consisted of eleven sessions and ran once a week from July 31, 2023, to November 6, 2023. The group art therapy program involved education and learning in each session to enable early-onset dementia patients to use the medium themselves and complete artworks. Based on this, participants were guided to complete artistic works. The research data were collected and analyzed using pre- and post-data (CIST and SGDS-K), therapist's session evaluations, observation notes, pre- and post-DAS (The Draw-a-Story) drawing test, and in-depth interviews with 2 participants and partners of 3 participants. The results of the in-depth interviews were cross-analyzed and categorized by two researchers under supervision to derive the findings.&#x0D; Results As a result, firstly, most of the patients who participated in the program maintained or developed their cognitive skills and lowered their depression inventory. Second, participants indicated improvement in their social skills and an increase in awareness and experience related to social engagement. Based on the experience of the art therapy group, participants’ showed positive changes in awareness of social engagement&#x0D; Conclusions This study is meaningful in confirming the impact of group art therapy using calligraphy on alleviating difficulties and promoting social engagement in early-onset dementia patients. Therefore, it is expected to contribute to the activation of social engagement for early-onset dementia patients.&#x0D;

Telemedical stroke care significantly improves patient outcome in rural areas: Long-term analysis of the German NEVAS network.

Comprehensive stroke centers (CSC) offer state-of-the-art stroke care in metropolitan centers. However, in rural areas, sufficient stroke expertise is much scarcer. Recently, telemedical stroke networks have offered instant consultation by stroke experts, enabling immediate administration of intravenous thrombolysis (IVT) on-site and decision on thrombectomy. While these immediate decisions are made during the consult, the impact of the network structures on stroke care in spoke hospitals is still not well described. This study was performed to determine if on-site performance in rural hospitals and patient outcome improve over time through participation and regular medical staff training within a telemedical stroke network. In this retrospective study, we analyzed data from stroke patients treated in four regional hospitals within the telemedical Neurovascular Network of Southwest Bavaria (NEVAS) between 2014 and 2019. We only included those patients that were treated in the regional hospitals until discharge at home or to neurorehabilitation. Functional outcome (modified Rankin scale) at discharge, mortality rate and periprocedural intracranial hemorrhage served as primary outcome parameters. Door-to-imaging and door-to-needle times were secondary outcome parameters. In 2014-2019, 5,379 patients were treated for acute stroke with 477 receiving IVT. Most baseline characteristics were comparable over time. For all stroke patients, door-to-imaging times increased over the years, but significantly improved for potential IVT candidates and those finally treated with IVT. The percentage of patients with door-to-needle time <30 min increased from 10% to 25%. Clinical outcome at discharge improved for all stroke patients treated in the regional hospitals. Particularly for patients treated with IVT, good clinical outcome (modified Rankin scale 0-2) at discharge increased from 2014 to 2019 by 19% and mortality rates dropped from 13% to 5%. 24-h/7-day telemedical support and regular on-site medical staff training within a structured telemedicine stroke network such as NEVAS significantly improve on-site stroke care in rural areas, leading to a considerable benefit in clinical outcome. The data that support the findings of this study are available upon reasonable request and in compliance with the local and international ethical guidelines.

The provision of general surgery in rural Australia: a narrative review.

Rural surgery is most commonly provided by general surgeons to the 29% of people (7 million) living in rural Australia. The provision of rural general surgery to enable equitable and safe surgical care for rural Australians is a multifaceted issue concerning recruitment, training, retention, surgical procedures and surgical outcomes. Sustaining the rural general surgical workforce will be dependent upon growing an increased number of resident rural general surgeons, as well as changed models of care, with a need for ongoing review to track the outcomes of these changes. To increase recruitment, rural general surgical training must improve to be less stressful for trainees and to be incorporated alongside a rural-facing generalist curriculum. Rural general surgical outcomes (excluding some oncology conditions) achieve comparable results to metropolitan centres. Access to, and outcomes of, surgical oncology services continues to be inequitable for rural Australians and should be a major focus for improved service delivery.

A216 MODERATE TO SEVERE ACUTE UPPER GASTROINTESTINAL BLEEDING IN RURAL NORTHERN ONTARIO: AN EPIDEMIOLOGICAL ANALYSIS OF AETIOLOGIES, GEOGRAPHIC LIMITATIONS, AND OUTCOMES

Abstract Background Hospitalizations for upper gastrointestinal bleeds (UGIBs) are resource-demanding as they often require blood transfusion, endoscopy, and intensive care unit admission. Referral centers that provide higher levels of care to remote regions treat illnesses, including UGIB, in much later stages of disease and of higher severity. The Thunder Bay Regional Health Sciences Center (TBRHSC) is a referral center servicing over 250,000 people over a geographically expansive region of Northern Ontario. Despite known barriers to accessing care, little data is currently available to guide our understanding of UGIB aetiologies, severity, and outcomes among patients living remotely in Canada. Aims This retrospective study aimed to evaluate epidemiological data among patients with UGIB at TBRHSC. Methods Of 441 patients with a discharge diagnosis of gastrointestinal hemorrhage from 2016–2022, inclusion criteria were met for 333. Patients under 18 y or with lower GIB were excluded. Patients were classified as regional if their primary address was outside the District of Thunder Bay. Results Patients were highly comorbid (median CCI = 5) and presented with a median (IQR) GBS of 9 (6) and Clinical Rockall Score of 3 (1). Of those who received inpatient endoscopy (n=248), findings included erosive gastritis (21%), gastric ulcer (14%), esophagitis (12%), duodenal ulcer (8%), AVM (7%), and variceal (6%). No definite lesion was observed in 62 patients (22%). The median (IQR) Complete Rockall Score was 4 (2) with major stigmata of recent hemorrhage found in 20%. There was a high prevalence (19%) of cirrhosis, of which 83% had a history of liver decompensation. In 49% of cirrhotic patients, culprit lesions did not include portal hypertensive gastropathy or variceal bleeding. Regional patients accounted for 14% of the population and travelled an average of 424 km to seek care at TBRHSC. Regional patients were younger and required more ICU admissions (p=0.01). ICU admission primarily due to UGIB was 5.4% and all-cause thirty-day mortality was 3.3%. Oral anti-coagulation use prevalence was 43.2% and was associated with a longer length of stay (pampersand:003C0.0001), higher proportion of all-cause 30-day mortality (pampersand:003C0.005). Forty-eight patients did not receive endoscopy due to bleeding stability, palliation, and preference. Conclusions Patients with UGIB at TBRHSC are a highly multimorbid population with a significantly burden of anticoagulant use, cirrhosis, and variceal bleeding. Comparative analysis with metropolitan centers will expand our understanding for providing UGIB care in Northern Ontario. Funding Agencies NOAMA

A142 PROGNOSTICATING FACTORS AND OUTCOMES OF EARLY ENDOSCOPIC EVALUATION IN ACUTE UPPER GASTROINTESTINAL BLEEDING

Abstract Background Current guidelines recommend esophagogastroduodenal endoscopy (EGD) early (ampersand:003C24 hours after presentation) for all suspected acute upper gastrointestinal bleeds (AUGIB). Among referral centers providing advanced tiers of care to large regions, treatment is often delayed secondary to geographic constraints. Metropolitan centers meet early EGD recommendations in up to 87.5% of patients. Some centers limit endoscopy to the ICU setting outside of normal hospital operational times. There is currently no data assessing Canadian referral center endoscopic timing, including factors delaying AUGIB endoscopy and outcomes. Aims The aim of this study was to report the prevalence of early EGD in AUGIB at a Northern Ontario referral center. Factors associated with delayed EGD and poor outcomes associated with AUGIB were also evaluated. Methods Of 441 patients retrospectively identified with an ICD-10 discharge diagnosis of gastrointestinal hemorrhage from 2016–22, 327 patients met inclusion criteria. Patients were excluded if they were below the age of 18 years at the time of presentation, had chronic UGIB, or lower gastrointestinal hemorrhage. Results Pre-endoscopic risk stratification via GBS and clinical Rockall score was high at 10 and 3, respectively. There were 279 patients who received early EGD for AUGIB, of which 56% were male. The median (IQR) time to endoscopy was 27.4 (29.3) hours with early EGD achieved in 46% of presentations. A significantly greater proportion of patients presenting to hospital on the weekend (n=105) had delayed EGD (pampersand:003C0.0001; Phi effect size 0.45). Patients presenting at times when EGD was unavailable (n=157) also experienced delayed EGD (pampersand:003C0.05). regional patients did not experience a greater proportion of delayed EGD. In multivariate analysis, presentation on the weekend, higher CCI, absence of pre-existing evidence of liver cirrhosis, and absence of major stigmata of recent hemorrhage on EGD were independent predictors of delayed EGD (Nagelkerke R2 = 0.379, pampersand:003C0.0001). The odds ratio for receiving late EGD was 8.9 times greater (95% CI 3.7–21.3) for patients presenting on the weekend (pampersand:003C0.0001). Longer endoscopy wait time was significant correlated with higher pre-EGD blood transfusions and longer length of stay (pampersand:003C0.001). Delayed EGD did not increase all-cause 30-day mortality. Conclusions Prevalence of delayed EGD in AUGIB was markedly elevated and associated with hospital presentation during times of limited endoscopic capabilities. Outcomes of delayed GED included increased length of stay and higher blood transfusion rates. Funding Agencies NOAMA

Environmental and social inequalities in health: Neighborhood-level composite indices as a decision-making tool

The environmental health research carried out on a broad scale does not provide decision-makers with tools for managing environmental and social inequalities in health on a fine scale. The goal of the present study was to develop a method for neighborhood-level territorial diagnosis that decision-makers can use to incorporate health issues into their planning policies. The primary objective was to analyze composite spatial vulnerability and resilience indices in the Lille metropolitan area in northern France. The secondary objective was to refine these results by taking account of neighborhood-level characteristics. The study highlights the interest of transdisciplinary research and collaboration with local experts to effectively evaluate and address environmental health issue (more than 30 experts gathered and 12 thematic workshops organized). The results showed that the proposed method allows for the comparison of neighborhoods; however, certain specificities may be underestimated. The real importance of certain variables linked to specific contexts can be minimized, which can distort our understanding of the challenges these neighborhoods face. Analyzing the environmental and social inequalities in health in the metropolitan area's center vs. its belt made it possible to take better account of the characteristics of the areas studied.

Establishing consensus recommendations for long-term osteoporosis care for patients who have attended an Australian fracture liaison service: a Delphi study

SummaryCoordinating healthcare activities between fracture liaison services (FLS) and primary care is challenging. Using a Delphi technique, we developed 34 consensus statements to support improved care coordination across this healthcare transition.PurposeEvidence supporting an optimal coordination strategy between fracture liaison services (FLS) and primary care is lacking. This study aimed to develop consensus statements to support consistency and benchmarking of clinical practice to improve coordination of care for patients transitioning from FLS to primary care following an osteoporotic fracture.MethodsA Delphi technique was used to develop consensus among a panel of experts, including FLS clinicians (medical and non-medical), general practitioners (GPs), and consumers.ResultsResults of a preparatory questionnaire (n = 33) informed the development of 34 statements for review by expert panellists over two Delphi rounds (n = 25 and n = 19, respectively). The majority of participants were from New South Wales (82%), employed as FLS clinicians (78.8%) and working in metropolitan centres (60.6%). Consensus was achieved for 24/34 statements in round one and 8/10 statements in round two. All statements concerning patient education, communication, and the GP-patient relationship achieved consensus. Expert opinions diverged in some areas of clinician roles and responsibilities and long-term monitoring and management recommendations.ConclusionWe found clear consensus among experts in many key areas of FLS integration with primary care. While experts agreed that primary care is the most appropriate setting for long-term osteoporosis care, overall confidence in primary care systems to achieve this was low. The role of (and responsibility for) adherence monitoring in a resource-limited setting remains to be defined.

The use of patient reported outcome measures in oncology clinical practice across Australia and New Zealand.

While there is increasing evidence on the benefits of PROMs in cancer care, the extent of routine collection and use of PROMs in clinical cancer practice across Australia and New Zealand (ANZ) is unknown. This study examined the prevalence and characteristics of PROMs use in routine clinical cancer care in ANZ. An online survey was designed and disseminated via professional societies and organisations using a snowball sampling approach to clinical and health administration professionals managing cancer care in ANZ. A poster advertising the study was also circulated on professional social media networks via LinkedIn and Twitter inviting health professionals from ANZ to participate if they were using or intending to use PROMs in clinical cancer practice. Responders opted into the survey via the survey link. From 132 survey views, 91(response rate, 69%) respondents from 56 clinical practices across ANZ agreed to participate in the survey, and of these 55 (n = 55/91, 60%) respondents reported collecting PROMs within their clinical practice. The majority of the respondents were from the State of New South Wales in Australia (n = 21/55, 38%), hospital (n = 35/55, 64%), and a public setting (n = 46/55, 83%). PROMs were collected in all cancer types (n = 21/36, 58%), in all stages of the disease (n = 31/36, 86%), in an adult population (n = 33/36, 92%), applied in English (n = 33/36, 92%), and used to facilitate communication with other reasons (27/36, 75%). A geospatial map analysis provided insights into the variation in PROMs uptake between the two countries and in certain jurisdictions within Australia. This study also highlights the limited resources for PROMs implementation, and a lack of systematic priority driven approach. PROM use across Australia and New Zealand seems variable and occurring predominantly in larger metropolitan centres with limited standardisation of approach and implementation. A greater focus on equitable adoption of PROMs in diverse cancer care settings is urgently needed.

Nutrition environments in early childhood education: do they align with best practice?

To assess the comprehensiveness (scope of nutrition guidance) and strength (clarity of written language) of centre-based nutrition policies (CBNP) within early childhood education (ECE) centres. To also consider the applicability of an existing CBNP assessment tool and policy alignment with best practice food provision and feeding practices. Cross-sectional online study to assess written ECE CNBP using the Wellness Child Care Assessment Tool. Licenced ECE centres in the state of Victoria, Australia. ECE centres (operating at least 8 h per d, 48 weeks per annum), stratified by location (rural and metropolitan), centre management type (profit and not-for-profit) and socio-economic area (low, middle, high). Included individual CBNP (n 118), predominantly from metropolitan centres (56 %) and low-medium socio-economic areas (78 %). Policies had low overall Wellness Child Care Assessment Tool scores, particularly strength scores which were low across all four domains (i.e. nutrition education, nutrition standards, health promotion and communication/evaluation). The nutrition standards domain had the lowest strength score. The communication/evaluation domain had the lowest comprehensiveness score. Content analysis indicated low scores may relate to the Wellness Child Care Assessment Tool applicability for the Australian context due to differences in best practice guidance. Despite the presence of written nutrition policies in ECE centres, many showed weak language and lacked comprehensiveness and strength. This may relate to poor implementation of best practice food provision or feeding practices. Low scores, however, may partly stem from using an assessment tool that is not country-specific. The redevelopment of country-specific tools to assess ECE CNBP may be warranted.

Let Us Build for Ourselves a City: A Biblical Look at the Correlation Between Secularism, Liberalism, and Urbanization in America

A map of the 2022 U.S. mid-term election results per House district shows a vastness of ‘Republican red’ engulfing most of the country’s landmass in comparison to small pockets of ‘Democrat blue’ that is concentrated upon the most urbanized metropolitan population centers. Such a unique phenomenon begs the following question: ‘What has happened within the most urbanized metropolitan populations to cause them to overwhelmingly vote for the politically liberal Democratic party, a party whose platform is antithetical in many ways to what is expressly taught in the Bible?’ This question also spawns another: ‘Why have the most populous areas in the country also become bastions of paganism, hedonism, and liberalism?’ This paper demonstrates that past human behavior detailed in biblical narratives is being replicated in today’s modern urbanized culture. As is seen in Scripture, for a large city or metropolitan area to obtain and maintain a consistent and achievable level of peace and prosperity, a compromising layer of tolerance towards immorality and evil must materialize. Subsequently, the sustained tolerance of evil and violence will eventually lead to the approval, propagation, and adoption of evil and violence. Then and now, to the degree an urban population ‘goes along to get along’, the further it drifts from the Lord and plunges downward into paganism, hedonism, and idolatry. Thus, when a society consciously usurps the sovereignty of God and thinks it possesses the highest level of authority, then it has arrived at the point where it believes it has the freedom to redefine societal rules according to what it determines to be “right in its own eyes” (Judg. 21:25). By dismissing God’s existence or discounting His holiness, justice, and power, a population cognitively thinks it has effectively shaken off the yoke of sin, guilt, and shame, and has achieved the human right to “call evil good and good evil” (Isa. 5:20).

Association of remoteness and ethnicity with major amputation following minor amputation to treat diabetes-related foot disease.

Minor amputation is commonly needed to treat diabetes-related foot disease (DFD). Remoteness of residence is known to limit access to healthcare and has previously been associated with poor outcomes. The primary aim of this study was to examine the associations between ethnicity and remoteness of residency with the risk of major amputation and death following initial treatment of DFD by minor amputation. A secondary aim was to identify risk factors for major amputation and death following minor amputation to treat DFD. This was a retrospective analysis of data from patients who required a minor amputation to treat DFD between 2000 and 2019 at a regional tertiary hospital in Queensland, Australia. Baseline characteristics were collected together with remoteness of residence and ethnicity. Remoteness was classified according to the 2019 Modified Monash Model (MMM) system. Ethnicity was based on self-identification as an Aboriginal and Torres Strait Islander or non-Indigenous person. The outcomes of major amputation, repeat minor amputation and death were examined using Cox-proportional hazard analyses. A total of 534 participants were included, with 306 (57.3%) residing in metropolitan or regional centres, 228 (42.7%) in rural and remote communities and 144 (27.0%) were Aboriginal or Torres Strait Islander people. During a median (inter quartile range) follow-up of 4.0 (2.1-7.6) years, 103 participants (19.3%) had major amputation, 230 (43.1%) had repeat minor amputation and 250 (46.8%) died. The risks (hazard ratio [95% CI]) of major amputation and death were not significantly higher in participants residing in rural and remote areas (0.97, 0.67-1.47; and 0.98, 0.76-1.26) or in Aboriginal or Torres Strait Islander people (HR 1.44, 95% CI 0.96, 2.16 and HR 0.89, 95% CI 0.67, 1.18). Ischemic heart disease (IHD), peripheral artery disease (PAD), osteomyelitis and foot ulceration (p<0.001 in all instances) were independent risk factors for major amputation. Major amputation and death are common following minor amputation to treat DFD and people with IHD, PAD and osteomyelitis have an increased risk of major amputation. Aboriginal and Torres Strait Islander People and residents of remote areas were not at excess risk of major amputation.

РЕГИОНАЛЬНЫЕ ФИНАНСОВЫЕ ЦЕНТРЫ РОССИЙСКОЙ ИМПЕРИИ ВО ВТОРОЙ ПОЛОВИНЕ XIX — НАЧАЛЕ XX ВЕКА

This study addresses the hierarchy of financial centers in the Russian Empire, which are evaluated via the volume of lending and money settlements in commercial banks. The study is based on balance sheet statistics of commercial banks for 1874, 1897, and 1913 as well as statistics on transfers between branches of the State Bank of the Russian Empire for 1868, 1878, 1888, and 1898. The settlements between these branches are visualized on geographical maps. The study proves that only St. Petersburg and Moscow had the status of national financial capitals, and they had a significant share of the financial system. In the Russian Empire, there were a few regional financial centers that always reached the top ten by sum of lending and number of transfers: Odessa, Kiev, Riga, Rostov-on-Don, and Kharkov. Warsaw and Nizhny Novgorod were close to making this list, although they do not meet all the criteria used in the present study. The hierarchy of smaller regional financial centers was volatile due to variance in the rates of regional development. However, the share of metropolitan and large regional centers gradually decreased due to the growth of operations in many ordinary regional centers. Thus, an important trait of Russian financial development was not the concentration of credits and settlements in the leading centers but rather their diversification across an increasing number of regional centers, which is undoubtedly a sign of the increasing influence of the financial system on the economic development of the empire.