Moorabbin Hospital

CONTEXT: Effective communication skills are at the core of good health care. Simulated patients (SPs) are increasingly engaged as an interactive means of teaching, applying and practising communication skills with immediate feedback. There is a large body of research into the use of manikin-based simulation but a gap exists in the body of research on the effectiveness of SP-based education to teach communication skills that impact patient outcomes. The aim of this systematic review was to critically analyse the existing research, investigating whether SP-based communication skills training improves learner-patient communication, how communication skill improvement is measured, and who measures these improvements. METHODS: The databases Medline, ProQuest (Health & Medical Complete, Nursing and Allied Health Source) and CINAHL (EBSCOhost) Education Resources Information Centre (ERIC) were searched for articles that investigated the effects of SP-based education on the communication skills of medical, nursing and allied health learners. RESULTS: There were 60 studies included in the review. Only two studies reported direct patient outcomes, one reporting some negative impact, and no studies included an economic analysis. Many studies reported statistically significant third-party ratings of improved communication effectiveness following SP-based education; however, studies were unable to be pooled for meta-analysis because of the outcome collection methods. There were a small number of studies comparing SP with no training at all and there were no differences between communication skills, contradicting the results from studies reporting benefits. Of the 60 studies included for analysis, 54 (90%) met the minimum quality score of 7/11, with four articles (7%) scoring 11/11. CONCLUSION: SP-based education is widely accepted as a valuable and effective means of teaching communication skills but there is limited evidence of how this translates to patient outcomes and no indication of economic benefit for this type of training over another method.

OBJECTIVE: To evaluate outcomes of radical excision of feline injection-site sarcomas (ISS) via assessment of local recurrence and metastasis rates, survival times, and complications associated with surgery. DESIGN: Retrospective case series. ANIMALS: 91 cats with ISS. PROCEDURES: Medical records of cats that had radical excision of ISS without adjunctive treatment were reviewed. Information extracted included sex, type of surgical procedure, histologic tumor grade, tumor diameter, time from tumor detection to definitive surgery, complications associated with surgery, whether tumors recurred locally or metastasized, and survival times. Diagnosis of ISS was histologically confirmed, and additional follow-up was performed. RESULTS: Overall median survival time was 901 days. Thirteen of 91 (14%) cats had local tumor recurrence; 18 (20%) cats had evidence of metastasis after surgery. Median survival time of cats with and without recurrence was 499 and 1,461 days, respectively. Median survival time of cats with and without metastasis was 388 and 1,528 days, respectively. Tumor recurrence and metastasis were significantly associated with survival time, whereas other examined variables were not. Major complications occurred in 10 cats, including 7 with incisional dehiscence. CONCLUSIONS AND CLINICAL RELEVANCE: Radical excision of ISS resulted in a metastasis rate similar to rates reported previously; the local recurrence rate appeared to be substantially less than rates reported after less aggressive surgeries, with or without adjuvant treatment. Major complication rates were similar to rates reported previously after aggressive surgical resection of ISS. Radical excision may be a valuable means of attaining an improved outcome in the treatment of feline ISS.

Much contemporary theorizing in leadership studies incorporates ideas and concepts that, in one form or another, derive from James MacGregor Burns’s conceptualization of transforming leadership, which overhauled many traditional assumptions about the phenomenon. In particular, his formulation emphasized the moral and educative nature of the relationship between leaders and followers, which Burns believed was consistent with contemporary democratic norms. However, from the standpoint of a coherentist epistemological framework, critical examination of Burns’s account uncovers philosophical and technical difficulties with some of his central claims, including those upholding the theory’s democratic and educational credentials. Thus, to the extent that current formulations of leadership look to Burns’s theory as a source of ideas, similar problems are likely to carry over and manifest themselves in these accounts too, with implications for administrative practice, and its further development.

The rapid response system (RRS) is a patient safety initiative instituted to enable healthcare professionals to promptly access help when a patient's status deteriorates. Despite patients meeting the criteria, up to one-third of the RRS cases that should be activated are not called, constituting a "missed RRS call". Using a case study approach, 10 focus groups of senior and junior nurses and physicians across four hospitals in Australia were conducted to gain greater insight into the social, professional and cultural factors that mediate the usage of the RRS. Participants' experiences with the RRS were explored from an interprofessional and collective competence perspective. Health professionals' reasons for not activating the RRS included: distinct intraprofessional clinical decision-making pathways; a highly hierarchical pathway in nursing, and a more autonomous pathway in medicine; and interprofessional communication barriers between nursing and medicine when deciding to make and actually making a RRS call. Participants also characterized the RRS as a work-around tool that is utilized when health professionals encounter problematic interprofessional communication. The results can be conceptualized as a form of collective incompetence that have important implications for the design and implementation of interprofessional patient safety initiatives, such as the RRS.

Abstract Laughter and humor therapy have been used in health care to achieve physiological and psychological health‐related benefits. The application of these therapies to the dialysis context remains unclear. This paper reviews the evidence related to laughter and humor therapy as a medical therapy relevant to the dialysis patient population. Studies from other groups such as children, the elderly, and persons with mental health, cancer, and other chronic conditions are included to inform potential applications of laughter therapy to the dialysis population. Therapeutic interventions could range from humorous videos, stories, laughter clowns through to raucous simulated laughter and Laughter Yoga. The effect of laughter and humor on depression, anxiety, pain, immunity, fatigue, sleep quality, respiratory function and blood glucose may have applications to the dialysis context and require further research.

BACKGROUND: Falls in hospitals are a major risk to patient safety. Health professional education has the potential to be an important aspect of falls prevention interventions. This scoping review was designed to investigate the extent of falls prevention education interventions available for health professionals, and to determine the quality of reporting. METHOD: A five stage scoping review process was followed based on Arksey and O'Malley's framework and refined by the Joanna Briggs Institute Methodology for JBI Scoping Reviews. Five online databases identified papers published from January 2008 until May 2019. Papers were independently screened by two reviewers, and data extracted and analysed using a quality reporting framework. RESULTS: Thirty-nine publications were included. Interventions included formal methods of educational delivery (for example, didactic lectures, video presentations), interactive learning activities, experiential learning, supported learning such as coaching, and written learning material. Few studies employed comprehensive education design principles. None used a reporting framework to plan, evaluate, and document the outcomes of educational interventions. CONCLUSIONS: Although health professional education is recognised as important for falls prevention, no uniform education design principles have been utilised in research published to date, despite commonly reported program objectives. Standardised reporting of education programs has the potential to improve the quality of clinical practice and allow studies to be compared and evaluated for effectiveness across healthcare settings.

Virtual communities of practice consist of individuals who use a common online platform to share professional expertise and experiences. In healthcare settings a virtual community of practice (VCoP) can optimise knowledge, skills, and the implementation of evidence-based practice. To ensure effective knowledge synthesis and translation into practice, it is essential to clarify the best methods for designing and implementing VCoPs within healthcare organisations. This scoping review aimed to identify the methods used to establish and facilitate online or digitally enabled communities of practice within healthcare organisations across the globe. Six online databases identified papers published from January 2010 to October 2020. Papers were independently screened by two reviewers using Covidence. Data were captured and analysed using a data extraction chart in Covidence. Twenty-four publications that detail methods for establishing a VCoP in healthcare were included. Few studies used a framework to establish a VCoP. It was difficult to identify details regarding methods of development and key elements such as roles, how they were coordinated, and types of technology used. Healthcare organisations can benefit from using a standardised framework for the establishment, implementation and evaluation of VCoPs to improve practice, staff engagement, and knowledge sharing.

Many organisms exhibit developmental plasticity only in sensitive phases and cannot respond to environmental perturbations at other times. However, we know little about the physiological events that define plastic and canalized phases. During egg production in insects, vitellogenin (Vg) accumulates first in the hemolymph and then in the eggs. In addition, storage proteins may be important resources for egg production. Therefore, we tested hypotheses on the relationships of Vg and TP (total hemolymph protein minus Vg) titers to the transition from flexible to inflexible development during egg production. In lubber grasshoppers, approximately 70% of TP is contained in three proteins that range from 68 to 83 kDa. We maintained females on food treatments that produced defined plastic and canalized periods, collected hemolymph every approximately 4 d, and determined the ages at which oviposition and the maximum Vg and TP titers occurred. Both Vg(max) titer and especially TP(max) titer were predictors of the number of eggs produced. The time from eclosion to Vg(max) was significantly affected by diet, but the time from Vg(max) to oviposition was not. Similarly, the time from eclosion to TP(max) was significantly affected by diet, while the time from TP(max) to oviposition was not. Hence, Vg(max) and TP(max) are physiological landmarks that occur during the canalized phase of egg production.

OBJECTIVE: To determine whether family history of migraine increased the likelihood of posttraumatic migraine (PTM) symptom presentation in adolescents following concussion, and examine the influence of family history of migraine and PTM on postinjury outcomes. SETTING: Outpatient concussion clinic. PARTICIPANTS: A total of 153 patients with concussion (103 males and 50 females) aged 15.72 ± 1.48 years (range 12-18 years). DESIGN: Cross-sectional, observational study of patients presenting for initial evaluation 4.72 ± 3.05 days (range 1-14) postinjury. MAIN MEASURES: Computerized neurocognitive testing, symptom report, and vestibular/oculomotor screening. RESULTS: Patients with a family history of migraine were 2.6 times (odds ratio = 2.60, confidence interval = 1.35-5.02, P = .003) more likely to present with PTM compared with patients without a family history. Results of multivariate analyses of covariance, controlling for concussion history, revealed significant main effects for PTM on (1) Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)/Post-Concussion Symptom Scale (PCSS) (F = 15.43, P <.001) and (2) Vestibular/Ocular Motor Screening (VOMS) (F = 8.52, P < .001). There was no main effect for family history of migraine on ImPACT/PCSS (P = .22) and VOMS (P = .83) or interaction between family history of migraine and PTM on ImPACT/PCSS (P = .84) and VOMS (P = .52). CONCLUSION: Family history of migraine is associated with PTM symptoms following sport-related concussion, suggesting a genetic predisposition for migraine may serve as a catalyst or trigger for onset of PTM. However, only presence of PTM, rather than family history of migraine, was related to worse neurocognitive and vestibular/oculomotor outcomes.

OBJECTIVE: Update concussion recovery curves by considering pre- and postinjury modifying factors. Determine whether there is a dose-response for modifying factors on recovery. SETTING: Sports medicine concussion clinic. PARTICIPANTS: A total of 314 athletes aged 12-23 years within 7 days of a concussion enrolled between 2015 and 2018. DESIGN: Prospective cohort study. MAIN MEASURES: Categorical recovery time defined as days from injury to full medical clearance for return to play per established criteria. Preinjury factors included age, gender, concussion history, and migraine history. Postinjury factors included loss of consciousness, posttraumatic amnesia, posttraumatic migraine symptoms, and high symptom burden. RESULTS: Average recovery was 27.5 ± 25 days. Five factors were prognostic of recovery: (1) younger than 18 years, (2) female, (3) history of migraine, (4) posttraumatic migraine symptoms, and (5) high symptom burden (P < .05). Recovery percentage at 21 days after injury was 96.7% for participants with 0 factor, 65.3% for those with 1 to 2, and 31.8% for those with 3 to 5-with prognostic separation in low- to high-risk groups of 62%. CONCLUSIONS: Findings support a dose-response for combined pre- and postinjury factors on recovery. Both the type and quantity of modifying factors influence recovery and should be considered in prognosis and approaches to multidisciplinary care.

BACKGROUND: Laughter Yoga consists of physical exercise, relaxation techniques and simulated vigorous laughter. It has been associated with physical and psychological benefits for people in diverse clinical and non-clinical settings, but has not yet been tested in a haemodialysis setting. The study had three aims: 1) to examine the feasibility of conducting Laughter Yoga for patients with end stage kidney disease in a dialysis setting; 2) to explore the psychological and physiological impact of Laughter Yoga for these patients; and 3) to estimate the sample size required for future research. METHODS: Pre/post intervention feasibility study. Eighteen participants were recruited into the study and Laughter Yoga therapists provided a four week intradialytic program (30-min intervention three times per week). Primary outcomes were psychological items measured at the first and last Laughter Yoga session, including: quality of life; subjective wellbeing; mood; optimism; control; self-esteem; depression, anxiety and stress. Secondary outcomes were: blood pressure, intradialytic hypotensive episodes and lung function (forced expiratory volume). Dialysis nurses exposed to the intervention completed a Laughter Yoga attitudes and perceptions survey (n = 11). Data were analysed using IBM SPSS Statistics v22, including descriptive and inferential statistics, and sample size estimates were calculated using G*Power. RESULTS: One participant withdrew from the study for medical reasons that were unrelated to the study during the first week (94 % retention rate). There were non-significant increases in happiness, mood, and optimism and a decrease in stress. Episodes of intradialytic hypotension decreased from 19 pre and 19 during Laughter Yoga to 4 post Laughter Yoga. There was no change in lung function or blood pressure. All nurses agreed or strongly agreed that Laughter Yoga had a positive impact on patients' mood, it was a feasible intervention and they would recommend Laughter Yoga to their patients. Sample size calculations for future research indicated that a minimum of 207 participants would be required to provide sufficient power to detect change in key psychological variables. CONCLUSIONS: This study provides evidence that Laughter Yoga is a safe, low-intensity form of intradialytic physical activity that can be successfully implemented for patients in dialysis settings. Larger studies are required, however, to determine the effect of Laughter Yoga on key psychological variables. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry - ACTRN12614001130651 . Registered 23 October 2014.

OBJECTIVE: To determine outcomes for dogs with soft tissue sarcomas in the distal aspects of the limbs that underwent second intention healing after wide excision (2-cm lateral surgical margins and a margin 1 fascial plane deep) of the tumors. DESIGN: Retrospective case series. ANIMALS: 31 dogs with soft tissue sarcomas in the distal aspects of the limbs that underwent second intention healing following wide local excision of their tumors. PROCEDURES: Tumors were excised with 2-cm lateral margins and a margin 1 fascial plane deep to tumors. Wounds healed by means of second intention. Time to healing, complications during healing, and information regarding tumor recurrence were recorded. RESULTS: All tumors were excised with histologically tumor-free margins. Twenty-nine (93.5%) wounds healed completely by second intention (median time, 53 days). Two (6.5%) dogs required free skin graft procedures to facilitate healing. Complications during open wound management developed for 7 (22.6%) dogs. Long-term complications were detected for 8 (25.8%) dogs, including intermittent epidermal disruption (5/31 [16.1%]) and wound contracture (3/31 [9.7%]). All complications were managed conservatively. Local tumor recurrence was detected for 1 (3.2%) dog. Median follow-up time was 980 days (range, 380 to 2,356 days). No patients died because of tumor-related causes. CONCLUSIONS AND CLINICAL RELEVANCE: Results of this study indicated second intention healing of large wounds in the distal aspects of the limbs was complete and typically without complications for dogs that underwent wide excision of soft tissue sarcomas. Wide local excision of soft tissue sarcomas in the distal aspects of the limbs with 2-cm lateral margins and margins 1 fascial plane deep to the tumors provided excellent long-term local tumor control.

INTRODUCTION: Chronic low back pain (CLBP) is pain that has persisted for greater than three months. It is common and burdensome and represents a significant proportion of primary health presentations. For the majority of people with CLBP, a specific nociceptive contributor cannot be reliably identified, and the pain is categorised as 'non-specific'. Exercise therapy is recommended by international clinical guidelines as a first-line treatment for non-specific CLBP. AIM: This comprehensive review aims to synthesise and appraise the current research to provide practical, evidence-based guidance concerning exercise prescription for non-specific CLBP. We discuss detailed initial assessment and being informed by patient preferences, values, expectations, competencies and goals. METHODS: We searched the Cochrane Database of Systematic Reviews, PubMed and the Physiotherapy Evidence Database (PEDro) using broad search terms from January 2000 to March 2021, to identify the most recent clinical practice guidelines, systematic reviews and randomised controlled trials on exercise for CLBP. RESULTS/DISCUSSION: Systematic reviews show exercise is effective for small, short-term reductions in pain and disability, when compared with placebo, usual care, or waiting list control, and serious adverse events are rare. A range of individualised or group-based exercise modalities have been demonstrated as effective in reducing pain and disability. Despite this consensus, controversies and significant challenges remain. CONCLUSION: To promote recovery, sustainable outcomes and self-management, exercise can be coupled with education strategies, as well as interventions that enhance adherence, motivation and patient self-efficacy. Clinicians might benefit from intentionally considering their own knowledge and competencies, potential harms of exercise and costs to the patient. This comprehensive review provides evidence-based practical guidance to health professionals who prescribe exercise for people with non-specific CLBP.

BACKGROUND: The Coronavirus disease 2019 (COVID-19) pandemic has had a major impact on healthcare services with many changes to telehealth care delivery. More information is needed about the patient perspective of telehealth in hospital services and the potential costs and benefits for patients. AIM: To measure patients' evaluation of telehealth, preferences for telehealth versus in-person appointments, and potential cost savings by patient characteristics. METHODS: A cross-sectional online survey (including patient and appointment characteristics, telehealth evaluation, preferences for care and costs) of adult patients using video telehealth in four metropolitan tertiary hospital services in Melbourne, Victoria. RESULTS: A total of 1045 patients (median age 44 years; interquartile range 29-59) participated with an overall response rate of 9.2%. For 98.7% patients, telehealth was convenient, 96.4% stated that it saved time, 95.9% found telehealth acceptable to receive care and 97.0% found that telehealth improved their access to care. Most (62.6%) preferred in-person consultations, although 86.9% agreed that telehealth was equivalent to an in-person consultation. Those in regional and rural areas were less likely to prefer in-person consultations. Patients attending for medical reasons were less likely to prefer in-person consultation compared with patients with surgical reasons. Patient preference to telehealth was independent of level of education, appointment type, self-rated health status and socio economic status. Patients saved an average of A$120.9 (standard deviation A$93.0) per appointment, with greater cost savings for patients from low and middle socio economic areas and regional or rural areas. CONCLUSION: Telehealth video consultations were largely evaluated positively with most patients considering the service to be as good as in-person. Understanding patient preference is critical to consider when implementing telehealth as mainstream across hospital health services.

OBJECTIVE: To provide a clinical framework and key guideline statements to assist clinicians in the evidence-based management of Peyronie's disease (PD). METHODS: We conducted a review of the published literature relevant to PD management, with an emphasis on published clinical guidelines. References used in the text have been assessed according to their level of evidence, and guideline recommendations have been graded based on the Oxford Centre for Evidence-based Medicine Levels of Evidence. RESULTS: The management of PD involves taking a detailed penile and sexual history, with a focused penile examination to identify plaque and hourglass deformity, and digital photographs of the erect curved (deformed) penis. Penile colour Duplex ultrasonography evaluates tunical plaque and underlying cavernosal smooth muscle and blood flow variables. The current therapy for PD can be divided into two main groups, namely, medical therapy and penile reconstructive surgery, and the patient should be counselled on the benefits and risks of each treatment option. CONCLUSIONS: Peyronie's disease remains a clinical challenge and presents a considerable therapeutic dilemma as the current therapy addresses existing penile curvature only and is not very effective in preventing future penile fibrosis and/or reversing underlying erectile dysfunction.

Heat pulse methods are a popular approach for estimating sap flow and transpiration. Yet, many methods are unable to resolve the entire heat velocity measurement range observable in plants. Specifically, the Heat Ratio (HRM) and Tmax heat pulse methods can only resolve slow and fast velocities, respectively. The Dual Method Approach (DMA) combines optimal data from HRM and Tmax to output the entire range of heat velocity. However, the transition between slow and fast methods in the DMA currently does not have a theoretical solution. A re-consideration of the conduction/convection equation demonstrated that the HRM equation is equivalent to the Péclet equation which is the ratio of conduction to convection. This study tested the hypothesis that the transition between slow and fast methods occurs when conduction/convection, or the Péclet number, equals one, and the DMA would be improved via the inclusion of this transition value. Sap flux density was estimated via the HRM, Tmax and DMA methods and compared with gravimetric sap flux density measured via a water pressure system on 113 stems from 15 woody angiosperm species. When the Péclet number ≤ 1, the HRM yielded accurate results and the Tmax was out of range. When the Péclet number > 1, the HRM reached a maximum heat velocity at approximately 15 cm hr -1 and was no longer accurate, whereas the Tmax yielded accurate results. The DMA was able to output accurate data for the entire measurement range observed in this study. The linear regression analysis with gravimetric sap flux showed an r2 of 0.541 for HRM, 0.879 for Tmax and 0.940 for DMA. With the inclusion of the Péclet equation, the DMA resolved the entire heat velocity measurement range observed across 15 taxonomically diverse woody species. Consequently, the HRM and Tmax are redundant sap flow methods and have been superseded by the DMA.

INTRODUCTION: The aims of this study were to investigate whether drug sequence (docetaxel followed by anthracyclines or the drugs in reverse order) affects changes in the maximal standard uptake volume (SUVmax) on [18F]fluorodeoxyglucose positron emission tomography (FDG-PET) during neoadjuvant chemotherapy in women with locally advanced breast cancer. METHODS: Women were randomly assigned to receive either drug sequence, and FDG-PET scans were taken at baseline, after four cycles and after eight cycles of chemotherapy. Tumour response to chemotherapy was evaluated based on histology from a surgical specimen collected upon completion of chemotherapy. RESULTS: Sixty women were enrolled into the study. Thirty-one received docetaxel followed by anthracyclines (Arm A) and 29 received drugs in the reverse order (Arm B). Most women (83%) had ductal carcinoma and 10 women (17%) had lobular or lobular/ductal carcinoma. All but one tumour were downstaged during therapy. Overall, there was no significant difference in response between the two drug regimens. However, women in Arm B who achieved complete pathological response had mean FDG-PET SUVmax reduction of 87.7% after four cycles, in contrast to those who had no or minor pathological response. These women recorded mean SUVmax reductions of only 27% (P < 0.01). Women in Arm A showed no significant difference in SUVmax response according to pathological response. Sensitivity, specificity, accuracy and positive and negative predictive values were highest in women in Arm B. CONCLUSIONS: Our results show that SUVmax uptake by breast tumours during chemotherapy can be dependent on the drugs used. Care must be taken when interpreting FDG-PET in settings where patients receive varied drug protocols.

OBJECTIVE: To determine whether there is evidence of myocardial injury in horses with acute abdominal disease. DESIGN: Prospective case series. ANIMALS: 18 healthy horses and 69 horses with acute abdominal disease. PROCEDURES: 18 healthy horses had been admitted to the hospital for investigation and were assigned to group 1. Horses examined for acute abdominal disease were assigned to 3 groups: strangulating obstruction, nonstrangulating obstruction, or inflammatory disease (groups 2, 3, and 4, respectively). Heart rate, Hct, and blood lactate and cardiac troponin I (cTnI) concentrations were measured at initial examination. Myocardial function was assessed by echocardiographic measurement of fractional shortening and left ventricular ejection time (LVET). Heart rhythm was evaluated via ECG. RESULTS: The proportion of horses with high (> 0.03 ng/mL) cTnI concentration was significantly greater among horses with strangulating (9/25 [36%]) or inflammatory (9/19 [47%]) lesions, compared with healthy horses (0/18). The proportion of horses with high cTnI concentration was significantly greater among nonsurvivors (12/24 [50%]) than among survivors (10/45 [22%]). Serum cTnI concentration was positively correlated with Hct, heart rate, and blood lactate concentration and negatively correlated with LVET. CONCLUSIONS AND CLINICAL RELEVANCE: Evidence of myocardial injury was observed in horses with acute abdominal disease, and this injury was associated with severity of illness. Recognition of myocardial injury could improve treatment of acute abdominal disease in horses.

OBJECTIVE: Describe changes in postconcussion activity levels and sleep throughout recovery in a sample of pediatric sport-related concussion (SRC) patients, and examine the predictive value of accelerometer-derived activity and sleep on subsequent clinical outcomes at a follow-up clinic visit. SETTING: Outpatient concussion clinic. PARTICIPANTS: Twenty athletes aged 12 to 19 years with diagnosed SRC. METHODS: Prospective study including visit 1 (<72 hours postinjury) and visit 2 (6-18 days postinjury). Linear regressions used to predict scores (ie, neurocognitive, vestibular/oculomotor) at visit 2 from accelerometer-derived data collected 0 to 6 days postinjury. Linear mixed models evaluated changes in activity and sleep across recovery. MAIN MEASURES: Symptom, neurocognitive, and vestibular/oculomotor scores; sleep and activity data (Actigraph GT3x+) RESULTS:: The maximum intensity of physical activity increased (P = .009) and time in bed decreased throughout recovery (P = .026). Several physical activity metrics from 0 to 6 days postinjury were predictive of worse vestibular/oculomotor scores at visit 2 (P < .05). Metrics indicative of poor sleep 0 to 6 days postinjury were associated with worse reaction time at visit 2 (P < .05). CONCLUSIONS: This exploratory study suggests physical activity and sleep change from the acute to subacute postinjury time period in adolescent SRC patients. In our small sample, excess physical activity and poor sleep the first week postinjury may be associated with worse outcomes at follow-up in the subacute stage of recovery. This study further supported the feasibility of research utilizing wearable technology in concussion patients, and future research in a large, diverse sample of concussion patients examined at concise time intervals postinjury is needed.

Child and adolescent school refusal is a complex problem that can paralyse parents and professionals alike. Families often present in desperation, often after the problem has become well established. The literature concerning ‘what works’ is clear: addressing the problem early relates to better prognosis, and supporting the child to return to school is the primary priority. In practice, however, the ‘how to’ is often complicated by parental anxiety or complacency, complex family dynamics, therapist uncertainty about how to help, and poor partnerships between family and school. In this paper, I will present a framework for intervention informed by Structural and post‐Milan ideas, developed from practice‐based evidence – witnessing what works for families in everyday practice. A model for family therapy intervention is presented and discussed, illustrated with a case vignette.