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Background: Numerous factors influence patient recruitment to, and retention on, peritoneal dialysis (PD), but a major challenge is a perceived “inaccessibility” to treating clinicians. It has been suggested that remote patient monitoring (RPM) could be a means of improving such oversight and, thereby, uptake of PD. Objective: To describe patient and clinician perspectives toward RPM and the use of applications (Apps) suitable for mobiles, tablets, or computers to support the provision of PD care. Design: Qualitative design using semi-structured interviews. Setting: All patient participants perform PD treatment at home under the oversight of an urban PD unit in Sydney, Australia. Patient and clinician interviews were conducted within the PD unit. Participants: 14 participants (5 clinicians [2 nephrologists, 3 PD nurses] and 9 patients treated with PD). Methods: Semi-structured interviews were conducted using interview guides tailored for clinician and patient participants. Transcripts were coded and analyzed by a single researcher using thematic analysis. Results: Six themes were identified: perceived benefits of RPM implementation (offering convenience and efficiency, patient assurance through increased surveillance, more complete data and monitoring adherence), uncertainty regarding data governance (protection of personal data, data reliability), reduced patient engagement (transfer of responsibility leading to complacency), changing patient-clinician relationships (reduced patient-initiated communication, the need to maintain patient independence), increased patient and clinician burden (inadequate technological literacy, overmanagement leading to frequent treatment changes), and clinician preference influencing patient behavior. Limitations: The interviews were conducted in English only and with participants from a single urban dialysis unit, which may limit generalizability. Conclusions: For patients and clinicians, advantages from the use of RPM in PD may include increased patient confidence and assurance, improved treatment oversight, more complete data capture, and overcoming barriers to data documentation. Careful patient selection and patient and clinician education may help to optimize the benefits of RPM, maintain patient independence, and reduce the risks of patient disengagement. The use of an App may support RPM; however, participants expressed concerns about increasing the burden on some patients through the use of unfamiliar technology. Human Research Ethics Committee Approval Number: CH62/6/2019-028

This study aimed to evaluate the effects, and timing of, a video educational intervention on medical student performance in manikin-based simulation patient encounters. This prospective mixed-methods study was conducted as part of the University of Toledo College of Medicine and Life Sciences undergraduate medical curriculum. One hundred sixty-six students second-year students participated in two simulations on a single day in September 2021. A 7-minute video intervention outlining the clinical diagnostic approach to pulmonary complaints was implemented. Students were randomized into 32 groups which were divided into two cohorts. One received the video prior to simulation-1 (n=83) and the other between simulation-1 and simulation-2 (n=83). Each simulation was recorded and assessed using a 44-point standardized checklist. Comparative analysis to determine differences in performance scores was performed using independent t-tests and paired t-tests. Independent t-tests revealed the video-prior cohort performed better in simulation-1 (t = 2.27, p= .03), however in simulation-2 no significant difference was observed between the cohorts. Paired t-test analysis revealed the video-between cohort had significant improvement from simulation-1 to simulation-2 (t = 3.06, p = .01); no significant difference was found for the video-prior cohort. Less prompting was seen in simulation-2 among both the video-prior (t = -2.83, p= .01) and video-between cohorts (t = -2.18, p= .04). Simulation training, and targeted educational interventions, facilitate medical students to become clinically competent practitioners. Our findings indicate that guided video instruction advances students' clinical performance greater than learning through simulation alone. To confirm these findings, similar investigations in other clinical training exercises should be considered.

Background: Most studies addressing hemodialysis initiation with a dialysis catheter focus on patients entering maintenance dialysis programs and exclude other patients, such as those with acute kidney injury (AKI), making interpretation and application of the results difficult for clinicians managing patients at the time of dialysis commencement. Objective: To compare the survival of all patients requiring a catheter for hemodialysis access according to the nature of clinical presentation. Design: Prospective observational. Setting: An Australian tertiary renal unit. Patients: All patients requiring a central venous catheter (CVC) for hemodialysis access between 2005 and 2015. Measurements: Baseline comorbidities, demographics, and nature of clinical presentation. Data regarding each episode of dialysis access insufficiency and each CVC were collected. The primary outcome was all-cause mortality. Methods: Patients were classified into 1 of 3 groups based on physician assessment at the time of presentation: patients believed to have AKI with expected renal recovery (AKI), patients considered to be entering the maintenance dialysis program without a functioning dialysis access (Maintenance Dialysis), patients unable to perform peritoneal dialysis, or use their existing hemodialysis access (Access Failure). Time-split multivariable Cox regression analyses were used to compare survival between groups. Results: A total of 557 eligible patients had complete prospective data regarding CVC use and were included in the analyses. The majority of patients were in the AKI (246/557, 44%) and Maintenance Dialysis groups (182/557, 33%) compared with the Access Failure group (129/557, 23%). During a median follow-up of 3 years, 302 (54%) of the 557 patients died. Following adjustment, risk of all-cause mortality was higher in the AKI group (hazard ratio [HR]: 2.01, 95% confidence interval [CI]: 1.31-3.60, P = .001) during the first 2 years after catheter insertion and lower in years 2 to 4 (HR: 0.42, 95% CI: 0.20-0.88, P = .02) than in the reference Maintenance Dialysis group. No difference in mortality risk between the Access Failure and reference group was found. Limitations: Single-center study. Possible residual confounding owing to the observational study design. Conclusions: Patients requiring acute or unplanned hemodialysis experience high mortality, and the nature of clinical presentation does influence outcomes. Most notable is the greater early mortality experienced by patients with AKI compared to other patient groups. Prospective definition of the nature of unplanned dialysis initiation is important to accurately measure and improve outcomes in this high-risk patient population. Human Research Ethics Committee Approval Number CH62/6/2017-042.

Chronic kidney disease (CKD) affects more than 1/10 people worldwide with a disproportionately high burden in disadvantaged communities. As CKD severity increases, the associated morbidity, mortality and treatment costs also increase. In the case of kidney failure, the most severe form of CKD, the costs of treatment, including life prolonging treatment with dialysis or kidney transplant, are often unaffordable in under-resourced healthcare settings.Data has been central to improving the outcomes of patients with CKD, but there continue to be important data gaps, especially in low- and lower-middle-income countries (LLMICs). In order to more comprehensively understand the burden of kidney disease, it is necessary to overcome the many challenges to data collection which exist globally. To explore how this could be achieved, this thesis examines how four different data sources can contribute to addressing gaps in understanding CKD.Firstly, the role of kidney replacement therapy (KRT) registries in LLMICs were assessed through a review of the literature and explored further by implementing a dialysis registry in Fiji. Secondly, extending data collection of a randomised controlled trial to examine how differing practice patterns across regions might impact outcomes was assessed through analysis of the extended follow-up of the Study of Heart and Renal Protection (SHARP). Thirdly, the role of administrative data was explored through a literature review and through two novel data linkage analyses. Lastly, semi-structured interviews were conducted with patients and clinicians to understand their perspectives on remote patient monitoring (RPM), a novel approach to patient data collection for dialysis treatment.The analyses examining the role of focused KRT registries in LLMICs and the utility of long-term follow-up of clinical trials to compare outcomes between regions suggest that whilst useful at describing the burden of disease and treatment, these data sources are unlikely to be central to solving major knowledge gaps due to their cost and complexity. The use of administrative data and data linkage offer an opportunity for efficient data collection in CKD and may represent a cost-effective investment for developing healthcare systems in the future. Novel data capture techniques, such as RPM, may improve CKD data collection, but a thorough understanding of the perspectives of user populations should be considered before their wider implementation.

The dominant conception of forensic science as a patchwork of disciplines primarily assisting the criminal justice system (i.e. forensics) is in crisis or at least shows a series of anomalies and serious limitations. In recent years, symptoms of the crisis have been discussed in a number of reports by various commentators, without a doubt epitomized by the 2009 report by the US National Academies of Sciences (NAS 2009 Strengthening forensic science in the United States: a path forward). Although needed, but viewed as the solution to these drawbacks, the almost generalized adoption of stricter business models in forensic science casework compounded with ever-increasing normative and compliance processes not only place additional pressures on a discipline that already appears in difficulty, but also induce more fragmentation of the different forensic science tasks, a tenet many times denounced by the same NAS report and other similar reviews. One may ask whether these issues are not simply the result of an unfit paradigm. If this is the case, the current problems faced by forensic science may indicate future significant changes for the discipline. To facilitate broader discussion this presentation focuses on trace evidence, an area that is seminal to forensic science both for epistemological and historical reasons. There is, however, little doubt that this area is currently under siege worldwide. Current and future challenges faced by trace evidence are discussed along with some possible answers. The current situation ultimately presents some significant opportunities to re-invent not only trace evidence but also forensic science. Ultimately, a distinctive, more robust and more reliable science may emerge through rethinking the forensics paradigm built on specialisms, revisiting fundamental forensic science principles and adapting them to the twenty-first century.

•Practical application of a generalised framework for forensic intelligence processes.•439 documents seized across 10 jurisdictions of known and unknown source level links.•Image processing performance evaluated through intra-variability and inter-variability.•Insights into criminal organisations possible through image processing. Forensic intelligence has recently gathered increasing attention as a potential expansion of forensic science that may contribute in a wider policing and security context. Whilst the new avenue is certainly promising, relatively few attempts to incorporate models, methods and techniques into practical projects are reported. This work reports a practical application of a generalised and transversal framework for developing forensic intelligence processes referred to here as the Transversal model adapted from previous work. Visual features present in the images of four datasets of false identity documents were systematically profiled and compared using image processing for the detection of a series of modus operandi (M.O.) actions. The nature of these series and their relation to the notion of common source was evaluated with respect to alternative known information and inferences drawn regarding respective crime systems. 439 documents seized by police and border guard authorities across 10 jurisdictions in Switzerland with known and unknown source level links formed the datasets for this study. Training sets were developed based on both known source level data, and visually supported relationships. Performance was evaluated through the use of intra-variability and inter-variability scores drawn from over 48,000 comparisons. The optimised method exhibited significant sensitivity combined with strong specificity and demonstrates its ability to support forensic intelligence efforts.

The dominant conception of forensic science as a patchwork of disciplines primarily assisting the criminal justice system (i.e. forensics) is in crisis or at least shows a series of anomalies and serious limitations. In recent years, symptoms of the crisis have been discussed in a number of reports by various commentators, without a doubt epitomized by the 2009 report by the US National Academies of Sciences (NAS 2009 Strengthening forensic science in the United States: a path forward). Although needed, but viewed as the solution to these drawbacks, the almost generalized adoption of stricter business models in forensic science casework compounded with everincreasing normative and compliance processes not only place additional pressures on a discipline that already appears in difficulty, but also induce more fragmentation of the different forensic science tasks, a tenet many times denounced by the same NAS report and other similar reviews. One may ask whether these issues are not simply the result of an unfit paradigm. If this is the case, the current problems faced by forensic science may indicate future significant changes for the discipline. To facilitate broader discussion this presentation focuses on trace evidence, an area that is seminal to forensic science both for epistemological and historical reasons. There is, however, little doubt that this area is currently under siege worldwide. Current and future challenges faced by trace evidence are discussed along with some possible answers. The current situation ultimately presents some significant opportunities to re-invent not only trace evidence but also forensic science. Ultimately, a distinctive, more robust and more reliable science may emerge through rethinking the forensics paradigm built on specialisms, revisiting fundamental forensic science principles and adapting them to the twenty-first century.