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Changes in the epidemiology and ecology of H5N1 highly pathogenic avian influenza are devastating wild bird and poultry populations, farms and communities, and wild mammals worldwide. Having originated in farmed poultry, H5N1 viruses are now spread globally by wild birds, with transmission to many mammal and avian species, resulting in 2024 in transmission among dairy cattle with associated human cases. These ecological changes pose challenges to mitigating the impacts of H5N1 highly pathogenic avian influenza on wildlife, ecosystems, domestic animals, food security, and humans. H5N1 highly pathogenic avian influenza highlights the need for One Health approaches to pandemic prevention and preparedness, emphasising multisectoral collaborations among animal, environmental, and public health sectors. Action is needed to reduce future pandemic risks by preventing transmission of highly pathogenic avian influenza among domestic and wild animals and people, focusing on upstream drivers of outbreaks, and ensuring rapid responses and risk assessments for zoonotic outbreaks. Political commitment and sustainable funding are crucial to implementing and maintaining prevention programmes, surveillance, and outbreak responses., Competing Interests: Declaration of interests All authors declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Precise mosquito identification is integral to effective arbovirus surveillance. Nonetheless, the conventional morphological approach to identifying mosquito species is laborious, demands expertise and presents challenges when specimens are damaged. DNA barcoding offers a promising alternative, surmounting challenges inherent in morphological identification. To integrate DNA barcoding into arbovirus surveillance effectively, a robust dataset of mosquito barcode sequences is required. This study established a comprehensive repository of Cytochrome Oxidase I (COI) barcodes, encompassing 177 samples representing 45 mosquito species from southern and northern Western Australia (WA), including 16 species which have not been previously barcoded. The average intraspecific and interspecific genetic distances were 1% and 6.8%, respectively. Anopheles annulipes sensu lato had the highest intraspecific distance at 9.1%, signifying a genetically diverse species. While validating the potential of COI barcodes to accurately differentiate mosquito species, we identified that some species pairs have low COI divergence. This includes Aedes clelandi and Ae. hesperonotius , Tripteroides atripes and Tp. punctolaeralis and Ae. turneri and Ae. stricklandi . In addition, we observed ambiguity in identification of the members of Culex sitiens subgroup ( Cx. annulirostris , Cx. palpalis and Cx. sitiens ) and three members of Cx. pipiens complex ( Cx. australicus , Cx. globocoxitus , Cx. quinquefasciatus ). In summary, despite presenting challenges in the identification of some mosquito species, the COI barcode accurately identified most of the species and generated a valuable resource that will support the WA arbovirus surveillance program and enhance public health intervention strategies for mosquito-borne disease control., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Author(s). Ecology and Evolution published by John Wiley & Sons Ltd.)

Ross River virus (RRV) and Barmah Forest virus (BFV) are arthritogenic arthropod-borne viruses (arboviruses) that exhibit generalist host associations and share distributions in Australia and Papua New Guinea (PNG). Using stochastic mapping and discrete-trait phylogenetic analyses, we profiled the independent evolution of RRV and BFV signature mutations. Analysis of 186 RRV and 88 BFV genomes demonstrated their viral evolution trajectories have involved repeated selection of mutations, particularly in the nonstructural protein 1 ( nsP1 ) and envelope 3 ( E3 ) genes suggesting convergent evolution. Convergent mutations in the nsP1 genes of RRV (residues 248 and 441) and BFV (residues 297 and 447) may be involved with catalytic enzyme mechanisms and host membrane interactions during viral RNA replication and capping. Convergent E3 mutations (RRV site 59 and BFV site 57) may be associated with enzymatic furin activity and cleavage of E3 from protein precursors assisting viral maturation and infectivity. Given their requirement to replicate in disparate insect and vertebrate hosts, convergent evolution in RRV and BFV may represent a dynamic link between their requirement to selectively 'fine-tune' intracellular host interactions and viral replicative enzymatic processes. Despite evidence of evolutionary convergence, selection pressure analyses did not reveal any RRV or BFV amino acid sites under strong positive selection and only weak positive selection for nonstructural protein sites. These findings may indicate that their alphavirus ancestors were subject to positive selection events which predisposed ongoing pervasive convergent evolution, and this largely supports continued purifying selection in RRV and BFV populations during their replication in mosquito and vertebrate hosts., Competing Interests: The authors declare that there are no conflicts of interest., (© The Author(s) 2024. Published by Oxford University Press.)

Photoperiod insensitivity (auto-flowering) in drug-type Cannabis sativa circumvents the need for short day (SD) flowering requirements making outdoor cultivation in high latitudes possible. However, the benefits of photoperiod insensitivity are counterbalanced by low cannabinoid content and poor flower quality in auto-flowering genotypes. Despite recent studies in cannabis flowering, a mechanistic understanding of photoperiod insensitivity is still lacking. We used a combination of genome-wide association study and genetic fine-mapping to identify the genetic cause of auto-flowering in cannabis. We then used gene expression analyses and transient transformation assays to characterize flowering time control. Herein, we identify a splice site mutation within circadian clock gene PSEUDO-RESPONSE REGULATOR 37 (CsPRR37) in auto-flowering cannabis. We show that CsPRR37 represses FT expression and its circadian oscillations transition to a less repressive state during SD as compared to long days (LD). We identify several key circadian clock genes whose expression is altered in auto-flowering cannabis, particularly under non-inductive LD. Research into the pervasiveness of this mutation and others affecting flowering time will help elucidate cannabis domestication history and advance cannabis breeding toward a more sustainable outdoor cultivation system., (© 2024 Society for Experimental Biology and John Wiley & Sons Ltd.)

Sindbis virus (SINV) is a widely dispersed mosquito-borne alphavirus. Reports of Sindbis disease are largely restricted to northern Europe and South Africa. SINV is frequently sampled in Australian mosquito-based arbovirus surveillance programs, but human disease has rarely been reported. Molecular epidemiological studies have characterized six SINV genotypes (G1-G6) based on E2 gene phylogenies, mostly comprising viruses derived from the African-European zoogeographical region and with limited representation of Australasian SINV. In this study, we conducted whole genome sequencing of 66 SINV isolates sampled between 1960 and 2014 from countries of the Australasian region: Australia, Malaysia, and Papua New Guinea. G2 viruses were the most frequently and widely sampled, with three distinct sub-lineages defined. No new G6 SINV were identified, confirming geographic restriction of these viruses to south-western Australia. Comparison with global SINV characterized large-scale nucleotide and amino acid sequence divergence between African-European G1 viruses and viruses that circulate in Australasia (G2 and G3) of up to 26.83% and 14.55%, respectively, divergence that is sufficient for G2/G3 species demarcation. We propose G2 and G3 are collectively a single distinct alphavirus species that we name Argyle virus, supported by the inapparent or mild disease phenotype and the higher evolutionary rate compared with G1. Similarly, we propose G6, with 24.7% and 12.61% nucleotide and amino acid sequence divergence, is a distinct alphavirus species that we name Thomson's Lake virus.

Competing Interests: The authors have declared that no competing interests exist.

Introduction: There is clinical equipoise as to whether hyperoxia is injurious to the myocardium, both in the setting of acute ischaemic insults and on the stable myocardium. This study examined the effect of extreme hyperoxia - in the form of hyperbaric oxygen treatment - on the myocardium through measurement of high-sensitivity cardiac troponin., Methods: Forty-eight individuals were enrolled to undergo a series of 30 exposures to hyperbaric oxygen for treatment of non-cardiac pathologies. High-sensitivity troponin T was measured before and after each session., Results: There was no clinically significant difference in troponin measurements following acute or recurrent sequential exposures to extreme hyperoxia, despite the studied patient population having a high rate of previous ischaemic heart disease or cardiovascular risk factors., Conclusions: This study demonstrates that profound hyperoxaemia does not induce any measurable cardiac injury at a biochemical level. Neither is there a reduction in cardiac troponin to suggest a cardioprotective effect of hyperbaric hyperoxia. This provides some reassurance as to the cardiac safety of the routine use of hyperbaric oxygen treatment in management of non-cardiac pathology., (Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.)

The health of humans, domestic and wild animals, plants, and the environment are inter-dependent. Global anthropogenic change is a key driver of disease emergence and spread and leads to biodiversity loss and ecosystem function degradation, which are themselves drivers of disease emergence. Pathogen spill-over events and subsequent disease outbreaks, including pandemics, in humans, animals and plants may arise when factors driving disease emergence and spread converge. One Health is an integrated approach that aims to sustainably balance and optimize human, animal and ecosystem health. Conventional disease surveillance has been siloed by sectors, with separate systems addressing the health of humans, domestic animals, cultivated plants, wildlife and the environment. One Health surveillance should include integrated surveillance for known and unknown pathogens, but combined with this more traditional disease-based surveillance, it also must include surveillance of drivers of disease emergence to improve prevention and mitigation of spill-over events. Here, we outline such an approach, including the characteristics and components required to overcome barriers and to optimize an integrated One Health surveillance system., Competing Interests: The authors declare no-conflict of interest., (© 2023 The Authors.)

Aim: This cluster-based randomised control trial examines the comparative efficacy of two eLearning programs that teach clinicians evidence-based bronchiolitis management for children less than 12 months of age., Methods: Six hospitals, matched for size, were randomly allocated to either video-based (arm A) or slide-based (arm B) eLearning programs. To assess behavioural change, participants (doctors and nurses) were asked to declare how they would manage a video scenario of an infant with bronchiolitis, before and after either eLearning method. Measured outcomes included the number of investigations and treatments ordered, admissions to hospital and discharge planning. Confidence scores and change in understanding for bronchiolitis management were also measured., Results: Both methods of eLearning instruction resulted in reductions in unnecessary investigations and treatments performed, as well as improved confidence and understanding of bronchiolitis management on the video scenario. Video-based eLearning instruction additionally demonstrated a significant reduction in unnecessary hospital admissions and better discharge planning, based on learners' declarations to the video scenario, relative to slide-based learning., Conclusion: Slide-based and video-based eLearning both demonstrate improvements in reported bronchiolitis management. However, video-based eLearning may yield more significant practice changes, improved clinician confidence in management, as well as improved patient experience., (© 2022 The Authors. Journal of Paediatrics and Child Health published by John Wiley & Sons Australia, Ltd on behalf of Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Background: A fatal case of Japanese encephalitis (JE) occurred in a resident of the Tiwi Islands, in the Northern Territory of Australia in February 2021, preceding the large JE outbreak in south-eastern Australia in 2022. This study reports the detection, whole genome sequencing and analysis of the virus responsible (designated JEV/Australia/NT_Tiwi Islands/2021)., Methods: Reverse transcription quantitative PCR (RT-qPCR) testing was performed on post-mortem brain specimens using a range of JE virus (JEV)-specific assays. Virus isolation from brain specimens was attempted by inoculation of mosquito and mammalian cells or embryonated chicken eggs. Whole genome sequencing was undertaken using a combination of Illumina next generation sequencing methodologies, including a tiling amplicon approach. Phylogenetic and selection analyses were performed using alignments of the Tiwi Islands JEV genome and envelope (E) protein gene sequences and publicly available JEV sequences., Results: Virus isolation was unsuccessful and JEV RNA was detected only by RT-qPCR assays capable of detecting all JEV genotypes. Phylogenetic analysis revealed that the Tiwi Islands strain is a divergent member of genotype IV (GIV) and is closely related to the 2022 Australian outbreak virus (99.8% nucleotide identity). The Australian strains share highest levels of nucleotide identity with Indonesian viruses from 2017 and 2019 (96.7-96.8%). The most recent common ancestor of this Australian-Indonesian clade was estimated to have emerged in 2007 (95% HPD range: 1998-2014). Positive selection was detected using two methods (MEME and FEL) at several sites in the E and non-structural protein genes, including a single site in the E protein (S194N) unique to the Australian GIV strains., Conclusion: This case represents the first detection of GIV JEV acquired in Australia, and only the second confirmed fatal human infection with a GIV JEV strain. The close phylogenetic relationship between the Tiwi Islands strain and recent Indonesian viruses is indicative of the origin of this novel GIV lineage, which we estimate has circulated in the region for several years prior to the Tiwi Islands case., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Sikazwe et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

A fatal case of Japanese encephalitis (JE) occurred in northern Australia in early 2021. Sequence studies showed that the virus belonged to genotype IV (GIV), a genotype previously believed to be restricted to the Indonesian archipelago. This was the first locally acquired case of Japanese encephalitis virus (JEV) GIV to occur outside Indonesia, and the second confirmed fatal human case caused by a GIV virus. A closely related GIV JEV strain subsequently caused a widespread outbreak in eastern Australia in 2022 that was first detected by fetal death and abnormalities in commercial piggeries. Forty-two human cases also occurred with seven fatalities. This has been the first major outbreak of JEV in mainland Australia, and geographically the largest virgin soil outbreak recorded for JEV. This outbreak provides an opportunity to discuss and document the factors involved in the virus' spread and its ecology in a novel ecological milieu in which other flaviviruses, including members of the JE serological complex, also occur. The probable vertebrate hosts and mosquito vectors are discussed with respect to virus spread and its possible endemicity in Australia, and the need to develop a One Health approach to develop improved surveillance methods to rapidly detect future outbreak activity across a large geographical area containing a sparse human population. Understanding the spread of JEV in a novel ecological environment is relevant to the possible threat that JEV may pose in the future to other receptive geographic areas, such as the west coast of the United States, southern Europe or Africa.

High temperature stress inhibits photosynthesis and threatens wheat production. One measure of photosynthetic heat tolerance is T crit - the critical temperature at which incipient damage to photosystem II (PSII) occurs. This trait could be improved in wheat by exploiting genetic variation and genotype-by-environment interactions (GEI). Flag leaf T crit of 54 wheat genotypes was evaluated in 12 thermal environments over 3 years in Australia, and analysed using linear mixed models to assess GEI effects. Nine of the 12 environments had significant genetic effects and highly variable broad-sense heritability (H 2 ranged from 0.15 to 0.75). T crit GEI was variable, with 55.6% of the genetic variance across environments accounted for by the factor analytic model. Mean daily growth temperature in the month preceding anthesis was the most influential environmental driver of T crit GEI, suggesting biochemical, physiological and structural adjustments to temperature requiring different durations to manifest. These changes help protect or repair PSII upon exposure to heat stress, and may improve carbon assimilation under high temperature. To support breeding efforts to improve wheat performance under high temperature, we identified genotypes superior to commercial cultivars commonly grown by farmers, and demonstrated potential for developing genotypes with greater photosynthetic heat tolerance., (© 2022 The Authors. The Plant Journal published by Society for Experimental Biology and John Wiley & Sons Ltd.)

Competing Interests: The authors have declared that no competing interests exist.

In early 2022, the Japanese encephalitis virus (JEV) was identified as the cause of stillborn and mummified piglets in pig farms in southeastern Australia. Human cases and additional pig farms with infected piglets were subsequently identified across a widespread area encompassing four states. To inform surveillance and control programs, we synthesized existing information on Australian vectors of JEV, much of which was generated in response to incursions of JEV into the northern state of Queensland between 1995 and 2005. Members of the Culex sitiens subgroup, particularly Culex annulirostris, should be considered the primary vectors of JEV in Australia, as they yielded >87% of field detections of JEV, were highly efficient laboratory vectors of the virus, readily fed on pigs and birds (the key amplifying hosts of the virus) when they were available, and are widespread and often occur in large populations. Three introduced species, Culex quinquefasciatus, Culex gelidus and Culex tritaeniorhynchus may also serve as vectors, but more information on their geographical distribution, abundance and bionomics in the Australian context is required. Mosquitoes from other genera, such as Aedes and Verrallina, whilst considered relatively poor vectors, could play a regional or supplemental role in transmission, especially facilitating vertical transmission as a virus overwintering mechanism. Additional factors that could impact JEV transmission, including mosquito survival, dispersal and genetics, are also discussed. Possible directions for investigation are provided, especially in the context of the virus emerging in a region with different mosquito fauna and environmental drivers than northern Australia.

Fast synaptic communication requires receptors that respond to the presence of neurotransmitter by opening an ion channel across the post-synaptic membrane. The muscle-type nicotinic acetylcholine receptor from the electric fish, Torpedo, is the prototypic ligand-gated ion channel, yet the structural changes underlying channel activation remain undefined. Here we use cryo-EM to solve apo and agonist-bound structures of the Torpedo nicotinic receptor embedded in a lipid nanodisc. Using both a direct biochemical assay to define the conformational landscape and molecular dynamics simulations to assay flux through the pore, we correlate structures with functional states and elucidate the motions that lead to pore activation of a heteromeric nicotinic receptor. We highlight an underappreciated role for the complementary subunit in channel gating, establish the structural basis for the differential agonist affinities of α/δ versus α /γ sites, and explain why nicotine is less potent at muscle nicotinic receptors compared to neuronal ones., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Medial epicondyle fracture displacement is notoriously difficult to determine on conventional radiography, and follow-up computed tomography (CT) is often obtained to measure precise displacement. Another option for fracture characterization is digital tomosynthesis (DT), a technology providing high in-plane resolution of bony anatomy by acquiring multiple low-dose images in a linear arc. Advantages of DT include lower radiation exposure and lower cost than CT, rapid image acquisition, and a similar patient experience to conventional radiography. The digital application of tomosynthesis is relatively new and is integrated as an add-on feature with modern radiography equipment. This study compares DT, CT and conventional radiography for measurement accuracy in medial epicondyle fractures with the goal of determining relative accuracy in measuring medial epicondyle fracture displacement., Methods: Medial epicondyle fractures were created in 5 cadaveric elbow specimens. Each specimen was imaged with conventional radiography, DT, and CT. True displacement measured by digital calipers was compared with "measured" displacement for each image acquisition. CT images included axial, sagittal, and coronal reformats. DT images of the elbow included anteroposterior (AP) longitudinal and transverse, lateral longitudinal and transverse, and axial longitudinal and transverse. Conventional radiographs included AP, lateral, and axial distal humerus images. Four physicians reviewed all images 3 months later. Each reviewer independently measured maximum apparent fracture displacement to the nearest 0.1 mm. Measurement accuracy was calculated as percent difference [(measured displacement-actual displacement)/actual displacement] for each acquisition. Mean, median, and SD for measurement accuracy were calculated. Two-tailed paired t tests were performed on each acquisition to compare the measurement accuracy., Results: Compared with conventional radiographs, accuracy of DT was superior in AP longitudinal (P=0.03), AP transverse (P=0.01), axial longitudinal (P=0.0001), and axial transverse projections (P=0.001). Accuracy of CT was superior to conventional radiography in the AP projection (P=0.03), but was equivalent in the axial projection (P=0.9). Accuracy of CT was similar to DT in AP longitudinal (P=0.6), AP transverse (P=0.5), and axial longitudinal projections (P=0.07). Accuracy of DT in the axial transverse projection was superior to CT (P=0.03)., Conclusion: DT is more accurate than conventional radiography (both AP and axial views) and as accurate as CT in assessing millimeters of displacement of medial epicondyle fracture fragments., Level of Evidence: Level IV-diagnostic study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: Lactate is frequently utilised in clinical practice. Some have concerns that tourniquet application for venous blood collection may falsely elevate venous lactate. The objective of the present study was to determine the effect of tourniquet time on varying venous lactate concentrations., Methods: This is a healthy volunteer study, in which subjects were their own controls. A cannula was inserted into each arm, with a tourniquet remaining on one. Subjects were allocated to one of three groups; rest (no activity), exercise (maximal exertion to elevate lactate concentrations) with immediate tourniquet application or exercise with delayed (5-min post-exercise) tourniquet application. In all blood was drawn simultaneously from both cannulas at 0, 2.5, 5, 10 and 15-min post-tourniquet application and analysed for lactate on a point-of-care device. The primary outcome was a clinically significant difference (>1 mmol/L) in tourniquet versus non-tourniquet arm lactate concentration., Results: There were 10 subjects per group; the exercise groups achieved a mean maximum lactate concentration of 10.4 mmol/L (standard deviation [SD] 3.6) (exercise with immediate tourniquet application group) and 8.9 mmol/L (SD 2.5) (exercise with delayed tourniquet application group). There was no clinically significant increase in lactate concentration in the tourniquet compared to non-tourniquet arm in all groups, across all tourniquet application times, and over a range of lactate concentrations. In the rest group after 15-min of tourniquet application the mean lactate concentration of the tourniquet versus non-tourniquet arm was 0.91 mmol/L (SD 0.55) versus 0.89 mmol/L (SD 0.46) (P = 0.99), respectively., Conclusion: In the present study tourniquet application for blood collection did not significantly increase lactate concentration. Hence, clinically a raised venous lactate concentration should not be attributed to prolonged tourniquet application., (© 2021 Australasian College for Emergency Medicine.)

Ross River virus (RRV) is the most medically significant mosquito-borne virus of Australia, in terms of human morbidity. RRV cases, characterised by febrile illness and potentially persistent arthralgia, have been reported from all Australian states and territories. RRV was the cause of a large-scale epidemic of multiple Pacific Island countries and territories (PICTs) from 1979 to 1980, involving at least 50,000 cases. Historical evidence of RRV seropositivity beyond Australia, in populations of Papua New Guinea (PNG), Indonesia and the Solomon Islands, has been documented. We describe the genomic characterisation and timescale analysis of the first isolate of RRV to be sampled from PNG to date. Our analysis indicates that RRV has evolved locally within PNG, independent of Australian lineages, over an approximate 40 year period. The mean time to most recent common ancestor (tMRCA) of the unique PNG clade coincides with the initiation of the PICTs epidemic in mid-1979. This may indicate that an ancestral variant of the PNG clade was seeded into the region during the epidemic, a period of high RRV transmission. Further epidemiological and molecular-based surveillance is required in PNG to better understand the molecular epidemiology of RRV in the general Australasian region.

Apnoeic oxygenation (ApOx) has been demonstrated to reduce the incidence of desaturation, although evidence of benefit has been conflicting depending on the technique used. The aim of this study was to compare the incidence of desaturation between patients who received ApOx via conventional nasal cannula (NC) and those who did not, using a large, multicentre airway registry., Methods: This study is an analysis of 24 months of prospectively collected data in the Australia and New Zealand Emergency Department Airway Registry (June 2013-June 2015). The registry includes information on all intubated adults from 43 emergency departments. Patients intubated during cardiac arrest (n=393), those who received active ventilation prior to the first intubation attempt (n=486), and where the use of ApOx was not recorded either way (n=312) were excluded. The proportion of patients who desaturated (Sa0 2 <93) in the group that received ApOx and those that did not were compared. To evaluate the association of ApOx with patient desaturation, a logistic regression model based on factors expected to influence desaturation was performed., Results: Of 2519 patients analysed, 1669 (66.3%) received ApOx via NC while 850 (33.7%) did not. Desaturation in the cohort receiving ApOx was 10.4% compared with standard care (no ApOx) 13.7%. ApOx had a protective effect for desaturation (OR 0.71 95% CI 0.53 to 0.95). Single intubation attempt was associated with reduced risk of desaturation of (OR 0.10, 95% CI 0.06 to 0.17); this was increased on second attempt (OR 0.37, 95% CI 0.21 to 0.68). Desaturation was also associated with the physician recording that they had anticipated a difficult airway (OR 1.83, 95% CI 1.34 to 2.48)., Conclusion: This large multicentre registry study provides evidence that ApOx delivered through a conventional NC is associated with a lower incidence of desaturation in patients undergoing rapid sequence intubation., Trial Registration Number: ACTRN12613001052729., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Observations among Israeli pediatric rheumatologists reveal that pediatric Juvenile Spondyloarthritis (JSpA) may present differently compared to patients from the United States (US). This study is aimed to compare the demographic and clinical variables of Israeli and US JSpA patients upon presentation., Methods: We performed a retrospective, cross-sectional, multicenter comparison of JSpA patients among 3 large Israeli pediatric rheumatology centers and a large US pediatric rheumatology center. Patients with diagnosis of Juvenile Ankylosing Spondylitis (JAS) and/or Enthesitis-related Arthritis (ERA) were included. The demographic, clinical and radiologic features were compared., Results: Overall 87 patients were included (39 Israeli, 48 US patients). Upon presentation, inflammatory back pain, sacroiliac joint tenderness and abnormal modified Schober test, were significantly more prevalent among Israeli patients (59% vs. 35.4, 48.7% vs. 16.7, and 41.2% vs. 21.5%, respectively, all p < 0.05), whereas peripheral arthritis and enthesitis were significantly more prevalent among US patients (43.6% vs. 91.7 and 7.7% vs. 39.6% in Israeli patients vs. US patients, p < 0.05). In addition, 96.7% of the Israeli patients versus 29.7% of the US patients demonstrated sacroiliitis on MRI (p < 0.001, N = 67). Less than one-third of the Israeli patients (32%) were HLA-B27 positive vs. 66.7% of US patients (p = 0.007)., Conclusion: Israeli children with JSpA presented almost exclusively with axial disease compared to US patients who were more likely to present with peripheral symptoms. HLA B27 prevalence was significantly lower in the Israeli cohort compared to the US cohort. Further studies are needed to unravel the genetic and possibly environmental factors associated with these findings.

Competing Interests: Competing interestsThe authors declare that they have no competing interests.

Barmah Forest virus (BFV) is a medically important mosquito-borne alphavirus endemic to Australia. Symptomatic disease can be a major cause of morbidity, associated with fever, rash, and debilitating arthralgia. BFV disease is similar to that caused by Ross River virus (RRV), the other major Australian alphavirus. Currently, just four BFV whole-genome sequences are available with no genome-scale phylogeny in existence to robustly characterise genetic diversity. Thirty novel genome sequences were derived for this study, for a final 34-taxon dataset sampled over a 44 year period. Three distinct BFV genotypes were characterised (G1-3) that have circulated in Australia and Papua New Guinea (PNG). Evidence of spatio-temporal co-circulation of G2 and G3 within regions of Australia was noted, including in the South West region of Western Australia (WA) during the first reported disease outbreaks in the state's history. Compared with RRV, the BFV population appeared more stable with less frequent emergence of novel lineages. Preliminary in vitro assessment of RRV and BFV replication kinetics found that RRV replicates at a significantly faster rate and to a higher, more persistent titre compared with BFV, perhaps indicating mosquitoes may be infectious with RRV for longer than with BFV. This investigation resolved a greater diversity of BFV, and a greater understanding of the evolutionary dynamics and history was attained.

Metagenomics revealed an impressive breadth of previously unrecognized viruses. Here, we report the virome of the Culex annulirostris Skuse mosquito, an important vector of pathogenic arboviruses in Australia. Mosquitoes were collected from three sites in the Kimberley region of Western Australia. Unbiased high-throughput sequencing (HTS) revealed the presence of 16 novel viral sequences that share less than 90% identity with known viruses. None were closely related to pathogenic arboviruses. Viruses were distributed unevenly across sites, indicating a heterogeneous Cx. annulirostris virome. Polymerase chain reaction assays confirmed HTS data and identified marked variation between the virus prevalence identified at each site.

A cluster of cases of pneumonia of unknown etiology emerged in Wuhan, China, at the end of December 2019. The cluster was largely associated with a seafood and animal market. A novel Betacoronavirus was quickly identified as the causative agent, and it is shown to be related genetically to SARS-CoV and other bat-borne SARS-related Betacoronaviruses . The number of cases increased rapidly and spread to other provinces in China, as well as to another four countries. To help control the spread of the virus, a "cordon sanitaire " was instituted for Wuhan on January 23, 2020, and subsequently extended to other cities in Hubei Province, and the outbreak declared a Public Health Emergency of International Concern by the Director General of the World Health Organization on January 30, 2020. The virus was named SARS-CoV-2 by the International Committee for the Taxonomy of Viruses, and the disease it causes was named COVID-19 by the World Health Organization. This article described the evolution of the outbreak, and the known properties of the novel virus, SARS-CoV-2 and the clinical disease it causes, and the major public health measures being used to help control it's spread. These measures include social distancing, intensive surveillance and quarantining of cases, contact tracing and isolation, cancellation of mass gatherings, and community containment. The virus is the third zoonotic coronavirus, after SARS-CoV and MERS-CoV, but appears to be the only one with pandemic potential. However, a number of important properties of the virus are still not well understood, and there is an urgent need to learn more about its transmission dynamics, its spectrum of clinical severity, its wildlife origin, and its genetic stability. In addition, more research is needed on possible interventions, particularly therapeutic and vaccines.

Background: Pediatric elbow fractures are common but remain challenging to accurately diagnose. Digital tomosynthesis is a technique that has shown promise in difficult adult fracture patterns but has not been formally studied in the pediatric population., Objective: To assess the added value of digital tomosynthesis on the detection and diagnostic confidence of pediatric elbow fractures., Materials and Methods: A retrospective study was performed between January 2016 and December 2017 in pediatric patients (≤18 years) to assess the ability of conventional elbow radiographs and digital tomosynthesis to detect elbow fractures. One hundred twenty-one pediatric patients with concern for pediatric elbow trauma (64 males, 57 females; mean age: 8.1 years, range: 1 year to 17 years) were imaged with both conventional elbow radiographs and digital tomosynthesis. Two blinded pediatric radiologists identified fractures and indicated their diagnostic confidence. Observer agreement was assessed with Cohen's Kappa coefficient and a nonparametric Wilcoxon rank sum test was used to compare the degree of diagnostic confidence between standard radiographs alone and standard radiographs with digital tomosynthesis. McNemar's test was used to assess the difference in the rate of fracture detection between the two methods and sensitivity, specificity, precision, accuracy and diagnostic odds ratios were calculated., Results: Compared with standard radiographs alone, standard radiographs with digital tomosynthesis improved inter-rater agreement, sensitivity, specificity, accuracy, precision and the diagnostic odds ratio for fracture detection and increased diagnostic confidence (Rater 1: P=0.01, Rater 2: P=0.003)., Conclusion: The addition of digital tomosynthesis with conventional elbow radiographs improves diagnostic confidence and performance for the detection of pediatric elbow fractures.

Mucopolysaccharidosis type VII (MPS7) is a lysosomal storage disorder (LSD) resulting from mutations in the β-glucuronidase gene, leading to multiorgan dysfunction and fetal demise. While postnatal enzyme replacement therapy (ERT) and hematopoietic stem cell transplantation have resulted in some phenotypic improvements, prenatal treatment might take advantage of a unique developmental window to penetrate the blood-brain barrier or induce tolerance to the missing protein, addressing two important shortcomings of postnatal therapy for multiple LSDs. We performed in utero ERT (IUERT) at E14.5 in MPS7 mice and improved survival of affected mice to birth. IUERT penetrated brain microglia, whereas postnatal administration did not, and neurological testing (after IUERT plus postnatal administration) showed decreased microglial inflammation and improved grip strength in treated mice. IUERT prevented antienzyme antibody development even after multiple repeated postnatal challenges. To test a more durable treatment strategy, we performed in utero hematopoietic stem cell transplantation (IUHCT) using congenic CX3C chemokine receptor 1-green fluorescent protein (CX3CR1-GFP) mice as donors, such that donor-derived microglia are identified by GFP expression. In wild-type recipients, hematopoietic chimerism resulted in microglial engraftment throughout the brain without irradiation or conditioning; the transcriptomes of donor and host microglia were similar. IUHCT in MPS7 mice enabled cross-correction of liver Kupffer cells and improved phenotype in multiple tissues. Engrafted microglia were seen in chimeric mice, with decreased inflammation near donor microglia. These results suggest that fetal therapy with IUERT and/or IUHCT could overcome the shortcomings of current treatment strategies to improve phenotype in MPS7 and other LSDs., (Copyright © 2020 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Ross River virus (RRV), an alphavirus of the Togaviridae family, is the most medically significant mosquito-borne virus of Australia. Past RRV phylogenetic and evolutionary analyses have been based on partial genome analyses only. Three geographically distinct RRV lineages, the Eastern, the Western, and the supposedly extinct North-Eastern lineage, were classified previously. We sought to expand on past phylogenies through robust genome-scale phylogeny to better understand RRV genetic diversity and evolutionary dynamics. We analyzed 106 RRV complete coding sequences, which included 13 genomes available on NCBI and 94 novel sequences derived for this study, sampled throughout Western Australia (1977-2014) and during the substantial Pacific Islands RRV epidemic (1979-1980). Our final data set comprised isolates sampled over 59 years (1959-2018) from a range of locations. Four distinct genotypes were defined, with the newly described genotype 4 (G4) found to be the contemporary lineage circulating in Western Australia. The prior geographical classification of RRV lineages was not supported by our findings, with evidence of geographical and temporal cocirculation of distinct genetic groups. Bayesian Markov chain Monte Carlo (MCMC) analysis revealed that RRV lineages diverged from a common ancestor approximately 94 years ago, with distinct lineages emerging roughly every 10 years over the past 50 years in periodic bursts of genetic diversity. Our study has enabled a more robust analysis of RRV evolutionary history and resolved greater genetic diversity that had been previously defined by partial E2 gene analysis. IMPORTANCE Ross River virus (RRV) causes the most common mosquito-borne infection in Australia and causes a significant burden of suffering to infected individuals as well as being a large burden to the Australian economy. The genetic diversity of RRV and its evolutionary history have so far only been studied using partial E2 gene analysis with a limited number of isolates. Robust whole-genome analysis has not yet been conducted. This study generated 94 novel near-whole-genome sequences to investigate the evolutionary history of RRV to better understand its genetic diversity through comprehensive whole-genome phylogeny. A better understanding of RRV genetic diversity will enable better diagnostics, surveillance, and potential future vaccine design., (Copyright © 2020 Michie et al.)

The discovery of hepaciviruses in non-human hosts has accelerated following the advancement of high-throughput sequencing technology. Hepaciviruses have now been described in reptiles, fish, birds, and an extensive array of mammals. Using metagenomic sequencing on pooled samples of field-collected Culex annulirostris mosquitoes, we discovered a divergent hepacivirus-like sequence, named Jogalong virus, from the Kimberley region in northern Western Australia. Using PCR, we screened the same 300 individual mosquitoes and found just a single positive sample (1/300, 0.33%). Phylogenetic analysis of the hepacivirus NS5B protein places Jogalong virus within the genus Hepacivirus but on a distinct and deeply rooted monophyletic branch shared with duck hepacivirus, suggesting a notably different evolutionary history. Vertebrate barcoding PCR targeting two mitochondrial genes, cytochrome c oxidase subunit I and cytochrome b, indicated that the Jogalong virus-positive mosquito had recently fed on the tawny frogmouth (Podargus strigoides), although it is currently unknown whether this bird species contributes to the natural ecology of this virus., Competing Interests: The authors have declared that no competing interests exist.

Imaging pediatric elbow trauma in the acute setting remains diagnostically challenging given difficult patient positioning, multiple ossification centers of the pediatric elbow, overlapping structures, and complex joint anatomy. Digital tomosynthesis is a technique where the X-ray source travels across a limited arc angle, obtaining a series of low-dose exposures that are in turn digitally reconstructed to produce high in-plane resolution at a relatively low overall radiation dose. Digital tomosynthesis is now more commonly integrated into standard radiographic machines and offers a new and exciting way to assess the pediatric elbow. In this review article we discuss the clinical applications of digital tomosynthesis in pediatric elbow trauma along with challenges related to technique, patient positioning and artifacts.

Background: Emergency departments (EDs) are pressured environment where patients with supportive and palliative care needs may not be identified. We aimed to test the predictive ability of the CriSTAL (Criteria for Screening and Triaging to Appropriate aLternative care) checklist to flag patients at risk of death within 3 months who may benefit from timely end-of-life discussions., Methods: Prospective cohorts of >65-year-old patients admitted for at least one night via EDs in five Australian hospitals and one Irish hospital. Purpose-trained nurses and medical students screened for frailty using two instruments concurrently and completed the other risk factors on the CriSTAL tool at admission. Postdischarge telephone follow-up was used to determine survival status. Logistic regression and bootstrapping techniques were used to test the predictive accuracy of CriSTAL for death within 90 days of admission as primary outcome. Predictability of in-hospital death was the secondary outcome., Results: A total of 1,182 patients, with median age 76 to 80 years (IRE-AUS), were included. The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% confidence interval [CI] = 7.7-8.6) versus 5.7 (95% CI = 5.1-6.2) and Irish mean of 7.7 (95% CI = 6.9-8.5) versus 5.7 (95% CI = 5.1-6.2). The model with Fried frailty score was optimal for the derivation (Australian) cohort but prediction with the Clinical Frailty Scale (CFS) was also good (areas under the receiver-operating characteristic [AUROC] = 0.825 and 0.81, respectively). Values for the validation (Irish) cohort were AUROC = 0.70 with Fried and 0.77 using CFS. A minimum of five of 29 variables were sufficient for accurate prediction, and a cut point of 7+ or 6+ depending on the cohort was strongly indicative of risk of death. The most significant independent predictor of short-term death in both cohorts was frailty, carrying a twofold risk of death. CriSTAL's accuracy for in-hospital death prediction was also good (AUROC = 0.795 and 0.81 in Australia and Ireland, respectively), with high specificity and negative predictive values., Conclusions: The modified CriSTAL tool (with CFS instead of Fried's frailty instrument) had good discriminant power to improve certainty of short-term mortality prediction in both health systems. The predictive ability of models is anticipated to help clinicians gain confidence in initiating earlier end-of-life discussions. The practicalities of embedding screening for risk of death in routine practice warrant further investigation., (© 2018 The Authors. Academic Emergency Medicine published by Wiley Periodicals, Inc. on behalf of Society for Academic Emergency Medicine (SAEM).)

Background: Optimized MRI parameters can be leveraged to improve signal intensity, accelerate imaging acquisition and increase resolution. Higher-resolution imaging with a small field of view (FOV) has been proposed as standard practice for investigating sacroiliac (SI) joints, but the improvement in disease detection and characterization over pelvic imaging with large FOV has not been established., Objective: The purpose of this study was to compare dedicated MR images of the SI joints with survey imaging (large-FOV pelvic MRI) for detecting sacroiliitis., Materials and Methods: Fifty-eight pediatric patients suspected of having sacroiliitis underwent dedicated sacroiliac joint and survey pelvic imaging at the same imaging session. We independently evaluated the small- and large-FOV image data sets for presence or absence of sacroiliitis, e.g., bone marrow edema, erosions and synovitis. We used nonparametric statistical tests to compare lesion scores for severity of inflammation. We created test characteristics for the survey pelvic images (low-resolution images of the sacroiliac joints) using dedicated sacroiliac images (small-FOV, high-resolution images) as the gold standard., Results: Dedicated sacroiliac small-FOV MRI detected more sacroiliitis compared to survey pelvic imaging with large FOV (χ 2 =6.125, P=0.013). Readers detected significantly more features of inflammation on small- compared to large-FOV images, e.g., erosions (P=0.039), synovitis (P=0.009), sclerosis (P=0.017) and osteitis (P=0.001). Test characteristics for pelvic large-FOV imaging were sensitivity=0.76, specificity=1.00, positive predictive value = 1.00 and negative predictive value = 0.75., Conclusion: This study provides test characteristics for survey pelvic MRI with lower-resolution large-field-of-view images as a screening tool for detecting sacroiliitis. Pelvic screening studies with large FOV have lower sensitivity, and dedicated sacroiliac MRI with small FOV is superior in detecting sacroiliitis when compared to pelvic screening MRI.

In recent years, it has become evident that a generational gap has developed in the community of arbovirus research. This apparent gap is due to the dis-investment of training for the next generation of arbovirologists, which threatens to derail the rich history of virus discovery, field epidemiology, and understanding of the richness of diversity that surrounds us. On the other hand, new technologies have resulted in an explosion of virus discovery that is constantly redefining the virosphere and the evolutionary relationships between viruses. This paradox presents new challenges that may have immediate and disastrous consequences for public health when yet to be discovered arboviruses emerge. In this review we endeavor to bridge this gap by providing a historical context for the work being conducted today and provide continuity between the generations. To this end, we will provide a narrative of the thrill of scientific discovery and excitement and the challenges lying ahead.

A new approach to stable, low resistance inexpensive printed flexible conductive inks is proposed. Silver inks have been extensively studied and commercialized for applications in printed electronics due to the inherent high conductivity and stability of silver, even in particulate-based percolation networks processed at temperatures compatible with low-cost polymer films such as poly(ethylene terephthalate) (PET). Recent interest in flexible and even stretchable circuits, however, has presented new challenges for particle-based inks as mechanical strains can result in the opening of critical particle-to-particle contacts. Here we report a facile, low-cost method for the single-step synthesis of stable, printable nanoscale Ag 2 O decorated Ag flake inks which can be converted to highly conductive Ag films at 150 °C curing temperature without the use of limited shelf life organometallics or low metal loading nanoparticles to modify the interface between silver flakes. Analysis indicates that decoration of Ag flakes with Ag 2 O nanoparticles (NPs) during ink synthesis improves the conductivity and flexibility of printed silver films by forming bridging interconnections between Ag flakes after low temperature reduction of the Ag 2 O NPs. In this work, printed nanodecorated silver conductors with starting oxide to metal weight ratios of 5:95 exhibited lateral resistivities lower than 1.5 × 10 -5 Ω·cm, which was 35% less than films derived from undecorated Ag flake inks of the same total Ag loading and binder system. This resistivity difference increased to 45% after cyclic bend testing showing increased resilience to repeated flexing for the nanodecorated inks. Through detailed compositional and morphological characterizations, we demonstrate that such improved conductivity and flexibility are due to a more effective bridging afforded by the in situ synthesized Ag NPs on the surface of Ag flakes. These properties, combined with the simplified syntheses method of the nanoink, make the material a viable, advantageous alternative to the limited number of stretchable conductors currently available.

Japanese encephalitis virus (JEV) is a major cause of neurological disease in Asia. It is a zoonotic flavivirus transmitted between water birds and/or pigs by Culex mosquitoes; humans are dead-end hosts. In 1995, JEV emerged for the first time in northern Australia causing an unprecedented outbreak in the Torres Strait. In this article, we revisit the history of JEV in Australia and describe investigations of JEV transmission cycles in the Australian context. Public health responses to the incipient outbreak included vaccination and sentinel pig surveillance programs. Virus isolation and vector competence experiments incriminated Culex annulirostris as the likely regional vector. The role this species plays in transmission cycles depends on the availability of domestic pigs as a blood source. Experimental evidence suggests that native animals are relatively poor amplifying hosts of JEV. The persistence and predominantly annual virus activity between 1995 and 2005 suggested that JEV had become endemic in the Torres Strait. However, active surveillance was discontinued at the end of 2005, so the status of JEV in northern Australia is unknown. Novel mosquito-based surveillance systems provide a means to investigate whether JEV still occurs in the Torres Strait or is no longer a risk to Australia., Competing Interests: The authors declare no conflict of interest.

Objectives: To determine the prevalence of frailty in Emergency Departments (EDs); examine the ability of frailty to predict poor outcomes post-discharge; and identify the most appropriate instrument for routine ED use., Methods: In this prospective study we simultaneously assessed adults 65+yrs admitted and/or spent one night in the ED using Fried, the Clinical Frailty Scale (CFS), and SUHB (Stable, Unstable, Help to walk, Bedbound) scales in four Australian EDs for rapid recognition of frailty between June 2015 and March 2016., Results: 899 adults with complete follow-up data (mean (SD) age 80.0 (8.3) years; female 51.4%) were screened for frailty. Although different scales yielded vastly different frailty prevalence (SUHB 9.7%, Fried 30.4%, CFS 43.7%), predictive discrimination of poor discharge outcomes (death, poor self-reported health/quality of life, need for community services post-discharge, or reattendance to ED after the index hospitalization) for all identical final models was equivalent across all scales (AUROC 0.735 for Fried, 0.730 for CFS and 0.720 for SUHB)., Conclusion: This study confirms that screening for frailty in older ED patients can inform prognosis and target discharge planning including community services required. The CFS was as accurate as the Fried and SUHB in predicting poor outcomes, but more practical for use in busy clinical environments with lower level of disruption. Given the limitations of objectively measuring frailty parameters, self-report and clinical judgment can reliably substitute the assessment in EDs. We propose that in a busy ED environment, frailty scores could be used as a red flag for poor follow-up outcome., (Copyright © 2018 The Author(s). Published by Elsevier B.V. All rights reserved.)

The detection and treatment monitoring of inflammatory states remain challenging in part due to the multifactorial mechanisms of immune activation and spectrum of clinical manifestations. Currently, diagnostic strategies tend to be subjective and limited quantitative tools exist to monitor optimal treatment strategies. Pro-inflammatory M1 polarized macrophages exhibit a distinct metabolic glycolytic phenotype compared to the continuum of M2 polarization states. In the present study, the distinct metabolic phenotypes of resting and activated macrophages were successfully characterized and quantified using hyperpolarized carbon-13 ( 13 C) labeled pyruvate and its metabolic products, i.e. lactate, as a biomarker of resting, disease and treated states. Methods : Mouse macrophage J774A.1 cells were used as a model system in an NMR compatible bioreactor to facilitate dynamic hyperpolarized 13 C measurements. The glycolytic metabolism of the cells in the quiescent or resting state were compared with macrophages stimulated by lipopolysaccharide, a classical M1 activator using hyperpolarized 13 C labeled pyruvate. Additionally, the activated macrophages were also treated with a non-steroidal anti-inflammatory drug to assess the changes in hyperpolarized lactate signal. The hyperpolarized lactate signals were then correlated using biochemical and molecular assays. Results : We first validated our model system of inflammatory cells by the hallmarks of M1 polarization using steady state metabolic profiling with high resolution NMR in conjunction with nitric oxide Greiss assay, enzyme activity, and mRNA expression. Subsequently, we clearly showed that the cutting edge technology of hyperpolarized 13 C NMR can be used to detect elevated lactate levels in M1 polarized macrophages in comparison to control and non-steroidal anti-inflammatory drug treated M2 states. Conclusion: Hyperpolarized 13 C lactate has the potential to serve as a biomarker to non-invasively detect and quantify pro-inflammatory state of immune regulatory cells and its response to therapy., Competing Interests: Competing Interests: The authors have declared that no competing interest exists.

Background: Prognostic uncertainty inhibits clinicians from initiating timely end-of-life discussions and advance care planning. This study evaluates the efficacy of the CriSTAL (Criteria for Screening and Triaging to Appropriate aLternative care) checklist in emergency departments., Methods: Prospective cohort study of patients aged ≥65 years with any diagnosis admitted via emergency departments in ten hospitals in Australia, Denmark and Ireland. Electronic and paper clinical records will be used to extract risk factors such as nursing home residency, physiological deterioration warranting a rapid response call, personal history of active chronic disease, history of hospitalisations or intensive care unit admission in the past year, evidence of proteinuria or ECG abnormalities, and evidence of frailty to be concurrently measured with Fried Score and Clinical Frailty Scale. Patients or their informal caregivers will be contacted by telephone around three months after initial assessment to ascertain survival, self-reported health, post-discharge frailty and health service utilisation since discharge. Logistic regression and bootstrapping techniques and AUROC curves will be used to test the predictive accuracy of CriSTAL for death within 90 days of admission and in-hospital death., Discussion: The CriSTAL checklist is an objective and practical tool for use in emergency departments among older patients to determine individual probability of death in the short-term. Its validation in this cohort is expected to reduce clinicians' prognostic uncertainty on the time to patients' death and encourage timely end-of-life conversations to support clinical decisions with older frail patients and their families about their imminent or future care choices., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: To describe the practice and procedure of emergency intubation in Whanganui Emergency Department, New Zealand and determine whether intubation can be carried out effectively in the rural setting., Method: A prospective observational study using the Australia and New Zealand Airway Registry proforma to collect data on the indication, lead intubator, first-pass success rate and peri-procedural complications. Data were also collected on whether a formal airway assessment was carried out and whether a checklist was used., Results: Twenty-three patients were intubated in the emergency department over a 12-month period. Sixty-two percent (14/23 cases) were medical encounters and the remaining 38% of indications due to a trauma. Head injury was the most common indication (23%). Ninety-two percent of primary intubators were emergency department-based Fellowship of the Australasian College for Emergency Medicine or resident medical officers, while anaesthetic-trained operators accounted for just 8%. Our first-pass intubation success rate was 87% and 16% of cases had procedural complications. Sixty-five percent (15/23) carried out a formal airway assessment and a checklist was only used in 23% of cases., Conclusion: This sequential case series is the first study looking at airway management in rural New Zealand emergency department airway practice. Overall intubation success rates were comparable to larger tertiary centres across Australasia. We have demonstrated that with adequate resources and adherence to interventions, a rural emergency department can provide effective airway management., (© 2017 National Rural Health Alliance Inc.)