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Background: Competent clinical reasoning forms the foundation for effective and efficient clinical swallowing examination (CSE) and consequent dysphagia management decisions. While the nature of initial CSEs has been evaluated, it remains unclear how new information gathered by speech–language therapists (SLTs) throughout a patient's acute‐care journey is integrated into their initial clinical reasoning and management processes and used to review and revise initial management recommendations. Aims: To understand how SLTs' clinical reasoning and decision‐making regarding dysphagia assessment and management evolve as patients transition through acute hospital care from referral to discharge. Methods & Procedures: A longitudinal, qualitative approach was employed to gather information from two SLTs who managed six patients at a metropolitan acute‐care hospital. A retrospective 'think‐aloud' protocol was utilized to prompt SLTs regarding their clinical reasoning and decision‐making processes during initial and subsequent CSEs and patient interactions. Three types of concept maps were created based on these interviews: a descriptive concept map, a reasoning map and a hypothesis map. All concept maps were evaluated regarding their overall structure, facts gathered, types of reasoning engaged in (inductive versus deductive), types of hypotheses generated, and the diagnosis and management recommendations made following initial CSE and during subsequent dysphagia management. Outcomes & Results: Initial CSEs involved a rich process of fact‐gathering, that was predominantly led by inductive reasoning (hypothesis generation) and some application of deductive reasoning (hypothesis testing), with the primary aims of determining the presence of dysphagia and identifying the safest diet and fluid recommendations. During follow‐up assessments, SLTs engaged in increasingly more deductive testing of initial hypotheses, including fact‐gathering aimed at determining the tolerance of current diet and fluid recommendations or the suitability for diet and/or fluid upgrade and less inductive reasoning. Consistent with this aim, SLTs' hypotheses were focused primarily on airway protection and medical status during the follow‐up phase. Overall, both initial and follow‐up swallowing assessments were targeted primarily at identifying suitable management recommendations, and less so on identifying and formulating diagnoses. None of the patients presented with adverse respiratory and/or swallowing outcomes during admission and following discharge from speech pathology. Conclusions & Implications: Swallowing assessment and management across the acute‐care journey was observed as a high‐quality, patient‐centred process characterized by iterative cycles of inductive and deductive reasoning. This approach appears to maximize efficiency without compromising the quality of care. The outcomes of this research encourage further investigation and translation to tertiary and post‐professional education contexts as a clear understanding of the processes involved in reaching diagnoses and management recommendations can inform career‐long refinement of clinical skills. WHAT THIS PAPER ADDS: What is already known on the subject: SLTs' clinical reasoning processes during initial CSE employ iterative cycles of inductive and deductive reasoning, reflecting a patient‐centred assessment process. To date it is unknown how SLTs engage in clinical reasoning during follow‐up assessments of swallowing function, how they assess the appropriateness of initial management recommendations and how this relates to patient outcomes. What this paper adds to the existing knowledge: Our longitudinal evaluation of clinical reasoning and decision‐making patterns related to swallowing management in acute care demonstrated that SLTs tailored their processes to each patient's presentation. There was an emphasis on monitoring the suitability of the initial management recommendations and the potential for upgrade of diet or compensatory swallowing strategies. The iterative cycles of inductive and deductive reasoning reflect efficient decision‐making processes that maintain high‐quality clinical care within the acute environment. What are the potential or actual clinical implications of this work?: Employing efficient and high‐quality clinical reasoning is a hallmark of good dysphagia practice in maximizing positive patient outcomes. Developing approaches to understanding and making explicit clinical reasoning processes of experienced clinicians may assist SLTs of all developmental stages to provide high standards of care. [ABSTRACT FROM AUTHOR]

Aim: Most mental disorders have their onset by age 25, disrupting normative vocational engagement. Factors associated with vocational disengagement at first contact with specialist treatment are important for service planning. The aim of this paper was to investigate the association between theoretically important factors and vocational disengagement for youth entering mental health treatment. Methods: A file audit was used to extract vocational data of 145 young people aged 15 to 25 years entering treatment in 2011 at a public youth mental health service in Melbourne, Australia. Comparisons were made across three specialist programs for: psychosis (n = 50), mood disorders (n = 52) and borderline personality pathology (n = 43). Individual characteristics were entered into univariate and multivariate logistic regressions to investigate their associations with vocational disengagement. Results: Educational disengagement was associated with being older (OR = 4.38, P = 0.004) and not living with parents (OR = 2.87, P = 0.038). Unemployment and being NEET (Not in Education, Employment or Training) were both associated with not having commenced tertiary education (OR = 0.23, P = 0.022; OR = 0.05, P = 0.002; respectively). Being NEET was also associated with being older (OR = 6.18, P = 0.004). Primary diagnostic grouping was not associated with vocational disengagement, once accounting for other factors. Conclusions: The likelihood of vocational disengagement did not differ across disorder groups, implying that intervention should be "transdiagnostic" and might best target education first, specifically post‐secondary qualifications. Other domains or variables not measured in this study are also likely to be important, and this might include young people's support systems and symptom severity. Qualitative studies may be useful for exploring further factors relevant to vocational engagement. [ABSTRACT FROM AUTHOR]

Background: Behavioural emergencies (BEs) are complex situations in the emergency department (ED) setting. Treatment decisions always must be made within a limited time and are based on incomplete patient data. As a result of the urgency and complexity, patients often are exposed to increased risk of harm. Aim: The aim of this paper is to describe the prescribing patterns and adverse events (AEs) associated with parenteral sedation for the management of BEs in Australian EDs. Methods: Ten Australian EDs enrolled a convenience sample of adult patients (aged ≥18 years) requiring parenteral sedative medication for BEs. Data were collected prospectively between March 2015 and April 2017 using a designated case report form. Results: In all, 564 cases were enrolled in this study. Incomplete cases (n = 17; 3%) were excluded. Of the 547 remaining cases, 63% were male and the median age was 34 years (range 18–95 years). Approximately half the patients (n = 230; 42.1%) required mechanical restraint and parenteral sedation to manage their BEs. Intramuscular monotherapy was administered in most cases (n = 390; 71.3%). The main sedative medications used as monotherapy were droperidol (n = 381; 69.7%), midazolam (n = 54; 9.9%) and olanzapine (n = 26; 4.8%). The most common combination therapy was midazolam + droperidol (n = 36; 6.6%). The incidence of AEs from sedative administration was 13.5%. No deaths or irreversible AEs were reported. Conclusions: Overall, the participating EDs provided safe pharmacological management for BEs. AEs following parenteral sedation are common, although serious AEs are rare. Because all patients receiving parenteral sedation for BEs are at risk of AEs, ongoing monitoring of vital signs after parenteral sedation should be a standard protocol in all EDs. [ABSTRACT FROM AUTHOR]

As treatment improves, people living with HIV (PLWHIV) can now expect to live longer, which means that the foci of HIV‐related care for them and their medical practitioners continue to change. With an increasingly older cohort of patients with HIV infection, practitioners’ key considerations are shifting from issues of acute treatment and patient survival to multiple comorbidities, toxicities associated with chronic therapy, and ongoing health maintenance. Within this context, this paper explores the current standard of practice for the management of HIV infection in Australia. We surveyed 56 Australian practitioners currently involved in managing HIV infection: ‘HIV section 100’ (HIV therapy‐prescribing) general practitioners (s100 GPs; n = 26), sexual health physicians (SHPs; n = 24) and hospital‐based physicians (HBPs; n = 6). Survey results for practice approaches and challenges were broadly consistent across the three practitioner specialties, apart from a few key areas. s100 GPs reported less prophylaxis use among patients whom they deemed at risk of HIV infection in comparison with SHPs, which may reflect differences in patient populations. Further, a higher proportion of s100 GPs nominated older HIV treatment regimens as their preferred therapy choices compared with the other specialties. In contrast with SHPs, s100 GPs were less likely to switch HIV therapies to simplify the treatment protocol, and to immediately initiate treatment upon patient request in those newly diagnosed with HIV infection. Considerably lower levels of satisfaction with current HIV practice guidelines were also reported by s100 GPs. It appears that greater support for s100 GPs may be needed to address these identified challenges and enhance approaches to HIV practice. Across all specialties, increasing access to mental health services for patients with HIV infection was reported as a key management issue. A renewed focus on providing improved mental health and wellbeing supports is recommended, particularly in the face of an ageing HIV‐infected population. [ABSTRACT FROM AUTHOR]

Introduction: Percutaneous transluminal angioplasty (PTA) and surgical bypass (BYP) are treatment options for symptomatic peripheral arterial disease (PAD). PTA and BYP have different clinical outcomes and cost implications. This paper aims to compare hospital-related costs of PTA and BYP for PAD of the lower limbs in an Australian health service.Methods: A retrospective cost analysis using clinical and financial data from an urban, tertiary hospital was performed. Patient cohorts were matched to existing published studies and 3-year findings were calculated. Outcomes measured were mean initial admission cost; mean bed stay; mean complication rate; mean cost of re-intervention at 12 months and extrapolated mean cost at 3 years.Results: The mean total admission costs for PTA compared to BYP were $8758 vs. $27,849 (P < 0.001). Patients undergoing BYP were admitted for 10.25 vs. 3.77 nights (P < 0.001). The complication rate was greater in the BYP group for infection only. Re-intervention was required by 13% of the PTA group and 16% of the BYP group, at a mean cost of $11,798 and $14,728, respectively (P = 0.453). The extrapolated total mean cost at 3 years was higher in the BYP group for patients with both intermittent claudication ($26,764 vs. $11,402) and critical limb ischaemia ($27,719 vs. $12,655).Conclusions: In this cohort, PTA is a favourable alternative to BYP for PAD of the lower limbs as it is less costly, does not result in a greater re-intervention rate at 1 year and has been previously demonstrated to have comparable clinical outcomes. Given the limitations of this retrospective analysis, a prospective cost-effectiveness analysis is recommended. [ABSTRACT FROM AUTHOR]

Introduction and Aims: Take-home naloxone (THN) programs commenced in Australia in 2012 in the Australian Capital Territory and programs now operate in five Australian jurisdictions. The purpose of this paper is to record the progress of THN programs in Australia, to provide a resource for others wanting to start THN projects, and provide a tool for policy makers and others considering expansion of THN programs in this country and elsewhere.Design and Methods: Key stakeholders with principal responsibility for identified THN programs operating in Australia provided descriptions of program development, implementation and characteristics. Short summaries of known THN programs from each jurisdiction are provided along with a table detailing program characteristics and outcomes.Results: Data collected across current Australian THN programs suggest that to date over 2500 Australians at risk of overdose have been trained and provided naloxone. Evaluation data from four programs recorded 146 overdose reversals involving naloxone that was given by THN participants.Discussion and Conclusions: Peer drug user groups currently play a central role in the development, delivery and scale-up of THN in Australia. Health professionals who work with people who use illicit opioids are increasingly taking part as alcohol and other drug-related health agencies have recognised the opportunity for THN provision through interactions with their clients. Australia has made rapid progress in removing regulatory barriers to naloxone since the initiation of the first THN program in 2012. However, logistical and economic barriers remain and further work is needed to expand access to this life-saving medication. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: UNAIDS 90‐90‐90 targets and Fast‐Track commitments are presented as precursors to ending the AIDS epidemic by 2030, through effecting a 90% reduction in new HIV infections and AIDS‐related deaths from 2010 levels (HIV epidemic control). Botswana, a low to middle‐income country with the third‐highest HIV prevalence, and Australia, a low‐prevalence high‐income country with an epidemic concentrated among men who have sex with men (MSM), have made significant strides towards achieving the UNAIDS 90‐90‐90 targets. These two countries provide lessons for different epidemic settings. This paper discusses the lessons that can be drawn from Botswana and Australia with respect to their success in HIV testing, treatment, viral suppression and other HIV prevention strategies for HIV epidemic control. Discussion: Botswana and Australia are on target to achieving the 90‐90‐90 targets for HIV epidemic control, made possible by comprehensive HIV testing and treatment programmes in the two countries. As of 2015, 70% of all people assumed to be living with HIV had viral suppression in Botswana and Australia. However, HIV incidence remains above one per cent in the general population in Botswana and in MSM in Australia. The two countries have demonstrated that rapid HIV testing that is accessible and targeted at key and vulnerable populations is required in order to continue identifying new HIV infections. All citizens living with HIV in both countries are eligible for antiretroviral therapy (ART) and viral load monitoring through government‐funded programmes. Notwithstanding their success in reducing HIV transmission to date, programmes in both countries must continue to be supported at current levels to maintain epidemic suppression. Scaled HIV testing, linkage to care, universal ART, monitoring patients on treatment over and above strengthened HIV prevention strategies (e.g. male circumcision and pre‐exposure prophylaxis) will all continue to require funding. Conclusions: The progress that Botswana and Australia have made towards meeting the 90‐90‐90 targets is commendable. However, in order to reduce HIV incidence significantly towards 2030, there is a need for sustained HIV testing, linkage to care and high treatment coverage. Botswana and Australia provide useful lessons for developing countries with generalized epidemics and high‐income countries with concentrated epidemics. [ABSTRACT FROM AUTHOR]

Abstract: Background: Rituximab, an anti‐CD20 B‐cell depleting monoclonal antibody, is increasingly prescribed off‐label for a range of autoimmune diseases. There has not previously been an audit of off‐label rituximab use in the Northern Territory, where the majority of patients are Aboriginal. Aims: To evaluate retrospectively off‐label rituximab use in autoimmune diseases in the Top End of the Northern Territory. Methods: We performed a retrospective audit of 8 years of off‐label rituximab use at the Royal Darwin Hospital, the sole tertiary referral centre for the Darwin, Katherine and East Arnhem regions. Electronic and paper records were reviewed for demographic information, diagnosis/indication for rituximab, doses, previous/concomitant immunosuppression, clinical outcomes and specific adverse events. Results: Rituximab was prescribed off‐label to 66 patients for 24 autoimmune diseases. The majority of patients (62.1%) were Aboriginal and 60.6% female. The most common indications were refractory/relapsing disease despite standard therapies (68.7%) or severe disease with rituximab incorporated into an induction immunosuppressive regimen (19.4%). Systemic lupus erythematosus was the underlying diagnosis in 28.8% of cases. A clinically significant response was demonstrated in 74.2% of cases overall. There were 18 clinically significant infections; however, 13 were in patients receiving concurrent immunosuppressive therapy. There was a total of nine deaths from any cause. Conclusion: Rituximab has been used off‐label for a range of autoimmune diseases in this population with a high proportion of Aboriginal patients successfully and safely in the majority of cases. [ABSTRACT FROM AUTHOR]

Data from the Australasian Bone Marrow Transplant Recipient Registry show a steady increase in the number of allogeneic haemopoietic stem cell transplantations (HSCT) performed annually in Australia and New Zealand. In 2012, 629 allogeneic HSCT were performed. Allogeneic HSCT is associated with numerous potential complications, including chronic graft-versus-host disease (cGVHD). The oral cavity is one of the most frequent sites affected by cGvHD, often leading to significant disability and reduced quality of life. Management strategies are often complex, of variable efficacy and influenced by the availability of various therapeutic agents, access to compounding pharmacies and associated costs. This paper summarises the current status of allogeneic HSCT in Australia and New Zealand with a focus on oral cGvHD and the associated challenges in its management. [ABSTRACT FROM AUTHOR]

Objective Previous Australian studies have suggested poorer survival of patients with colorectal cancer in remote areas. To date no studies have assessed the geographic disparity in patients with metastatic disease. This retrospective cohort study looks at geographic differences in the surgical care and survival of patients with metastatic colorectal disease. The paper utilises data from the South Australian Clinical Registry for Metastatic Colorectal Cancer ( SACRMCC). Design, participants, interventions and main outcome measures Data on patients' socio-economic status, primary and metastatic tumour characteristics, treatment and survival was extracted from the SACRMCC database. A binomial model analysis was used to identify geographical differences in the surgical treatment of patients and a Cox proportional hazards model was used to identify any geographic differences in survival. Results The findings showed no differences in the diagnosis of liver metastases or provision of liver surgery between geographic areas, however there was a reduced likelihood of liver surgery with increasing age. The median overall survival rate, from the date of diagnosis of metastatic disease, was 20.0 months and the distribution by geographic remoteness was 19.1 months, 20.2 months, 22.0 months and 20.4 months in Major Cities, Inner Regional, Outer Regional and Remote areas respectively. This was not statistically significant. Conclusion Overall, there was no evidence of a geographical disparity in the diagnosis, surgical treatment or survival in metastatic colorectal cancer. This may be due to the shift toward centralising surgical care in South Australia. Nevertheless, there remains a need to improve the uptake of surgical care in the growing elderly population. [ABSTRACT FROM AUTHOR]

An introduction is presented which discusses articles within the issue on topics including aged care services to the increasing number of Australians living with dementia.

Individuals with depressive symptoms often experience changes in physical activity and lifestyle factors. Despite the benefits of exercise, mental health clinicians often do not refer for or prescribe exercise as part of traditionally accepted models of care for consumers with depression and anxiety. The aims were to investigate: (i) mental health clinicians' understanding of the relationship between exercise and mental health, (ii) if and how exercise is used by mental health clinicians in treatment for depression and anxiety, and (iii) the barriers to prescription of exercise. A descriptive qualitative method was used, and data were collected via individual semi‐structured interviews. Ten mental health clinicians with varying backgrounds participated in this study. The data driven inductive analysis of participants views identified three themes: (i) knowing and not knowing, (ii) consumer comorbidities – the risk and benefit dilemma, and (iii) protecting vulnerable consumers. Enhancing clinicians' knowledge of the beneficial role of exercise in treatment for consumers' experiencing depression and anxiety is an important step. Mental health services can support integration of exercise by implementing policies and training for staff to support exercise prescription, and the role and referral of exercise and physical activity specialists, as part of routine care to improve clinical outcomes for consumers. Additional considerations should be given to fiscal support to access exercise as an adjunct therapy. [ABSTRACT FROM AUTHOR]

Signs of Irukandji syndrome (IS) suggest an underlying catecholamine storm with research demonstrating that Carukia barnesi venom causes a significant rise in adrenaline/noradrenaline serum levels. A systematic review was undertaken to ascertain the current evidence in treating IS with magnesium salts. A literature search was conducted using Scopus, Medline and ScienceDirect. Further articles were discarded via title description and/or abstract details. The remaining were read in full, and those identified as not having sufficient information regarding magnesium and patient outcomes were removed. Nine articles were identified. One article was a randomised controlled trial, which concluded that there appears to be no beneficial difference between those patients who received the magnesium sulphate (MgSO4) and those who received the placebo and recommended against the use of MgSO4 in IS. Of the remaining eight, one reported the failure of MgSO4 and the remaining seven were case series reporting varying success in its use. This systematic review found insufficient evidence to support any clear recommendation regarding the use of magnesium, but nor was there clear evidence to recommend against its use in IS. Two case series describe significant reduction in key symptoms and hypertension but are a non-randomised albeit prospective series with the limitations accompanying this. The reporting of recrudescence of symptoms with reduction of dose does suggest a dose-response relationship. The evidence for the use of MgSO4 is at best anecdotal, and further research is required to either confirm its benefit or confirm the randomised controlled trial. [ABSTRACT FROM AUTHOR]

Objectives A cross-sectional empirical design was used to compare differences in alexithymia between Australian psychiatric and community samples and examine the influence of sample type on the relation between alexithymia and psychological distress. Method Psychiatric outpatients ( N = 151) and a convenience sample of the general community ( N = 216) completed questionnaires measuring alexithymia and psychological distress. Results Alexithymia was several times more prevalent in the psychiatric sample than the community sample. While the psychiatric sample reported greater psychological distress, no difference was found in the strength of the association between alexithymia and psychological distress between the study samples. Conclusion These findings emphasize the pervasive problem alexithymia presents within the Australian psychiatric population and the importance of increasing recognition of alexithymia for the future research about and treatment of psychiatric patients. [ABSTRACT FROM AUTHOR]

Introduction: Following 2016 legislation permitting limited access to cannabis for research and medicinal purposes, the number of randomized clinical trials (RCTs) investigating the effectiveness of medicinal cannabis (MC) on symptom burden relief in cancer contexts has increased in Australia. This study aimed to understand the perceptions, hopes and concerns of people with advanced cancer regarding the future availability and regulation of MC in Australia. Methods: This qualitative study draws on semistructured interviews conducted between February 2019 and October 2020 in Brisbane, Australia, as part of an MC RCT substudy. Interviews were undertaken on 48 patients with advanced cancer in palliative care eligible to participate in an MC trial (n = 26 participated in an RCT; n = 2 participated in a pilot study; n = 20 declined). Interviews included a discussion of patients' decision‐making regarding trial participation, concerns about MC and perceptions of future availability, including cost. Transcribed interviews were analysed inductively and abductively, informed by constructivist thematic analysis conventions. Results: Overall, participants supported making MC legally accessible as a prescription‐only medication. Fear of financial toxicity, however, compromised this pathway. Steep posttrial costs of accessing MC prompted several people to decline trial participation, and others to predict—if found effective—that many would either access MC through alternative pathways or reduce their prescribed dosage to enable affordable access. Conclusions: These findings suggest that—despite a relatively robust universal healthcare system—Australians are potentially vulnerable to and fearful of financial toxicity. Prevalent in the United States, financial toxicity occurs when disadvantaged cancer patients access necessary but expensive medications with lasting consequences: bankruptcy, ongoing anxiety and cancer worry. Interview transcripts indicate that financial fears—and the systems sustaining them—may pose a threat to RCT completion and to equitable access to legal MC. Such findings support calls for embedding qualitative substudies and community partnerships within RCTs, while also suggesting the importance of subsidisation to overcoming injustices. Patient or Public Contribution: A patient advisory committee informed RCT design. This qualitative substudy foregrounds patients' decision‐making, perceptions and experiences. [ABSTRACT FROM AUTHOR]

Background: The presence of treatment limitations in patients with frailty at intensive care unit (ICU) admission is unknown. We aimed to evaluate the presence and predictors of treatment limitations in patients with and without COVID‐19 pneumonitis in those admitted to Australian and New Zealand ICUs. Methods: This registry‐based multicenter, retrospective cohort study included all frail adults (≥16 years) with documented clinical frailty scale (CFS) scores, admitted to ICUs with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome (ARDS) over 2 years between January 01, 2020 and December 31, 2021. Frail patients (CFS ≥5) coded as having viral pneumonitis or ARDS due to COVID‐19 were compared to those with other causes of viral pneumonitis or ARDS for documented treatment limitations. Results: 884 frail patients were included in the final analysis from 129 public and private ICUs. 369 patients (41.7%) had confirmed COVID‐19. There were more male patients in COVID‐19 (55.3% vs 47.0%; p = 0.015). There were no differences in age or APACHE‐III scores between the two groups. Overall, 36.0% (318/884) had treatment limitations, but similar between the two groups (35.8% [132/369] vs 36.1% [186/515]; p = 0.92). After adjusting for confounders, increasing frailty (OR = 1.72; 95%‐CI 1.39–2.14), age (OR = 1.05; 95%‐CI 1.04–1.06), and presence of chronic respiratory condition (OR = 1.58; 95%‐CI 1.10–2.27) increased the likelihood of instituting treatment limitations. However, the presence of COVID‐19 by itself did not influence treatment limitations (odds ratio [OR] = 1.39; 95%‐CI 0.98–1.96). Conclusions: The proportion of treatment limitations was similar in patients with frailty with or without COVID‐19 pneumonitis at ICU admission. [ABSTRACT FROM AUTHOR]

Background: Poor health outcomes amongst marginalized groups result in part from health inequities related to social and structural determinants of health. Marginalized people report higher incidences of comorbidities, chronic disease and adverse health behaviours than their nondisadvantaged peers. The objective of this review is to examine marginalized Australians' experiences of and access to community‐based primary health services in urban locations. Methods: A systematic search incorporating related MeSH terms and synonyms pertaining to marginalized Australian populations and their health‐seeking was conducted across seven databases. We included qualitative studies that reported experiences of health‐seeking within community‐based primary health care in metropolitan Australia. Participant populations experiencing marginalization due to social stigma and isolation, early‐life disadvantage, poor health and/or financial hardship were included. A meta‐ethnographic framework was used to synthesize themes across selected studies and researcher triangulation was employed to develop higher‐order themes. Results: Search results revealed 26 studies included for critical appraisal and synthesis. Seven higher‐order themes were developed describing experiences of health service engagement amongst marginalized groups: (1) Understanding the patient within the context of family and community, (2) Health and cultural beliefs influence health‐seeking, (3) Lack of information and poor cultural competence limit utilization of services, (4) Motivation for treatment influences health service engagement, (5) Accessing services, a spectrum of experience—from discrimination to validation, (6) Navigating a complex system in a complex society, (7) Preferences for health care and expectations for systemic change. Conclusion: Marginalized Australians experience health disadvantage across micro, meso and macro levels of health system navigation and commonalities in health‐seeking were identified across each of the distinct marginalized groups in our analysis. This review outlines important areas of consideration for health care provision and policy development essential to helping address health inequities for a diversity of marginalized populations. Patient or Public Contribution: Whilst patient voices were reported across all studies included within this review, no further patient or public contribution applies to this study. [ABSTRACT FROM AUTHOR]

Objectives: Chronic pain (CP) impacts individuals and society and is the leading cause of disability globally. Pain education interventions are often evaluated in patients and health professional students, but not in non‐health student groups. Increasing knowledge of pain may facilitate shifts in attitudes and beliefs towards sufferers. We report on changes in pain knowledge, attitudes and beliefs of predominantly non‐health‐related tertiary degree students participating in online education. Methods: Quantitative cohort study design. Students reported demographics and completed the Chronic Pain Myth Scale and 12‐item Neurophysiology of Pain Questionnaire (NPQ) before (T1) and after (T2) the 7‐week online module at The University of Sydney in 2020. Results: Twenty‐two students undertaking predominantly non‐health‐related bachelor's degrees (16.5% response rate, 90.9% female, mean = 19.5 years) participated. NPQ scores increased from 47.3% to 62.9%. Attitudes and beliefs towards biopsychosocial impact improved (p < 0.027) but not towards individuals suffering from CP or treatment of CP. A negative correlation was found between age and people suffering from CP (ρ = −0.437, p < 0.042) and age and towards treatment of CP; ρ = −0.556, p < 0.007) at T2. Conclusion: Completing the elective online module resulted in improved knowledge and biopsychosocial attitudes towards CP in this predominantly non‐health cohort, as reported in health and patient cohorts. [ABSTRACT FROM AUTHOR]

Introduction and Aims: Opioid overdose prevention programs providing take-home naloxone have been expanding internationally. This paper summarises findings and lessons learnt from the Overdose Prevention and Emergency Naloxone Project which is the first take-home naloxone program in Australia implemented in a health care setting.Methods: The Project intervention provided education and take-home naloxone to opioid-using clients at Kirketon Road Centre and The Langton Centre in Sydney. The evaluation study examined uptake and acceptability of the intervention; participants' knowledge and attitudes regarding overdose and participants' experience in opioid overdose situations six months after the intervention. Participants completed baseline, post-training and follow-up questionnaires regarding overdose prevention and management which were analysed using repeated measures analysis of variance.Results: Eighty-three people participated in the intervention, with 35 (42%) completing follow-up interviews-51% reporting using naloxone with 30 overdoses successfully reversed. There were significant improvements in knowledge and attitudes immediately following training with much retained at follow-up, particularly regarding feeling informed enough (97%) and confident to inject naloxone (100%).Discussion: Take-home naloxone programs can be successfully implemented in Australian health settings. Barriers to uptake, such as lengthy processes and misperceptions around interest in overdose prevention, should be addressed in future program implementation. [ABSTRACT FROM AUTHOR]

Aim: To determine if the management of paediatric status epilepticus (SE) follows accepted clinical practice guidelines. Methods: Retrospective, consecutive series of patients with SE who attended the emergency departments from two NSW sites over a 12‐month period. SE was defined as a convulsive seizure, 5 min or more in duration. Time to presentation to the ED, time to first‐ and second‐line treatment, number of benzodiazepine (BZD) doses given prior to intubation and adherence to guidelines were evaluated. The outcomes included seizure duration, need for respiratory support, admission to intensive care, morbidity and mortality. Results: The time from onset of seizure to ED presentation was a median (p25–p75) time of 22 (15–40) min. Forty‐eight of 59 presentations received pre‐hospital midazolam. The median (p25–p75) time to first‐line treatment was 15 (8–25) min and to second‐line treatment was 43.5 (35–59) min. There was no significant difference in the results in the two hospitals. The total number of BZD doses ranged from 1 to 7 (median 3). There was non‐adherence to the clinical practice guidelines in 55 (93.2%) of 59 presentations. Conclusions: We found excessive benzodiazepine use and delay in both definitive treatment of status epilepticus and in escalation from first‐ to second‐line anticonvulsant treatment. This raises the need for rapid escalation of treatment. We propose a 'status epilepticus code' for emergency departments. [ABSTRACT FROM AUTHOR]

In this article, the authors comment on a study related to the effect of Mindfulness Based Interventions (MBIs) in reducing the symptoms of depression. Topics discussed include use of MBIs in reducing anxiety which is not much effective, an analysis by the World Health Organization that depression affects people's health and an evidence base to use MBIs as a first line intervention in patient with acute depression.

Background: In many jurisdictions worldwide, individuals with a mental illness may be forced to receive care and treatment in the community. In Australia, legislation states that such care should be driven by a care plan that is recovery‐focussed. Key components in the care planning process include engagement and decision‐making about a person's support needs and care options, with trust being an essential component of care planning relationships. Objective: This study examines how these components were enacted during service care contacts for individuals on community treatment orders. Methods: The study was located at two community mental health teams in South Australia. Ethnographic observations of care planning discussions between consumers, their carers and clinicians, and interviews with individuals from these groups, were conducted over 18 months. Carspecken's critical ethnography provided a rigorous means for examining the data to identify underlying cultural themes that were informing day‐to‐day care interactions. Results: Care planning was not occurring as it was intended, with service culture and structures impeding the development of trusting relationships. Clinicians striving to work collaboratively with consumers had to navigate a service bias and culture that emphasized a hierarchy of 'knowing', with consumers assumed to have less knowledge than clinicians. Conclusions: Services and clinicians can challenge prejudicial ethical injustice and counter this through testimonial justice and implementation of tools and approaches that support genuine shared decision‐making. Patient or Public Contribution: This study included individuals with lived experience of mental illness, their carers and clinicians as participants and researchers. [ABSTRACT FROM AUTHOR]

There are no published studies investigating the effectiveness of relationship counselling (RC) where only one individual attends (individual relationship counselling (IRC)), in improving client psychological distress (PD). This is important to investigate considering the high prevalence of PD in this client group and the potential for its negative effects to cascade into other domains of an individual's life. The current study aims to address this gap by investigating the short‐term effectiveness of IRC on PD. This study further builds on previous research by investigating variables that may explain changes in counselling outcomes, including client demographics, interpersonal factors, and therapeutic factors. Data were collected from a national sample of 273 individuals presenting for RC at an Australian not‐for‐profit organisation. Results from multilevel modelling showed a significant reduction in PD over time with moderate effect size. Further, relationship status, family functioning, and the Task subscale of the Working Alliance Inventory emerged as significant predictors of PD. The results of this study have important implications for routine practice in informing opportunities to target these key variables as an avenue to increasing the effectiveness of IRC. [ABSTRACT FROM AUTHOR]

The availability of efficacious systemic therapies for metastatic clear cell renal cell carcinoma has heralded improved survival for Australians. The Pharmaceutical Benefits Schedule registry was interrogated to assess nation‐wide prescribing patterns. Sunitinib remained the most commonly prescribed agent. Prescribing rates were significantly lower in Northern Territory than in other states, raising questions of disparities in access to care. [ABSTRACT FROM AUTHOR]

Background and aims: Recovery from alcohol problems in the absence of treatment or mutual‐aid is very common, but under‐researched. This study explores the lives of people who had resolved their alcohol problems without treatment, seeking to situate experiences of recovery in social contexts and broader life narratives. Design The in‐depth qualitative interviews were aided by a life‐history methodology that invited participants to account retrospectively for their lives. A narrative analysis was undertaken. Setting: Two major cities (Sydney and Melbourne) in Australia. Participants: People who had resolved an alcohol problem in the absence of treatment (n = 12) were recruited from the general community using convenience sampling. Measurements Eligible participants had received 'minimal treatment' for an alcohol use disorder: fewer than three sessions in an outpatient treatment programme or nine sessions with mutual‐aid groups (e.g. Alcoholics Anonymous), or having accessed mental health treatment for problems other than drinking at least 2 years prior or 1 year after having resolved an alcohol problem. Participants were considered to have had an alcohol use disorder if they reported two or more symptoms (DSM‐V) within a 1‐year period prior to the past year, using questions endorsed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). People were considered to have resolved their alcohol use disorder by responding to the recruitment message calling for people who "used to have an alcohol problem but no longer do". The Alcohol Use Disorders Identification Test (AUDIT‐C) was used to understand participant's drinking behaviours in the past 12 months. Findings Four different narratives were identified in the analysis. In the emancipation narrative, identity development and major changes across the life‐curve were associated with separating oneself from an oppressive circumstance. In discovery narratives, art culture and other consciousness‐expanding experiences were sources of identity development, but sometimes a barrier to alcohol recovery. In mastery narratives, life events were understood as failures or successes, and recovery was positioned as an individual journey accomplished through increased problem awareness. Finally, in coping narratives, changes were understood as a series of continuous struggles, and recovery was made sense of through diagnostic discourses. Conclusions: People who resolve an alcohol use disorder in the absence of treatment or mutual‐aid appear to explain their recovery in terms of at least four different life narratives: emancipation, discovery, mastery or coping. Social contexts and cultures outside the treatment setting, and the various identities and narratives they provide, shape change processes. [ABSTRACT FROM AUTHOR]

Background: Adherence to ADHD medication is a complex phenomenon as the decision to adhere is influenced by a range of factors. To design tailored interventions to promote adherence, it is important to understand the factors that influence adherence in the context of its three phases: initiation, implementation and discontinuation. Objective: The objective of this study was to explore the phase‐specific factors that influence adherence to medication in adults who have a diagnosis of ADHD. Methods: Three focus groups (FGs) were conducted with twenty adults with ADHD in different metropolitan areas of Sydney, Australia. FGs were transcribed verbatim and thematically analysed. Results: Participants' decision to initiate medication (the initiation phase) was influenced by their perceived needs (desire to improve academic and social functioning) and concerns (fear of side‐effects) about medication following a similar process as defined by the Necessity‐Concerns Framework (NCF). The balance between benefits of medication (needs) and side‐effects (concerns) continued to determine participants' daily medication‐taking (the implementation phase) and persistence (or discontinuation) with their medication. Forgetfulness and stigma were reported as concerns negatively impacting the implementation phase, while medication cost and dependence influenced the discontinuation phase of adherence. Conclusions: Adults' decision to initiate, continue or discontinue medication is influenced by a range of factors; some are unique to each phase while some are common across the phases. Participants balanced the needs for the medication against their concerns in determining whether to adhere to medication at each phase. It appears that the NCF has applicability when decision making about medication is explored at the three phases of adherence. [ABSTRACT FROM AUTHOR]

Introduction: To report the clinical presentation, laboratory and imaging findings, treatment and outcome of abdominal cryptococcosis in dogs and cats in Australia. Materials and Methods: Canine and feline cases from Australia were retrospectively identified (2000 to 2018) via laboratory and referral centre searches for abdominal cryptococcosis diagnosed by cytology (needle aspirates) or histopathology (biopsy or necropsy) of abdominal organs/tissues. Signalment, presenting complaints, clinical signs, laboratory findings, medical imaging, latex cryptococcal antigen agglutination test (LCAT) titres, treatment and outcome data was collected. Results: Thirty‐eight cases were included (35 dogs, three cats) in the study. Median age of presentation was 2 years for dogs and 6 years for cats. Common presenting complaints included vomiting (23/38), lethargy (19/38) and inappetence/anorexia (15/38). Abdominal ultrasound (25/38 cases) revealed mesenteric and intestinal lesions in most of the cases. On surgical exploration, seven cases had an intestinal lesion associated with an intussusception. Nineteen cases had a pre‐treatment LCAT performed, with a median initial titre of 1:2048 (range 1:2 to 65,536). Twenty‐four cases (23 dogs, one cat) received treatment, either medical, surgical or both. Median survival time for cases with combined medical and surgical treatment, surgical treatment alone or medical treatment alone was 730, 140 and 561 days, respectively. Eleven remain alive at the time of follow up. Clinical Significance: Abdominal cryptococcosis although rare should be a considered as a diagnostic possibility in an especially young dog presenting with gastro‐intestinal signs. Older dogs can also present with this condition and should not be euthanised based on imaging alone due to the likenesses with neoplasia. With appropriate treatment and monitoring many dogs may have a prolonged survival period and some may be cured. [ABSTRACT FROM AUTHOR]

Introduction: Australia's first proton beam therapy (PBT) service, The Australian Bragg Centre for Proton Therapy and Research, is scheduled to open in the near future providing PBT for patients closer to home. Patients currently access Commonwealth funding for PBT via the Medicare Medical Treatment Overseas Program (MTOP). Proton versus photon treatment planning is a pre-requisite for the MTOP application. The Royal Adelaide Hospital (RAH) Department of Radiation Oncology has been providing this since 2016. We aim to provide a descriptive overview of our proton versus photon treatment planning process, presenting a summary of the comparative planning results and the treatment pathways selected for the patients referred.Methods: All patients referred to the RAH for comparative planning between January 2016 and December 2018 were included in the analysis. Comparative plans were generated for each case using Pinnacle or Eclipse treatment planning systems. The planning techniques used and plan quality metrics were reported.Results: Forty three patients were referred for comparative planning. The age range was 1-63 years, with the majority (72%) being paediatric patients (age ≤18 years). Of the 19 cases that have been submitted to MTOP, 16 have been accepted and 3 denied. Two of the accepted cases chose not to travel abroad for PBT. The other 14 cases have received PBT overseas.Conclusions: The RAH has provided an important service to demonstrate the dosimetric difference between PBT and photon therapy for Australian patients, an important step in supporting the funding of patients for treatment overseas. [ABSTRACT FROM AUTHOR]

AATD is a common inherited disorder associated with an increased risk of developing pulmonary emphysema and liver disease. Many people with AATD‐associated pulmonary emphysema remain undiagnosed and therefore without access to care and counselling specific to the disease. AAT augmentation therapy is available and consists of i.v. infusions of exogenous AAT protein harvested from pooled blood products. Its clinical efficacy has been the subject of some debate and the use of AAT augmentation therapy was recently permitted by regulators in Australia and New Zealand, although treatment is not presently subsidized by the government in either country. The purpose of this position statement is to review the evidence for diagnosis and treatment of AATD‐related lung disease with reference to the Australian and New Zealand population. The clinical efficacy and adverse events of AAT augmentation therapy were evaluated by a systematic review, and the GRADE process was employed to move from evidence to recommendation. Other sections address the wide range of issues to be considered in the care of the individual with AATD‐related lung disease: when and how to test for AATD, changing diagnostic techniques, monitoring of progression, disease in heterozygous AATD and pharmacological and non‐pharmacological therapy including surgical options for severe disease. Consideration is also given to broader issues in AATD that respiratory healthcare staff may encounter: genetic counselling, patient support groups, monitoring for liver disease and the need to establish national registries for people with AATD in Australia and New Zealand. [ABSTRACT FROM AUTHOR]

Objective: Improving antimicrobial stewardship in the livestock sector requires an understanding of the motivations for antimicrobial use and the quantities consumed. However,detailed information on antimicrobial use in livestock sectors is lacking. This cross‐sectional study aimed to better understand antimicrobial use in the beef feedlot sector in Australia. Design: A self‐administered questionnaire asking about antimicrobial use and reasons for use was designed and mailed to beef feedlot operators in Australia. Respondents were asked to report the percentage of animals treated, purpose of use, and disease conditions targeted for 26antimicrobial agents. Results: In total, 83 of 517 (16.1%) beef feedlot operators completed the survey. Monensin (61.0%of respondents) and virginiamycin (19.5%of respondents) were the most commonly reported in‐feed antimicrobials. In‐feed antimicrobial agents were most frequently used by respondents for treatment of gastrointestinal diseases (52.8%). Antimicrobials were used for growth promotion by 42.1% of respondents, with most (85.7%) reporting the use of ionophores(a group of compounds not used in human medicine). Short‐acting penicillin(69.1%), short‐acting oxytetracycline, and tulathromycin (both 57.3%) werethe most common injectable antimicrobial agents used. Injectable antimicrobials were most frequently used to treat respiratory (72.3%) and musculoskeletal (67.5%) conditions. Conclusion: Overall,the use of antimicrobials was appropriate for the purpose indicated, and there was a strong preference for drugs of low‐importance in human medicine. The data described here stand to be a strong influence on the implementation of an antimicrobial stewardship program in the sector. [ABSTRACT FROM AUTHOR]

Background: Anthocyanins represent an important subgroup of non‐nutritive components of food as evidence continues to build related to their beneficial bioactive effects. Using a recently developed Australian anthocyanin database, the present study aimed to estimate the intake of both total anthocyanins and their subclasses, identify food sources of anthocyanins, and determine associations between anthocyanin intake and measured blood pressure (BP). Methods: The present study comprised a secondary analysis of the 2011–12 National Nutrition and Physical Activity component of the Australian Health Survey. Anthocyanin intake was estimated using an Australian anthocyanin database. Usual anthocyanin intake, as estimated from 24‐h diet recall data, was computed using multiple source methods, whereas food sources were determined by calculating contribution of food groups to total anthocyanin intake. Regression analysis, adjusted for covariates (age, gender, body mass index, high BP diagnosis, smoking status and physical activity) assessed the relationship between anthocyanin intake and BP in adults aged ≥50 years. Results: Mean anthocyanin intake was 24.17 ± 0.32 mg day−1. Across age groups, berries were the top sources: blackberry (5–65%), cherry (2–24%), blueberry (2–13%) and raspberry (3–12%). There was a significant inverse association between anthocyanin intake and systolic BP (β = −0.04, F = 16.8, d.f. = 6, r2 = 0.05, P < 0.01) and diastolic BP (β = 0.01, F = 5.35, d.f. = 6, R2 = 0.013, P < 0.01), in models that adjusted for covariates. Conclusions: In comparison with the world composite database, anthocyanin intake in the Australian population was above average [mean (SD): 24.17 (0.32) mg day−1 versus 18.05 (21.14) mg day−1]. Berries were the primary source of anthocyanins. Anthocyanin intake in older adults aged ≥50 years was inversely associated with BP. [ABSTRACT FROM AUTHOR]

Background: Interest in potential adverse outcomes associated with maternal subclinical hypothyroidism (normal free T4, elevated thyroid‐stimulating hormone (TSH)) has increased significantly over recent years. In turn, the frequency of maternal thyroid function testing has risen, despite universal thyroid function screening not being recommended, leading to a marked increase in referrals to obstetric endocrinology clinics. In 2017 the American Thyroid Association revised their diagnostic and management guidelines. Although welcome, these new guidelines contain recommendations that may cause confusion in clinical practice. Aim: To ensure uniform practice in the diagnosis and management of subclinical hypothyroidism in pregnancy across all Melbourne public hospitals. Methods: Endocrinology and obstetric representatives from all Melbourne public hospital networks reviewed the 2017 American Thyroid Association guidelines and other relevant literature to develop a consensus for diagnosing and treating subclinical hypothyroidism during pregnancy in Melbourne. The consensus guidelines were then referred to the Endocrine Society of Australia for comment and endorsement. Results: Consensus was achieved and the guidelines were endorsed by the Council of the Endocrine Society of Australia. Trimester and assay‐specific TSH reference intervals derived from healthy local populations should be used, where available. When unavailable, a TSH cut‐off of 4 mU/L (replacing the previously recommended 2.5 mU/L) should be used to initiate treatment, irrespective of thyroid auto‐antibody status. The recommended starting dose of levothyroxine is 50 μg daily, with a therapeutic TSH target of 0.1–2.5 mU/L. Levothyroxine should generally be ceased after delivery, with some exceptions. Hospitals will ensure smooth transfer of care back to the woman's general practitioner with clear documentation of pregnancy thyroid management and a recommended plan for follow‐up. Conclusion: Fewer women will be classified as having subclinical hypothyroidism during pregnancy, which is likely to lead to reductions in emotional stress, hospital visits, repeated blood tests and financial costs. Uniform clinical practice will occur across Melbourne. [ABSTRACT FROM AUTHOR]

Painful animal husbandry procedures are routinely performed in a range of livestock species without analgesia. Recently, innovative strategies have been developed to address wound pain in these animals. In particular, a farmer‐applied "spray and stay" approach that is administered directly to open wounds was developed (Tri‐Solfen® Medical Ethics Pty Ltd., Melbourne, Victoria, Australia). This strategy anaesthetises the wounds immediately upon their formation, with long‐lasting effect. This development, described as a "pain management revolution," has become firmly established in the Australian livestock industries and has global potential. The positive outcomes of this approach provide insights and highlight potential benefits that may be accrued from its use in human wound care, providing rapid‐onset wound analgesia and/or anaesthetising wounds prior to cleansing and debridement procedures. If these benefits are realised from a clinician and patient perspective for wound debridement as an initial indication, it could provide new horizons in pain management for a spectrum of wound‐related procedures. Evidence from use in animal husbandry does support the concept that multimodal anaesthesia holds great potential in the field of wound management across many procedures. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the prevalence of potentially inappropriate prescribing (PIP), as defined by the internationally validated Screening Tool of Older Person's Prescriptions (STOPP) criteria, in 12 months before and after initiation of medicines for dementia. Methods: A retrospective cohort study was carried out involving people with their first claim for dispensing of medicines for dementia (cholinesterase inhibitor or memantine) between 1 January 2015 and 31 December 2015, aged ≥65 years at 1 January 2016 and alive at the end of 2016. The index date was defined as the date of first supply of medicines for dementia. PIP was identified using the Screening Tool of Older Person's Prescriptions criteria, and PIP prevalence was compared in the 12 months pre‐ and post‐index date. The McNemar's test was used to test differences in the prevalence of PIP between the two time periods. Results: The cohort included 1176 patients: 60% were women and the median age was 80 years. The overall PIP prevalence was 85% in the 12 months pre‐initiation of medicines for dementia compared with 89% in the 12 months post‐initiation (P < 0.0001). The median number of Screening Tool of Older Person's Prescriptions criteria was two (interquartile range 1–4) in the 12 months pre‐initiation of medicines for dementia, increasing to three (range 2–4) in the 12 months post‐initiation. Conclusions: PIP was common in people dispensed medicines for dementia, with a significant increase in prevalence post‐initiation of medicines for dementia compared with pre‐initiation. These results highlight the need for targeted interventions to minimize inappropriate use of medicines in people with dementia. Geriatr Gerontol Int 2019; 19: 654–659. [ABSTRACT FROM AUTHOR]

With the demonstration of the effectiveness of antibiotic treatment, the management of Mycobacterium ulcerans disease has changed from a predominantly surgically to a predominantly medically treated disease. However, research among Australian patients has revealed that antibiotic treatment alone is associated with prolonged wound healing times, high rates of treatment toxicity, and the potential for significant tissue destruction associated with severe paradoxical reactions. We present the current state of M. ulcerans management in Barwon Health, Australia, where a close working relationship exists between the Plastic Surgical and Infectious Diseases units. Here treatment has evolved based on nearly 20 years of experience gained from managing more around 600 patients from a M. ulcerans epidemic on the nearby Bellarine and Mornington Peninsulas. In our experience, surgery has re‐emerged to play an important role in the treatment of M. ulcerans in improving the rate of wound healing, minimizing antibiotic associated toxicity and preventing further tissue loss associated with severe paradoxical reactions. For selected small lesions surgery without antibiotics may also be an effective treatment option, however aggressive surgical resection of lesions with wide margins through uninvolved tissue should no longer be performed. Furthermore, extensive excisional surgery that will require the use of split skin grafts and vascularized tissue flaps to repair skin defects should be avoided if possible. [ABSTRACT FROM AUTHOR]

Background: The use of colonoscopy has been increasing in Australia. This case series describes management and outcomes of colonoscopic perforation managed by a single tertiary referral unit. Methods: An analysis of 13 years (2003–2015) of prospectively collected data on patients who had a colonoscopic perforation and were managed by the colorectal unit at a single tertiary referral centre was performed. Main outcomes were time of diagnosis, modality of management, time to theatre, length of stay, cost of admission and complications. Results: Sixty‐two patients had perforations (median age of 69 years). Thirty‐eight (61.2%) patients had their colonoscopy performed in another institution. The incidence rate decreased to 0.37 perforations per 1000 colonoscopies within Western Health. Overall, diagnostic colonoscopies accounted for 56% of perforations and perforations were likely to occur in the left colon (P = 0.006). Fifty‐one (82%) patients underwent surgery during their admission, with 24% of these being laparoscopic procedures. An earlier diagnosis was associated with significantly less intra‐abdominal contamination. Gross peritoneal contamination was more likely to be associated with the decision to form a stoma (37%, n = 19, P = 0.04). Thirty‐day mortality was 1.6% (n = 1). Conclusions: Colonoscopic perforations occur in experienced hands and may have serious implications. We demonstrated a difference in patterns of injury between therapeutic and diagnostic colonoscopies. Those who have an earlier diagnosis are less likely to have severe intra‐abdominal contamination requiring a stoma formation. [ABSTRACT FROM AUTHOR]

Background: Delirium in hospitalised patients is common, and a risk factor for adverse outcomes. Health services require accurate delirium data to monitor the impact of initiatives designed to improve detection and prevention of delirium. Aim: To determine the extent to which International Classification of Disease codes represent delirium occurrence. Methods: A cross‐sectional point prevalence survey was used to audit delirium occurrence in 25 inpatient wards of an Australian health service. All adult patients were eligible. Exclusion was for coma, end of life or behaviour that posed a risk to delirium assessors. Specially trained nurses and allied health professionals (AHP) screened patients for any cognitive impairment using the 4 A's Test (4AT). Those with abnormal screen test results were assessed using the '3‐Minute Diagnostic Interview for the Confusion Assessment Method' (3D‐CAM). Delirium detected by 3D‐CAM was the reference standard. Results: Of potentially eligible patients, 559 of 667 (83.8%) patients were assessed. The mean age was 73 years (±16.4), 54.5% were female and 43.8% (245/559) had cognitive impairment (4AT score ≥1). The occurrence of delirium during hospitalisation as identified by ICD codes was 10.4% (58/559; 95% confidence interval (CI), 7.9–12.7) compared with a point prevalence of 16.2% (91/559; 95% CI, 13.2–19.1). Only 31 of 91 (34.1%) of those with delirium had ICD delirium codes assigned. Conclusion: ICD coding is inadequate to determine in‐hospital delirium incidence. Instead, a point prevalence detection of delirium using the methods described above could be used. Health services could apply the described survey method to evaluate their local initiatives for the improvement of delirium detection and prevention. [ABSTRACT FROM AUTHOR]

Gout is an inflammatory musculoskeletal disorder with a prevalence of 1.6–6.8% in Australia. Gout is characterised by acute attacks of severe joint pain secondary to raised serum concentrations of uric acid and joint deposits of monosodium urate crystals. Recurrent attacks can affect quality of life and lead to irreversible joint damage. The prevalence of gout is increased in older people, and age‐related renal impairment, altered drug distribution and increased prevalence of comorbidities have significant consequences for safe and effective gout pharmacotherapy. For treatment of acute attacks in older people, dose reduction of colchicine may be needed due to renal impairment, and potential drug interactions require consideration. Use of non‐steroidal anti‐inflammatory drugs is limited by peptic ulceration, ischaemic heart disease, hypertension and renal impairment. Short courses of oral glucocorticoids may be preferable. For long‐term urate‐lowering therapy, allopurinol, probenecid and febuxostat are available in Australia. Lower starting doses of allopurinol are recommended in patients with renal impairment, but dose escalation to achieve target urate should follow. Concerns regarding increased cardiovascular risk with febuxostat are relevant to older patients. Despite the availability of effective therapy, gout remains undertreated, with maintenance of urate‐lowering therapy a major challenge. Education of patients and health professionals is essential to improve adherence to therapy. [ABSTRACT FROM AUTHOR]

Background: Current information on the patterns of medication use in nursing home residents living with dementia is conflicting. Aim: The aim of this study was to investigate medication use and its associations with dementia diagnosis in Australian nursing home residents. Methods: A cross‐sectional study of 541 residents from 17 Australian nursing homes was performed. Results: Over 12 months, nursing home residents were prescribed a mean (±SD) of 14.5 ± 6.8 medications each. Approximately 95% of residents were prescribed medications for the nervous system, and 94% were prescribed medications for the alimentary tract and metabolism. After adjustment for potential confounders, those with dementia were less likely to be prescribed medications for the cardiovascular system (odds ratio (OR) 0.45, 95% confidence interval (CI) 0.27–0.77, p = 0.0032) and respiratory system (OR 0.38, 95% CI: 0.25–0.60, p < 0.0001). Further analysis of specific medications showed that residents with dementia were more likely to be prescribed risperidone (OR: 9.38, 95% CI: 4.01–21.94, p < 0.0001), buprenorphine (OR 3.37, 95% CI: 1.78–6.36, p = 0.0002) and trimethoprim (OR 1.78, 95% CI: 1.06–2.97, p = 0.0282), but less likely to be prescribed glyceryl trinitrate (OR 0.42, 95% CI: 0.19–0.94, p = 0.0340) and salbutamol (OR 0.34, 95% CI: 0.2–0.6, p = 0.0002) in addition to other specific medications. Conclusions: Increased awareness of possible undertreatment of cardiovascular and respiratory conditions, and possible overtreatment of urinary tract infection, in those living with dementia in nursing home settings may improve management of this vulnerable population. [ABSTRACT FROM AUTHOR]

Aim: To conduct a comprehensive analysis of surf lifeguards' real and perceived ability in paediatric cardiopulmonary resuscitation (CPR), knowledge of child resuscitation protocols and technical competency during a simulated CPR scenario.Methods: Surf lifeguards aged 16 years and over were invited to complete a written survey and simulated test of five cycles of single-rescuer CPR on a paediatric manikin. In accordance with the latest Australia and New Zealand Committee on Resuscitation (ANZCOR) guidelines, practical skills were assessed by trained observers. A manikin fitted with electronic data-collection capability recorded technical compression and ventilation skills.Results: A total of 244 participants were entered into the study. Most previous CPR training did not include a paediatric component (53%). Lifeguards rated their ability to perform CPR on an adult as 'highly effective' or 'effective' in 56% of responses. Less than a quarter (23%), however, gave this response when compared to a child. Observed CPR skills were mostly compliant with ANZCOR guidelines (80-99%). Manikin data provided a median compression rate of 115.6 min-1 , compression depth of 3.7 cm and tidal volume of 220.0 mL. Almost half of ventilations were too little (45%), and around one fifth were too much (22%).Conclusions: Surf lifeguards are less confident in paediatric CPR. The overall performance of observed and technical CPR skills, which were mostly ANZCOR guideline compliant, suggests that performance could be improved if paediatric-specific training is provided to supplement the adult-focused methods currently in use. The use of electronic feedback manikins is recommended to address the technical compression and ventilation issues identified in this study. [ABSTRACT FROM AUTHOR]

Background: Spirometry forms the foundation investigation for the diagnosis and monitoring of common pulmonary conditions. However, potential variation in spirometry interpretation for airflow obstruction may impact subsequent clinical management. Aim: To audit spirometry interpretation practices for airflow obstruction in Thoracic Society of Australia and New Zealand accredited laboratories. Methods: Thirty‐nine accredited complex lung function laboratories were invited to participate in an online survey. The survey enquired about demographics, definition of lower limit of normal range for spirometry parameters, spirometric parameters used for identifying airflow obstruction, spirometric definition of airflow obstruction, definition of significant bronchodilator response and chosen spirometry reference equations. Results: Thirty‐six laboratories provided complete responses (response rate, 92%). To define the lower limit of normal, 26 of 36 used the 5th percentile, 7 of 36 used a fixed cut‐off and 3 used other. Twenty‐nine laboratories utilised forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) as the sole parameter to identify airflow obstruction, 3 of 36 used FEV1/FVC and FEF25–75%, and 4 used other. To define airflow obstruction, 25 of 36 laboratories used FEV1/FVC < 5th percentile, 9 of 36 used a fixed cut‐off (FEV1/FVC < 0.7, 6/36; FEV1/FVC < 0.8, 2/36; FEV1/FVC < 0.75, 1/36) and 2 of 36 used other. Twenty‐six laboratories defined a significant bronchodilator response as an increase of at least 200 mL and 12% in FEV1 and/or FVC, 9 of 36 used ≥200 mL and ≥ 12% increase in FEV1 only, and 1 used other criteria. Reference equations utilised for interpretation of spirometry data included: Quanjer 2012 Global Lung Initiative (16/36), the third National Health and Nutritional Examination Survey (8/36), European Community of Coal and Steel (8/36) and other (4/36). Conclusions: Significant heterogeneity in spirometry interpretation for airflow obstruction exists across Australian and New Zealand accredited lung function laboratories. Lack of standardisation may translate into clinically appreciable differences for the diagnosis and management of common respiratory conditions. Ongoing discussion regarding formal standardisation is required. [ABSTRACT FROM AUTHOR]

Background: Carer mental health literacy and help seeking are areas that are not well researched in the intellectual disability field. This study aimed to explore the above including service utilization experiences of Australian parents with an offspring with an intellectual disability and a comorbid psychiatric disorder. Method: Forty‐one parents took part in an online survey assessing satisfaction and helpfulness ratings of received services. Twenty‐six parents also completed items to assess mental health literacy and attitudinal barriers to help seeking. Results: Parents showed good mental health literacy with depression and with challenging behaviour associated with autism and poorer literacy with mixed presentations. Few attitudinal barriers to help seeking were reported. Parents reported varied helpfulness and satisfaction ratings with disability and mental health services. Conclusions: Parents are capable of recognizing the need to seek professional help for their offspring. Implications for service coordination, provision and carer involvement are discussed. [ABSTRACT FROM AUTHOR]

Background: The aim was to explore the relationship between quality of active support and communication support for people in group homes with high and low support needs. Methods: Data from 182 service users, 20–81 years (mean = 40), 89 with high support needs, were observed to have either good (n = 142) or poor (n = 40) communication support. Measures were of quality of active support, engagement and staff contact; field notes provided examples of good and poor communication supports. Results: We found a relationship between the quality of communication support and active support. Receiving good communication was associated with higher levels of engagement. Field notes included some examples of appropriate communication supports, but limited use of augmentative and alternative communication (AAC). Conclusions: Staff show limited use of appropriate communication with people having high support needs who require AAC. Strategies to improve quality of practice are discussed. [ABSTRACT FROM AUTHOR]

An editorial is presented on the need to counter the increasing instances of antibiotic resistance in bacteria. It expresses the use of oral fosfomycin trometamol for urinary tract infection in women over 12-years of agethe results of fosfomycin susceptibility testing as per the testing standards based on the Clinical and Laboratory Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility Testing (EUCAST).

This exploratory, descriptive study aimed to identify and describe the pressure injury preventative interventions prescribed by nurses following the assessment of a patient's pressure injury risk and to compare the prescribed interventions relative to the assessed risk level. A total of 200 inpatients in a tertiary Australian hospital were included. Patients' charts were audited within 24 hours of admission. Data collected included patient characteristics, pressure injury risk assessment score and level, and preventative interventions prescribed. Most patients were assessed as not being at risk, with the largest group of at‐risk patients assessed as being at high risk. Some not‐at‐risk patients were prescribed interventions intended for those at risk, while prescription rates of preventative interventions recommended for those at any level of risk were variable (6%–64%). Significant associations were found between assessed pressure injury risk and preventative intervention prescription. Preventative intervention prescription was inadequate, potentially exposing some patients to pressure injury. However, the association between intervention prescription and risk level suggests that nurses are prescribing interventions relative to risk. A more structured approach to intervention prescription according to risk level, such as a care bundle, may help to improve nurses' preventative intervention prescription and ensure that all at‐risk patients receive appropriate preventative interventions. [ABSTRACT FROM AUTHOR]

Background: Children with speech‐sound disorders (SSD) constitute a significant proportion of speech–language pathologists' (SLPs) caseloads. Previous research has investigated the clinical practice of SLPs intervening with children with SSD; however, little is known about the clinical decision‐making underpinning their practice. Aims: The clinical decision‐making of SLPs working with children with SSD was explored to understand how their clinical decisions were influenced by: (1) beliefs about what works in therapy; (2) prior clinical experience; and (3) client and service‐related variables. Methods & Procedures: Semi‐structured, individual, in‐depth interviews were conducted with 11 SLPs. Inductive thematic analysis was used to identify and explore key ideas and themes. Outcomes & Results: Four themes emerged: (1) clinical decision‐making procedures were highly individualized; (2) parental involvement was viewed as central to the success and progression of therapy; (3) therapy procedures were influenced by practice‐setting constraints; and (4) engaging in evidence‐based practice within clinical settings was perceived as challenging. Conclusions & Implications: In clinical settings, a range of factors influence decision‐making and therapy provided by SLPs to children with SSD. These SLPs had a high regard for clients' values and preferences. Prior clinical experiences also shaped clinical practice. Clinical decision‐making was influenced by practice‐setting constraints. SLPs are under pressure in their workplaces and are struggling to manage the competing demands on their time. Large clinical caseloads, heavy workloads, current service‐delivery models and changing family structures are all impacting on the provision of therapy to children with SSD and therapy outcomes. As a profession, there is a need to consider these barriers and identify ways to overcome them in order to assist SLPs to routinely adopt the highest standards of clinical practice for children with SSD. [ABSTRACT FROM AUTHOR]

Abstract: Acute hand and wrist injuries are a common presentation to the ED and are associated with large individual and societal costs. Appropriate management of these injuries in the ED is crucial given that optimal hand function is essential for daily activities and quality of life. This rapid review investigated best practice for the assessment and management of common closed hand and wrist injuries in the ED. Databases were searched in 2017, including PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites. Primary studies, systematic reviews and guidelines published in English language in the past 12 years that addressed the acute assessment, management, follow‐up plan or prognosis were considered for inclusion. Data extraction of included articles was conducted, followed by quality appraisal to rate the level of evidence. The search revealed 2454 articles, of which 55 were included in the review (n = 23 primary articles, n = 26 systematic reviews and n = 6 guidelines). This rapid review provides clinicians who manage common closed fractures and soft tissue injuries of the hand and wrist in the ED, a summary of the best available evidence to enhance the quality of care for optimal patient outcomes. There is evidence to support taking a thorough history and physical examination with consideration of occupational and functional factors, restoring alignment and immobilising when necessary and referring onwards. Key points regarding the diagnosis and management of these injuries are provided. [ABSTRACT FROM AUTHOR]

This retrospective study was conducted to identify the incidence and characteristics associated with readmissions for surgical site infections following caesarean section in a tertiary hospital from 2012 to 2015. Of 6334 patients who underwent caesarean section, 165 (2.6%) were readmitted, most commonly for surgical site infection (25.5%, n = 42). Thirty‐seven of these patients (88%) had an emergency caesarean compared to five (12%) following an elective caesarean section. Of the women with surgical site infections, 69% were overweight and 14% had diabetes. Emergency caesarean sections were responsible for the majority of readmissions, particularly in women with co‐morbidities that predisposed them to infection. [ABSTRACT FROM AUTHOR]