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OBJECTIVE: To determine the nature, extent, and cost of discrepancies between the quantities of medications supplied to medical departments and administered to patients in public hospitals. DESIGN: Multicentre, retrospective observational study; analysis of electronic pharmacy drug management system (medication supply) and medication administration data for twenty frequently used medications. SETTING, PARTICIPANTS: Medical, surgical, and emergency department (ED) wards in each of four public hospitals in Melbourne, Victoria, during the 2019 calendar year. MAIN OUTCOME MEASURES: Discrepancy between the quantity of medication supplied and administered to patients (as proportion of medication supplied), overall and by hospital and ward type; direct cost to the hospitals of the discrepancies. RESULTS: The overall discrepancy rate (all medications, hospitals, ward types) was 19.2% (95% CI, 19.0-19.4%); overall rates by hospital ranged from 5.8% (95% CI, 5.7-5.9%) to 26.7% (95% CI, 26.6-26.9%). The discrepancies were largest for medications useful for self-treatment: oral antibiotics (eg, phenoxymethylpenicillin 250 mg capsule, 86.8%; 95% CI, 83.1-89.9%) and gastrointestinal medications (eg, ondansetron 4 mg tablet, 53.3%; 95% CI, 52.9-53.7%). Discrepancies were larger for oral than equivalent (or similar) parenteral formulations; they were generally low for controlled medications (temazepam, diazepam, oxycodone). Overall discrepancies were larger for EDs (32.3%; 95% CI, 32.2-32.5%) than for admitted patient wards, but differed between EDs (range: 25.7%; 95% CI, 25.5-26.0% to 39.5%; 95% CI, 39.2-39.7%). The estimated direct cost to hospitals of the discrepancies for the selected medications was $27 800. CONCLUSION: Substantial quantities of medications supplied to hospital wards and EDs are not accounted for in electronic administration records.

INTRODUCTION: Breast cancer surgery aims to excise lesions with clear margins and provide optimal cosmesis with a low re-excision rates. These aims are aided by accurate lesion localisation and a surgical choice of incision site with minimal removal of healthy tissue. Problems associated with hookwires have led to adoption of non-wire methods including radioguided occult lesion localisation using iodine-125 (ROLLIS). This paper outlines the problems encountered and lessons learnt during the largest RCT involving 659 participants, conducted at eight sites (seven Australian, one New Zealand centres) between September 2013 and April 2018.* METHODS: Data, along with substantive comments, regarding each ROLLIS procedure, documenting each step from the seed insertion, ease of operative retrieval, to return of the seed to medical physics, from a shared on-line secure database and a separate site email survey, were synthesised and categorised. RESULTS: The Australian and New Zealand ROLLIS RCT experience highlights several important issues. Lessons learned were related to licencing the seed and tracking protocols. A Designated Team Lead, who is a good communicator, ensuring the Tracking Protocols were accurately followed and updated, subspecialty leads and a Co-ordinator, responsible for training, logbook maintenance and seed ordering, enhanced the success and acceptance of the programme. Addressing radiation issues, fears, education of staff and seed loss was imperative. CONCLUSION: The Australian and New Zealand ROLLIS RCT experience highlights the need for adherence to local licencing laws and protocols, appointing a dedicated ROLLIS Designated Team Lead with good communication and a ROLLIS Co-ordinator. These facilitate the adoption of a successful ROLLIS programme.

BACKGROUND: Currently no consensus exists regarding what pre-reversal investigations are required to assess integrity of the rectal anastomosis. The objective of this study was to compare pre-reversal assessments of anastomotic integrity and to evaluate trends that might have influenced timings for reversal. METHODS: From a prospectively maintained database, patients with colorectal cancer resections between March 2012 and October 2019 were identified. Patient characteristics, pre-reversal contrast enema and flexible sigmoidoscopy findings were recorded, and management of complications were recorded. Time-to-ileostomy reversal and time series for trends were analysed. RESULTS: There were 154 patients included. Pre-reversal contrast enema or sigmoidoscopy detected a possible stricture or leak at the rectal anastomotic site in 11% (15/132) and 15% (18/112), respectively. When both modalities were used there was concordance of 86.1% and a positive likelihood ratio of 5.73. Of 125 (81.2%) ileostomies reversed, the median time-to-reversal was 11.99 months; time series analysis over the 7-year period showed no significant trend for average patient-days from booking to reversal (P = 0.60). Cox regression modelling did not identify any influential risk factors for the times taken to reversal. CONCLUSION: This study supports the use of both contrast enema and flexible sigmoidoscopy in the assessment of rectal anastomosis integrity. Most patients with complications can have their ileostomies reversed. Patients who have adjuvant chemotherapy have a prolonged time to reversal.

BACKGROUND: Hookwire localization (HWL) is the gold standard for localizing impalpable tumours for breast conserving surgery. An alternative technique, radioguided occult lesion localization using iodine-125 seeds (ROLLIS), has been associated with lower re-excision rates. This paper investigates if cosmetic outcomes differ in women undergoing breast conserving surgery with HWL or ROLLIS. METHODS: Women who had ROLLIS or HWL guided excision for impalpable breast cancer within a multicentre randomized controlled trial (RCT) (ANZCTR 12613000655741) were recruited. Exclusions were level 2 oncoplasty and mastectomy. Cosmetic outcome was calculated using BCCT.core, the Hopwood Body Image Scale and estimated percentage breast volume excised. Chi-squared analysis was used to determine the difference between the intervention groups. RESULTS: Analysis was performed for 123 participants (66 ROLLIS and 57 HWL). The cosmetic outcome determined by BCCT.core for all participants was good with no significant difference between the ROLLIS and HWL groups. When reviewing the number of patients who experienced either a good or excellent result, there was a significantly higher number of patients in the ROLLIS group (n = 53, 82%) compared to the HWL group (n = 42, 74%, P = 0.02. There were no differences in Hopwood Body Image Scale or estimated percentage breast volume excised between groups. There was a reduction in the frequency of re-excision in the ROLLIS group (n = 3, 4.5%) versus HWL group (n = 8, 14%); however, this was not significant (P = 0.06). CONCLUSION: Pre-operative localization of impalpable breast lesions using either ROLLIS or HWL resulted in a good cosmetic outcome with no significant difference between localization techniques.

Aim We aimed to test the performance of the quick Sequential Organ Failure Assessment score (qSOFA) in predicting the outcomes of oncology patients admitted to the emergency department (ED) with suspected infection. Methods Retrospective cohort analysis of all oncology patients presenting to the ED of a tertiary hospital with suspected infection from 1 December 2014 to 1 June 2017. Patients were identified by cross‐linkage of ED and Oncology electronic health records. The primary outcome was in‐hospital mortality and/or ICU stay ≥ 3 days. Results A total of 1655 patients were included in this study––1267 (76.6%) with solid tumor and 388 (23.4%) with hematological malignancies. At presentation, 495 patients had chemotherapy, and 140 had radiotherapy within the preceding 6 months. Four hundred patients received chemotherapy and/or radiotherapy in the previous 4 weeks. Overall, 371 (22.4%) patients had qSOFA ≥ 2. Such patients had a higher likelihood of respiratory infections compared to patients with a qSOFA < 2 (43.9% vs 29%) and were more likely to be admitted to ICU or require mechanical ventilation. In‐hospital mortality or in‐hospital mortality and/or ICU stay ≥ 3 days were 17.3% and 21%, for qSOFA ≥ 2 patients versus 4.7% and 6.9% for qSOFA < 2 patients (P < .001). qSOFA ≥ 2 had a negative predictive value of 95% for in‐hospital mortality and 93% for in‐hospital mortality or ICU stay ≥ 3 days. Conclusion Among oncology patients presenting to the ED with suspected infection, a qSOFA ≥ 2 is associated with a threefold risk of hospital mortality/prolonged ICU stay. Its absence helps identify low‐risk patients.

AIMS: Co-design implies genuine partnership in the generation of knowledge between service users and researchers. Service user involvement in research has been encouraged in government policy, but it is rarely achieved, especially at trial initial stages. Co-designed with service users, we adapted existing manualised social cognition intervention for people with a first episode of psychosis to a virtual world environment. METHODS: We invited a group of young people who have used mental health services to co-design a virtual environment to deliver an accessible social cognition intervention to a hard to engage service user group. We used an iterative process with young service users and the design team that included developing initial ideas, creating a prototype and testing the virtual world. RESULTS: Twenty young service users of local mental healthcare services provided feedback on the design and delivery of the intervention. Reflecting the demographic of the sample, young people felt the virtual environment should be familiar, urban spaces, akin to therapy rooms or classrooms they have used in real-life situations rather than non-traditional therapy spaces that were initially proposed. CONCLUSION: The co-design process led to the development of a specific design, approach and protocol to be tested in a proof-of-concept trial. Young service users were integral to an agile and iterative design. Technological innovations should be routinely co-designed and co-produced if they are to realise their potential to deliver acceptable and affordable mental health interventions.