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Objective: To identify factors that health and allied health practitioners consider central to excellence in residential aged care facilities (RACFs) with the objective of supporting improvements in monitoring, accountability and service delivery within the sector. Methods: In a qualitative, exploratory designed study, interviews were undertaken with seventeen participants from 10 health and allied health disciplines (general practice, dentistry, pharmacy, psychiatry, psychology, neuropsychology, physiotherapy, speech pathology, occupational therapy and palliative care) with experience of working in Victorian RACFs. The interviews focused on how practitioners perceived excellence within RACFs. Data were analysed thematically. Results: Thematic analysis yielded five themes, which correspond with different dimensions or ways of understanding excellence, including resident well-being, residences as a true home, good practice models, effective management and skilled staff, and unmet needs. Under each of these themes, participants referred to issues closely related to the concerns of their particular professions as well as those more general in nature. Conclusions: The diversity in issues to which participants drew attention highlights the importance of obtaining the perspectives of a broad range of practitioners providing services to RACF residents to achieving excellence in the sector. Commonalities in their responses indicate the potential for a greater level of collaboration among the health and allied health professions.

Objective To investigate decision-making around hospital transfer and/or referral of residents to a Residential InReach (RiR) service in north-eastern metropolitan Melbourne, Australia, from the perspectives of residential aged care facility (RACF) staff, general practitioners (GPs) and RiR registered nurses (RNs). Methods Thirty-one staff from eight RACFs, five GPs and four RiR RNs participated in individual or group interviews. Results Residential aged care facility staff and GPs valued and relied upon RiR to manage unwell residents. Thematic analysis identified RiR utilisation was driven by the following: (i) complexity of decision-making processes in RACFs; (ii) variability in facility-based medical and nursing care; and (iii) impact of RiR service outcomes on patients and referrers. Conclusion Availability of timely and appropriate medical and nursing care in RACFs was reported to influence transfers to the hospital and/or referrals to RiR. RiR was used to complement or substitute usual care available to residents. Further research and improvements in RACF and RiR resources are required.

As the Australian population ages the demand for nursing care which focuses on responding to the needs of the older person will increase. Few newly graduated Registered Nurses (RNs) currently enter the aged care workforce and few select a career in caring for older people; yet older people are the largest patient group in most health care environments. This research, conducted by the Australian Hartford Consortium of Gerontological Nursing Excellence (Aus-HCGNE), explored how care of the older person is currently taught in Australian schools of nursing (SoN). The interview guide included questions about: whether care of the older person is taught in separate subjects or integrated across the curriculum; academics’ qualifications; subject content; and aged care clinical placements. The head of each of the 33 Australian schools of nursing was contacted, invited to participate and asked to nominate the appropriate academics (undergraduate/curriculum co-ordinators) who would be the most appropriate person to participate in the interview. These academics were then contacted, written informed consent was obtained, interviews were scheduled and completed. This research is timely given the current Royal Commission into Aged Care Quality and Safety in Australia, one focus of which is nurses in residential aged care in respect to numbers, education and competence. This research will be completed by mid-2019. The results will be fed back to SoN to inform the development of their curricula and the preparation of future RNs who will undoubtably need to be expert in the care of older people across the health sector.

Identification of pregnancies that are higher risk than average is important to allow the possibility of interventions aimed at preventing adverse outcomes like preterm birth. Many scoring systems designed to classify the risk of a number of poor pregnancy outcomes (e.g. perinatal mortality, low birthweight, and preterm birth) have been developed, but they have usually been introduced without evaluation of their utility and validity.To determine whether the use of a risk-screening tool designed to predict preterm birth (in combination with appropriate consequent interventions) reduces the incidence of preterm birth and very preterm birth, and associated adverse outcomes.We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2010), CENTRAL (The Cochrane Library 2010, Issue 4), MEDLINE (1966 to 17 December 2010), EMBASE (1974 to 17 December 2010), and CINAHL (1982 to 17 December 2010).All randomised or quasi-randomised (including cluster-randomised) or controlled clinical trials that compared the incidence of preterm birth between groups that used a risk scoring instrument to predict preterm birth with those who used an alternative instrument, or no instrument; or that compared the use of the same instrument at different gestations. The reports may have been published in peer reviewed or non-peer reviewed publications, or not published, and written in any language.All review authors planned to independently assess for inclusion all the potential studies we identified as a result of the search strategy. However, we identified no eligible studies.Extensive searching revealed no trials of the use of risk scoring systems to prevent preterm birth.The role of risk scoring systems in the prevention of preterm birth is unknown.There is a need for prospective studies that evaluate the use of a risk-screening tool designed to predict preterm birth (in combination with appropriate consequent interventions) to prevent preterm birth, including qualitative and/or quantitative evaluation of their impact on women's well-being. If these prove promising, they should be followed by an adequately powered, well-designed randomised controlled trial.

Integrative medicine, a popular movement in the USA and Europe, is taught in many US medical schools. This study describes how Australian doctors define integrative medicine, what motivates them to work in integrative medicine and the incorporation of complementary and alternative medicines (CAM) into their practice.Semi-structured interviews were conducted between May and December 2009 with 23 doctors in two Australian states working in integrative medicine. A thematic analysis of interview transcripts was undertaken.Doctors' interpretations of the term 'integrative medicine' varied considerably. All maintained a strong belief in the usefulness of conventional medicine, while a holistic and patient-centred approach, promoting well-being, was central to their practice. Doctors' motivations for choosing an integrative approach to their practice of medicine also varied, but personal and professional experiences of alternative approaches to illness were influential in this decision. The nature of their clinical practice was also diverse; few doctors in this sample practice or professionally use CAM; a small number were happy to advise patients on the use of different modalities while even less referred to complementary practitioners.The concept and practice of integrative medicine among the doctors interviewed were diverse. This has implications for the Royal Australian College of General Practitioners inclusion criteria for the membership of their integrative medicine chapter. More broadly, the findings have implications for all medical practice and the education of medical students, as much of what integrative medicine doctors do may be considered simply as 'good medical practice'.

Many tissues, including hepatobiliary cells, express neutral endopeptidase (CD10), encoded by MME. Serum neutral endopeptidase activity (NEA) has been recommended as a marker of cholestasis in adults but not in children with Alagille syndrome (AGS). We investigated ontogenic and disease-related differences in the expression of CD10. CD10 was found on canalicular surfaces of hepatocytes throughout the lobule in 16 adults and in 31 children agedor =24 months, with and without cholestasis, but not in 39 children aged24 months, with and without cholestasis. Ten AGS children aged 2 months to 6 years lacked any canalicular CD10 expression. Cholangiocyte apices and/or intrasinusoidal granulocytes marked for CD10 in all subjects. Liver membrane fractions from a child with cholestasis aged24 months and from 2 AGS patients aged24 months contained reduced levels of CD10. In contrast, AGS children and all controls expressed CD10 similarly on granulocytes. MME mRNA was found in the liver of children aged24 months and of adults, all with cholestasis, and of AGS patients. Granulocyte MME mRNA levels were similar among all study subjects; however, liver MME mRNA levels were 6- to 140-fold less than in normal adults in all cholestatic subjects, including AGS children. Methylation of the MME promoter was not detected in the liver of AGS children. In conclusion, hepatocytes in early childhood physiologically lack immunohistochemically detectable CD10. Reduced MME mRNA in AGS is not due to MME promoter methylation. Liver CD10 in childhood appears to undergo reduced synthesis or rapid degradation, which persists in AGS. Absence of CD10 expression thus may limit NEA as a marker of cholestasis in young patients and in AGS.

Aim: To describe the process involved in obtaining ethics approval for a study aiming to recruit women from all maternity hospitals in Victoria, Australia. Design: Observational data of the application process involving 85 hospitals throughout Victoria in 2001. Results: Twenty three of the 85 hospitals had a Human Research Ethics Committee (HREC) constituted in accordance with the National Health and Medical Research Council requirements; 27 agreed to accept decisions from other hospitals having HRECs and 27 relied on ethics advisory committees, hospital managers, clinical staff, quality assurance committees or lawyers for ethics decisions. Four of the latter did not approve the study. Eight hospitals no longer provided maternity services in the recruitment period. The process took 16 months, 26 000 sheets of paper, 258 copies of the application and the cost was about $30 000. Approval was eventually obtained for recruitment at 73 hospitals. Discussion: Difficulties exist in obtaining timely ethics approval for multicentre studies due to a complex uncoordinated system. All hospitals should have explicit protocols for dealing with research ethics applications so that they can be processed in a straightforward and timely manner. To facilitate this, those without properly constituted HRECs should be affiliated with one hospital that has an HREC. (author abstract)

Objective Public health research is an endeavour that often involves multiple relationships, far-reaching collaborations, divergent expectations and various outcomes. Using the Tall Girls Study as a case study, this paper will present and discuss a number of methodological, ethical and legal challenges that have implications for other public health research. Approach The Tall Girls Study was the first study to examine the long-term health and psychosocial effects of oestrogen treatment for tall stature. Results In undertaking this study the research team overcame many hurdles: in maintaining collaboration with treating clinicians and with the women they had treated as girls - groups with opposing points of view and different expectations; using private practice medical records to trace women who had been patients up to forty years earlier; and exploring potential legal issues arising from the collection of data related to treatment. Conclusion While faced with complex challenges, the Tall Girls Study demonstrated that forward planning, ongoing dialogue between all stakeholders, transparency of processes, and the strict adherence to group-developed protocols were keys to maintaining rigour while undertaking pragmatic research. Implications Public health research often occurs within political and social contexts that need to be considered in the planning and conduct of studies. The quality and acceptability of research findings is enhanced when stakeholders are engaged in all aspects of the research process.

Background & Aims: Patients with severe bile salt export pump (BSEP) deficiency present as infants with progressive cholestatic liver disease. We characterized mutations of ABCB11 (encoding BSEP) in such patients and correlated genotypes with residual protein detection and risk of malignancy. Methods: Patients with intrahepatic cholestasis suggestive of BSEP deficiency were investigated by single-strand conformation polymorphism analysis and sequencing of ABCB11. Genotypes sorted by likely phenotypic severity were correlated with data on BSEP immunohistochemistry and clinical outcome. Results: Eighty-two different mutations (52 novel) were identified in 109 families (9 nonsense mutations, 10 small insertions and deletions, 15 splice-site changes, 3 whole-gene deletions, 45 missense changes). In 7 families only a single heterozygous mutation was identified despite complete sequence analysis. Thirty-two percent of mutations occurred in > 1 family, with E297G and/or D482G present in 58% of European families (52/89). On immunohistochemical. analysis (88 patients), 93% had abnormal or absent BSEP staining. Expression varied most for E297G and D482G, with some BSEP detected in 45% of patients (19/42) with these mutations. Hepatocellular carcinoma or cholangiocarcinoma developed in 15% of patients (19/128). Two protein-truncating mutations conferred particular risk; 38% (8/21) of such patients developed malignancy versus 10% (11/107) with potentially less severe genotypes (relative risk, 3.7 [confidence limits, 1.7-8.1; P = .003]). Conclusions: With this study, > 100 ABCB11 mutations are now identified. Immunohistochemically detectable BSEP is typically absent, or much reduced, in severe disease. BSEP deficiency confers risk of hepatobiliary malignancy. Close surveillance of BSEP-deficient patients retaining their native liver, particularly those carrying 2 null mutations, is essential.

Background Concerns have been raised in Australia and internationally regarding the quality and effectiveness of hospital postnatal care, although Australian women receiving postnatal care in the private maternity sector rate their satisfaction with care more highly than women receiving public maternity care. In Victoria, Australia, two-thirds of women receive their maternity care in the public sector and the remainder in private health care sector. A statewide review of public hospital postnatal care in Victoria from the perspective of care providers found many barriers to care provision including the busyness of postnatal wards, inadequate staffing and priority being given to other episodes of care; however the study did not include private hospitals. The aim of this study was replicate the review in the private sector, to explore the structure and organisation of postnatal care in private hospitals and identify those aspects of care potentially impacting on women's experiences and maternal and infant care. This provides a more complete overview of the organisational structures and processes in postnatal care in all Victorian hospitals from the perspective of care providers. Methods A mixed method design was used. A structured postal survey was sent to all Victorian private hospitals (n = 19) and key informant interviews were undertaken with selected clinical midwives, maternity unit managers and obstetricians (n = 11). Survey data were analysed using descriptive statistics and interview data analysed thematically. Results Private hospital care providers report that postnatal care is provided in very busy environments, and that meeting the aims of postnatal care (breastfeeding support, education of parents and facilitating rest and recovery for women following birth) was difficult in the context of increased acuity of postnatal care; prioritising of other areas over postnatal care; high midwife-to-woman ratios; and the number and frequency of visitors. These findings were similar to the public review. Organisational differences in postnatal care were found between the two sectors: private hospitals are more likely to have a separate postnatal care unit with single rooms and can accommodate partners' over-night; very few have a policy of infant rooming-in; and most have well-baby nurseries. Private hospitals are also more likely to employ staff other than midwives, have fewer core postnatal staff and have a greater dependence on casual and bank staff to provide postnatal care. Conclusions There are similarities and differences in the organisation and provision of private postnatal care compared to postnatal care in public hospitals. Key differences between the two sectors relate to the organisational and aesthetic aspects of service provision rather than the delivery of postnatal care. The key messages emerging from both reviews is the need to review and monitor the adequacy of staffing levels and to develop alternative approaches to postnatal care to improve this episode of care for women and care providers alike. We also recommend further research to provide a greater evidence-base for postnatal care provision.

Background Studies exploring the use of complementary and alternative medicine (CAM) to enhance fertility are limited. While Australian trends indicate that women are using CAM during pregnancy, little is known about women's use of CAM for fertility enhancement. With the rising age of women at first birth, couples are increasingly seeking assisted reproductive technologies (ART) to achieve parenthood. It is likely that CAM use for fertility enhancement will also increase, however this is not known. This paper reports on an exploratory study of women's use of CAM for fertility enhancement. Methods Three focus groups were conducted in Melbourne, Australia in 2007; two with women who used CAM to enhance their fertility and one with CAM practitioners. Participants were recruited from five metropolitan Melbourne CAM practices that specialise in women's health. Women were asked to discuss their views and experiences of both CAM and ART, and practitioners were asked about their perceptions of why women consult them for fertility enhancement. Groups were digitally recorded (audio) and transcribed verbatim. The data were analysed thematically. Results Focus groups included eight CAM practitioners and seven women. Practitioners reported increasing numbers of women consulting them for fertility enhancement whilst also using ART. Women combined CAM with ART to maintain wellbeing and assist with fertility enhancement. Global themes emerging from the women's focus groups were: women being willing to 'try anything' to achieve a pregnancy; women's negative experiences of ART and a reluctance to inform their medical specialist of their CAM use; and conversely, women's experiences with CAM being affirming and empowering. Conclusions The women in our study used CAM to optimise their chances of achieving a pregnancy. Emerging themes suggest the positive relationships achieved with CAM practitioners are not always attained with orthodox medical providers. Women's views and experiences need to be considered in the provision of fertility services, and strategies developed to enhance communication between women, medical practitioners and CAM practitioners. Further research is needed to investigate the extent of CAM use for fertility enhancement in Australia, and to explore the efficacy and safety of CAM use to enhance fertility, in isolation or with ART.