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Evaluative reporting provides a balanced approach to evidence interpretation. The use of evaluative reporting in forensic DNA analysis is common practice and well understood in Australia and New Zealand. However, it is less common and perhaps less understood in the pattern and trace evidence areas. Recent publications, such as the 2015 'European Network of Forensic Science Institutes (ENFSI) Guideline for Evaluative Reporting in Forensic Science', have prompted discussion in Australia and New Zealand about the benefits and risks of expanding its application in forensic science. To aid discussions and build a common understanding of evaluative reporting, the Australia New Zealand Policing Advisory Agency National Institute of Forensic Science (ANZPAA NIFS) convened a project working group to create 'An introductory guide to evaluative reporting'. The guide covers terminology and uses examples to illustrate the concepts. It also provides advice on the implementation of evaluative reporting in forensic science disciplines. This article provides an overview of the project, and the methodology and thinking behind the development of the guide and its associated fact sheet and process poster. [ABSTRACT FROM AUTHOR]

Prickly acacia ( Vachellia nilotica subsp. indica), a native of the Indian subcontinent, is a serious weed of the grazing areas of northern Australia and is a target for classical biological control. Native range surveys in India identified a leaf webber, Phycita sp. (Lepidoptera: Pyralidae) as a prospective biological control agent for prickly acacia. In this study, we report the life cycle and host-specificity test results Phycita sp. and highlight the contradictory results between the no-choice tests in India and Australia and the field host range in India. In no-choice tests in India and Australia, Phycita sp. completed development on two of 11 and 16 of 27 non-target test plant species, respectively. Although Phycita sp. fed and completed development on two non-target test plant species ( Vachellia planifrons and V. leucophloea) in no-choice tests in India, there was no evidence of the insect on the two non-target test plant species in the field. Our contention is that oviposition behaviour could be the key mechanism in host selection of Phycita sp., resulting in its incidence only on prickly acacia in India. This is supported by paired oviposition choice tests involving three test plant species ( Acacia baileyana, A. mearnsii and A. deanei) in quarantine in Australia, where eggs were laid only on prickly acacia. However, in paired oviposition choice trials, only few eggs were laid, making the results unreliable. Although oviposition choice tests suggest that prickly acacia is the most preferred and natural host, difficulties in conducting choice oviposition tests with fully grown trees under quarantine conditions in Australia and the logistic difficulties of conducting open-field tests with fully grown native Australian plants in India have led to rejection of Phycita sp. as a potential biological control agent for prickly acacia in Australia. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate reported ingested dose of paracetamol as a risk assessment tool in acute paracetamol overdose. Methods: Data was retrospectively obtained from a clinical toxicology database linked to one Australian and two United Kingdom hospitals. Plasma paracetamol concentrations (PPCs) of adult patients presenting with acute single ingestion, non-staggered paracetamol deliberate self-poisoning between 2006 and 2012 were recorded and plotted on a treatment nomogram to determine accuracy of reported dose ingested as an indicator for antidotal treatment. PPC plotted on a treatment nomogram with a line intersecting a 4-h concentration of 100 mg/L [667 μmol/L] was considered an indication for antidotal treatment in the UK; the corresponding Australasian population utilised a line intersecting 150 mg/L [1000 μmol/L]. Results: Of 1246 patients, 65.7 % were female and 88 % were from the UK. Fifty-two percent of patients reporting ingestion of ≥8 g paracetamol had a PPC above the 100 mg/L treatment line; PPV 52 % [95 % confidence interval (CI) 49 %, 55 %], sensitivity 81 % [95 %CI 78 %, 85 %]. Forty-four of patients reporting percent ingestion of ≥10 g had a PPC above the 150 mg/L treatment line; PPV 44 % [95 % CI 41 %, 49 %], sensitivity 85 % [95 % CI 78 %, 89 %], 72 % of patients reporting ingestion of ≥16 g had a PPC above the 100 mg/L treatment line; PPV 72 % [95% CI 67 %, 77 %], sensitivity 50 % [95 % CI 45 %, 54 %]. Overall, there was moderate correlation ( R = 0.58) between reported paracetamol dose ingested and extrapolated 4-h PPC. Conclusions: There is a positive correlation between reported ingested dose of paracetamol and subsequent chance of a PPC being above a defined treatment line; however, ingested dose of paracetamol alone is a poor risk assessment tool in accurately determining need for treatment with an antidote. [ABSTRACT FROM AUTHOR]

Background Spontaneous pneumothorax can be managed initially by observation, aspiration or chest drain insertion. Aims To determine the clinical features of spontaneous pneumothorax in patients presenting to the emergency department ( ED), interventions, outcomes and potential risk factors for poor outcomes after treatment. Methods Retrospective chart review from ED of three major referral and two general hospitals in Australia of presentations with primary spontaneous pneumothorax ( PSP) or secondary spontaneous pneumothorax ( SSP). Main outcomes were prolonged air leak (>5 days) and pneumothorax recurrence within 1 year. Results We identified 225 people with PSP and 98 with SSP. There were no clinical tension pneumothoraces with hypotension. Hypoxaemia (haemoglobin oxygen saturation measured by pulse oximetry ≤92%) occurred only in SSP and in older patients (age >50 years) with PSP. Drainage was performed in 150 (67%) PSP and 82 (84%) SSP. Prolonged air leak occurred in 16% (95% confidence interval 10-23%) of PSP and 31% (21-42%) of SSP. Independent risk factors for prolonged drainage were non-asthma SSP and pneumothorax size >50%. Complications were recorded in 11% (7.5-16%) of those having drains inserted. Recurrences occurred in 5/91 (5%, 1.8-12%) of those treated without drainage versus 40/232 (17%, 13-23%) of those treated by drainage, of which half occurred in the first month after drainage. Conclusion Pneumothorax drainage is associated with substantial morbidity including prolonged air leak. As PSP appears to be well tolerated in younger people even with large pneumothoraces, conservative treatment in this subgroup may be a viable option to improve patient outcomes, but this needs to be confirmed in a clinical trial. [ABSTRACT FROM AUTHOR]

In younger women at high risk for developing breast cancer the value of mammography is limited by a higher prevalence of breast tissue density, low rate of DCIS in gene carriers, faster growing tumours and concerns over radiation exposure. We report on our experience of MR screening in high risk patients over a three year period. Women at high risk of developing breast cancer were offered an MRI scan and an Ultrasound in addition to their annual mammogram for two years. The following MR-protocol was used: pre-contrast T2 STIR sequence and pre contrast 3D FLASH sequence, post contrast axial dynamic 3D FLASH sequence. Seventy two women consented to participate in this study. One hundred thirty nine breast MRI examinations were performed. Two pre-cancerous lesions and an axillary lymph node metastasis were found, but the majority of the lesions were benign. Difficulties in screening young women at high risk are discussed in this paper. In our study three lesions of significance were detected. Two lesions were precancerous thus curable. The recall rates show the difficult nature of screening younger breasts. MRI generated more findings judged as uncertain, so short term-term follow up studies or MR-guided biopsy techniques are required. [ABSTRACT FROM AUTHOR]

Abstract: The warm greenhouse world of the Late Cretaceous created oceans that were poorly stratified latitudinally and vertically. Periodically these oceans experienced globally significant events where oxygen minimum zones enveloped the continental margins. Evidence of the effect of one of these Ocean Anoxic Events (OAEs) is preserved in the southern high latitude strata of the offshore Otway Basin in southeast Australia. During the Late Cretaceous, thick successions (up to 6 km) of mudstone-dominated deltaic to upper bathyal sediments (the Otway Delta) were deposited in an elongate inlet (ca. 500 km wide) between Antarctica and Australia located at least 70° S. The initial Turonian strata of this succession (the Waarre Formation) were deposited in upper delta plain to delta front conditions. The overlying late Turonian Flaxman Formation and basal Belfast Mudstone Formation preserve evidence of transgressive lower delta plain to prodelta conditions at inner to middle shelf depths. These units were subject to periodic dysoxia during deposition caused by intermittent freshwater input and deepening seas resulting in periods of thermohaline stratification and reduced bottom waters. Rapid subsidence from 89.3 Ma to 85.7 Ma created significant accommodation space leading to the seaward progradation of normal marine prodelta to upper bathyal mudstone-dominated facies at middle shelf to upper slope depths. After a period when the oxygen minimum zone contracted near the base of the Coniacian, upward-increasing dysoxia in the Belfast Mudstone Formation heralds the onset of Coniacian to Santonian dysoxic conditions. This event in the Otway Basin correlates to OAE 3, the last Ocean Anoxic Event of the warm Cretaceous before the onset of cooler conditions in the uppermost Cretaceous. The evidence suggests that, rather than confined to low latitude tropical areas, the effects of OAE 3 reached southern high latitude regions during the warm Late Cretaceous. The cessation of growth faulting after 85.7 Ma reduced accommodation space and delta front to prodelta facies prograded rapidly seaward. Hyposaline conditions and higher sedimentation rates due to delta front progradation and shallowing during this time caused the local extinction and dissolution of many of the calcareous benthic foraminiferal taxa of the Belfast Mudstone Formation. [Copyright &y& Elsevier]

Abstract Advance directives (ADs) are rarely avail­able in Australia to guide management but may become more important as our population ages. The present study aimed to determine patient knowledge, perception and ownership rates of ADs and the factors that impact upon these variables. A cross-sectional survey of emergency department patients was undertaken. The main outcome measures were: (i) prior discussion about the extent of medical treatment and ADs, (ii) knowledge and perceptions of ADs, (iii) present AD ownership rates and (iv) likelihood of future AD ownership. Generalized linear models were used for analysis. Four hundred and three patients were enrolled. The mean age of patients was 73 years and 239 (59.3%) were male. Two hundred and forty patients (59.6%) had discussed the extent of treatment. Only 81 patients (20.1%) had discussed the use of an AD. One hundred and thirty-seven patients (34.0%) knew of one type of AD and 333 patients (82.6%) thought some ADs were a good idea. Only 32 patients (7.9%) owned an AD, although 276 (68.5%) would consider owning one. The main reason for never obtaining an AD was ‘always wanting full treatment’ (93 patients, 23.1%). Level of education was the only characteristic that impacted significantly upon an outcome measure. Patients with a higher level of education were more likely to have known and spoken about ADs, to own an AD and to consider owning one. AD knowledge and ownership rates were low. However, most patients perceive them favourably and many would consider owning one. Intervention strategies to improve AD awareness are indicated. This may empower patients to more effectively participate in their own advance care planning. (Intern Med J 2003; 33: 586−592) [ABSTRACT FROM AUTHOR]

Aeromagnetic and field data suggest that meta-igneous rocks exposed on the south coast of central Victoria at Waratah Bay, Phillip Island, Barrabool Hills and inland near Licola, are continuous—beneath Bass Strait—with Proterozoic/Cambrian igneous rocks in King Island and Tasmania. This correlation is supported by a pre-Early Ordovician unconformity above gabbro protomylonite at Waratah Bay, age equivalent to the Tasmanian Tyennan unconformity. Cambrian volcanics at Licola and unusual features of the Melbourne Zone sequence indicate that Tyennan continental crust extends north as basement to the central Victorian portion of the Lachlan Fold Belt. In contrast, adjacent parts of the Lachlan Fold Belt in Victoria contain conformable sea-floor sequences that span the Early Cambrian to Late Ordovician, with no evidence of either Cambrian deformation or underlying continental basement. The block of Tyennan continental crust beneath central Victoria—the Selwyn Block—is fundamentally different, and has influenced temporal and spatial patterns of sedimentation, deformation, metamorphism and plutonism. Palaeogeographical reconstructions suggest that the block was a submarine plateau that lay outboard of the Australian craton, upon which a condensed Ordovician sequence was deposited. The sequence above the Selwyn Block unconformity at Waratah Bay is similar to widespread post-Tyennan sediments in western Tasmania. During Late Ordovician and Early Silurian deformation, the Selwyn Block protected much of the overlying sedimentary sequence. Instead, shortening was focused into the Stawell and Bendigo Zones to the west. These zones were sandwiched between the Selwyn Block and the Australian craton in a ‘vice’ scenario reminiscent of some Appalachian orogenic events. The region above the Selwyn Block was downwarped adjacent to the overthrust Bendigo Zone as a foreland deep, into which a conformable clastic wedge of sediment was... [ABSTRACT FROM AUTHOR]

The article discuses the testing of direct acting antiviral agents purchased overseas such as daclatasvir, sofosbuvir and ledipasvir. It examines the necessary precautions needed for the protection of patients. It featured the case of a 70-year-old man with Child Pugh A cirrhosis secondaary to hepatitis C genotype after acquiring sofosbuvir tablets from Egypt for his 16 weeks of therapy.

The article presents an Australian randomised controlled trial which looks into the significant role played by a validated fraction of exhaled nitric oxide (FENO) in the management of asthma exacerbations during pregnancy. The trial discovers that there is a lower exacerbation rate in the FENO group compared to the control group. However, researchers call for further study on the application of the algorithm in other clinical settings.

During the Pliocene the global climate fluctuated markedly with the expansion and contraction of the Northern and Southern Hemisphere ice sheets. The signals of this change are well preserved in the thick (up to 1 km) Seaspray Group cool-water carbonate sediments in the Gippsland region and associated thin terrestrial deposits in southeastern Australia. This study uses seismic, facies, foraminiferal proxy data and palaeobotanical data to chart the Pliocene climate and environmental change in the marine and terrestrial realms of southeastern Australia. Complex submarine canyoning occurred at the shelf/upper bathyal transition during the Pliocene in Gippsland. Low-energy pelagic marl (wackestone/packstone) characterise canyon and inter-canyon environments in the earliest Pliocene, depositing plankton oozes with interbedded calciturbidites. From upper Early Pliocene to Late Pliocene time high-energy limestone (grainstone) facies infilled these submarine canyons associated with progradation of the succession from outer to middle shelf palaeoenvironments. Plankton proxy data suggest cool conditions in the basal part of Early Pliocene. Relatively stable warmer marine conditions prevailed throughout most of the Early Pliocene, corresponding to a period of globally low δ18O values in the oceans associated with minor Antarctic ice sheet expansion. From middle to Late Pliocene time marked fluctuations in the abundance of cool and warmer water plankton taxa occurred, corresponding to a time of global marine δ18O fluctuations and generally heavier δ18O values associated with the expansion of the Antarctic ice and Northern Hemisphere ice sheets. Upwelling is interpreted to have occurred throughout much of the warmer Early Pliocene, caused by a more northerly (compared to today) positioned and weaker Subtropical Front. Upwelling was prevalent in the outer shelf to upper slope facies at the ‘palaeo’ Bass Canyon and the Subtropical Front migrated northwards to Gippsland during Late Pliocene glacial periods. Terrestrial palaeobotanical records indicate a shift from widespread Araucarian forests and rainforest, including ‘tropical’ taxa now extinct in the region, to a landscape by the end of the Late Pliocene similar to that of the present day with a mosaic of Eucalyptus–Acacia–Casuarinaceae sclerophyllous forests and open vegetation, with local areas of Nothofagus-dominated cool temperate rainforests. Palaeobotanical proxy data indicate that regional climate oscillated between warm–wet and cool–dry phases, with an overall cooling–drying trend through the Pliocene. Earliest Pliocene climates in southeast Australia were warm–wet with a summer rainfall peak (mean annual temperature, MAT, 2–4°C higher than present, mean annual precipitation, MAP, 50–70% higher than present), whereas terminal Late Pliocene climates were drier–cooler with a winter rainfall peak (MAT 0–2°C higher than present, MAP 0–30% higher than present). [Copyright &y& Elsevier]

Commensal relationships between wild plants and their dispersers play a key ecological and evolutionary role in community structure and function. While non-human dispersers are often considered critical to plant recruitment, human dispersers have received much less attention, especially when it comes to non-domesticated plants. Australia, as a continent historically characterized by economies reliant on non-domesticated plants, is thus a key system for exploring the ecological role of people as seed dispersers in the absence of agriculture. Here, we utilize a controlled observation research design, employing ecological surveys and ethnographic observations to examine how seed dispersal and landscape burning by Martu Aboriginal people affects the distribution of three preferred plants and one (edible, but non-preferred) control species. Using an information theoretic approach, we find that the three preferred plants show evidence of human dispersal, with the strongest evidence supporting anthropogenic dispersal for the wild bush tomato, Solanum diversiflorum., (© 2024. The Author(s).)

Introduction: Contrast-enhanced mammography (CEM) and MRI detect 'contrast-only' lesions (COLs) occult on standard breast imaging (ultrasound and conventional mammography). Until recently, MRI was the only reliable method of biopsy. This study presents the first Australian experience with CEM-guided biopsy (CEMBx) and the lessons learnt., Methods: A prospective audit of the first 15 consecutive patients who underwent CEMBx for COLs was performed. Indications for contrast imaging, patient and lesion characteristics, procedural details, radiation dose and pathology data were collected., Results: The 15 women were aged 37-81 years (mean 59 years). Indications for contrast imaging were problem solving (n = 3), moderate risk screening (n = 2), cancer staging (n = 9) and symptoms (n = 1). The COLs were non-mass (n = 14), mass (n = 1) and an enhancing asymmetry (n = 1). For one patient, two lesions were sampled during the same event. All lesions enhanced and were successfully sampled followed by marker clip insertion. Most biopsies (87.5%) were performed with the breast in cranio-caudal compression using a horizontal approach. Procedural duration ranged from 13 to 33 min (mean 22 min). Radiation dose was similar to standard stereotactic biopsy. Post-biopsy hematomas occurred in three patients, none required intervention. Clip displacement occurred in three cases. Core biopsy histopathology results were benign (n = 8), malignant (n = 7) and a borderline breast lesion (BBL) (n = 1). Patient satisfaction rates were high. Imaging follow-up is ongoing., Conclusions: CEMBx is a quick, safe and reliable alternative to MRIBx to sample COLs., (© 2024 The Authors. Journal of Medical Imaging and Radiation Oncology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Radiologists.)

Background: Digital breast tomosynthesis (DBT) for breast cancer screening has been shown in international trials to increase cancer detection compared with mammography; however, results have varied across screening settings, and currently there is limited and conflicting evidence on interval cancer rates (a surrogate for screening effectiveness). Australian pilot data also indicated substantially longer screen-reading time for DBT posing a barrier for adoption. There is a critical need for evidence on DBT to inform its role in Australia, including evaluation of potentially more feasible models of implementation, and quantification of screening outcomes by breast density which has global relevance., Methods: This study is a prospective trial embedded in population-based Australian screening services (Maroondah BreastScreen, Eastern Health, Victoria) comparing hybrid screening comprising DBT (mediolateral oblique view) and digital mammography (cranio-caudal view) with standard mammography screening in a concurrent group attending another screening site. All eligible women aged ≥40 years attending the Maroondah service for routine screening will be enrolled (unless they do not provide verbal consent and opt-out of hybrid screening; are unable to provide consent; or where a 'pushback' image on hybrid DBT cannot be obtained). Each arm will enrol 20,000 women. The primary outcomes are cancer detection rate (per 1000 screens) and recall rate (percentage). Secondary outcomes include 'opt-out' rate; cohort characteristics; cancer characteristics; assessment outcomes; screen-reading time; and interval cancer rate at 24-month follow-up. Automated volumetric breast density will be measured to allow stratification of outcomes by mammographic density. Stratification by age and screening round will also be undertaken. An interim analysis will be undertaken after the first 5000 screens in the intervention group., Discussion: This is the first Australian prospective trial comparing hybrid DBT/mammography with standard mammography screening that is powered to show differences in cancer detection. Findings will inform future implementation of DBT in screening programs world-wide and provide evidence on whether DBT should be adopted in the broader BreastScreen program in Australia or in subgroups of screening participants., Trial Registration: The trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR, ACTRN12623001144606, https://www.anzctr.org.au/). Registration will be updated to reflect trial progress and protocol amendments., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

An automated system of DNA profile processing (termed a 'lights-out' workflow) was trialled for no-suspect cases over a three-month period at Forensic Science SA (FSSA). The lights-out workflow utilised automated DNA profile reading using the neural network reading feature in FaSTR™ DNA with no analytical threshold. The profile information from FaSTR™ DNA was then processed in STRmix™ using a top-down analysis and automatically compared to a de-identified South Australian searchable DNA database. Computer scripts were used to generate link reports and upload reports and these were compared to the links and uploads that were obtained for the cases during their standard processing within the laboratory. The results of the lights-out workflow was an increase in both uploads and links compared to the standard workflow, with minimal adventitious links or erroneous uploads. Overall, the proof-of-concept study shows the potential for using automated DNA profile reading and top-down analysis to improve workflow efficiency in a no-suspect workflow., Competing Interests: Declaration of Competing Interest One of the authors of this paper is a developer of the software STRmix™, which was used to produce the reported results. The developers of STRmix are public servants and do not financially benefit from the sales or use of the software., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Falls prevention interventions are effective for community dwelling older adults however, the same cannot be said for older adults living in long-term care (LTC). The Staying UpRight (SUp) randomized controlled trial was designed to test the effectiveness of a progressive strength and balance group exercise program delivered to LTC residents. This paper explores the factors impacting LTC providers' decisions to continue the program on completion of the funded trial period., Methods: A qualitative study using an Interpretive Description approach. Semi-structured interviews and focus groups were conducted with 15 LTC staff involved in the randomized controlled trial. Data were analysed using conventional content analysis., Results: Practice change occurred following participation in the trial with some facilities starting exercise groups, some increasing the number of exercise groups offered and physical therapists selecting elements of the program to adopt into their practice. Decisions about continuing with SUp as designed were constrained by organizational decisions regarding funding and resources. Three factors were identified which informed decision-making: business models and philosophies, requirements for evidence, and valuing physical therapy., Conclusions: Managers and facilitators adapted SUp by selecting and delivering components of the program in response to the changes they had observed in participating residents. However, our findings highlight that while SUp was valued, the tight financial environment created by the current funding model in New Zealand did not support funding physical therapist delivered falls prevention exercise programs in LTC. This study may provide policy makers with important information on changes needed to support falls prevention service delivery in LTC., Trial Registration: This study is a sub-study of a randomized controlled trial which was registered to the Australian New Zealand Clinical Trials Registry ACTRN12618001827224 on 09/11/2018. Universal trial number U1111-1217-7148., (© 2022. The Author(s).)

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., (© 2022 The Authors. Journal of Medical Imaging and Radiation Oncology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Radiologists.)

Aims: Clozapine is licensed for treatment-resistant psychosis and remains underutilised. This may berelated to the stringent haematological monitoring requirements that are mandatory in most countries. We aimed to compare guidelines internationally and develop a novel Stringency Index. We hypothesised that the most stringent countries would have increased healthcare costs and reduced prescription rates., Method: We conducted a literature review and survey of guidelines internationally. Guideline identification involved a literature review and consultation with clinical academics. We focused on the haematological monitoring parameters, frequency and thresholds for discontinuation and rechallenge after suspected clozapine-induced neutropenia. In addition, indicators reflecting monitoring guideline stringency were scored and visualised using a choropleth map. We developed a Stringency Index with an international panel of clozapine experts, through a modified-Delphi-survey. The Stringency Index was compared to health expenditure per-capita and clozapine prescription per 100 000 persons., Results: One hundred twocountries were included, from Europe ( n = 35), Asia ( n = 24), Africa ( n = 20), South America ( n = 11), North America ( n = 7) and Oceania and Australia ( n = 5). Guidelines differed in frequency of haematological monitoring and discontinuation thresholds. Overall, 5% of included countries had explicit guidelines for clozapine-rechallenge and 40% explicitly prohibited clozapine-rechallenge. Furthermore, 7% of included countries had modified discontinuation thresholds for benign ethnic neutropenia. None of the guidelines specified how long haematological monitoring should continue. The most stringent guidelines were in Europe, and the least stringent were in Africa and South America. There was a positive association ( r = 0.43, p < 0.001) between a country's Stringency Index and healthcare expenditure per capita., Conclusions: Recommendations on how haematological function should be monitored in patients treated with clozapine vary considerably between countries. It would be useful to standardise guidelines on haematological monitoring worldwide.

Objectives: This study examined the impact of the residential environment, measured by the Healthy Ageing/Vulnerable ENvironment (HAVEN) Index, on risk of mortality or entry into Permanent Residential Aged Care (PRAC)., Design: A retrospective cohort study using data from the Registry of Senior Australians (ROSA) was conducted. HAVEN Index values were matched to the ROSA by residential postcode., Study Setting and Participants: Older individuals living in metropolitan Adelaide and receiving their first eligibility assessment for aged care services between 2014 and 2016 (N = 16,944)., Main Outcome Measure: Time to death and entry into PRAC were the main outcomes., Results: A higher HAVEN Index value, which represents a favourable residential environment, was associated with a lower risk of mortality and delayed entry to PRAC. For every 0.1 unit increase in HAVEN Index value, the risk of mortality is 3% lower (adjusted hazard ratio [HR], 95% confidence interval [CI] = 0.97, 0.96-0.99) and the risk of entry to PRAC is 5% lower (adjusted subdistribution HR, 95%CI = 0.95, 0.94-0.97) in the first 2 years following aged care assessment. After 2 years, the HAVEN Index was not associated with the risk of transition to PRAC., Conclusion: Place-based health inequalities were identified in Australians seeking aged care services, demonstrating that a better understanding of local neighbourhoods may provide insight into addressing ageing inequalities. Spatial indexes, such as the HAVEN Index, are useful tools to identify areas where populations are more vulnerable to adverse health outcomes, informing responses to prioritise local improvements and health interventions to enable healthy ageing., (© The Author(s) 2022. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

DNA profiles are generated in forensic biology laboratories around the world. It is possible that these profiles are assessed by two independent people in order for the profiles to be 'read'. Recent work has been carried out to develop a neural network model to classify fluorescence in a DNA profile electropherogram and potentially replace one, or both human readers. The ability to use neural networks for this function has been programmed into the software FaSTR™ DNA, which has been validated for use in at least one laboratory in Australia. The work that previously developed a neural network system had a number of limitations, specifically it was computer intensive, did not make the best use of available data, and consequently the performance of this model was sub-optimal in some conditions (particularly for low-intensity peaks). In the current work a new neural network model is developed that makes various improvements on the old model, by using convolutional layers, a multi-head architecture and data augmentation. Results indicate that an improved performance can be expected for low-intensity profiles., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objectives: To determine the differences in information between prescribing guidelines and drug labeling, as well as to compare the approval of psychotropic medicines for major depression in pediatric patients ("pediatric depression") across countries. Methods: The recommendations of The Maudsley Prescribing Guidelines in Psychiatry (MPGP) for the treatment of pediatric depression (<18 years) were compared against the regulatory-approved drug-labeling documents from the United Kingdom, Australia, New Zealand, Canada, and the United States. The use of medicines outside of their regulatory approval is defined as off-label use, so differences between the drug labeling and MPGP were characterized according to unapproved age, indication, dosage, or route of administration. Information in the drug labeling was also compared across countries. Results: MPGP provides recommendations for 6 medicines for the treatment of pediatric depression, for which, 30 drug labeling were retrieved. Three of 30 drug labeling were consistent with MPGP recommendations (fluoxetine in the United Kingdom, fluoxetine and escitalopram in the United States). Differences in information between MPGP and the drug labeling were identified in 26 of 30 drug labeling analyzed, most often due to age (24/26) followed by indication (2/26). No differences pertaining to dosage or route of administration information were identified. The number of approved psychotropic medicines varied across the studied countries and we found cross-country discrepancies in information in the drug labeling. Conclusion: Significant differences in information exists between MPGP and the drug labeling for psychotropic medicines for pediatric depression, due to unapproved ages or indications. Additionally, approval information in the drug labeling are not consistent across countries. Further research into reasons for variability and impact on practice may be warranted.

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., (© 2020 Royal Australasian College of Surgeons.)

Importance: Quality of life (QoL) is a core outcome of occupational therapy, but it is decreased among autistic adolescents and adults. This is the first review of QoL from an occupational therapy standpoint., Objective: To identify self-reported QoL differences between autistic and nonautistic samples; investigate sex differences in QoL among autistic people; examine consistency in QoL among autistic people across age, intellectual disability (ID), and self- versus proxy-report method; and appraise occupational therapy-related interventions addressing QoL among autistic people., Data Sources: Articles published in peer-reviewed journals between 2010 and 2020, located through Academic Search Ultimate, PubMed, and OTseeker, along with the American Journal of Occupational Therapy, British Journal of Occupational Therapy, Canadian Journal of Occupational Therapy, and Australian Occupational Therapy Journal. Study Selection and Data Collection: Article samples consisted of at least 20% autistic females and used self-reported QoL measures. Qualitative research was excluded, as well as studies with participants younger than age 13 yr. Twenty-seven articles qualified (3 Level 1B, 13 Level 3B, and 11 Level 4)., Findings: Autistic adolescents and adults demonstrated decreased self-reported QoL compared with nonautistic peers across age and ID presence. One article compared sex differences in QoL among autistic people. Interventions improved QoL among autistic people., Conclusions and Relevance: Autistic adolescents and adults demonstrate decreased QoL in comparison with nonautistic peers. Questions remain related to sex differences in QoL among autistic people, an area for future research. Multiple evidence-based approaches to improve QoL in the autistic population are relevant to occupational therapy practice. What This Article Adds: Self-reported QoL among autistic adolescents and adults is clearly lower than among their nonautistic counterparts. This article provides information on multiple interventions related to occupational therapy to improve QoL among autistic people., (Copyright © 2021 by the American Occupational Therapy Association, Inc.)

Background: Australia's healthcare system is complex and fragmented which can create challenges in healthcare, particularly in rural and remote areas. Aboriginal people experience inequalities in healthcare treatment and outcomes. This study aimed to investigate barriers and enablers to accessing healthcare services for Aboriginal people living in regional and remote Australia., Methods: Semi-structured interviews were conducted with healthcare delivery staff and stakeholders recruited through snowball sampling. Three communities were selected for their high proportion of Aboriginal people and diverse regional and remote locations. Thematic analysis identified barriers and enablers., Results: Thirty-one interviews were conducted in the three communities ( n = 5 coastal, n = 13 remote, and n = 13 border) and six themes identified: (1) Improved coordination of healthcare services; (2) Better communication between services and patients; (3) Trust in services and cultural safety; (4) Importance of prioritizing health services by Aboriginal people; (5) Importance of reliable, affordable and sustainable services; (6) Distance and transport availability. These themes were often present as both barriers and enablers to healthcare access for Aboriginal people. They were also present across the healthcare system and within all three communities., Conclusions: This study describes a pathway to better healthcare outcomes for Aboriginal Australians by providing insights into ways to improve access.

Spirometry has been established as an essential test for diagnosing and monitoring respiratory disease, particularly asthma and COPD, as well as in occupational health surveillance. In Australia and New Zealand, there is currently no pathway for spirometry operators in community-based healthcare settings to demonstrate spirometry competence. The Australia and New Zealand Society of Respiratory Science (ANZSRS) has identified a need for developing a pathway for operators working in community-based practices in Australia and New Zealand to demonstrate spirometry competence and certification. Spirometry certification provides evidence to patients, clients, employers and organizations that an individual has participated in an assessment process that qualifies them to perform spirometry to current international spirometry standards set out by the American Thoracic Society and the European Respiratory Society (ATS/ERS). This document describes a competence assessment pathway that incorporates a portfolio and practical assessment. The completion of this pathway and the award of certification confer an individual is competent to perform spirometry for 3 years, after which re-certification is required. The adoption of this competency assessment and certification process by specialist organizations, and the commitment of operators performing spirometry to undergo this process, will enhance spirometry quality and practice in community-based healthcare settings., (© 2020 The Authors. Respirology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Respirology.)

Objectives: The aim of this study was to investigate whether perceptions of the neighbourhood environment (NE) and objective measures of the NE were associated with frailty in older adults., Methods: A cross-sectional study in Adelaide, Australia, recruited a sample of 115 community-dwelling adults aged ≥60 years. Respondents' perceptions of their NEs were assessed using the Neighbourhood Environment Walkability Scale (NEWS). An objective assessment of these NEWS survey questions was conducted using seven variables: residential density, land use mix diversity, street connectivity, accessibility, seasonal persistent green cover, road crash density and crime rate. Frailty was evaluated using the FRAIL (fatigue, resistance, ambulation, illnesses and loss of weight) scale. Multivariable linear regression analyses were employed to assess the associations between NEWS and frailty, and to assess the associations between objective neighbourhood variables and frailty., Results: Frail and pre-frail older adults were more likely to live in areas with lower residential density, lower density of road crashes, and higher accessibility than robust participants. Additionally, a poorer perception of the overall environment, worse land-use mix and accessibility and worse crime safety were associated with frailty and pre-frailty after adjustment of covariates and objective GIS variables., Discussion: Neighbourhood characteristics, both objective and perceived, are associated with frailty levels in older adults, and that strategies to tackle frailty must consider the impact of the neighbourhood environment., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: We aimed to identify the possible chain of events leading to fatal scuba diving incidents in Australia from 2001-2013 to inform appropriate countermeasures., Methods: The National Coronial Information System was searched to identify scuba diving-related deaths from 2001-2013, inclusive. Coronial findings, witness and police reports, medical histories and autopsies, toxicology and equipment reports were scrutinised. These were analysed for predisposing factors, triggers, disabling agents, disabling injuries and causes of death using a validated template., Results: There were 126 known scuba diving fatalities and 189 predisposing factors were identified, the major being health conditions (59; 47%), organisational/training/experience/skills issues (46; 37%), planning shortcomings (29; 23%) and equipment inadequacies (24; 19%). The 138 suspected triggers included environmental (68; 54%), exertion (23; 18%) and gas supply problems (15; 12%) among others. The 121 identified disabling agents included medical-related (48; 38%), ascent-related (21; 17%), poor buoyancy control (18; 14%), gas supply (17; 13%), environmental (13; 10%) and equipment (4; 3%). The main disabling injuries were asphyxia (37%), cardiac (25%) and cerebral arterial gas embolism/pulmonary barotrauma (15%)., Conclusions: Chronic medical conditions, predominantly cardiac-related, are a major contributor to diving incidents. Divers with such conditions and/or older divers should undergo thorough fitness-to-dive assessments. Appropriate local knowledge, planning and monitoring are important to minimise the potential for incidents triggered by adverse environmental conditions, most of which involve inexperienced divers. Chain of events analysis should increase understanding of diving incidents and has the potential to reduce morbidity and mortality in divers., (Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.)

Introduction: Near-peer learning, where peers from more senior year levels teach more junior peers is a popular teaching strategy in healthcare education. There is an emerging trend to utilise this teaching strategy in preparing students for Objective Structured Clinical Examinations (OSCEs) in the form of near-peer led formative OSCEs (NP-OSCE). However, there is little exploration of this teaching strategy in medical imaging education, nor how students perceive NP-OSCEs as beneficial to their learning. This study addresses this gap., Methods: Using a students as partners inquiry approach, 47 near-peer learners' (NPLs) and 6 near-peer teachers' (NPTs) perceptions of participating in a NP-OSCE were examined using an anonymous self-report questionnaire., Results: NPLs reported that participating in the immersive NP-OSCE helped their performance in the summative OSCE by helping with their preparedness; including understanding expectations, experiencing emotions and being able to identify gaps in their knowledge and skills, which they then used to direct their revision in a manner that demonstrated the development of skills in evaluative judgement. There were mixed findings regarding the impact the NP-OSCE had on NPLs' levels of anxiety. NPTs also found the NP-OSCE beneficial for identifying gaps in their own knowledge and skills, yet found taking on the role of an examiner challenging., Conclusion: Students perceive NP-OSCEs as a valuable learning activity that helps them prepare for their OSCEs by providing a student perspective of an authentic immersive learning experience. NP-OSCEs enable students to focus their revision and develop skills in evaluative judgement., Implications for Practice: Educators should consider including NP-OSCEs in their medical imaging curriculum as students perceive it as a valuable learning experience that assists them to prepare for their OSCE., (Copyright © 2019 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.)

Background and Objectives: Detailed information about the current and future geographic distribution of Australia's frail population provides critical evidence to inform policy, resource allocation and planning initiatives that aim to treat and reverse frailty. Frailty is associated with poor health outcomes, including disability and death. It is also characterised by increased health care usage and costs. Understanding the distribution and growth of frailty is important for planning and budgeting service provision and health interventions aimed to support the needs of Australia's growing ageing population. The objective of this research is to provide baseline mapping and area level population estimates of Australia's current and future frail and pre-frail populations., Research Design and Methods: Geospatial modelling was applied to national frailty prevalence rates to provide estimates of the size, distribution and potential growth of Australia's frail and pre-frail population., Results: It is estimated that in 2016 approximately 415,769 people living in Australia aged 65 years or more are frail and almost 1.7 million people are pre-frail. In future years, as the population ages, these figures will increase rapidly, reaching 609,306 frail and 2,248,977 pre-frail by 2027, if prevalence continues at current levels. The geographic distribution of this projected growth is not uniform and while the largest frail populations will continue to be located in the major cities, the fastest growth will be in the outer metropolitan, regional and remote areas., Discussion and Implications: The projected growth of frail populations in outer metropolitan, regional and remote areas may be reduced by targeting health interventions in these areas and improving access to support services. Frailty is a dynamic condition that is amenable to intervention. Reducing frailty will lead to benefits in wellbeing for older Australians in addition to reductions in health care costs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To compare performance and factors predicting failure to reach Ontario and Australian government time targets between a Canadian (Sunnybrook Hospital) and an Australian (Austin Health) academic tertiary-level hospitals in 2012, and to assess for change of factors and performance in 2016 between the same hospitals., Methods: This was a retrospective, observational study of patient administrative data in two calendar years. The main outcome measure was reaching Ontario and Australian ED time targets for admissions, high and low urgency discharges. Secondary outcomes were factors predicting failure to reach these targets., Results: Between 2012 and 2016, Sunnybrook and Austin experienced increased patient volume of 10.2% and 19.2%, respectively. Bed capacity decreased at Sunnybrook (-10.8%) but increased at the Austin (+30.3%). For both years, Austin failed to achieve the Australian time target, but succeeded for all Ontario targets except for low urgency discharges. Sunnybrook failed all targets irrespective of year. The top factors for failing Ontario ED length-of-stay targets for both hospitals in 2012 and 2016 were bed request greater than 6 h, access block greater than 1 h, use of cross-sectional imaging, consultation and waiting for the emergency physician greater than 2 h., Conclusion: Austin outperformed Sunnybrook for Ontario and Australian government time targets. Both hospitals failed the Australian targets. Factors predicting failure to achieve targets were different between hospitals, but were mainly clinical resources. Sunnybrook focussed on increasing human resources. Austin focussed on increasing human resources, observation unit and hospital beds. Intrinsic hospital characteristics and infrastructure influenced target success., (© 2019 Australasian College for Emergency Medicine.)

Objective: To identity differences between a general access index (Accessibility/ Remoteness Index of Australia; ARIA+) and a specific acute and aftercare cardiac services access index (Cardiac ARIA)., Research Design and Methods: Exploratory descriptive design. ARIA+ (2011) and Cardiac ARIA (2010) were compared using cross-tabulations (chi-square test for independence) and map visualisations. All Australian locations with ARIA+ and Cardiac ARIA values were included in the analysis (n = 20,223). The unit of analysis was Australian locations., Results: Of the 20,223 locations, 2757 (14% of total) had the highest level of acute cardiac access coupled with the highest level of general access. There were 1029 locations with the poorest access (5% of total). Approximately two thirds of locations in Australia were classed as having the highest level of cardiac aftercare. Locations in Major Cities, Inner Regional Australia, and Outer Regional Australia accounted for approximately 98% of this category. There were significant associations between ARIA+ and Cardiac ARIA acute (χ2 = 25250.73, df = 28, p<0.001, Cramer's V = 0.559, p<0.001) and Cardiac ARIA aftercare (χ2 = 17204.38, df = 16, Cramer's V = 0.461, p<0.001)., Conclusions: Although there were significant associations between the indices, ARIA+ and Cardiac ARIA are not interchangeable. Systematic differences were apparent which can be attributed largely to the underlying specificity of the Cardiac ARIA (a time critical index that uses distance to the service of interest) compared to general accessibility quantified by the ARIA+ model (an index that uses distance to population centre). It is where the differences are located geographically that have a tangible impact upon the communities in these locations-i.e. peri-urban areas of the major capital cities, and around the more remote regional centres. There is a strong case for specific access models to be developed and updated to assist with efficient deployment of resources and targeted service provision. The reasoning behind the differences highlighted will be generalisable to any comparison between general and service-specific access models., Competing Interests: The authors have declared that no competing interests exist.

We investigate the ability of the 31 SNP loci in the Global AIMs Nano set to distinguish self-declared Australian Aboriginal individuals from European, Oceanic, African, Native American and East Asian populations. Human evolution suggests that Australian Aboriginal individuals came to Australia approximately 50 000 years ago, during the time it made up part of Sahul. Since then the colonisation of Australia by Europeans has meant significant admixture within the Australian Aboriginal population. These two events present themselves in our study with the Aboriginal population creating a continuous genetic cline between the Oceanic and European groups. We also assigned the Aboriginal individuals into their traditional regional groups to determine whether there was any ability to distinguish these from each other. We found similar results to studies using other markers, namely that the more remote regions (that have been less affected by admixture) diverged from the rest. Overall, we found the ability of the GNano system to differentiate self-declared Australian Aboriginal individuals was reasonable but had limitations that need to be recognised if these assignments are applied to unknown individuals., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Epidemic thunderstorm asthma (ETSA) refers to large-scale acute bronchospasm events associated with thunderstorm. The most serious episode ever recorded occurred in Melbourne, Australia, in November 2016, where more than 3500 patients were treated in hospitals and 10 died. Previous work has been focused primarily on patient presentations to emergency departments. The prevalence of individuals with milder, non-emergent symptoms and who may be at risk of more serious episodes in the future has not previously been explored., Aim: To characterise the nature and extent of respiratory symptoms in healthcare workers during the Melbourne ETSA event., Methods: A survey was conducted among staff and volunteers across Eastern Health, distributed on the intranet homepage, by email and by word of mouth. Anonymous survey questions were constructed to assess prior and current diagnoses of relevance, symptoms, and demography., Results: There were 515 participants (80% female, n = 411) of approximately 9000 potential respondents (~6% response rate) who completed the survey; 132 (25.6%) had symptoms suggestive of asthma during the Melbourne ETSA event, the majority of whom did not seek professional medical help. Notably, of those with ETSA-like symptoms, only 58 (43.9%) had a history of asthma, while 97 (73.5%) had a history of allergic rhinitis. Specifically, a history of allergic rhinitis (OR 2.77, P < 0.001), a history of asthma (OR 1.67, P = 0.037) and being of self-identified Asian ethnicity (OR 3.24, P < 0.001) were all strong predictors of ETSA-like symptoms. Being predominantly indoors was not protective., Conclusions: Our study provides evidence of the presence of a large cohort of sufferers during the Melbourne ETSA event of 2016 that did not come to the attention of medical services, implying a potentially hidden and significant susceptible population. Further research should help clarify the true prevalence of vulnerability in the general population, with important public health implications., (© 2018 Royal Australasian College of Physicians.)

Objective: Understanding the origins of Aboriginal Australians is crucial in reconstructing the evolution and spread of Homo sapiens as evidence suggests they represent the descendants of the earliest group to leave Africa. This study analyzed a large sample of Y-chromosomes to answer questions relating to the migration routes of their ancestors, the age of Y-haplogroups, date of colonization, as well as the extent of male-specific variation., Methods: Knowledge of Y-chromosome variation among Aboriginal Australians is extremely limited. This study examined Y-SNP and Y-STR variation among 657 self-declared Aboriginal males from locations across the continent. 17 Y-STR loci and 47 Y-SNPs spanning the Y-chromosome phylogeny were typed in total., Results: The proportion of non-indigenous Y-chromosomes of assumed Eurasian origin was high, at 56%. Y lineages of indigenous Sahul origin belonged to haplogroups C-M130*(xM8,M38,M217,M347) (1%), C-M347 (19%), K-M526*(xM147,P308,P79,P261,P256,M231,M175,M45,P202) (12%), S-P308 (12%), and M-M186 (0.9%). Haplogroups C-M347, K-M526*, and S-P308 are Aboriginal Australian-specific. Dating of C-M347, K-M526*, and S-P308 indicates that all are at least 40,000 years old, confirming their long-term presence in Australia. Haplogroup C-M347 comprised at least three sub-haplogroups: C-DYS390.1del, C-M210, and the unresolved paragroup C-M347*(xDYS390.1del,M210)., Conclusions: There was some geographic structure to the Y-haplogroup variation, but most haplogroups were present throughout Australia. The age of the Australian-specific Y-haplogroups suggests New Guineans and Aboriginal Australians have been isolated for over 30,000 years, supporting findings based on mitochondrial DNA data. Our data support the hypothesis of more than one route (via New Guinea) for males entering Sahul some 50,000 years ago and give no support for colonization events during the Holocene, from either India or elsewhere., (© 2015 Wiley Periodicals, Inc.)

Objective: To determine the prevalence and nature of off-label and unlicenced (off-label/unlicenced) medicine administration to paediatric ED patients., Methods: We undertook a retrospective, observational study in six EDs (July 2011 to June 2012, inclusive). Patients, aged 0-17 years, who were administered a medicine in the ED were included. At each site, 50 eligible patients were randomly selected each month of the study period. An explicit review of each patient's records was undertaken. Medicines were classified as on or off-label/unlicenced according to categories of use approved by the Therapeutic Goods Administration., Results: There were 3343 patients enrolled (56.5% men, mean ± SD age 6.7 ± 5.4 years). Of the 6786 medicine doses administered, 2072 (30.5%, 95% CI 29.4-31.7%) were off-label/unlicenced. The off-label/unlicenced doses were administered to 1213 (36.3%, 95% CI 34.7-37.9%) patients. Patients administered an off-label/unlicenced medicine were younger than those who were not (P < 0.01). Salbutamol, ondansetron, ipratropium, fentanyl and oxycodone were the medicines most commonly administered off-label. In 910 (44.0%) cases, the dose/frequency was not approved; in 592 (28.6%), there was an unapproved indication for treatment; in 158 (7.6%), the medicine was administered via an unapproved route; in 154 (7.4%) the medicine was not approved for the weight or age; and in 74 (3.5%) an unlicenced product was administered. The remaining cases had combinations of reasons., Conclusions: Off-label/unlicenced medicine administration is common. A registry of commonly used off-label medicines is recommended in which the safety and efficacy of their off-label use have been demonstrated by published evidence., (© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

We report on successful amplification of DNA profiles from a single hair. Direct amplification was used on the root tip of both anagen and telogen hairs using a kit to amplify 15 STR loci. All 30 anagen hairs tested from five different people gave full DNA profiles after 29 cycles with no allelic drop-in or heterozygous imbalance. Six of the 30 telogen hairs tested resulted in a full DNA profile, and a further four telogen hair samples tested produced a DNA profile of five or more complete loci that could be up-loaded to the National DNA Database (Australia). A full DNA profile was also obtained from the shaft of an anagen hair. Current practice for many laboratories is that a single hair may not be subjected to DNA testing as there is little chance of success, hence this 100 % success rate from anagen hairs is a significant advancement. A full DNA profile was obtained from a 5 year-old single hair illustrating the success when using direct PCR rather than attempting an extraction prior to the amplification step. The process described deliberately uses current DNA profiling methods with no increase in cycle number, such that the methodology can be incorporated readily into operational practice. For the first time in the field of human identification, single hairs can be analyzed with confidence that a meaningful DNA profile will be generated and the data accepted by the criminal justice system.

Objective: Under- or overdosing of N-acetylcysteine (NAC), when used to treat paracetamol toxicity, is associated with significant morbidity and mortality. This study evaluated the effect of a weight-based dosing chart (WBDC) introduced to decrease NAC prescription errors., Methods: We undertook a pre- and post-intervention trial in a single ED. The intervention (the NAC WBDC) was introduced in January 2011 and publicised by posters and presentations at medical handovers and education sessions. ED staff were not aware that use of the WBDC was to be evaluated. Data were collected using a retrospective explicit medical record review by a single investigator. The study end-point was the proportion of NAC prescriptions with errors., Results: The 81 and 42 patients enrolled in the pre- and post-intervention periods, respectively, did not differ in age, sex or weight (P > 0.05). Post-intervention, there were significant reductions in prescription errors of fluid type/volume (50.6% vs 4.8%, P < 0.001), NAC dosage (13.6% vs 0.0%, P = 0.01) and infusion rate (11.1% vs 0.0%, P = 0.03). The proportion of prescriptions with any errors also decreased (56.8% vs 14.3%, P < 0.001). However, there were no improvements in the documentation of patient weight (65.4% vs 64.3%, respectively, P = 0.90) or the proportion of incomplete prescriptions (4.9% vs 11.9%, P = 0.16)., Conclusion: The introduction of a WBDC did not produce a clinically significant reduction in major NAC prescription error rates (as pre-defined in this study); however, there was a clear trend towards a reduction. The WBDC significantly reduced total and minor NAC prescription error rates., (© 2012 The Authors. EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

Y-chromosome specific STR profiling is increasingly used in forensic casework. However, the strong geographic clustering of Y haplogroups can lead to large differences in Y-STR haplotype frequencies between different ethnicities, which may have an impact on database composition in admixed populations. Aboriginal people have inhabited Australia for over 40,000 years and until ∼300 years ago they lived in almost complete isolation. Since the late 18th century Australia has experienced massive immigration, mainly from Europe, although in recent times from more widespread origins. This colonisation resulted in highly asymmetrical admixture between the immigrants and the indigenes. A State jurisdiction within Australia has created an Aboriginal Y-STR database in which assignment of ethnicity was by self-declaration. This criterion means that some males who identify culturally as members of a particular ethnic group may have a Y haplogroup characteristic of another ethnic group, as a result of admixture in their paternal line. As this may be frequent in Australia, an examination of the extent of genetic admixture within the database was performed. A Y haplogroup predictor program was first used to identify Y haplotypes that could be assigned to a European haplogroup. Of the 757 males (589 unique haplotypes), 445 (58.8%) were identified as European (354 haplotypes). The 312 non-assigned males (235 haplotypes) were then typed, in a hierarchical fashion, with a Y-SNP panel that detected the major Y haplogroups, C-S, as well as the Aboriginal subgroup of C, C4. Among these 96 males were found to have non-Aboriginal haplogroups. In total, ∼70% of Y chromosomes in the Aboriginal database could be classed as non-indigenous, with only 169 (129 unique haplotypes) or 22% of the total being associated with haplogroups denoting Aboriginal ancestry, C4 and K* or more correctly K(xL,M,N,O,P,Q,R,S). The relative frequencies of these indigenous haplogroups in South Australia (S.A.) were significantly different to those seen in samples from the Northern Territory and Western Australia. In S.A., K* (∼60%) has a much higher frequency than C4 (∼40%), and the subgroup of C4, C4(DYS390.1del), comprised only 17%. Clearly admixture in the paternal line is at high levels among males who identify themselves as Australian Aboriginals and this knowledge may have implications for the compilation and use of Y-STR databases in frequency estimates., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: To interrogate the National Coroners Information System (NCIS) to determine the recurrent themes among coroners' recommendations that aimed to increase the safety of ED care., Methods: This was a retrospective analysis of NCIS closed cases, from Queensland, New South Wales, Tasmania, Victoria, Australian Capital Territory, South Australia and North Territory, entered since its inception in 2000. The keyword 'emergency department' returned 1645 cases, of which 180 were found to be relevant. The primary outcomes were the number and nature of cases where recommendations for improvements in ED care had been made and the recurrent themes of these recommendations that could inform education initiatives., Results: Of the 180 cases, 108 (60.0%) were of deceased men and subject age ranged from 2 days to 91 years. The commonest causes of death were trauma (26.7%), infection (24.4%), cardiac events (15.0%) and poisoning (8.9%). No coronial recommendations were required in 19 cases. For the remainder, recommendation themes related to issues of risk management/medico-legal, diagnostic/therapeutic error, education, documentation/communication and re-presentation. The themes associated with the different doctor designations (consultant, registrar, resident/intern) were similar, although registrars and residents/interns tended towards more diagnostic/therapeutic errors. The themes associated with hospital type (referral, urban, regional/rural) were also similar. Although theme analysis is important, some individual cases were particularly instructive., Conclusion: The NCIS data theme analysis identifies important high-risk patients and presenting complaints. These should be incorporated into emergency physician training. EDs should review the coronial recommendations to ensure that, where possible, they have been adopted., (© 2012 The Authors. EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

Aim: We aimed to compare the precipitants of acute decompensated heart failure (ADHF) among patients admitted with diagnoses inclusive of ADHF (community patients) and patients admitted without ADHF but who developed it during their stay (hospital patients)., Methods: This was a prospective, analytical, observational study undertaken in the Austin Hospital, a major metropolitan teaching hospital (September 2008-February 2010). Consecutive patients admitted to a general medicine unit, and diagnosed and treated for ADHF were enrolled. The unit medical staff completed a specifically designed data collection document., Results: Three hundred and fifty-nine patients were enrolled (42.9% male, mean age 81.9 years). The community (n=312) and hospital (n=47) patient groups did not differ in age, gender, risk variables (living alone, cognitive impairment, multiple medications, compliance), cardiac failure medication use or cause of known heart failure (ischaemia, hypertension, valve dysfunction, 'other') (p>0.05). The ADHF precipitants comprised infection (39.8% patients), myocardial ischaemia (17.3%), tachyarrhythmia (16.2%), non-compliance with fluid and salt restriction (9.2%), non-compliance with medication (6.7%), renal failure (5.8%), medication reduction (5.0%), intravenous fluid complication (3.9%) and 'other' causes (13.9%). Significantly more hospital patients had their ADHF precipitated by intravenous fluid complications (25.5% versus 0.6%, p<0.001). Hospital patients also had a significantly greater death rate (25.5% versus 9.3%, p<0.01)., Conclusion: Acute decompensated heart failure precipitated in hospital is a dangerous condition with a high mortality. While infection and myocardial ischaemia are the common precipitants, complications of intravenous fluid use, an iatrogenic condition, may be considerable and are potentially avoidable., (Copyright © 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

The burden of cancer is growing, and the disease is becoming a major economic expenditure for all developed countries. In 2008, the worldwide cost of cancer due to premature death and disability (not including direct medical costs) was estimated to be US$895 billion. This is not simply due to an increase in absolute numbers, but also the rate of increase of expenditure on cancer. What are the drivers and solutions to the so-called cancer-cost curve in developed countries? How are we going to afford to deliver high quality and equitable care? Here, expert opinion from health-care professionals, policy makers, and cancer survivors has been gathered to address the barriers and solutions to delivering affordable cancer care. Although many of the drivers and themes are specific to a particular field-eg, the huge development costs for cancer medicines-there is strong concordance running through each contribution. Several drivers of cost, such as over-use, rapid expansion, and shortening life cycles of cancer technologies (such as medicines and imaging modalities), and the lack of suitable clinical research and integrated health economic studies, have converged with more defensive medical practice, a less informed regulatory system, a lack of evidence-based sociopolitical debate, and a declining degree of fairness for all patients with cancer. Urgent solutions range from re-engineering of the macroeconomic basis of cancer costs (eg, value-based approaches to bend the cost curve and allow cost-saving technologies), greater education of policy makers, and an informed and transparent regulatory system. A radical shift in cancer policy is also required. Political toleration of unfairness in access to affordable cancer treatment is unacceptable. The cancer profession and industry should take responsibility and not accept a substandard evidence base and an ethos of very small benefit at whatever cost; rather, we need delivery of fair prices and real value from new technologies., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Unlabelled: A neurological substrate for subjective well-being (SWB) has received little research attention., Purpose: This study was designed to conduct exploratory investigation into the neuroanatomical correlates of SWB, by monitoring the SWB of a head-injured population over a six-month period., Method: Seventy people with head injury (HI), aged 10-65, were studied. The SWB of each participant was measured, and computed tomography (CT) scans were analysed to obtain regional brain injury location (BIL)., Results: SWB was associated with BIL. However, the hypothesis that individuals with left frontal injury would report lower SWB was not supported. Instead, it was observed that participants with injury to their right frontal lobe reported higher SWB than individuals with injury to other regions of the brain., Conclusions: This study provides initial exploration into the neuroanatomical correlates of SWB.

Introduction: We aimed to determine factors that are significantly associated with a high level of patient satisfaction with their pain management., Methods: We undertook an observational study in a large metropolitan ED. Adult patients with a triage pain score of ≥4 (0-10 scale) were enrolled. Data collected included demographics, presenting complaint, pain scores every 30 min, whether nurse-initiated analgesia was administered, the nature of the pain relief administered, time to first dose of analgesia, elements of staff communication and whether 'adequate analgesia' was provided (defined as a decrease in pain score to <4 and a decrease from the triage pain score of ≥2). The primary end-point, determined at follow up within 48 h, was the level of satisfaction with pain management (6-point scale: very unsatisfied-very satisfied)., Results: One hundred and sixty-seven (82.7%) of 202 enrolled patients were followed up - mean (SD) age 46.4 (18.3) years, 75 (44.9%) men. Eighty-one (48.5%) patients were very satisfied with their pain management. Only two clinical variables were significantly associated with a high level of satisfaction: receipt of 'adequate analgesia' (as defined) and specific communication regarding pain management. Forty-four (58.7%) versus 37 (40.2%) patients who did/did not receive 'adequate analgesia', respectively, were very satisfied (difference 18.5%, 95% CI 2.3-34.7, P= 0.027). Seventy-seven (53.9%) and four (16.7%) patients who were/were not advised by ED staff that their pain management was important, respectively, were very satisfied (difference 37.2%, 95% CI 17.7-56.6, P= 0.002)., Conclusions: Our 'adequate analgesia' definition might provide a useful clinical target, which, combined with adequate communication, might help maximize patient satisfaction., (© 2011 The Authors. EMA © 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

Objective: To determine problems resulting from ED handover, deficiencies in current procedures and whether patient care or ED processes are adversely affected., Methods: A prospective observational study at three large metropolitan ED comprising three components: observation of handover sessions, 2 h post-handover surveys of the receiving doctors and a general survey of ED doctors., Results: The handovers of 914 patients were observed during 60 handover sessions in a 3-month period. Medical information, including presenting complaints, was handed over better than communication and disposition information. Seven hundred and seven (77.4%) of 914 potential post-handover interviews were undertaken. Most (88.3%) doctors thought the handover was 'adequate/good'. However, information was perceived as lacking in 109 (15.4%) handovers, especially details of management (35, 5.0%), investigations (33, 4.7%) and disposition (33, 4.7%). There was a significant difference in the perceived quality of handovers (1-5 scale where 5 = excellent) when all required information was handed over and when it was not (median scores 4.0 vs 3.0, respectively, P < 0.001). As a result of perceived inadequate handovers, the doctor/ED and patient were affected adversely in 62 (8.8%) and 33 (4.7%) cases, respectively, for example, repetition of assessment, delays in disposition and care. Fifty doctors completed the general survey. Most believed communications made to inpatient units, inaccurate/incomplete information and disorganization were problematic., Conclusion: Deficiencies in handover processes exist, especially in communication and disposition information. These affect doctors, the ED and patients adversely. Recommendations for improvement include guideline development to standardize handover processes, the greater use of information technology facilities, ongoing feedback to staff, and quality assurance and education activities.