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The fragmented nature of the medical device market limits our understanding of how particular sub-markets navigate the device development process. Despite the widespread use of transcutaneous neuromuscular electrical stimulation (NMES), its use for acquired dysarthria treatment has not been sufficiently explored. This study aims to provide a preliminary understanding of the stages involved in the development of NMES devices designed for neurorehabilitation. It also aims to investigate manufacturers' perceptions concerning factors that facilitate or impede its development and determine its applicability for acquired dysarthria. In-depth semi-structured online interviews were conducted with eight NMES device manufacturers located across Europe, North America and Oceania. The interviews were video-recorded, automatically transcribed, manually reviewed, and analysed using a qualitative content analysis. NMES device development for neurorehabilitation involves six complex phases with sequential and overlapping activities. Some emerging concepts were comparable to established medical device models, while others were specific to NMES. Its adaptability to different neurological disorders, the positive academia-industry collaborations, the industry's growth prospects and the promising global efforts for standardised regulations are all key facilitators for its development. However, financial, political, regulatory, and natural constraints emerged as barriers. Indications and challenges for the applicability of NMES for acquired dysarthria treatment were also discussed. The findings provide a foundation for further investigations on the NMES market sub-sector, particularly in the context of neurorehabilitation. The study also provides insights into the potential adoption of NMES for acquired dysarthria, which can serve as a reference for future research. The mapped neuromuscular electrical stimulation (NMES) development phases and processes can serve as a framework for new device development initiatives Opportunities for NMES development included its adaptability to neurological disorders, its growth prospects, academia-industry relationships and regulatory standardisation initiatives Financial, political, regulatory, and natural barriers were barriers for concern. From an anatomical and practical standpoint, it seems feasible to use NMES to treat several features of acquired dysarthria, however, clinicians' limited education on the use of electrical stimulation for neurorehabilitation may pose several constraints. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study is to understand the needs and interests of occupational medicine physicians (OMPs) as they transition to retirement. Methods: An electronic survey was distributed through member organizations in the United States (ACOEM), United Kingdom (SOM/FOM), India (IAOH), South Africa (SASOM), and Medichem. Results: Four hundred ninety-seven OMPs at various career stages responded, including 282 from the United States, 97 from the United Kingdom, 36 from India, 30 from South Africa, and 52 from other countries. Two hundred seventy-eight work full-time, 160 part-time, and 58 are not doing paid work. Approximately 60% serve as volunteers. Sixty percent have a written financial plan. Thirty-five percent are very comfortable with their retirement plans. After leaving full-time work, 85% plan to work part-time. There is a high level of interest in learning about opportunities for part-time work and volunteering. Conclusions: Occupational medicine physicians are very interested in learning more about compensated and uncompensated work in retirement. [ABSTRACT FROM AUTHOR]

The applicability of a UK‐validated genetic risk score (GRS) was assessed in 158 participants in the Fremantle Diabetes Study Phase II diagnosed between 20 and <40 years of age with type 1 or type 2 diabetes or latent autoimmune diabetes of adults (LADA). For type 1 versus type 2/LADA, the area under the receiver operating characteristic curve (AUC) was highest for serum C‐peptide (0.93) and lowest for the GRS (0.66). Adding age at diagnosis and body mass index to C‐peptide increased the AUC minimally (0.96). The GRS appears of modest diabetes diagnostic value in young Australians. [ABSTRACT FROM AUTHOR]

Objective: Orthostatic hypotension (OH) is associated with increased morbidity and there is limited research on the prevalence in the Australian ED population. The aim was to determine the prevalence of OH in an Australian ED population. Secondary outcomes included any associations of OH with symptoms, presenting complaints, patient demographics, or hospital admission, and the timing of OH findings. Methods: Patients presenting to a regional Australasian ED underwent orthostatic measurements at 1, 3 and 5 min of standing following 5 min of supine bed rest. OH was defined as a drop in systolic and/or diastolic blood pressure by ≥20 and ≥10 mmHg, respectively. Results: Of the 312 patients who were enrolled in the study, 69 (22.1%, 95% confidence interval 17.7–27.2%) had OH and 76.8% of cases were detected after 3 min of standing. There was evidence of difference in the prevalence of OH with age (P < 0.001). Similarly, there was evidence of a difference in supine systolic and diastolic blood pressure measurements (P = 0.012 and P < 0.001, respectively) between orthostatic and normotensive subjects. No association was found with OH and hospital admission, presenting complaints or comorbid medical illnesses. Conclusions: In this single Australian ED population, there was a high prevalence of OH (22.1%) with most cases detected within 3 min of standing. A higher‐powered study across multiple sites would better substantiate these findings. [ABSTRACT FROM AUTHOR]

The changing phenotype of coronarvirus disease 2019 (COVID‐19) may quickly render guideline‐recommended interventions obsolete. We developed a 40‐question clinician survey in consultation with the Australasian COVID‐19 Trial site investigators. The survey was designed to assess clinician perceptions of the current treatment strategies and future research priorities in the management of non‐critically ill patients admitted to hospital with SARS‐CoV‐2 infection. There were 84 complete responses from predominantly Australian and New Zealand clinicians. The perceived prevalence of patients with incidental COVID‐19, nosocomial infection, underlying illness exacerbated by COVID‐19, and/or immunocompromised status suggests new populations to target. The results highlighted clinician interest in antiviral therapies for future research in both immunocompetent and immunocompromised cohorts. These survey results underscore the need for ongoing surveillance of COVID‐19 disease phenotypes and clinician and patient priorities for future research. [ABSTRACT FROM AUTHOR]

The article offers information on disaster management, focusing on the increasing frequency of disasters and the need for improved disaster response expertise. Topics include the evolving landscape of complex humanitarian emergencies, the role of Australasian ED teams in disaster preparedness and response, and the challenges faced by ED clinicians in transitioning from normal operations to disaster leadership.

The rail system relies on the effective coordination of multiple disciplines and teams situated within an operational hierarchy to meet a single operational objective—the safe and timely movement of rail traffic. Power and status dispersals across these teams and the various roles within them impact interaction and communication. This study drew on the perceptions of network controllers, to identify organisational factors influencing power imbalances that generate authority gradients between network controllers and other team members. Network controllers (N = 55) across eight Australasian organisations engaged in interviews using the Scenario Invention Task Technique to explore perceptions of risk. Thematic analysis revealed relationships between teams were affected by: (1) the accountability mechanisms adopted by organisations; (2) the way power was vested in roles; and (3) the status attached to roles. This insight into organisational power hierarchies and the generation of authority gradients provides opportunities for understanding teamwork error. Practitioner summary: Communication is impaired by authority gradients across teams in rail and is a contributing factor in incidents occurring on the network. This paper explores the organisational influences on power hierarchies across teams from the perspective of the network controller, pointing to an adversarial culture, resulting in tribalism impeding team interactions. [ABSTRACT FROM AUTHOR]

Aim: To determine low‐density lipoprotein cholesterol (LDL‐C) screening frequency and levels, and factors associated with elevated LDL‐C, in Australasian youth with type 1 diabetes (T1D). Methods: Data were extracted from the Australasian Diabetes Data Network (ADDN), a prospective clinical quality registry, on all T1D healthcare visits attended by young people aged 16–25 years (with T1D duration of >1 year) between January 2011 and December 2020. The primary outcomes were elevated LDL‐C > 2.6 mmol/L (100 mg/dL) and threshold for treatment: >3.4 mmol/L (130 mg/dL), according to consensus guidelines. Multivariable Generalised Estimated Equations (GEE) were used to examine factors associated with elevated LDL‐C across all visits. Results: A cohort of 6338 young people (52.6% men) were identified, of whom 1603 (25.3%) had ≥1 LDL‐C measurement documented. At last measurement, mean age, age at T1D diagnosis and T1D duration were 18.3 ± 2.4, 8.8 ± 4.5 and 8.9 ± 4.8 years, respectively. LDL‐C was elevated in 737 (46.0%) and at the treatment threshold in 250 (15.6%). In multivariable GEE elevated LDL‐C continuously was associated with older age (OR = 0.07; 0.01–0.13, p = 0.02), female sex (OR = 0.31; 0.18–0.43; p < 0.001), higher HbA1c (OR = 0.04; 0.01–0.08; p = 0.01) and having an elevated BMI (OR = 0.17, 0.06–0.39, p < 0.001). Conclusions: LDL‐C screening and levels are suboptimal in this cohort, increasing future cardiovascular complication risk. There is an urgent need to understand how healthcare services can support improved screening and management of dyslipidaemia in this population. [ABSTRACT FROM AUTHOR]

Background: Magnetic Resonance Imaging is used for evaluation of bone in Gaucher disease (GD), but a widely available quantitative scoring method remains elusive. Aims: The study purpose was to assess the reproducibility of the LiverLab tool for assessing bone marrow fat fraction (FF) and determine whether it could differentiate GD patients from healthy subjects. Methods: Ten healthy volunteers and 18 GD patients were prospectively recruited. FF was calculated at L3, L4 and L5. GD patient bone marrow burden (BMB) score assessed by one observer. Inter and intra‐rater agreement assessed with Bland–Altman data plots. Differences in FF between healthy volunteers versus GD patients and between subjects treated versus not treated assessed using two‐sample t‐tests. In GD patients, the relationship between FF, BMB and glucosylsphingosine was determined using the Pearson's correlation coefficient. Results: Healthy volunteer mean FF was 0.36, standard deviation (SD) 0.10 (range 0.20–0.57). Intra and inter‐rater SD were both 0.02. GD patient mean FF was 0.40, SD 0.13 (range 0.09–0.57). No statistical difference was shown between healthy volunteers and GD patients (P = 0.447) or between GD patients whether on enzyme replacement therapy or not (P = 0.090). No significant correlation between mean FF and total BMB (r = −0.525, P = 0.253) or between FF and glucosylsphingosine levels (r = 0.287, P = 0.248). Conclusion: Excellent reproducibility of LiverLab FF measurements across studies and observers is comparable to Dixon quantitative chemical shift imaging (QCSI). Lack of statistical difference between GD patients and controls may be explained by limited patient numbers, active treatment or mild disease severity in untreated patients. [ABSTRACT FROM AUTHOR]

Background: Few Australasian autologous stem cell transplantation (ASCT) programmes perform ASCT in the private sector. Relatively little is known about ASCT outcomes in the private sector, which varies in care delivery models to the public system. Aims: To investigate transplantation activity and survival outcomes at Icon Cancer Centre's Brisbane‐based private clinical and laboratory ASCT programme over a 23‐year period. Methods: Retrospective, observational study of all adults who underwent ASCT at Icon between 1996 and 2018. Main outcome measures were transplant activity, overall survival (OS) and 100‐day and 1‐year transplant‐related mortality (TRM). Outcomes were benchmarked against the Australasian Bone Marrow Transplant Recipient Registry (ABMTRR). Results: Between 1996 and 2018, 1676 ASCT were performed in 1454 patients. From 2010 to 2018, ASCT performed at Icon contributed 40% of all South East Queensland ASCT. In the past 5 years, 21% of Icon's patients were aged ≥70 years, compared with 5% across Australasia. For the entire cohort, 100‐day and 1‐year TRM was 1.1% and 1.7%, respectively, while for those aged ≥70 years, it was 2.0% and 3.1%. For ASCT performed between 2014 and 2018, 100‐day and 1‐year TRM was 0.8% and 1.4%, which was half the TRM rates reported by the ABMTRR. The 10‐year post‐transplant OS at Icon was higher than the ABMTRR data, across all disease subtypes. Conclusion: We report excellent OS and low TRM, demonstrating the critical role of the private sector in the administration of this highly complex therapy. The Icon ASCT programme is the largest ASCT contributor in Queensland. It is inclusive of patients aged ≥70 years, demonstrating low and acceptable TRM. [ABSTRACT FROM AUTHOR]

Background: Cross‐border surrogacy and egg donor arrangements are an increasingly common means to family building. Establishing patterns of use has always been difficult in relation to Australian patients. Accurate data is stymied by lack of documentation of international third‐party reproductive care available to Australian authorities. When international travel bans came into effect, it is hypothesised that those planning to use cross‐border reproductive care had to rely significantly more on local in vitro fertilisation (IVF) clinics for services such as sperm freezing, embryo creation and gamete release procedures. Aim: To quantify and characterise the impact of the Covid‐19‐related travel ban on international and interstate gamete shipping by Australian IVF clinics. Materials and methods: Thirty‐one Australian and New Zealand IVF clinics were invited to provide de‐identified data on interstate and international gamete export applications from two 12 month time periods pre‐ and during Covid‐19‐related international travel lockdowns. Seven IVF organisations provided data on: patient age; type of gametes exported; destination country/state; and date gamete release approved. Results: Most gametes (78%) were shipped to another Australian IVF clinic and 22% internationally. Patient‐initiated shipping domestically and internationally both showed significant increases when comparing pre‐ and post‐Covid datasets. Of the 21 destination countries reported for international shipments, the US was the commonest (39%), followed by Ukraine (21%) and Canada (9%). Conclusions: The inability of involuntarily infertile patients to travel internationally, rather than halt cross‐border reproductive care, has led to a significant increase in the uptake of gamete shipping. The high proportion of internationally shipped gametes going to the US and Ukraine is likely a reflection of the availability of surrogates and donors and more amenable legal frameworks. [ABSTRACT FROM AUTHOR]

Primary snoring impacts a significant portion of the adult population and has the potential to significantly impair quality of life. The purpose of these guidelines is to provide evidence‐based recommendations to assist Australasian practitioners in the management of adult patients who present with primary snoring without significant obstructive sleep apnoea. The Timetable, Methodology and Standards by which this Position Statement has been established is outlined in the Appendix S1. The main recommendations are:Weight loss, and reduced alcohol consumption should be recommended, where appropriateIf clinical judgement dictates, benzodiazepine and opioid reduction or avoidance may be advisedPositional therapy should be considered in supine dominant snorersIn dentate patients, Mandibular advancement devices (MAD) should be recommended as a first line treatment following assessment by both an appropriate Dentist and Sleep physicianContinuous positive airway pressure (CPAP) devices may be recommended in patients with primary snoring in those already committed to their use or willing to trySurgical treatment of primary snoring by an appropriately credentialled surgeon may be advised and includes nasal (adjunctive), palatal and other interventions This position statement has been designed based on the best available current evidence and our combined expert clinical experience to facilitate the management of patients who present with primary snoring. It provides clinicians with a series of both non‐surgical and surgical options with the aim of achieving optimal symptom control and patient outcomes. This is the first such set of recommendations to be established within Australasia and has also been reviewed and endorsed by the Australasian Sleep Association. [ABSTRACT FROM AUTHOR]

Background: The goal of therapy in type 1 diabetes (T1D) is to achieve optimal glycaemic targets and reduce complications. Robust data representing glycaemic outcomes across the lifespan are lacking in Australasia. Aims: To examine contemporary glycaemic outcomes and rate of use of diabetes technologies in Australasian people with T1D. Methods: Cross‐sectional analysis of de‐identified data from 18 diabetes centres maintained in the Australasian Diabetes Data Network registry during 2019. Glycaemia was measured using glycated haemoglobin (HbA1c). The proportion of people with T1D achieving the international HbA1c target of <53 mmol/mol (7%) was calculated. Rates of continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) use were determined. Results: A total of 7988 individuals with T1D with 30 575 visits were recorded in the registry. The median (interquartile range) age was 15.3 (10.0) years and diabetes duration was 5.7 (9.4) years with 49% on multiple daily injections (MDI) and 36% on CSII. The mean HbA1c for the whole cohort was 66 mmol/mol (8.2%). HbA1c increased with age, from 60 mmol/mol (7.6%) in children <10 years, increasing during adolescence and peaking at 73 mmol/mol (8.8%) in the 20–25 years age group. The HbA1c target of <53 mmol/mol (7%) was met in 18% of children and 13% of adults. HbA1c was lower on CSII as compared with those on MDI (P < 0.0001). Conclusions: Only a minority of children and adults achieve the recommended glycaemic goals despite access to specialist care in major diabetes centres. There is a need to identify factors that improve glycaemic outcomes. [ABSTRACT FROM AUTHOR]

Aim: To explore the perceptions and practices of Australasian paediatric gastroenterologists in diagnosing coeliac disease (CD) before and during the COVID‐19 pandemic. Methods: Paediatric gastroenterologists in Australasia were invited via email to complete an anonymous online questionnaire over a 2‐week period in 2021. Results: The questionnaire was completed by 39 respondents: 33 from Australia and six from New Zealand (NZ) equating to a 66% response rate. Thirty‐four (87%) of the 39 respondents reported they currently practised non‐biopsy diagnosis of CD in eligible children, while the rest diagnosed CD using biopsy confirmation only. All NZ respondents practised non‐biopsy CD diagnosis. A majority of responders (76%) who practised non‐biopsy CD diagnosis followed the 2020 European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines. Twenty‐two (56%) respondents reported that they started using a non‐biopsy CD diagnosis protocol before the pandemic and did not change their practice during the pandemic, 10 (26%) started diagnosing non‐biopsy CD during the pandemic, 5 (13%) stated their practices of CD were not impacted by the pandemic and 2 (5%) did not respond on whether the pandemic changed their practice. Conclusion: The majority of Australasian gastroenterologist respondents reported they routinely utilised the 2020 ESPGHAN diagnostic criteria in eligible children; half of them started prior to the pandemic and another quarter started this approach due to the pandemic. A minority of practitioners routinely rely only on biopsy confirmation to diagnose CD. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The relationship between diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes and long-term glycemic control varies between studies. We aimed, firstly, to characterize the association of DKA and its severity with long-term HbA1c in a large contemporary cohort, and secondly, to identify other independent determinants of long-term HbA1c. RESEARCH DESIGN AND METHODS: Participants were 7,961 children and young adults diagnosed with type 1 diabetes by age 30 years from 2000 to 2019 and followed prospectively in the Australasian Diabetes Data Network (ADDN) until 31 December 2020. Linear mixed-effect models related variables to HbA1c. RESULTS: DKA at diagnosis was present in 2,647 participants (33.2%). Over a median 5.6 (interquartile range 3.2, 9.4) years of follow-up, participants with severe, but not moderate or mild, DKA at diagnosis had a higher mean HbA1c (+0.23%, 95% CI 0.11,0.28; [+2.5 mmol/mol, 95% CI 1.4,3.6]; P < 0.001) compared with those without DKA. Use of continuous subcutaneous insulin infusion (CSII) was independently associated with a lower HbA1c (−0.28%, 95% CI −0.31, −0.25; [−3.1 mmol/mol, 95% CI −3.4, −2.8]; P < 0.001) than multiple daily injections, and CSII use interacted with severe DKA to lower predicted HbA1c. Indigenous status was associated with higher HbA1c (+1.37%, 95% CI 1.15, 1.59; [+15.0 mmol/mol, 95% CI 12.6, 17.4]; P < 0.001), as was residing in postcodes of lower socioeconomic status (most vs. least disadvantaged quintile +0.43%, 95% CI 0.34, 0.52; [+4.7 mmol/mol, 95% CI 3.4, 5.6]; P < 0.001). CONCLUSIONS: Severe, but not mild or moderate, DKA at diagnosis was associated with a marginally higher HbA1c over time, an effect that was modified by use of CSII. Indigenous status and lower socioeconomic status were independently associated with higher long-term HbA1c. [ABSTRACT FROM AUTHOR]

At the time of the inauguration of the Royal Australasian College of Physicians in 1938, there were 232 Foundation Fellows, but only five were women. Those who wished to gain a postgraduate qualification for internal medicine or related specialties then sat for Membership of the new College. In the first decade (1938–1947), 250 gained Membership, but only 20 were women. These women lived in an era of professional and societal restrictions. Still, they all showed great determination and contributed significantly to their chosen fields, while many combined a busy practice with family life. They improved the path for those women who followed. Their stories, however, are rarely reported. [ABSTRACT FROM AUTHOR]

Objective: Paediatric status epilepticus (SE) has potential for long‐term sequelae. Existing data demonstrate delays to aspects of care. The objective of the present study was to examine the feasibility of collecting data on children with paediatric SE and describe current management strategies in pre‐hospital and in‐hospital settings. Methods: A pilot, prospective, observational cohort study of children 4 weeks to 16 years of age with SE, in four EDs in Australia. Clinical details including medications administered, duration of seizure and short‐term outcomes were collected. Follow up occurred by telephone at 1 month. Results: We enrolled 167 children with SE. Mean age was 5.4 years (standard deviation [SD] 4.1), and 81 (49%) male. Median seizure duration was 10 min (interquartile range 7–30). Midazolam was the first medication administered in 87/100 (87%) instances, mean dose of 0.21 mg/kg (SD 0.13). The dose of midazolam was adequate in 30 (35%), high (>0.2 mg/kg) in 44 (51%) and low (<0.1 mg/kg) in 13 (15%). For second‐line agents, levetiracetam was administered on 33/55 (60%) occasions, whereas phenytoin and phenobarbitone were administered on 11/55 (20%) occasions each. Mean dose of levetiracetam was 26.4 mg/kg (SD 13.5). One hundred and four (62%) patients were admitted to hospital, with 13 (8%) admitted to ICU and seven (4%) intubated. Conclusion: In children presenting with SE in Australia medical management differed from previous reports, with midazolam as the preferred benzodiazepine, and levetiracetam replacing phenytoin as the preferred second‐line agent. This pilot study indicates the feasibility of a paediatric SE registry and its utility to understand and optimise practice. [ABSTRACT FROM AUTHOR]

Background: Competing challenges in adolescence and young adulthood can distract from optimal type 1 diabetes (T1D) self‐management, and increase risks of premature morbidity and mortality. There are limited data mapping the glycemic control of people with T1D in this age group, across Australasia. Research Design and Methods: Clinical data were extracted from the Australasian Diabetes Data Network, a prospective clinical diabetes registry. Inclusion criteria were individuals with T1D aged 16–25 years at their last recorded T1D healthcare visit (from 1st January 2011 to 31st December 2020), with T1D duration of at least 1 year. Data were stratified by two last recorded T1D healthcare visit ranges, while generalized estimated equation (GEE) modeling was used to examine factors associated with HbA1c across visits during the 10 year period. Results: Data from 6329 young people (52.6% male) attending 24 diabetes centers across Australasia were included. At the last visit within the most recent 5 years, mean ± SD age was 18.5 ± 2.3 years, T1D duration was 8.8 ± 4.7 years and HbA1c was 8.8 ± 1.8% (72.2 ± 19.9 mmol/mol); only 12.3% had an HbA1c below the international target of <7.0% (53 mmol/mol). Across all T1D healthcare visits, in GEE modeling, higher HbA1c was associated with female sex (B = 0.20; 95% CI 0.12 to 0.29, p < 0.001), longer T1D duration (B = 0.04, 0.03 to 0.05, p < 0.001). Lower HbA1c was associated with attendance at a pediatric T1D healthcare setting (B = −0.33, −0.45 to −0.21, p < 0.001) and use of CSII versus BD/MDI therapy (B = −0.49, −0.59 to 0.40, p < 0.001). Conclusions: This Australasian study demonstrates widespread and persistent sub‐optimal glycemic control in young people with T1D, highlighting the urgent need to better understand how healthcare services can support improved glycemic control in this population. [ABSTRACT FROM AUTHOR]

Wherever there are people there will be a need for surgical care. Rural people have all kinds of problems and need all kinds of surgeons. The Royal Australasian College of Surgeons (RACS) Rural Health Equity Strategic Action Plan (RHESAP) was endorsed by Council in December 2020. The goal is to increase the rural surgical workforce and increase access to care, through providing motivated surgeons with the training they need to work where they are needed most. The Royal Australasian College of Surgeons Surgical Education and Training Programs (SET) aim to train generalist surgeons across all nine surgical disciplines. To increase the rural surgical workforce and increase access to care, we need to select for rural origin, rural medical school and rural work experience, provide all trainees with the opportunity for positive rural work exposure with an aligned rural curriculum, and we need to support surgeons already living and working in rural areas. In future, with persistent health inequity for underserved populations and the impacts of climate change, we anticipate an increasing need for a culturally and emotionally intelligent, broad‐scope surgical workforce, across all surgical disciplines, with the skills, confidence and motivation to work collaboratively and effectively in surgical teams, in areas of need and limited resource environments, including globally. [ABSTRACT FROM AUTHOR]

Objective: Emergency ultrasound (EUS) has become an integral part of emergency medicine, and the core pillars of governance, infrastructure, administration, education and quality assurance (QA) are vital for its quality and continued growth. We aimed to assess the status of these vital pillars among Australasian EDs. Methods: A survey among the clinical leads in ultrasound (CLUS) in Australasian EDs from November 2020 to April 2021. Results: We analysed a total of 98 responses from CLUS representing 98 EDs. Most CLUS (85%) held EUS qualifications (CCPU 57%, DDU 18%, other 9%) but 15% had none. Only 66% of CLUS had dedicated clinical support time, and a mere 5% had administrative personnel support. Up to three ultrasound machines in 62% of EDs, but only 26% of EDs had secured image archiving facilities. In‐house credentialing and the Australasian College for Emergency Medicine (ACEM) trainee special skills placement were available in 50% and 32% of EDs, respectively. Only 11% of EDs had regular EUS training for FACEMs, and only 66% of EDs had regular EUS education for emergency medicine trainees. Only 20 EDs had sonographer educators. Regarding EUS QA, only 33% of EDs provided formal EUS report, 23% of EDs conducted regular image reviews and 37% of EDs audited EUS performance. Only 35% of EDs had high‐level disinfection equipment, and 56% of EDs had formal transducer disinfection protocols. Conclusion: Despite ACEM recommendations for the practice of EUS, Australasian EDs still lack vital governance, administrative support, infrastructure, education and QA processes. Prompt actions such as ACEM mandating these recommendations are required to improve resource allocation by health services. [ABSTRACT FROM AUTHOR]

Background: The application of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) celiac disease (CeD) guidelines by pediatric gastroenterologists in Australia and New Zealand (Australasia) is unknown. Similarly, long-term management practices for patients with CeD are also unknown in this region. Aims: This study aimed to explore the perceptions and practices of Australasian pediatric gastroenterologists in diagnosing and managing patients with CeD. Methods: Australasian pediatric gastroenterologists and trainees were invited to complete an anonymous online survey over a 3-week period. Results: The survey was completed by 28 respondents, 24 from Australia and four from New Zealand. Tissue transglutaminase antibody IgA was the most frequently ordered initial serologic test. Fifteen (54%) respondents relied on duodenal biopsies for the confirmation of CeD, six (21%) followed the ESPGHAN guidelines and the remaining seven offered either biopsy confirmation or no-biopsy diagnosis according to the parents' wishes. Following diagnosis, five (18%) respondents discharged patients from care, three (11%) discharged patients after one follow-up visit, one (4%) reviewed patients for 12 months, six (21%) reviewed patients until celiac antibodies normalized and children were clinically asymptomatic, and 13 (46%) reviewed patients until transition to adult care. Conclusion: Tissue transglutaminase antibody IgA was the most common initial serologic test ordered by this group of Australasian pediatric gastroenterologists. Half of these physicians rely solely on duodenal biopsy for the confirmation of CeD diagnosis: a minority routinely use the ESPGHAN guidelines. Physicians reported a wide range of CeD follow-up practices. [ABSTRACT FROM AUTHOR]

In Australia, nicotine vaping products (NVPs) are only legally available to those with a prescription from a doctor. We investigated the proportion of people using NVPs to quit smoking who had a prescription, and whether this increased following regulatory changes in 2021 that strengthened the prescription requirement. Australian data from the 2018, 2020 and 2022 International Tobacco Control (ITC) Project Survey were analysed using GEE models with Poisson regressions to analyze differences between years. Data from participants who reported making a quit attempt in the previous two years and reported use of NVPs on their last quit attempt were included (480 observations across 418 individuals). Participants reported whether they had a prescription for NVPs on their last quit attempt. In 2022, they were also asked whether they sourced their prescription from their usual medical practice. Among those using NVPs for a quit attempt, use with a prescription increased significantly from 2020 to 2022 (IRR = 0.35 (0.17–0.73), p =.005) but was still low at 16.5 % (95 % CI 11.4–23.1). In 2022, among the small number who reported getting a prescription for NVPs, 27 % reported getting it from their regular practice; the remainder from a specialist online doctor service. There was a modest increase in obtaining a prescription among those who used NVPs for their last quit attempt after regulations were strengthened, however most NVP use for quitting was without a prescription. [ABSTRACT FROM AUTHOR]

• Limited research on non-injecting and licit drug use among people who inject drugs. • Diversity in types of drugs and routes of administration used in this population globally. • Licit drug use commonly reported; tobacco was the most widely used drug overall. • Need for increased availability of non-injection harm reduction interventions. A better understanding of global patterns of drug use among people who inject drugs can inform interventions to reduce harms related to different use profiles. This review aimed to comprehensively present the geographical variation in drug consumption patterns among this population. Systematic searches of peer reviewed (PsycINFO, Medline, Embase) and grey literature published from 2008–2022 were conducted. Data on recent (past year) and lifetime drug use among people who inject drugs were included. Data were extracted on use of heroin, amphetamines, cocaine, benzodiazepines, cannabis, alcohol, and tobacco; where possible, estimates were disaggregated by route of administration (injecting, non-injecting, smoking). National estimates were generated and, where possible, regional, and global estimates were derived through meta-analysis. Of 40,427 studies screened, 394 were included from 81 countries. Globally, an estimated 78.1 % (95 %CI:70.2–84.2) and 71.8 % (65.7–77.2) of people who inject drugs had recently used (via any route) and injected heroin, while an estimated 52.8 % (47.0–59.0) and 19.8 % (13.8–26.5) had recently used and injected amphetamines, respectively. Over 90 % reported recent tobacco use (93.5 % [90.8–95.3]) and recent alcohol use was 59.1 % (52.6–65.6). In Australasia recent heroin use was lowest (49.4 % [46.8–52.1]) while recent amphetamine injecting (64.0 % [60.8–67.1]) and recent use of cannabis (72.3 % [69.9–74.6]) were higher than in all other regions. Recent heroin use (86.1 % [78.3–91.4]) and non–injecting amphetamine use (43.3 % [38.4–48.3]) were highest in East and Southeast Asia. Recent amphetamine use (75.8 % [72.7–78.8]) and injecting heroin use (84.8 % (81.4–87.8) were highest in North America while non–injecting heroin use was highest in Western Europe (45.0 % [41.3–48.7]). There is considerable variation in types of drugs and routes of administration used among people who inject drugs. This variation needs to be considered in national and global treatment and harm reduction interventions to target the specific behaviours and harms associated with these regional profiles of use. [ABSTRACT FROM AUTHOR]

Introduction: The Australasian Resuscitation Outcomes Consortium (Aus-ROC) out-of-hospital cardiac arrest (OHCA) Epistry (Epidemiological Registry) now covers 100% of Australia and New Zealand (NZ). This study reports and compares the Utstein demographics, arrest characteristics and outcomes of OHCA patients across our region.Methods: We included all OHCA cases throughout 2019 as submitted to the Epistry by the eight Australian and two NZ emergency medical services (EMS). We calculated crude and age-standardised incidence rates and performed a national and EMS regional comparison.Results: We obtained data for 31,778 OHCA cases for 2019: 26,637 in Australia and 5,141 in NZ. Crude incidence was 107.9 per 100,000 person-years in Australia and 103.2/100,000 in NZ. Overall, the majority of OHCAs occurred in adults (96%), males (66%), private residences (76%), were unwitnessed (63%), of presumed medical aetiology (83%), and had an initial monitored rhythm of asystole (64%). In non-EMS-witnessed cases, 38% received bystander CPR and 2% received public defibrillation. Wide variation was seen between EMS regions for all OHCA demographics, arrest characteristics and outcomes. In patients who received an EMS-attempted resuscitation (13,664/31,778): 28% (range across EMS = 13.1% to 36.7%) had return of spontaneous circulation (ROSC) at hospital arrival and 13% (range across EMS = 9.9% to 20.7%) survived to hospital discharge/30-days. Survival in the Utstein comparator group (bystander-witnessed in shockable rhythm) varied across the EMS regions between 27.4% to 42.0%.Conclusion: OHCA across Australia and NZ has varied incidence, characteristics and survival. Understanding the variation in survival and modifiable predictors is key to informing strategies to improve outcomes. [ABSTRACT FROM AUTHOR]

Belief in conspiracies is not restricted to the fringe dwellers of society. International research suggests that such beliefs are quite common and that conspiracy theories may serve three basic psychological motives (i.e., epistemic, existential, and relational) for individuals. Yet, little is known about conspiracy theory awareness or belief in Australasia. We report the first large systematic investigation of system‐justifying motives using two nationally representative samples of Australians (n = 1011) and New Zealanders (n = 754). Our findings show that almost all are aware of local and international conspiracies, the majority endorse one or more, and that all three psychological motives consistently relate to conspiracy belief, but not to awareness. In a series of hierarchical multiple regressions, we find that relational (i.e., increased anomie and disillusionment with the government) and existential motives (i.e., less trust in others and increased religiosity) are uniquely and relatively more important than epistemic needs (i.e., decreased analytic thinking) as predictors of increased local and international conspiracy belief. Findings are discussed in terms of the importance of understanding conspiracy theories as an ideological belief system that may function to serve underlying psychological motives. [ABSTRACT FROM AUTHOR]

During the 1970s and 1980s, a number of predominantly white, working- and middle-class women from across Europe, Australasia, North America and elsewhere travelled across the globe, establishing short or longer-term residence in rural and urban separatist communities. This article explores the role of these women in disseminating post-68 feminist ideas and literature, as well as in the creation of transnational lesbian feminist networks. Drawing on oral history interviews and feminist literature, this work traces these networks and explores some of the central ideological concerns of rural women's lands and the ways in which these differed between specific locations in Australia, Wales and Denmark. [ABSTRACT FROM AUTHOR]

The goal of this position paper on ventilatory support at home for children is to provide expert consensus from Australia and New Zealand on optimal care for children requiring ventilatory support at home, both non-invasive and invasive. It was compiled by members of the Thoracic Society of Australia and New Zealand (TSANZ) and the Australasian Sleep Association (ASA). This document provides recommendations to support the development of improved services for Australian and New Zealand children who require long-term ventilatory support. Issues relevant to providers of equipment and areas of research need are highlighted. [ABSTRACT FROM AUTHOR]

Recurrent vulvovaginal candidiasis (RVVC) is a subtype of vulvovaginal candidiasis, with debilitating effects on physical and emotional well‐being affecting up to 10% of Australian women. Current evidence suggests that the induction and maintenance approach for RVVC is not particularly effective with post‐treatment relapse rates as high as 57%. Frequently accessed Australasian RVVC prescribing resources and guidelines were examined showing a variety of adaptations of current evidence‐based induction and maintenance therapies, making it difficult to select best treatment in clinical practice. The ways to introduce more clarity and consistency into these guidelines are outlined. [ABSTRACT FROM AUTHOR]

Background/Objectives: Vulval lichen sclerosus (VLS) is a chronic inflammatory skin condition predominantly affecting the anogenital region in women and children. To date, there is lack of agreement amongst experts on a severity scale to aid assessment, research and treatment stratification on VLS. Furthermore, literature on best practice for long‐term management of VLS is lacking. The aim of this consensus is to provide broad guidelines on the short and long‐term management of VLS. Methods: An initial focus group of Australasian experts in vulval dermatology developed a draft consensus statement for the management of VLS. Based on the results of the draft statement, a consensus panel of 22 Australasian experts, comprised of the initial and additional members, participated in an anonymous four‐stage eDelphi process. Round 1 involved generation and voting on statements from the draft consensus statement developed by the focus group. In Rounds 2, 3 & 4, panel members were presented formal feedback from previous rounds and asked to indicate their level of agreement. Consensus was reached if there was ≥70% agreement on the importance of an item in the 4 (agree) to 5 (strongly agree) range. Results: The expert panel, with a total of 504 collective years of experience in the field of VLS, reached consensus on a core set of 51 management statements related to diagnosis, severity, initial and long‐term management, follow‐up, and complications of VLS. Conclusions: This study has identified a set of management statements for VLS that may be useful in clinical practice in the Australasian population. [ABSTRACT FROM AUTHOR]

In the article, the authors discuss the 2020 Academy of Nutrition and Dietetics and Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for nutrition in chronic kidney disease (CKD) and its effects on the practice of Australasian dietitians. Other topics include the recommended conduct of routine nutrition screening, the Renal Nutrition Screening Tool (R-NST) from New Zealand, and the 7-Point Subjective Global Assessment nutrition assessment tool in dialysis cohorts.

Background: Refugee women are one of the most vulnerable groups in our society and exhibit some of the highest rates of chronic pain. However, the relationship between migration experiences and the development and perpetuation of chronic pain remains unclear. Aim/Objective: To identify the pre- and post-migration factors associated with chronic pain in refugee women living in Australia. Methods: A secondary analysis of a prospective longitudinal cohort was conducted using resettlement data from the 'Building a New Life in Australia', a study of humanitarian refugees living in Australia. The primary outcome was chronic pain and predictors include migration and resettlement factors collected between October 2013 to March 2018. Logistic regression modelling was used to examine the association between predictor variables and chronic pain. Findings: 310 refugee women aged between 18 to 75 years were included in this study. Almost half reported having chronic pain, 65% of whom also reported having a long-term disability. After controlling for potential covariates, the strongest predictors associated with chronic pain were age, Women at Risk visa category, general health, region of settlement and discrimination. Our final model showed that women who migrate on the Women at Risk visa had 2.3 times higher odds of reporting chronic pain than women migrating on any other visa category (95% CI 1.20, 4.24). Implications: This study has provided rich insights into the health of resettling refugee women, informing an evidence base for chronic pain assessment and guiding broader practice protocols, to support women resettling and dealing with chronic pain. [ABSTRACT FROM AUTHOR]

Objectives: To assess the clinical and demographic characteristics of children and adolescents across Australia and New Zealand (NZ) with type 2 diabetes. Methods: We performed a descriptive audit of data prospectively reported to the Australasian Diabetes Data Network (ADDN) registry. Data were collected from six tertiary pediatric diabetes centers across Australia (New South Wales, Queensland, South Australia, Western Australia, and Victoria) and NZ (Auckland). Children and adolescents diagnosed with type 2 diabetes aged ≤ 18 years with data reported to ADDN between 2012 and 2017 were included. Age, sex, ethnicity, HbA1c, blood pressure, BMI, waist circumference and lipid profile at first visit were assessed. Results: There were 269 cases of type 2 diabetes in youth reported to ADDN between 2012 and 2017. The most common ethnicities were Indigenous Australian in 56/243 (23%) and NZ Maori or Pacifica in 47 (19%). Median age at diagnosis was 13.7 years and 94% of participants were overweight or obese. Indigenous Australian and Maori/Pacifica children were younger at diagnosis compared with nonindigenous children: median 13.3 years (indigenous Australian); 13.1 years (Maori/Pacifica); 14.1 years (nonindigenous), p = 0.005. HbA1c was higher in indigenous Australian (9.4%) and Maori/Pacifica youth (7.8%) compared with nonindigenous (6.7%) p < 0.001. BMI‐SDS was higher in Maori/Pacifica youth (2.3) compared with indigenous Australian (2.1) and nonindigenous (2.2) p = 0.011. Conclusions: Indigenous Australian and Maori/Pacifica youth in ADDN were younger and had worse glycaemic control at diagnosis of type 2 diabetes. Our findings underscore the need to consider targeted and earlier screening in these "high‐risk" populations. [ABSTRACT FROM AUTHOR]

Background: Psoriasis is a chronic inflammatory disease affecting ~2–3% of the Australasian population. Therapeutic options include topical agents, phototherapy, systemic immunomodulators and biologic agents. Biologics present an acceptable short‐ and medium‐term safety profile, derived mainly from randomised controlled trials (RCTs) and, however, may not represent real‐world rates of adverse events (AEs). Methods: A retrospective, observational study of patients enrolled in The Australasian Psoriasis Registry from April 2008 to October 2018 was conducted. Data were collected from 104 sites in Australia and New Zealand. Patient characteristics, treatments and AE data were collected. AEs were classified by MedDRA System events. Results: 2094 patients were included (3765 patient‐treatments), comprising; 1110 phototherapy, 1280 systemic and 1375 biologic therapy patient‐treatments. Treatment arms were not mutually exclusive. The mean ± SD from date of diagnosis of psoriasis to commencement of biologic therapy was 8.9 ± 12.3 years. Methotrexate had the longest exposure time (3740.3 patient‐years), and ustekinumab had the longest median (95% CI) time on treatment, 4.3 years (2.2, 6.6). AE differences on biologic treatment were present between patients who would have been eligible or ineligible for RCTs. Approximately 29% of registry patients would have been excluded from clinical trials enrolment. Patients ineligible for RCTs had increased adjusted hazard ratios (95% CI) of: infections and infestations (2.3, 1.7–3.1; P < 0.001), cardiac (8.2, 3.5–25.6; P < 0.001), gastrointestinal (3.5, 1.52–8.0; P < 0.001), hepatobiliary (5.6 1.7–19.1; P < 0.001), psychiatric (4.7, 1.5–14.1; P = 0.006) and eye disorders (4.8 1.5–15.6; P = 0.008), compared to those eligible for RCTs. Incidence rates in the trial eligible patients were similar to those reported from RCT rates. Conclusions: This study establishes treatment modalities in use for severe psoriasis and the clinical rates of AEs associated with biologic therapy. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to explore clinician and parent opinions of risk limits on resuscitation and intensive care (IC) for extremely premature infants born at the margin of viability. Methods: Two anonymous on‐line surveys were conducted from August 2016 to January 2017. Survey participants were: (i) clinicians affiliated with neonatal intensive care units in Australia; and (ii) parents or individuals who expressed interest in premature babies through the Facebook page of Miracle Babies Foundation. Results: A total of 961 responses were received. Among 204 clinicians, 52% were neonatologists, 22% obstetricians, 20% neonatal intensive care unit nurses and 4% were midwives. Among 757 parents, 98% had a premature baby. Only 75% of clinicians responded to the risk limits questions. Median mortality risk above which they would not recommend resuscitation/IC was 70% (interquartile range (IQR) 50–80%); major disability risk in survivors 60% (IQR 50–75%); and composite risk of mortality and major disability 70% (IQR 50–80%). All parents answered the risk limit questions. The median mortality risk for not planning resuscitation was 90% (IQR 60–90%); major disability risk in survivors 50% (IQR 30–90%); and composite risk 90% (IQR 50–90%). Most clinicians (82%) stated that decisions should be guided by parent opinions if there are uncertainties. Parents had varying perception of previous counselling, and 57% stated that both their viewpoint and doctor's predicted risk influenced their decision‐making. Conclusions: Clinicians and parents had different views on mortality and major disability risks when deciding on resuscitation/neonatal IC treatment. When there was uncertainty, both agreed on working together. [ABSTRACT FROM AUTHOR]

Summary: Background: In the absence of rigorous evidence of cost‐effectiveness for early childhood obesity prevention interventions, the next‐best option may be for decision‐makers to consider the relevant costs of interventions when allocating resources. Objectives: This study aimed to estimate systematically the cost of five obesity prevention interventions in children aged 0‐2 years, undertaken in research settings in Australia and New Zealand. Methods: A standardised costing protocol informed the costing methodology, ensuring comparability of results across interventions. Micro‐costing was undertaken, with intervention costs defined from the funder perspective and valued in 2018 Australian dollars using unit costs from the trials or market rates. Results: Interventions varied widely in their resource use. The total cost per participant ranged from $80 for the CHAT SMS intervention arm (95% UI $77‐$82) to $1135 for the Healthy Beginnings intervention (95% UI $1059‐$1189). Time costs of personnel delivering interventions contributed >50% of total intervention costs for all included studies. Conclusions: An understanding of the costs associated with intervention delivery modes is important, alongside effectiveness. Telephone delivery may include unexpected costs associated with connection to intervention participants at convenient times. A SMS‐based intervention had the lowest delivery cost in this study. [ABSTRACT FROM AUTHOR]

The COVID19 pandemic has redefine the way nuclear medicine is practiced. The threat from COVID19 to health and to the nuclear medicine community is rapidly changing. During the acute phase of COVID19, there were significant direct and indirect impacts on nuclear medicine practice that have been previously detailed (1,2). It is useful to consider how COVID19 will shape nuclear medicine practice as we re-emerge from the acute phase (first wave) and prepare for both the second wave and practice after the COVID19 crisis. With the impact and the Government responses varying across the globe, there is some value in gleaning a global perspective. Here, a perspective from an Australian and New Zealand context is provided. [ABSTRACT FROM AUTHOR]

Objectives: To describe haemodynamic resuscitation practices in ED patients with suspected sepsis and hypotension. Methods: This was a prospective, multicentre, observational study conducted in 70 hospitals in Australia and New Zealand between September 2018 and January 2019. Consecutive adults presenting to the ED during a 30‐day period at each site, with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation, were eligible. Data included baseline demographics, clinical and laboratory variables and intravenous fluid volume administered, vasopressor administration at baseline and 6‐ and 24‐h post‐enrolment, time to antimicrobial administration, intensive care admission, organ support and in‐hospital mortality. Results: A total of 4477 patients were screened and 591 were included with a mean (standard deviation) age of 62 (19) years, Acute Physiology and Chronic Health Evaluation II score 15.2 (6.6) and a median (interquartile range) systolic blood pressure of 94 mmHg (87–100). Median time to first intravenous antimicrobials was 77 min (42–148). A vasopressor infusion was commenced within 24 h in 177 (30.2%) patients, with noradrenaline the most frequently used (n = 138, 78%). A median of 2000 mL (1500–3000) of intravenous fluids was administered prior to commencing vasopressors. The total volume of fluid administered from pre‐enrolment to 24 h was 4200 mL (3000–5661), with a range from 1000 to 12 200 mL. Two hundred and eighteen patients (37.1%) were admitted to an intensive care unit. Overall in‐hospital mortality was 6.2% (95% confidence interval 4.4–8.5%). Conclusion: Current resuscitation practice in patients with sepsis and hypotension varies widely and occupies the spectrum between a restricted volume/earlier vasopressor and liberal fluid/later vasopressor strategy. [ABSTRACT FROM AUTHOR]

Introduction: A survey investigated physician reported use, prescribing practices and adverse renal events of topical NSAIDs. Method: This survey was sent to members of the Australian Rheumatology Association and the Australian and New Zealand Society of Nephrology. Results: Sixty physicians responded, 55% (n = 33) were nephrologists; 45% (n = 27) rheumatologists. Nearly all (n = 56, 93.3%) had managed at least one patient using topical NSAIDs, including those with an eGFR <45 mL/min (n = 55, 91.7%). Concern was expressed that patients may use topical NSAIDs without the physician's knowledge. The majority (n = 40, 66.6%) have prescribed (or recommended) a topical NSAID, slightly less in patients with a reduced eGFR <45 mL/min (n = 36, 60.0%). Participants would advise topical NSAIDs for osteoarthritis and musculoskeletal pain, though be mindful to monitor the renal function and blood pressure. There was a variance in comments in advising use in CKD (eGFR <45 mL/min) from avoidance in those with an eGFR <30 mL/min to minimal concern. Most respondents (n = 55, 91.7%) had not encountered an acute kidney injury (AKI) suspected from topical NSAID use. Of the five that did, three were thought to be an adverse renovascular event and two were uncertain. All patients had an eGFR <45 mL/min, all had recovery f their renal function with NSAID cessation. Discussion Patients commonly use topical NSAIDs, often without the physician's knowledge. Most respondents would recommend their use in osteoarthritis and musculoskeletal pain, though with caution in CKD. While an AKI is uncommon due to topical NSAIDs, it may occur, especially in those with CKD. [ABSTRACT FROM AUTHOR]

Objectives: To describe the epidemiology, clinical practice and outcomes of paediatric ED intubation in Australia and New Zealand. Method: Prospectively collected airway management audit data from 43 EDs in Australia and New Zealand that was submitted to the Australia and New Zealand Emergency Department Airway Registry between 2010 and 2015. Results: Paediatric cases accounted for 4.94% (270/5463) of cases (median age = 3, interquartile range [IQR] = 2–9). A median of 5 (IQR = 2–9) intubations were reported per department per year. Most intubations were performed for medical indications (72.2%), including seizure (25.2%) and respiratory failure (15.2%). Patients were physiologically compromised prior to intubation with 69.5% comatose, 50.9% outside of the normal age‐adjusted range for respiratory rate, 15.9% hypoxic and 12.6% hypotensive. Complication rate was 33.3% and desaturation was the most common (18.5%). The ED mortality rate was 3.8%. First pass success (FPS) was 80% (95% CI 75.2–84.8). Infants less than 1 year of age had lower FPS, higher rates of difficult laryngoscopy and higher rates of desaturation than other age groups. Conclusion: Paediatric intubation in Australasian EDs is rare from a departmental and individual provider viewpoint. Success rates are similar to contemporary international registries. Complications are common and ongoing collaborative multicentre audit with resultant quality improvement is desirable to facilitate improved success and reduced complications. [ABSTRACT FROM AUTHOR]

Objective: Emergency medicine (EM) is an emerging profession with complex clinical and leadership demands. However, studies of leadership in EM are in their infancy. The present study makes a novel contribution to empirical research in this area by examining the leadership challenges faced by Australasian directors of emergency medicine (DEMs). Methods: An online Delphi study was conducted with 87 Australasian DEMs. To structure the process, participants were sorted into four panels reflecting their leadership experience and geographical location. Using a three‐phase Delphi process, participants were guided through the process of brainstorming leadership challenges, narrowing down these challenges, and ranking these challenges from most to least important. Results: Four leadership challenges were shared across all panels, regardless of experience and location; namely, administrative overload, overcrowding and access block, managing challenging colleagues and engaging with hospital executive. However, the low consensus achieved within and across panels highlights the complexity of leadership in EM and cautions against simplistic approaches to addressing leadership challenges. Conclusion: The recommendation for DEMs is that they need to engage in programmes which will support the development of the leadership and non‐clinical skills required to enable them to cope with responsibilities of hybrid role of physician‐leader. The development and delivery of specialised leadership programmes attuned to the hybridity of the director role and the complexity of hospitals is vital for ensuring high‐quality patient care and successful running of EDs. [ABSTRACT FROM AUTHOR]