Search

The world's coral reefs are under threat as climate change causes increases in frequency and severity of acute thermal stress. This is compounded by chronic pressures including rises in sea surface temperature, overfishing and decline in water quality. Monitoring to understand the recovery dynamics of corals is paramount to enable effective management of coral reefs. While detailed mechanistic models provide insight into reef recovery patterns, colony scale monitoring is not viable for reefs over a large geographical extent, such as the Great Barrier Reef (GBR). Consequently, aggregated coral cover data are utilised in practice and phenomenological analysis directly applicable to these monitoring programmes is essential for reef health reporting. These analyses are especially challenging for assessment of recovery potential of reefs reduced to very low coral cover (

Ocean warming is increasing the incidence, scale, and severity of global-scale coral bleaching and mortality, culminating in the third global coral bleaching event that occurred during record marine heatwaves of 2014-2017. While local effects of these events have been widely reported, the global implications remain unknown. Analysis of 15,066 reef surveys during 2014-2017 revealed that 80% of surveyed reefs experienced significant coral bleaching and 35% experienced significant coral mortality. The global extent of significant coral bleaching and mortality was assessed by extrapolating results from reef surveys using comprehensive remote-sensing data of regional heat stress. This model predicted that 51% of the world’s coral reefs suffered significant bleaching and 15% significant mortality, surpassing damage from any prior global bleaching event. These observations demonstrate that global warming’s widespread damage to coral reefs is accelerating and underscores the threat anthropogenic climate change poses for the irreversible transformation of these essential ecosystems.

Background: Clinical guidelines recommend that patients using inhaled corticosteroids should rinse their mouth following inhalation. There is however, a paucity of research regarding patient implementation of this recommendation and the impact it has on the occurrence of adverse effects. Objective: The aim of this study was to determine how well patients implement mouth rinsing after using inhaled corticosteroids in practice and their understanding of the rationale, information sources and the impact of mouth rinsing on adverse effects. Setting: Australians aged 18 years and over with a diagnosis of asthma and/or chronic obstructive pulmonary disease who were currently using an inhaled corticosteroid. Method: Participants were recruited via Facebook to complete an online survey. Main outcome measure: Implementation of a mouth rinse which aligned to current guideline recommendations. Results: Of 380 eligible responses, 30.5% of patients reported suboptimal mouth rinsing after using inhaled corticosteroids. Receiving advice on mouth rinsing from a healthcare professional increased the likelihood of correct implementation (P

To understand how environmental conditions and reproductive events affect coral energetic status, seasonal variations in lipid and fatty acid profiles of the common scleractinian coral, Acropora millepora, were studied from pre-spawning in November 2009 until post-spawning in November 2010 at Halfway Island (in the Keppel Island Group, Southern Great Barrier Reef, Australia). Seasonal chlorophyll levels, photosynthetically active radiation (PAR), rainfall and water temperature were major drivers of the overall coral lipid profile, and this was particularly pronounced in correlations with the important, high-energy lipid, triacylglycerol. This likely reflected changing food sources and feeding modes (i.e. phototrophy vs heterotrophy), which corresponds to the opportunistic feeding behaviour of corals. Water temperature was also a major influencer of the coral fatty acid profile. In particular, saturated fatty acids correlated positively with water temperature, while polyunsaturated fatty acids correlated negatively, reflecting cell membrane fluidity regulation, which is necessary for coral to tolerate changing temperatures. Spawning and maternal provisioning also proved to be a major driver of change in the coral lipid profile. The mass spawning events in spring for both 2009 and 2010 caused reductions in the important coral egg constituents: wax ester, triacylglycerol, phosphatidylcholine and fatty acid 10:0. Interestingly, lipid accumulation was significantly lower in the 2010 spawn compared to 2009, possibly due to lower PAR and chlorophyll levels, reflecting reduced photosynthetic activity and phytoplankton availability. Regardless, in 2010, resource provisioning to egg production was greater than in 2009, suggesting increased reproductive effort in the face of environmental stress. This study demonstrates the strong influence of opportunistic heterotrophy and autotrophy and maternal provisioning on the coral lipid profile. Such information is fundamental to understanding the environmental and biochemical processes underlying coral health and predicting how anomalous events and climate-driven changes will affect coral reef assemblages.

Background: Acute pain is common following surgery, with opioids frequently employed in its management. Studies indicate that commencing an opioid during a hospital admission increases the likelihood of long-term use. This study aimed to identify the prevalence of opioid persistence amongst opioid-naive patients following surgery as well as the indication for use. Methods: A retrospective review of patients who underwent a surgical procedure at the Royal Hobart Hospital, Tasmania, Australia, between August and September 2016 was undertaken. Patients were linked to the Tasmanian real-time prescription monitoring database to ascertain if they were subsequently dispensed a Schedule 8 opioid (morphine, codeine oxycodone, buprenorphine, hydromorphone, fentanyl, methadone, or tapentadol) and the indication for use. Results: Of the 3275 hospital admissions, 1015 opioid-naive patients were eligible for inclusion. Schedule 8 opioids were dispensed at or within 2 days of discharge in 41.7% of admissions. Thirty-nine (3.9%) patients received prescribed opioids 2-months post-discharge; 1.8% of the patients were approved by State Health to be prescribed Schedule 8 opioids regularly for a chronic condition at 6 months, and 1.3% received infrequent or one-off prescriptions for Schedule 8 opioids at 6 months. Thirteen (1.3%) patients continued Schedule 8 opioids for at least 6 months following their surgery, with the indication for treatment either related to the surgery or the condition which surgery was sought for. Conclusion: This study found that there was a low rate of Schedule 8 opioid persistence following surgery, indicating post-surgical pain is not a significant driver for persistent opioid use.

Seawater acidification from increasing CO2 is often enhanced in coastal waters due to elevated nutrients and sedimentation. Our understanding of the effects of ocean and coastal acidification on present-day ecosystems is limited. Here we use data from three independent large-scale reef monitoring programs to assess coral reef responses associated with changes in mean aragonite saturation state (Ωar ) in the Great Barrier Reef World Heritage Area (GBR). Spatial declines in mean Ωar are associated with monotonic declines in crustose coralline algae (up to 3.1-fold) and coral juvenile densities (1.3-fold), while non-calcifying macroalgae greatly increase (up to 3.2-fold), additionally to their natural changes across and along the GBR. These three key groups of organisms are important proxies for coral reef health. Our data suggest a tipping point at Ωar 3.5-3.6 for these coral reef health indicators. Suspended sediments acted as an additive stressor. The latter suggests that effective water quality management to reduce suspended sediments might locally and temporarily reduce the pressure from ocean acidification on these organisms.

Cumulative impacts assessments on marine ecosystems have been hindered by the difficulty of collecting environmental data and identifying drivers of community dynamics beyond local scales. On coral reefs, an additional challenge is to disentangle the relative influence of multiple drivers that operate at different stages of coral ontogeny. We integrated coral life history, population dynamics and spatially-explicit environmental drivers to assess the relative and cumulative impacts of multiple stressors across 2,300 km of the world’s largest coral reef ecosystem, Australia’s Great Barrier Reef (GBR). Using literature data, we characterized relationships between coral life history processes (reproduction, larval dispersal, recruitment, growth and mortality) and environmental variables. We then simulated coral demographics and stressor impacts at the organism (coral colony) level on >3,800 individual reefs linked by larval connectivity, and exposed to temporally- and spatially-realistic regimes of acute (crown-of-thorns starfish outbreaks, cyclones and mass coral bleaching) and chronic (water quality) stressors. Model simulations produced a credible reconstruction of recent (2008–2020) coral trajectories consistent with monitoring observations, while estimating the impacts of each stressor at reef and regional scales. Overall, corals declined by one third across the GBR, from an average ∼29% to ∼19% hard coral cover. By 2020, less than 20% of the GBR had coral cover higher than 30%. Global annual rates of coral mortality were driven by bleaching (48%) ahead of cyclones (41%) and starfish predation (11%). Beyond the reconstructed status and trends, the model enabled the emergence of complex interactions that compound the effects of multiple stressors while promoting a mechanistic understanding of coral cover dynamics. Drivers of coral cover growth were identified; notably, water quality (suspended sediments) was estimated to delay recovery for at least 25% of inshore reefs. Standardized rates of coral loss and recovery allowed the integration of all cumulative impacts to determine the equilibrium cover for each reef. This metric, combined with maps of impacts, recovery potential, water quality thresholds and reef state metrics, facilitates strategic spatial planning and resilience-based management across the GBR.

In the final article in this three‐part series, Angus Thompson completes his reflections on some of the differences in prescribing and medicines management between Australia and the UK, this time looking at formularies, the primary‐secondary care interface and repeat prescriptions.

In the second of three articles, Angus Thompson continues his reflections on the differences in prescribing and medicines management between the UK and Australia, this time looking at prescription costs, quantities and generics.

In the first in a series of three articles, Angus Thompson introduces his reflections on some of the differences in prescribing and medicines management between the UK and Australia.

Cumulative impacts assessments on marine ecosystems have been hindered by the difficulty of collecting environmental data and identifying drivers of community dynamics beyond local scales. On coral reefs, an additional challenge is to disentangle the relative influence of multiple drivers that operate at different stages of coral ontogeny. We integrated coral life history, population dynamics and spatially-explicit environmental drivers to assess the relative and cumulative impacts of multiple stressors across 2,300 km of the world’s largest coral reef ecosystem, Australia’s Great Barrier Reef (GBR). Using literature data, we characterized relationships between coral life history processes (reproduction, larval dispersal, recruitment, growth and mortality) and environmental variables. We then simulated coral demographics and stressor impacts at the organism (coral colony) level on >3,800 individual reefs linked by larval connectivity, and exposed to temporally- and spatially-realistic regimes of acute (crown-of-thorns starfish outbreaks, cyclones and mass coral bleaching) and chronic (water quality) stressors. Model simulations produced a credible reconstruction of recent (2008–2020) coral trajectories consistent with monitoring observations, while estimating the impacts of each stressor at reef and regional scales. Overall, corals declined by one third across the GBR, from an average ∼29% to ∼19% hard coral cover. By 2020, less than 20% of the GBR had coral cover higher than 30%. Global annual rates of coral mortality were driven by bleaching (48%) ahead of cyclones (41%) and starfish predation (11%). Beyond the reconstructed status and trends, the model enabled the emergence of complex interactions that compound the effects of multiple stressors while promoting a mechanistic understanding of coral cover dynamics. Drivers of coral cover growth were identified; notably, water quality (suspended sediments) was estimated to delay recovery for at least 25% of inshore reefs. Standardized rates of coral loss and recovery allowed the integration of all cumulative impacts to determine the equilibrium cover for each reef. This metric, combined with maps of impacts, recovery potential, water quality thresholds and reef state metrics, facilitates strategic spatial planning and resilience-based management across the GBR.

Ecosystem-based management on coral reefs has historically focussed on biodiversity conservation through the establishment of marine reserves, but it is increasingly recognised that a subset of species can be key to the maintenance of ecosystem processes and functioning. Specific provisions for these key taxa are essential to biodiversity conservation and resilience-based adaptive management. While a wealth of literature addresses ecosystem functioning on coral reefs, available information covers only a subset of specific taxa, ecological processes and environmental stressors. What is lacking is a comparative assessment across the diverse range of coral reef species to synthesise available knowledge to inform science and management. Here we employed expert elicitation coupled with a literature review to generate the first comprehensive assessment of 70 taxonomically diverse and functionally distinct coral reef species from microbes to top predators to summarise reef functioning. Although our synthesis is largely through the lens of the Great Barrier Reef, Australia, a particularly data-rich system, it is relevant to coral reefs in general. We use this assessment to evaluate which taxa drive processes that maintain a healthy reef and whether management of these taxa is considered a priority (i.e. are they vulnerable?) or is feasible (i.e. can they be managed?). Scientific certainty was scored to weight our recommendations, particularly when certainty was low. We use five case studies to highlight critical gaps in knowledge that limit our understanding of ecosystem functioning. To inform the development of novel management strategies and research objectives, we identify taxa that support positive interactions and enhance ecosystem performance, including those where these roles are currently underappreciated. We conclude that current initiatives effectively capture many priority taxa but that there is significant room to increase opportunities for underappreciated taxa in both science and management to maximally safeguard coral reef functioning.

Background Despite increasing interest in antimicrobial stewardship (AMS), little is known about the related practices and perceptions of community pharmacists. Objective To develop and validate a questionnaire to measure the current practices of, and barriers to community pharmacists’ participation in AMS. Setting Community pharmacists in Tasmania, Australia. Method A questionnaire to explore AMS knowledge, current practices and perceptions of community pharmacists was developed. It was designed after rigorous literature review, expert opinion, and feedback from a group of community pharmacists. A convenience sample of 140 Tasmanian community pharmacists was used for this study. Cronbach’s alpha and exploratory factor analysis (EFA) were used for reliability and validity. The questionnaire was hosted online, a link to which was sent by invitation e-mails, fax and post to community pharmacists in Tasmania, Australia. Main outcome measure Current AMS practices, perceived importance, barriers and facilitators of AMS. Results Eighty-five pharmacists responded to the survey yielding a response rate of 61%. EFA identified one factor solution for each of three perceptions scales and showed acceptable reliability. The Cronbach’s alpha of perceived importance-understanding was 0.699, perceived importance-motivating was 0.734, perceived support from GPs was 0.890, operational barriers was 0.585, general facilitators was 0.615. Most pharmacists reported that they counselled patients on adverse effects (86%), drug interactions (94%), and allergies (96%). In contrast, less than half (43%) intervened with prescribers regarding antibiotic selection. Lack of training, lack of access to patients’ records, limited interactions with general practitioners and absence of a reimbursement model were major barriers limiting community pharmacists’ participation in AMS. Conclusion The questionnaire was of acceptable reliability and validity; a larger study will further contribute in its reliability and validity. Future studies utilising the questionnaire at national and international level may provide further insights into the determinants of community pharmacist’s involvement in AMS. Electronic supplementary material The online version of this article (10.1007/s11096-018-0701-1) contains supplementary material, which is available to authorized users.

Up to 80% of residents in aged care facilities (ACFs) experience pain, which is often suboptimally managed. The purpose of this study was to characterize pain management in ACFs and identify the barriers to optimal pain management. This exploratory descriptive qualitative study used semistructured interviews in five Southern Tasmania, Australian ACFs. Interviewees included 23 staff members (18 nurses and 5 facility managers) and were conducted from September to November 2015. Interviews included questions about how pain was measured or assessed, what happened if pain was identified, barriers to pain management, and potential ways to overcome these barriers. Interviewees noted that there were no formal requirements regarding pain assessment at the ACFs reviewed; however, pain was often informally assessed. Staff noted the importance of adequate pain management for the residents' quality of life and employed both nonpharmacologic and pharmacologic techniques to reduce pain when identified. The barriers to optimal pain management included difficulty identifying and assessing pain, residents' resistance to reporting pain and/or taking medications, and communication barriers between the nursing staff and GPs. Staff interviewed were dedicated to managing residents' pain effectively; however, actions in a number of areas could improve resident outcomes. These include a more consistent approach to documenting pain in residents' progress notes and improving nurse-GP communications to ensure that new or escalating pain is identified and expedient changes can be made to the resident's management. Additionally, resident, family, nurse, and carer education, conducted within the facilities on a regular basis, could help improve the pain management of residents.

Background: Repeat prescribing of antibiotics is widespread in Australia. This may be associated with risks to individual patients and contribute to inappropriate antibiotic use. Aim: To characterise the time intervals between dispensing of initial and repeat antibiotic prescriptions, and identify any associations between these intervals and information on treatment duration included in dosing directions. Method: A retrospective study of de-identified antibiotic repeat dispensing records from 186 Australian pharmacies. Results: A total of 12 516 repeat dispensings for amoxicillin/amoxycillin (5198, 41.5%) and cefalexin/cephalexin (7318, 58.5%) were analysed. Of these, 50.7% (6340) and 78.8% (9863) were collected within 2 and 30 days of the date on which the original supply should have been completed, respectively. The remainder were dispensed throughout the following 11 months. Compared to prescriptions with no reference to duration or a generic statement regarding course completion, specifying a course length exceeding that provided by the initial pack was associated with a significantly shorter interval between the dispensing of original and repeat prescriptions. Conclusion: Around half of all supplied repeats appear to be used to extend initial courses, while around 1 in 5 repeat dispensings occur at least 1 month after the initial prescription, suggesting that they may be used to treat separate episodes of infection. The inclusion of specific information regarding treatment durations on prescriptions and in dispensing directions appears to influence patient behaviour. While addressing the whole practice of issuing antibiotic repeats remains desirable, these findings may be relevant for prescribers and pharmacists, and help efforts to extend antimicrobial stewardship principles to the community.

Climate change threatens coral reefs across the world. Intense bleaching has caused dramatic coral mortality in many tropical regions in recent decades, but less obvious chronic effects of temperature and other stressors can be equally threatening to the long-term persistence of diverse coral-dominated reef systems. Coral reefs persist if coral recovery rates equal or exceed average rates of mortality. While mortality from acute destructive events is often obvious and easy to measure, estimating recovery rates and investigating the factors that influence them requires long-term commitment. Coastal development is increasing in many regions, and sea surface temperatures are also rising. The resulting chronic stresses have predictable, adverse effects on coral recovery, but the lack of consistent long-term data sets has prevented measurement of how much coral recovery rates are actually changing. Using long-term monitoring data from 47 reefs spread over 10 degrees of latitude on Australia's Great Barrier Reef (GBR), we used a modified Gompertz equation to estimate coral recovery rates following disturbance. We compared coral recovery rates in two periods: 7 years before and 7 years after an acute and widespread heat stress event on the GBR in 2002. From 2003 to 2009, there were few acute disturbances in the region, allowing us to attribute the observed shortfall in coral recovery rates to residual effects of acute heat stress plus other chronic stressors. Compared with the period before 2002, the recovery of fast-growing Acroporidae and of "Other" slower growing hard corals slowed after 2002, doubling the time taken for modest levels of recovery. If this persists, recovery times will be increasing at a time when acute disturbances are predicted to become more frequent and intense. Our study supports the need for management actions to protect reefs from locally generated stresses, as well as urgent global action to mitigate climate change.

Coral reef management is increasingly focused on supporting the resilience of coral communities to increasing and cumulative pressures. The coral index provides a concise summary of coral community resilience that can be efficiently communicated to a range of management and policy stakeholders. We detail the development of the index both as a technical reference for users but also as an example of an approach that could be more generally applied to the reporting of ecosystem resilience. The index is sensitive to acute impacts that are expected when coral communities are exposed to disturbances such as cyclones, bleaching events or crown-of-thorns outbreaks. Importantly, spatial and temporal trends in the index enable the identification of areas and periods of reduced resilience that suggest chronic environmental pressure imposed by runoff. The ability to summarise complex ecological processes into a single index provides an efficient and intuitive tool for the communication of where, when and which pressures are impacting ecosystem resilience.

Objectives: To identify the prevalence of oxycodone immediate release (IR) prescribed during an ED admission and the persistence of Schedule 8 (S8) opioids following an ED admission. Methods: A retrospective cross‐sectional audit was undertaken reviewing all admission at the ED of the Royal Hobart Hospital, Tasmania, between 1 August and 30 September 2016. The admissions lists for ED were cross matched with the narcotic registers for oxycodone IR (the most commonly supplied S8 in ED) to identify how many patients received IR oxycodone during their ED admissions. Determination of the persistence of opioid use in opioid naive patients was then undertaken using the Tasmanian real time reporting database of all S8 opioid dispensed in Tasmania (DAPIS). Results: There were 8432 ED admissions for 7065 patients aged over 13 years. IR oxycodone was prescribed during 1049 of these admissions (12.4%). Of the patients who were not taking regularly prescribed S8 opioids prior to their ED admission (n = 853), 48 patients (5.6%) were taking S8 opioids at both 2 and 6 months following their ED admission. Thirty patients (2.8%) were approved for authorities for long‐term opioids for non‐cancer pain. Conclusion: These findings suggest that prescribing of IR oxycodone within ED is lower than previous studies. Additionally, the progression to regular chronic opioid use following an ED admission where IR oxycodone was given was relatively low with 3.0% of opioid naive patients being approved for indications related to chronic non‐cancer pain in the following 6 months.

BACKGROUND Antimicrobial stewardship (AMS) programs are well established in hospitals, yet such programs have not been widely implemented in the community. Understanding of the current practices and perceptions of community pharmacists about AMS may provide insights into the implementation of AMS in community pharmacies. OBJECTIVES To validate a questionnaire to measure community pharmacists’ perceptions of AMS, and to explore barriers and facilitators of their involvement in community based AMS initiatives. METHODS A 44-item survey questionnaire, comprising sections on demographics, AMS practices and perceptions of community pharmacists, and barriers and facilitators to AMS, was hosted online. Community pharmacists were recruited through social media pages of community pharmacist groups across Australia. Cronbach’s alpha and exploratory factor analysis were used to measure the reliability and validity of the survey tool, respectively. RESULTS Three hundred and thirty community pharmacists started the survey, with 255 of them completing at least one or more questions. Pharmacists were more likely to intervene with General Practitioners (GP) (80% of the time or above) for allergies, dosing and drug-interactions and less likely to intervene if they felt the choice of antibiotic is inappropriate (45%). Major barriers limiting pharmacists’ participation in AMS were lack of access to patient’s data (82.6%) and lack of access to a standard guideline to implement AMS programs (72.1%). Almost all pharmacists (98%) reported that better collaboration with GPs will improve their participation in AMS initiative. CONCLUSIONS Future studies utilising the knowledge gained from this study may provide a framework for AMS in community pharmacy settings.

Coral reefs are under increasing pressure from a variety of stressors, highlighting the need for information about the status of coral reef communities including the distribution, abundance and composition of juvenile and adult coral assemblages. This information is currently limited for the Great Barrier Reef (GBR) and is necessary for understanding the impacts of disturbances and the system&rsquo, s potential for recovery. This study reports juvenile and adult hard coral abundance and composition from 122 reefs on the GBR during a period of limited acute disturbance. The data represent baseline observations for juvenile hard coral assemblages spanning the longitudinal cross-shelf gradient of the GBR and 12 degrees of latitude and augment reported distribution of adult coral assemblages over the same scale with inclusion of additional reefs. Juvenile and adult coral assemblages reflected broad differences imposed by the gradient of environmental conditions across the GBR. The mean density of juvenile hard corals was lower in the inshore reefs (5.51 m2) than at either the mid-shelf (11.8 m2) or outer shelf reefs (11.2 m2). The composition of juvenile and adult coral assemblages covaried overall, although there were different relationships between these two life stages across the continental shelf and among community types. Dissimilarity between juvenile and adult coral assemblages was greater on inshore and outer shelf reefs than on reefs in the mid-shelf, although, there were differences in community types both within these shelf positions and those that spanned mid- and outer shelf reefs. Dissimilarity was greatest for Inshore branching Acropora and high for Southern Acropora communities, although very high coral cover and very low juvenile densities at these reefs precluded interpretation beyond the clear competitive dominance of Acropora on those reefs. Dissimilarity was also high between juvenile and adult coral assemblages of Turbid inshore communities suggesting water quality pressures, along with synergistic effects of other stressors, pose ongoing selective pressures beyond the juvenile stage. Conversely, relatively low dissimilarity between juvenile and adult coral assemblages on mid-shelf and lower latitude outer shelf reefs suggests pressures beyond those influencing settlement and early post-settlement survival were having less influence on the composition of adult coral assemblages.

Changes in coral reef health and status are commonly reported using hard coral cover, however such changes may also lead to substantial shifts in coral community composition. Here we assess the extent to which coral communities departed from their pre-disturbance composition following disturbance (disassembly), and reassembled during recovery (reassembly) along an environmental gradient across the continental shelf on Australia&rsquo, s Great Barrier Reef. We show that for similar differences in coral cover, both disassembly and reassembly were greater on inshore reefs than mid- or outer-shelf reefs. This pattern was mostly explained by spatial variation in the pre-disturbance community composition, of which 28% was associated with chronic stressors related to water quality (e.g., light attenuation, concentrations of suspended sediments and chlorophyll). Tropical cyclones exacerbated the magnitude of community disassembly, but did not vary significantly among shelf positions. On the outer shelf, the main indicator taxa (tabulate Acropora) were mostly responsible for community dissimilarity, whereas contribution to dissimilarity was distributed across many taxa on the inner shelf. Our results highlight that community dynamics are not well captured by aggregated indices such as coral cover alone, and that the response of ecological communities to disturbance depends on their composition and exposure to chronic stressors.

Background: Appropriate antibiotic prescribing improves patient outcomes and miti‐ gates antimicrobial resistance. As the majority of antibiotics are used in the commu‐ nity, rational prescribing in this setting is of paramount importance. Objectives: We aimed to (1) evaluate the concordance of community antibiotic pre‐ scribing with guidelines for three common infection types among patients who pre‐ sented to hospital, and (2) identify relationships between guideline concordance and patient‐related factors. Methods: Medical records were evaluated from the Royal Hobart Hospital (Tasmania, Australia) for patients presenting with respiratory tract, urinary tract or skin and soft tissue infections within a 12‐month period. Prior‐to‐hospital antibiotic therapy was assessed for concordance with prescribing guidelines based on presenting diagno‐ sis. Concordance was assessed against first‐line recommendations in the Australian Therapeutic Guidelines ‐ Antibiotic, based on drug choice, dose, frequency and patient factors. Descriptive statistics were performed to address Objective 1. Multivariate logistic regressions were conducted to address Objective 2 with the fol‐ lowing independent variables: infection type, age, allergies, diabetes status, gender and residential setting. Results: A total of 285 patient records were eligible for data analysis; 28.8% (n = 82) were fully guideline concordant. The most common reason for non‐concordance was inappropriate drug choice (n = 143, 50.2%). Patients with the following charac‐ teristics were less likely to receive concordant therapy: diabetes (OR = 0.3, 95% CI 0.1‐0.8, P = .02) and increasing age (OR = 0.99, 95% CI 0.98‐1.00, P = .04). Conclusions: Almost three‐quarters of patients received community‐initiated an‐ tibiotic therapy that was not fully guideline concordant. Antimicrobial stewardship interventions are urgently needed to improve guideline concordance for community‐ initiated antibiotic therapy.

Coral bleaching, cyclones, outbreaks of crown-of-thorns seastar, and reduced water quality (WQ) threaten the health and resilience of coral reefs. The cumulative impacts from multiple acute and chronic stressors on “reef State” (i.e., total coral cover) and “reef Performance” (i.e., the deviation from expected rate of total coral cover increase) have rarely been assessed simultaneously, despite their management relevance. We evaluated the dynamics of coral cover (total and per morphological groups) in the Central and Southern Great Barrier Reef over 25 years, and identified and compared the main environmental drivers of State and Performance at the reef level (i.e. based on total coral cover) and per coral group. Using a combination of 25 environmental metrics that consider both the frequency and magnitude of impacts and their lagged effects, we find that the stressors that correlate with State differed from those correlating with Performance. Importantly, we demonstrate that WQ metrics better predict Performance than State. Further, inter-annual dynamics in WQ (here available for a subset of the data) improved the explanatory power of WQ metrics on Performance over long-term WQ averages. The lagged effects of cumulative acute stressors, and to a lesser extent poor water quality, correlated negatively with the Performance of some but not all coral groups. Tabular Acropora and branching non-Acropora were the most affected by water quality demonstrating that group-specific approaches aid in the interpretation of monitoring data and can be crucial for the detection of the impact of chronic pressures. We highlight the complexity of coral reef dynamics and the need of evaluating Performance metrics in order to prioritise local management interventions.

Coral reefs have been heavily affected by elevated sea-surface temperature (SST) and coral bleaching since the late 1980s; however, until recently coastal reefs of north-western Australia have been relatively unaffected compared to Timor Sea and eastern Australian reefs. We compare SST time series with changes in coral cover spanning a period of up to 36 years to describe temporal and spatial variability in bleaching and associated coral mortality throughout the Pilbara–Ningaloo region. Declines in coral cover ranged from 12.5 to 51.3%, with relative declines ranging from 38 to 92%. Since 2013, coral cover throughout the region has declined to historically low levels at four of five subregions, with impaired recovery occurring at two subregions. Observations are consistent with global trends of repeated severe heat waves, coral bleaching and acute declines in coral cover. Locations within this study region have already experienced multiple coral-bleaching events within a period of less than 5 years. There is a high likelihood that reefs in the western Pilbara and northern Ningaloo regions will experience more frequent marine heatwaves, coral bleaching and mortality events in the future. Action, therefore, needs to be taken now to support the resilience of coral reef ecosystems in the region, which is arguably the most important coral-reef province on Australia’s western coast.

Introduction: Brief lung scan protocols have been recommended as a useful adjunct to identify pulmonary oedema in the breathless elderly patient. Some papers quote diagnostic accuracies above that of chest x‐ray. Method: We recruited a prospective convenience sample of patients over sixty years of age reporting any breathlessness on presentation to the emergency department. Those who received both bedside lung scan and chest x‐ray later had their case notes audited by an expert cardiologist for the cause of their breathlessness at presentation. Admission diagnosis was also extracted. Results: 204 comparative data sets were collected. Compared with cardiologist chart review, delayed expert radiology report had a diagnostic accuracy of 92.2% (95%CI 87.6 to 95.1). Bedside interpretation of lung scan protocol had a diagnostic accuracy of 85.3% (95%CI 79.8 to 89.5). The difference of 6.9% between the two accuracy measures was significant (95%CI 0.69 to 13.1). Admission diagnosis accuracy, which encompasses inexpert x‐ray interpretation was 70.2%(95%CI 62.9 to 76.6), significantly less than either lung scan or expert chest x‐ray report. Conclusion: For identifying heart failure in breathless patients, urgent chest x‐ray with delayed formal report has not been shown to be redundant. Basic lung scan protocols should not yet replace chest x‐ray, but may be more reliable in the interim than inexpert clinician interpretation of chest x‐rays.

© 2015, Springer International Publishing Switzerland. Guideline-based management of acute coronary syndrome (ACS) is well established, yet some may challenge that strict implementation of guideline recommendations can limit the individualization of therapy. The use of all recommended medications following ACS places a high burden of responsibility and cost on patients, particularly when these medications have not been previously prescribed. Without close attention to avoiding non-adherence to these medications, the full benefits of the guideline recommendations will not be realized in many patients. Using a case example, we discuss how the recognition of adherence barriers can be an effective and efficient process for identifying patients at risk of non-adherence following ACS. For those identified as at risk, the World Health Organization’s model of adherence barriers is explored as a potentially useful tool to assist with individualization of therapy and promotion of adherence.

This study aims to update and validate quality prescribing indicators (QPIs) for Australian general practice. The study comprised two phases: (1) developing preliminary potential QPIs based on the 2006 National Prescribing Service (NPS) MedicineWise indicators, published literature, international indicators and guidelines, and through qualitative focus group discussions; and (2) validating the proposed QPIs through a two-round online survey using the Delphi technique. The Delphi panel included four GPs, four pharmacists and two clinical pharmacologists. The Delphi panel rated the potential QPIs for their validity, importance and feasibility using a 1–10 Likert scale. In round one, all proposed QPIs presented as ‘prescribing rules’ achieved high scores regarding validity, importance and feasibility No rule was eliminated and three new rules were introduced. Rules were reworded into ‘prescribing indicators’ for round two, which resulted in 35 indicators being accepted and two indicators being eliminated. The final QPIs also include seven drug–drug interactions, which received high scores in round one. In conclusion, 42 QPIs were nominated for use in Australian general practice, based on their validity, importance and feasibility. If implemented, these QPIs have the potential to assist in efforts to improve the quality and safety of medicines management.

In the face of increasing cumulative effects from human and natural disturbances, sustaining coral reefs will require a deeper understanding of the drivers of coral resilience in space and time. Here we develop a high-resolution, spatially explicit model of coral dynamics on Australia's Great Barrier Reef (GBR). Our model accounts for biological, ecological and environmental processes, as well as spatial variation in water quality and the cumulative effects of coral diseases, bleaching, outbreaks of crown-of-thorns starfish (Acanthaster cf. solaris), and tropical cyclones. Our projections reconstruct coral cover trajectories between 1996 and 2017 over a total reef area of 14,780 km(2), predicting a mean annual coral loss of -0.67%/year mostly due to the impact of cyclones, followed by starfish outbreaks and coral bleaching. Coral growth rate was the highest for outer shelf coral communities characterized by digitate and tabulate Acropora spp. and exposed to low seasonal variations in salinity and sea surface temperature, and the lowest for inner-shelf communities exposed to reduced water quality. We show that coral resilience (defined as the net effect of resistance and recovery following disturbance) was negatively related to the frequency of river plume conditions, and to reef accessibility to a lesser extent. Surprisingly, reef resilience was substantially lower within no-take marine protected areas, however this difference was mostly driven by the effect of water quality. Our model provides a new validated, spatially explicit platform for identifying the reefs that face the greatest risk of biodiversity loss, and those that have the highest chances to persist under increasing disturbance regimes.

Introduction: In the setting of patients presenting with shortness of breath to an Emergency Department a simple lung ultrasound protocol aimed at detecting pulmonary oedema has been shown to have diagnostic accuracy of 85%. This article reviews data from the original study, in an attempt to determine whether adjusting the protocol and/or interpretive criteria would improve results. Method: A large lung ultrasound project provided the dataset. Inter‐rater and intertest discrepancies were reviewed. Then original stored images and comments were retrospectively analysed using alternate interpretive criteria. Specific variations included changing the number of B‐lines required to define ‘wet lung’ and assessing other pleural line abnormalities. Where they had been acquired cardiac loops were reviewed in addition to the lung images. Results: The 204 original studies available were reviewed. Some disagreement could be attributed to inexperience and unclear definitions. Adjusting the number of B‐lines did not improve diagnostic accuracy. All positive scans, with numerous B‐lines were reviewed using more advanced diagnostic criteria (pleural line abnormalities) and the number of false positives was decreased. In cases where cardiac views were available, their inclusion was beneficial. Conclusion: A simple lung ultrasound protocol to assess for ‘wet lung’ in patients presenting to Emergency Departments provides diagnostic accuracy of around 85% in the hands of relative novices. More advanced interpretation of the same_ultrasound images, and the addition of cardiac views, is likely to further improve diagnostic accuracy.