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To evaluate the accuracy of maxilla and mandibular repositioning during two-jaw orthognathic surgery using computerassisted surgical simulation (CASS)

Background: There is a scarcity of prospective studies investigating the relative roles of skin prick and intradermal testing, serum specific IgE, and extended oral challenges in diagnosing children with reported β-lactam allergies., Objective: To determine the sensitivity and specificity of skin testing and serum specific IgE in children with β-lactam allergies, with immediate and nonimmediate historic reactions., Methods: Four hundred children with parent-reported β-lactam allergies were recruited into an open-label prospective study. Detailed allergy histories were collected. Those with medically observed and documented histories of anaphylaxis, requiring epinephrine, or severe cutaneous adverse reactions were excluded. In total, 380 children underwent all testing modalities and a direct provocation test. Each child was followed up for a minimum of 3 years., Results: True allergy in children was uncommon; 8.3% reacted to the direct provocation challenge or the 5-day extended oral provocation challenge. Children reporting cephalosporin allergy or a reaction within 1 year were more likely to react to direct provocation testing. The sensitivity, specificity, and positive predictive value of skin testing were 12.5%, 98.8%, and 20.0% for direct challenge outcomes, 4.76%, 99.0%, and 25.0% for extended challenge outcomes, and 6.9%, 99.0%, and 40.0% for both challenges combined, respectively. Follow-up investigations revealed that 5.7% of children had a mild repeat reaction and 2.7% continued to avoid the culprit despite successful delabeling. The relabeling rate for children readmitted to hospital was 15%, with the relabeing being unfounded., Conclusions: Genuine β-lactam allergies were rare, with over 90% of children effectively delabeled. Skin and serum specific IgE testing did not aid the diagnosis of β-lactam antibiotic allergy in children, regardless of medical history. Extended oral challenges proved valuable in confirming allergies and boosted parental confidence., (Copyright © 2024. Published by Elsevier Inc.)

Background: Diagnosing drug reaction with eosinophilia and systemic symptoms (DRESS) can be challenging., Objectives: We sought to identify clinical and laboratory features outside of the Registry of Severe Cutaneous Adverse Reaction (RegiSCAR) criteria that distinguish patients with probable DRESS (RegiSCAR ≥ 4) from those with drug rash and eosinophilia (DRE)., Methods: Using international coding classifications of drug-induced fever, generalized skin eruption due to medications, and eosinophilia, a retrospective audit from 2008 to 2023 of hospitalized patients was performed., Results: Forty-four cases of DRESS were compared to 80 cases of DRE. In addition to the RegiSCAR distinguishing factors for DRESS were longer drug latency before symptom onset (median 21 vs 5 days, P  < .001) and higher alanine transaminase levels (increase by a factor of 2.49 [95% confidence interval, 1.56, 4.00; P  = .009]). Follow-up (mean 5.67 years) revealed a low rate of statewide drug alert reporting (29.6%) and drug allergy testing in DRESS (20.5%). Inadvertent reexposure to a culprit or structurally related drug resulted in recurrent DRESS in 3 patients (7.5%), and tolerance of structurally related drugs occurred in 8 patients (17.5%)., Conclusion: In this large study evaluating DRE patients whose disease does not meet the RegiSCAR criteria for DRESS, we found that additional factors outside the RegiSCAR criteria may help clinicians differentiate DRESS, which is critical for optimal and timely patient management. Our study also highlights the need for development of local protocols to ensure appropriate allergy labeling and testing are performed to prevent recurrent DRESS., Competing Interests: Disclosure of potential conflict of interest: The authors declare that they have no relevant conflicts of interest., (Crown Copyright © 2024 Published by Elsevier Inc. on behalf of the American Academy of Allergy, Asthma & Immunology.)

Introduction: Trauma is the most common cause of morbidity and mortality in older people, and it is important to determine the predictors of outcomes after major trauma in older people., Methods: MEDLINE, Embase, and Web of Science were searched, and manual search of relevant papers since 1987 to February 2023 was performed. Random-effects meta-analyses were performed. The primary outcome of interest was mortality, and secondary outcomes were medical complications, length of stay, discharge destination, readmission, and intensive care requirement., Results: Among 6,064 studies in the search strategy, 136 studies qualified the inclusion criteria. Forty-three factors, ranging from demographics to patient factors, admission measurements, and injury factors, were identified as potential predictors. Mortality was the commonest outcome investigated, and increasing age was associated with increased risk of in-hospital mortality (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.07) along with male sex (OR, 1.40; 95% CI, 1.24-1.59). Comorbidities of heart disease (OR, 2.59; 95% CI, 1.41-4.77), renal disease (OR, 2.52; 95% CI, 1.79-3.56), respiratory disease (OR, 1.40; 95% CI, 1.09-1.81), diabetes (OR, 1.35; 95% CI, 1.03-1.77), and neurological disease (OR, 1.42; 95% CI, 0.93-2.18) were also associated with increased in-hospital mortality risk. Each point increase in the Glasgow Coma Scale lowered the risk of in-hospital mortality (OR, 0.85; 95% CI, 0.76-0.95), while each point increase in Injury Severity Score increased the risk of in-hospital mortality (OR, 1.07; 95% CI, 1.04-1.09). There were limited studies and substantial variability in secondary outcome predictors; however, medical comorbidities, frailty, and premorbid living condition appeared predictive for those outcomes., Conclusion: This review was able to identify potential predictors for older trauma patients. The identification of these factors allows for future development of risk stratification tools for clinicians., Level of Evidence: Systematic Review and Meta-Analysis; Level III., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: As hearing loss is a modifiable risk factor of dementia, allied hearing-healthcare professionals (AHHPs) frequently see older patients who are affected by both conditions. However, little is known about how well Australian AHHP's understand the complexities of providing care to patients with comorbid hearing loss and dementia, as well as their associated views and practices. Thus, the current study used a survey to explore the knowledge, attitudes, and practices (KAPs) of Australian AHHPs in managing comorbid patients., Materials and Methods: A cross-sectional design was used, wherein a KAP survey was developed and distributed to eligible AHHPs via Qualtrics. Data were analysed with descriptive statistics and binary logistic regression., Results: 101 Australian AHHPs met inclusion criteria (2.5% of approximately 4,000 invited AHHPs), and participated in the study. Although participants generally possessed a high level of knowledge for the association between hearing loss and cognitive impairment, their specific knowledge and practices in relation to cognitive screening tests and referral pathways was limited. Participants also expressed mostly positive attitudes towards their role in assisting patients with comorbid hearing loss and dementia. Furthermore, our results suggested that some KAPs relevant to comorbid patients differed based on sex, qualification, and ethnicity., Conclusion: This study identified gaps in the knowledge and practices of Australian AHHPs with regard to the complexities of addressing comorbid cognitive impairment and hearing loss. These findings will help to develop training programs to empower AHHPs to deliver optimal healthcare services to comorbid patients., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Jayakody, Je, Livings, McIlhiney, Trevenen, Kekez and Mavaddat.)

Background: The clinical consequences of an antibiotic allergy label are detrimental, impacting health care delivery and patient outcomes. We assessed hospital inpatients with intent to offer free antibiotic allergy labeling (AAL) assessment within a randomized controlled trial., Objective: We sought to determine the feasibility of establishing an adult antibiotic allergy delabeling service in a Western Australian tertiary public hospital., Methods: Inpatients (N = 1503) with AAL were identified through medical records and screened for eligibility to participate in a randomized controlled trial. Those recruited were randomized to undergo assessment by skin testing ± oral challenge, or direct oral challenge. A control group received usual care., Results: Of the 1503 inpatients with an AAL, 429 (28.5%) were eligible for AAL assessment. The primary excluding factor (1074 [71.5%]) was contraindicated medication use (387 [36.0%]), followed by cognitive impairment (298 [27.9%]). Thirty-nine patients were randomized, of which 20 received allergy testing and 19 usual care; all patients were followed up for 5 years. Older patients were less likely to be eligible (10-year increase: odds ratio, 0.82; 95% CI, 0.77-0.88; P  < .0001), whereas surgical patients were more likely to be eligible than medical patients (odds ratio, 2.49; 95% CI, 1.97-3.16; P  < .0001)., Conclusions: Antibiotic allergy delabeling in the acute care context is not straightforward. Competing clinical concerns and patient acceptance are some barriers to an inpatient service. Nor is it apparent that inpatient versus outpatient testing is cost saving although select patient groups may benefit. Testing younger people and those with predicted high antibiotic usage will derive maximal individual and health system benefits., Competing Interests: The Government of Western Australia, Department of Health, Research Translation Project. BSvUS is partly funded by the 10.13039/501100020265Stan Perron Charitable Foundation and through a 10.13039/501100000925National Health and Medical Research Council Investigator Grant (grant no. 2009322). Disclosure of potential conflict of interest: The authors declare that they have no relevant conflicts of interest., (© 2024 The Authors.)

Objectives: As people age, rates of morbidity and mortality are heterogenous. Balance and strength performance may contribute to this, offering modifiable risk factors for mortality. We aimed to compare relationships of balance and strength performance with all-cause and cause-specific mortality., Design: The Health in Men Study, a cohort study, using wave 4 as baseline for analyses (2011-2013)., Setting and Participants: 1335 older men (>65 years old), initially recruited April 1996-January 1999 in Western Australia, were included., Methods: Physical tests included a strength (knee extension test) and balance measure (modified Balance Outcome Measure for Elder Rehabilitation (mBOOMER) Score), derived from baseline physical assessments. Outcome measures included all-cause, cardiovascular, and cancer mortality, ascertained via the WADLS death registry. Data were analyzed using Cox proportional hazards regression models (age as analysis time, adjusted for sociodemographic data, health behaviors, and conditions)., Results: Four hundred seventy-three participants died before the end of follow-up (December 17, 2017). Better performance on both the mBOOMER score and knee extension test was associated with lower likelihood of all-cause [hazard ratio (HR) 0.83, 95% CI 0.80-0.87, and HR 0.96, 95% CI 0.95-0.98, respectively] and cardiovascular mortality (HR 0.82, 95% CI 0.77-0.87, and HR 0.96, 95% CI 0.94-0.98, respectively). Better mBOOMER score performance was associated with lower likelihood of cancer mortality (HR 0.90, 95% CI 0.83-0.98) only when including participants with prior cancer., Conclusions and Implications: In summary, this study demonstrates an association of poorer performance in both strength and balance with future all-cause and cardiovascular mortality. Notably, these results clarify the relationship of balance with cause-specific mortality, with balance equaling strength as a modifiable risk factor for mortality., (Copyright © 2023 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: The recently developed Hospital Frailty Risk Score (HFRS) allows ascertainment of frailty from administrative data. We aimed to compare the HFRS against the widely used FRAIL Scale and Frailty Index., Design: Population-based cohort study linked to Western Australian Hospital Morbidity Data Collection and Death Registrations., Setting and Participants: The Health in Men Study with frailty determined at Wave 2 (2001/2004), mortality in the 1-year period following Wave 2, and disability at Wave 3 (2008). Participants were 4228 community-based men aged ≥75 years, followed until Wave 3., Measurements: We used multivariable regression to determine the association between each frailty measure and outcomes of length of stay (LOS), death, and disability. We also determined if the additional cases of frailty identified by one measure over the other was associated with these outcomes., Results: Of 4228 men studied, the HFRS (n = 689) identified fewer men as frail than the FRAIL Scale (n = 1648) and Frailty Index (n = 1820). In the fully adjusted models, all 3 frailty measures were associated with longer LOS and mortality, whereas only the FRAIL Scale and Frailty Index were significantly associated with disability. The additional cases of frailty identified by the FRAIL Scale and Frailty Index had longer LOS and greater risks of death and disability. The fully adjusted hazard ratio for death among the additional cases of frailty identified by the FRAIL Scale (compared to being not frail on both HFRS and FRAIL Scale) was 2.14 (95% CI 1.48-3.08)., Conclusions and Implications: The HFRS is associated with adverse outcomes. However, it identified approximately 60% fewer men who were frail than the FRAIL Scale and Frailty Index, and the additional cases identified were also at high risks of adverse outcomes. Users of the HFRS should be aware of the differences with other frailty measures., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Although common, antimicrobial allergy labels (AAL) rarely reflect immunologically-mediated hypersensitivity and can lead to poorer outcomes from alternative antimicrobial agents. Antimicrobial stewardship programs are ideally placed to assess AAL early as a means of improving antimicrobial use., Aims: To quantify the prevalence of AAL in patients referred for antimicrobial stewardship review and assess their impact on antibiotic prescribing, patient mortality, hospital length of stay, readmission and rates of multidrug-resistant infections., Methods: We conducted a retrospective analysis of adult patients referred for inpatient antimicrobial prospective audit and feedback rounds (PAFR) through an electronic referral system (eReferrals) over a 12-month period in 2015. Outcome data were collected for a period of 36 months following the initial review., Results: Of the 639 patient records reviewed, 630 met inclusion criteria; 103 (16%) had an AAL, of which 82 (13%) had reported allergies to β-lactam antibiotics. Those with AAL were significantly less likely to be receiving guideline-recommended antimicrobial therapy (50% vs 64%, P = 0.0311); however, there were no significant difference in mortality, hospital length of stay, readmission or increased incidence of multidrug-resistant infections., Conclusions: Our cohort demonstrated that AAL was associated with reduced adherence to antibiotic guidelines. The lack of association with adverse outcomes may reflect limitations within the study including retrospective cohort study numbers and observational nature, further skewed by high rates of poor documentation. A clear opportunity exists for antimicrobial stewardship programs to incorporate allergy assessment, de-labelling, challenge and referral into these rounds., (© 2020 Royal Australasian College of Physicians.)

Objective: To determine if hearing loss is associated with increased risk of frailty in later life., Study Design: Cross-sectional study of a community sample of 4,004 men aged 70 years and above living in the metropolitan region of Perth, Western Australia. Data were retrieved from the Health in Men Study (HIMS) and the Western Australian Data Linkage System (WADLS). Frailty was assessed using the FRAIL scale and the Frailty Index. Hearing loss was defined by self-report or by diagnosis recorded in the WADLS. We also collected demographic, lifestyle and social support information., Main Outcome Measures: Frailty was assessed using the FRAIL scale and the Frailty Index., Results: The prevalence of frailty in the sample population was 16.1% and 25.4% when assessed using the FRAIL scale and the Frailty Index respectively. After adjusting for participant demographic, lifestyle and social factors, hearing loss was significantly associated with the prevalence of frailty when diagnosed by either measure (FRAIL scale: odds ratio [OR] 1.59, 95 CI% 1.32 to 1.91; Frailty Index: OR 1.76, 95 CI% 1.50 to 2.05). The proportion of men with hearing loss increased with increasing severity of frailty., Conclusion: Hearing loss is associated with increased prevalence of frailty in older men when assessed using the FRAIL scale and the Frailty Index. Future longitudinal studies using objective measures of hearing will be helpful in determining if this association is likely to be causal., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Recent single-center studies promote oral penicillin challenges, without skin testing, in patients with low risk/likelihood of true allergy. However, how best to define a low-risk penicillin allergy history is uncertain., Objective: To statistically determine an optimal low-risk definition, to select patients for safe outpatient penicillin challenges, without skin testing., Methods: In a multicenter Australian study (February 2016 to May 2018), testing strategy (skin test and/or oral penicillin challenge) and outcomes were retrospectively collected for all penicillin-allergic patients. Statistical modeling was performed with 8 low-risk definitions, to determine an optimal low-risk definition., Results: A total of 447 subjects (mean age, 45.3 years; 63.8% females) were analyzed. A history of benign, immediate, or delayed rash, more than 1 year before review, was the optimal low-risk definition. A total of 244 of 447 (54.6%) patients met this definition, of which 97.1% tolerated a 1- or 2-dose penicillin challenge, with no anaphylaxis in those who reacted. Of 203 patients designated higher risk, 54 (26.6%) had their allergy confirmed by skin test (n = 45) or challenge (n = 9)., Conclusions: History of penicillin-associated rash (without angioedema, mucosal ulceration, or systemic involvement), more than 1 year ago, is sufficient to select a patient for a direct oral penicillin challenge. This large multicenter study demonstrates that this approach appears safe, and risk is comparable to that in other procedures being performed in primary care in Australia. The higher risk patients are more likely to benefit from skin testing. This simple risk-based delabeling strategy could potentially be used by nonallergists, leading to more efficient penicillin allergy delabeling service provision., (Copyright © 2019 American Academy of Allergy, Asthma & Immunology. All rights reserved.)

Background and aims The painDETECT questionnaire (PD-Q) has been widely used as a screening tool for the identification of neuropathic pain (NeP) as well as a tool for the characterization of patients' pain profile. In contrast to other NeP screening tools, the PD-Q is the only screening tool with weighted sensory descriptors. It is possible that responses to the PD-Q sensory descriptors are influenced by psychological factors, such as catastrophizing or anxiety, which potentially might contribute to an overall higher score of PD-Q and a false positive identification of NeP. This study aimed to explore (i) the relationship between psychological factors (catastrophizing, anxiety, depression and stress) and the total PD-Q score and (ii) if psychological factors are associated with false positive identifications of NeP on the PD-Q compared to clinically diagnosed NeP. Methods The study was a retrospective review of 1,101 patients attending an outpatient pain centre. Patients were asked to complete the PD-Q, the Pain Catastrophizing Scale (PCS), the Depression, Anxiety and Stress Scale (DASS) and the Brief Pain Inventory (BPI). For patients who were identified by PD-Q as having NeP, their medical records were reviewed to establish if they had a clinical diagnosis of NeP. Results Accounting for missing data, complete datasets of 652 patients (mean age 51 (SD14) years, range 18-88; 57% females) were available for analysis. Based on PD-Q scoring, NeP was likely present in 285 (44%) patients. Depression, anxiety, stress, catastrophizing, BPI pain and BPI interference were all significantly related to each other (p < 0.0001) and patients displaying these traits were significantly more likely to have a positive PD-Q score (p < 0.0001). For patients classified by PD-Q as having NeP, only 50% of patients had a clinical diagnosis of NeP. Anxiety was significantly associated with a false positive classification of NeP on PD-Q (p = 0.0036). Conclusions Our retrospective study showed that psychological factors including catastrophizing, depression, anxiety, and stress were all influential in producing a higher score on the PD-Q. We observed a high rate of false positive NeP classification which was associated with the presence of anxiety. Implications Clinicians and researchers should be aware that a patient's psychological state may influence the responses to PD-Q and consequently the final PD-Q score and its NeP classification.

Background: Breast milk is important to infant health, yet shorter breastfeeding duration is reported for preterm infants. Both breast and bottle feeds are given in the neonatal unit, with full oral feeding often the last milestone to be achieved prior to discharge home. Unlike standard bottle teats, a vacuum release teat requires the application of negative intra-oral pressure to release milk, and so may facilitate breastfeeding in preterm infants. The objective of this study was to determine the effect of vacuum release teat use on timing of achievement of the first full oral feed and on first completion of 24 h full oral feeds. Feeding method at discharge home, 2 weeks, 6 weeks and 12 weeks corrected gestational age were also examined., Methods: A randomized controlled trial was completed with mothers of preterm infants born 24-33 weeks gestation in the neonatal unit of a tertiary women's hospital. Infants were randomized to one of two parallel groups using a vacuum release teat or standard teat for oral feeds when the mother was not available to breastfeed. Test weights were completed for all oral feeds. It was not possible to blind participants, care givers and outcome assessors to group assignment due to the nature of the study., Results: The groups did not differ with regard to timing of achievement of first full oral feed or 24 h of full oral feeds. Significantly more infants in the vacuum release teat group were exclusively fed breast milk at discharge from hospital and breastfed at 3 months corrected gestational age., Conclusions: Use of a vacuum release teat when the mother is not available to breastfeed may promote preterm breastfeeding skills, resulting in higher rates of exclusivity and longer breastfeeding duration., Trial Registration: The trial is registered with the Australian New Zealand Clinical Trials Registry ACTRN12615000245594., Competing Interests: The salaries of SP and DG are paid by The University of Western Australia from an unrestricted research grant from Medela AG (Switzerland, https://www.medela.com/company), and the salary of KN was paid from an unrestricted research grant from Channel 7 Telethon Trust (https://www.telethon7.com). Medela AG and Channel 7 Telethon Trust had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: Self-reported antibiotic allergies are common among hospitalized adults and children. However, there is a paucity of studies investigating the impact of an antibiotic allergy label in childhood., Objective: To investigate the impact of antibiotic allergy labeling on clinical outcomes in children., Methods: A retrospective study was conducted in a major pediatric tertiary hospital to capture inpatient admissions (N = 1672) in April 2014 and April 2015. Data, collected by chart review, included documented antibiotic allergy labels, antibiotic prescriptions, admitting specialty, hospital length of stay, and hospital readmissions., Results: Of the 1672 pediatric patients surveyed, 58.1% were male and 44.8% were prescribed antibiotics. Antibiotic allergy labels were recorded in 5.3% of patients; most were β-lactam allergy labels (85%), mostly to unspecified penicillins. There was an increasing incidence of antibiotic allergy label with age, which was statistically significant (P < .001); no sex effect was seen. Patients with antibiotic allergy labels received more macrolide (P = .045), quinolones (P = .01), lincosamide (P < .001), and metronidazole (P = .009) antibiotics than did patients without an antibiotic allergy label. After adjusting for patient age, sex, principal diagnosis, and admitting specialty, children with any antibiotic or β-lactam allergy label had longer hospital stays (odds ratio, 1.62; 95% CI, 1.05-2.50; P = .03) with a mean length of hospital stay of 3.8 days for those without a label and 5.2 days for those with a β-lactam allergy label., Conclusions: This is the first study demonstrating the negative impact of antibiotic allergy labels on clinical outcomes in children, as evidenced by significant alternate antibiotic use and longer hospital stays., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Background: Most patients admitted to the hospital via the emergency department (ED) do so with a peripheral intravenous catheter/cannula (PIVC). Many PIVCs develop postinsertion failure (PIF)., Objective: To determine the independent factors predicting PIF after PIVC insertion in the ED., Methods: We analyzed data from a prospective clinical cohort study of ED-inserted PIVCs admitted to the hospital wards. Independent predictors of PIF were identified using Cox proportional hazards regression modeling., Results: In 391 patients admitted from 2 EDs, the rate of PIF was 31% (n=118). The types of PIF identified were infiltration, occlusion, pain and/or peripheral intravenous assessment score >2 (ie, the hospital's assessment of PIVC phlebitis), and dislodgement (ie, accidental securement device failure or purposeful removal). Of the PIVCs that failed, infiltration and occlusion combined were the most common causes of PIF (n=55, 47%). The median PIVC dwell time was 28.5 hours (interquartile range [IQR], 17.4-50.8 hours). The following variables were associated with increased risk of PIF: being an older patient (for a 1-year increase, hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.01-1.03; P=.0001); having an Australian Triage Scale score of 1 or 2 compared to a score of 3, 4, or 5 (HR, 2.04; 95% CI, 1.39-3.01; P=.0003); having an ultrasound-guided PIVC (HR, 6.52; 95% CI, 2.11-20.1; P=.0011); having the PIVC inserted by a medical student (P=.0095); infection prevention breaches at insertion (P=.0326); and PIVC inserted in the ante cubital fossa or the back of hand compared to the upper arm (P=.0337)., Conclusion: PIF remains at an unacceptable level in both traditionally inserted and ultrasound-inserted PIVCs.Clinical trial registrationAustralian and New Zealand Trials Registry (ANZCTRN12615000588594).

Objective The aim of the present study was to provide a current snapshot of the body mass index (BMI) of the entire patient cohort of an Australian tertiary hospital on one day and compare these data with current published Australian and state (Western Australia) population norms. Methods A single-centre prospective point prevalence study was performed whereby BMI was calculated following actual measurement of patient weight (nurse) and height (physiotherapist) on one day during 2015. Variables were summarised descriptively, and one-way analysis of variance was used to investigate the relationship between continuous BMI and hospital speciality. Multivariate Cox proportional hazards regression was used to analyse the time to leaving hospital, where those who died were censored at their date of death. Results Data were collected from 416 patients (96% of the hospital population on that day). The mean (± s.e.m.) BMI across the whole hospital population was 26.6±2.2kgm-2, with 37% of patients having normal BMI, 8% being underweight, 32% being overweight, 19% being obese and 4% being severely obese. Comparison with both national and state population norms for 2014-15 reflected higher proportions of the hospital population in the underweight and extremely obese categories, and lower proportions in the overweight and obese categories. There was no significant difference in BMI across medical specialties. Conclusions Despite health warnings about the direct relationship between illness and being overweight or obese, the results of the present study reveal fewer hospitalised patients in these BMI categories and more underweight patients than in the non-hospitalised general Australian population. Being overweight or obese may offer some protection against hospitalisation, but there is a point where the deleterious effect of obesity results in more extremely obese individuals being hospitalised than the proportion represented in the general population. What is known about the topic? Although there is significant current published data relating to general Australian population BMI, there is little pertaining specifically to the hospitalised population. Accordingly, although we know that as an affluent Western country we are seeing growing rates of overweight and obese people and relatively few underweight or undernourished people in the general population, we do not know whether these trends are mirrored or magnified in those who are sick in hospital. We also know that although caring for obese patients carries a significant burden, there is the suggestion in some healthcare literature of an 'obesity paradox', whereby in certain disease states being overweight actually decreases mortality and promotes a faster recovery from illness compared with underweight people, who have poorer outcomes. What does this paper add? This paper is the first of its kind to actually measure and calculate the BMI of a whole tertiary Australian hospital population and provide some comparison with published Australian norms. On average, the hospital cohort was overweight, with a mean (± s.e.m.) BMI of 26.6±2.2kgm-2, but less so than the general population, which had a mean BMI of 27.5±0.2kgm-2. The results also indicate that compared with state and national norms, underweight and extremely obese patients were over-represented in the hospitalised cohort, whereas overweight or obese patients were under-represented. What are the implications for practitioners? Although only a single-centre study, the case-mix and socioeconomic catchment area of the hospital evaluated in the present study suggest that it is a typical tertiary urban West Australian facility and, as such, there may be some implications for practitioners. Primarily, administrators need to ensure that we are able to accommodate people of increasing weight in our hospital facilities and have the resources with which to do so, because, on average, hospitalised patients were overweight. In addition, resources need to be available for managing the extremely obese if numbers in this subset of the population increase. Finally, practitioners may also need to consider that although the management of underweight and undernourished patients may be less of a physical burden, there are actually more of these patients in hospital compared with the general population, and they may require a different package of resource utilisation.

Purpose: To compare the accuracy of two common reference marking methods for toric intraocular lens alignment before and after using the novel toriCAM application., Methods: In this prospective, randomized study, 22 participants were randomly allocated to two groups, either freehand or slit-lamp-assisted marking. Corneal markings at 0° and 180° were made using either method. The toriCAM application on a smartphone was then used to assess the rotational alignment of these markings and compared to the actual alignment as measured by the Zaldivar calipers on the iTrace Topographer (Tracey Technologies, Houston, TX) as a reference. The errors in marking with and without using the application were analyzed for all patients in each cohort and determined for each marking method., Results: Twenty eyes of 11 patients were marked using the freehand method and 20 eyes of the other 11 patients were marked using the slit-lamp method. The mean absolute error of all markings before toriCAM adjustment was 3.18° ± 2.22°. This was significantly reduced to 1.28° ± 1.34° after using the application (P < .001). This improvement was also noted separately in the freehand and slit-lamp groups. Comparison of the freehand and slit-lamp methods did not show any statistically significant difference in accuracy at both time points., Conclusions: The novel toriCAM application is able to significantly improve the accuracy of reference marking for both freehand and slit-lamp methods. [J Refract Surg. 2018;34(3):150-155.]., (Copyright 2018, SLACK Incorporated.)

There are many indications in Australia and globally that asthma management is suboptimal. Ideally, patients need to proactively self-manage the condition with the support of health professionals. Community pharmacists are a highly accessible resource for patients but currently provide inconsistent services. General practitioners also face many barriers to the provision of chronic disease management for asthma patients. The aim of this research was to characterise patients with asthma who present to community pharmacy. The objective was to identify opportunities to develop the role of pharmacists in the context of the primary healthcare setting and in view of the needs of the patients they routinely encounter. The results of a comprehensive survey of 248 patients recruited from community pharmacies indicated there was discordance between patient perceptions of asthma control and actual asthma control. Almost half the patients surveyed had poorly controlled asthma, whereas almost three quarters perceived their asthma to be well or completely controlled. Fewer than 20% of patients were utilising written asthma action plans, and issues around quality use of medicines were identified. The significance of the incongruent perceptions regarding asthma control is that patients are unlikely to proactively seek intervention and support from healthcare professionals. Community pharmacists provide a significant opportunity to address these issues by direct intervention. There is scope to investigate pharmacists preparing written asthma action plans for patients, using software to monitor medication adherence and prescribe on-going medication. To maximise the potential of pharmacists, barriers to practice need to be identified and addressed., Competing Interests: KW is the proprietor of a community pharmacy in Perth, Western Australia, and thus has a financial interest in community pharmacy. The remaining authors declare no conflict of interest.

Objectives: Pharmacy assistants are often the first point of contact for patients presenting in community pharmacies. The current role of pharmacy assistants in the supply of asthma-reliever medications (short-acting β-agonists) was identified as a barrier to appropriate guideline-based care. The aim of this research was to devise and evaluate a team-based intervention to formalise the role of pharmacy assistants and to improve asthma guideline-based care in community pharmacy., Design: A controlled pre-post intervention study was conducted in 336 metropolitan pharmacies located in Perth, Western Australia. Pharmacies were stratified into 2 groups (187 intervention and 149 control) based on known confounders for asthma control. The intervention was designed using a common-sense approach and resources developed included a checklist, videos and web page. Delivery was via workshops (25 pharmacies) or academic detailing (162 pharmacies). Pharmacy practice was assessed preintervention and postintervention via covert simulated patient methodology. Primary outcome measures included patient medical referral, device use demonstration and counselling, internal referral and/or direct involvement of a pharmacist in consultations., Results: There was a significant increase in patient medical referral in intervention pharmacies from 32% to 47% (p=0.0007) from preintervention to postintervention, while control pharmacies showed a non-significant decrease from 50% to 44% (p=0.22). Device counselling was not routinely carried out at any stage or in any cohort of this research and no significant changes in internal referral were observed., Conclusions: Increases in medical referral indicate that asthma guideline compliance can be improved in community pharmacy if implementation employs a team-based approach and involves pharmacy assistants. However, results were variable and the intervention did not improve practice related to device counselling or internal referral/pharmacist involvement. Undertaking more workshops may have improved results. Guideline implementation in community pharmacy should consider the role of pharmacy assistants and how to overcome logistical barriers to pharmacy participation in implementation activities., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: The Australian health survey (2011-2012) reported that 63.4% of Australian adults were overweight or obese. Critical care medicine is expensive, with intensive care unit (ICU) services accounting for a substantial proportion of total hospital costs. These costs may be multiplied in the overweight cohort., Objectives: The primary aim was to compare the body mass index (BMI) of a critically ill ICU patient cohort to Australian population norms in order to see if overweight people were over-represented. The secondary aim was to identify if any medical specialty was associated with overweight patients., Methods: A retrospective observational case note audit of 230 ICU patients between November 2012 and August 2013, with BMI as the primary outcome measure., Results: Approximately 75% of the cohort were overweight or obese (median BMI 28.7; IQR 25.0-32.7) representing a rate 12% higher than Australian normative data. Based on population, this equates to an estimated additional 5279 unanticipated overweight or obese ICU patients at our facility during 2013., Conclusions: This study has shown that Australian ICU patients may have higher BMI than those of the general Australian population, and therefore there may be unanticipated costs associated with their care. No medical specialty was associated with higher BMI than another., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Introduction: To evaluate the detection rate of positive choline PET-CT and its clinical role in assisting with management decisions and the correlation between positive choline PET-CT and clinical/pathological parameters in prostate cancer patients with biochemical relapse following radical prostatectomy., Methods: This was a longitudinal observational pilot study of 34 patients who received choline PET-CT scans with biochemical relapse after radical prostatectomy. Variables including peak PSA, PSA doubling time (DT), Gleason score, age, initial PSA at diagnosis, use of ADT prior to PET and initial clinical staging were statistically analysed to assess for independent predictive factors for positive PET findings., Results: Choline PET-CT was positive in 38.2% of patients (13/34). The only statistically significant predictor for positive PET-CT was the use of ADT prior to PET-CT, with OR 18.7 (95% CI, 2.87-122.45), P < 0.01. Mean peak PSA for patients with positive PET-CT was 5.5 ± 4.8 ng/mL. Patients with positive PET-CT had a mean PSA DT of 5.1 ± 3.8 months and mean total Gleason of 7.6 ± 0.8. Although these variables were not statistically significant, they showed a tendency towards significance. At Receiver Operator Characteristics (ROC) analysis, a peak PSA value of 1.65 ng/mL and PSA DT of 4.4 months were determined to be the optimal cut-off values predicting positive PET-CT., Conclusion: Choline PET-CT has its potential as a diagnostic modality enabling the detection of occult prostate cancer recurrence and to differentiate localised disease from systemic disease thus guiding management. Use of ADT prior to PET-CT is a significant predictor of positive PET-CT. Patients with a short PSA DT, high-peak PSA and high Gleason score should also be considered for choline PET-CT., (© 2016 The Royal Australian and New Zealand College of Radiologists.)

Tumour infiltrating lymphocytes in primary melanoma have been found to correlate with patient outcomes. A subpopulation of tumour infiltrating lymphocytes expresses the transcription factor forkhead box protein 3 (FOXP3). These are known as FOXP3+ T-regulatory cells (Tregs) and are thought to play an immune suppressive role in tumourigenesis. In most tumours, including melanoma, a high density of intratumoural FOXP3+ Tregs has been associated with poor prognosis. It is not known whether these cells also influence the response to BRAF inhibition therapy in metastatic melanoma. In the present study we retrospectively investigated the density of FOXP3+ Tregs in primary melanomas, with known subsequent metastasis, in relation to various clinicopathological parameters including BRAF and NRAS mutation status, and response to BRAF inhibitor therapy. The intratumoural density of FOXP3+ Tregs was two-fold higher in melanomas with mutant BRAF compared to those with wild type BRAF status (p = 0.03). In patients treated with BRAF kinase inhibitors FOXP3+ Treg density in the primary tumour was not predictive of treatment response (p = 0.38).