Background: Both abiraterone and enzalutamide have shown to improve overall survival (OS), progression-free survival (PFS) and prostate-specific antigen (PSA) response in patients with metastatic castration-resistant prostate cancer (mCRPC) regardless of previous treatment with chemotherapy (COU-AA3011, COU-AA3022, AFFIRM3 and PREVAIL4). The data regarding the impact of these treatments in the real world setting is scarce. This study assessed the real world survival and disease outcomes in mCRPC patients in a regional health service in Victoria with the use of abiraterone and enzalutamide. Methods: This retrospective clinical audit included 75 patients with diagnosis of mCRPC treated with either abiraterone or enzalutamide between January 1, 2014, and December 31, 2019, at Goulburn Valley Health. Patients were stratified according to the drug received, Eastern Cooperative Oncology Group (ECOG) performance status, Gleason score, burden of disease at diagnosis, presence of visceral metastases and use of previous chemotherapy. The primary end point was PSA response (defined as a reduction in the PSA level from baseline by 50% or more). The secondary outcomes were PSA PFS, radiographic PFS, and OS. Results: Thirty-seven patients received enzalutamide, and the other 38 received abiraterone. Only 20% of patients in either group had visceral metastases. 32% of patients receiving enzalutamide had a high burden of disease, compared to 53% receiving abiraterone. 38% of patients in the enzalutamide group and 53% in the abiraterone group had received prior chemotherapy. PSA response rates were higher in the enzalutamide group than abiraterone group (70.3% vs 37.8%). Both PSA and radiographic PFS were longer in the enzalutamide group than abiraterone group; 7 months vs 5 months for both end points. OS was also found to be longer in patients receiving enzalutamide; 30 months compared to only 13 months in patients receiving abiraterone. Conclusion: Both abiraterone and enzalutamide have shown to result in significant PSA response rates, as well as PFS and OS benefit in mCRPC patients in the real world setting. The difference in responses and survival benefit are probably impacted by the unbalanced burden of disease.

BACKGROUND: Genetic risk factors for dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS) and dengue fever (DF) are limited, in particular there are sparse data on genetic risk across diverse populations. METHODS: We conducted a genome-wide association study (GWAS) in a derivation and validation sample of 7, 460 participants of Latin American, South Asian, and South East Asian ancestries. We then developed a weighted polygenic risk score (PRS) for each participant in each of the validation cohorts of the three ancestries to predict the risk of DHF/DSS compared to DF, DHF/DSS compared to controls, and, DF compared to controls. FINDINGS: The risk of DHF/DSS was significantly increased, odds ratio [OR] 1.84 (95%CI 1.47 to 2.31) (195 SNPs), compared to DF, fourth PRS quartile versus first quartile, in the validation cohort. The risk of DHF/DSS compared to controls was increased (OR=3.94; 95% CI 2.84 to 5.45) (278 SNPs), as was the risk of DF compared to controls (OR=1.97; 95%CI 1.63 to 2.39) (251 SNPs). Risk increased in a dose-dependent manner with increase in quartiles of PRS across comparisons. Significant associations persisted for PRS built within ancestries and applied to the same or different ancestries as well as for PRS built for one outcome (DHF/DSS or DF) and applied to the other. INTERPRETATION: There is a strong genetic effect that predisposes to risk of DHF/DSS and DF. The genetic risk for DHF/DSS is higher than that for DF when compared to controls, and this effect persists across multiple ancestries.

Changes in health-seeking behaviours and challenges in accessing care have been reported during the COVID-19 pandemic. This qualitative study examines Australian experiences related to healthcare access during the early months of the pandemic. The study aimed to identify key areas of concern as well as opportunities for services to prevent, manage and treat health concerns when normal access was disrupted. Fifty-nine semi-structured interviews were analysed. Participants were interviewed between August and December in 2020 over telephone or Zoom and were located across Australia. Rapid identification of themes with an audio recordings technique was used to generate themes from the data. Participants described a variety of influences on their health-seeking behaviours, resulting in decisions to delay care or being unable to reach care. Many individuals accessed health services via telehealth and offered a range of perceptions and views on its effectiveness and appropriateness. The findings illustrate that maintenance of health and access to healthcare and psychosocial support were compromised for some individuals, leading to negative impacts on both mental and physical health. This highlights the need to provide mechanisms to facilitate a person's ability to access care in a timely manner during a pandemic.

BACKGROUND: Transcutaneous electrical stimulation (TES) for one to two months has produced some improvement in treatment-resistant slow-transit constipation (STC) in children. Optimal parameters for treatment are not known. It is possible that more improvement would occur with stimulation for longer. This study examined the effectiveness of stimulation for six months. METHODS: Children with STC confirmed by nuclear transit study (NTS) were enrolled prospectively. All had chronic constipation for greater than two years and had failed medical treatment. TES was performed for one hour/day for six months using the INF 4160 (Fuji Dynamics) portable stimulator and 4 cm × 4 cm electrodes near the belly button and on the back. Families kept bowel diaries and completed PEDSQLCore QOL (4.0) questionnaires before and at end of treatment. RESULTS: Sixty-two children (34 females; seven years, 2-16 year) with STC were studied. Defecation frequency increased in 57/62 (91%, mean ± SEM pre- 1.49 ± 0.20 vs. post- 3.25 ± 0.25 defecation/week, p < 0.0001) with the number with ≥3BA increasing from 6 to 37 (10-59%). Soiling frequency decreased from 4.8 to 1.1 days/week (p <0.001). Abdominal pain decreased from 1.7 to 0.3 days/week (<0.0001), and spontaneous urge to defecate improved. Quality of life (p < 0.01), mean transit index and gastric emptying on NTS improved (p < 0.005). CONCLUSION: Treatment-resistant STC responds to TES using interferential current across the abdomen when given daily for many months. Battery operated stimulators allowed stimulation at home for an hour each day. Stimulation for six months produced clinically significant improvement in defecation frequency, soiling, abdominal pain, urge to defecate, and quality of life in half of these chronic patients.

Undescended testis (UDT) occurs when something goes wrong with testicular descent from high in the abdominal cavity to the scrotum. Normal descent occurs in two steps, with the transabdominal phase controlled by a new testicular hormone, insulin-like hormone 3, and the inguinoscrotal phase controlled by androgens. The latter phase requires a complex process of migration from the inguinal abdominal wall to the scrotum and is commonly defective, leading to the high incidence (2-4%) of UDT at birth. The clinical examination of babies and infants aims to confirm the persistence of congenital UDT by 3-6 months, so surgery can be optimally timed at 6-12 months. For those boys who develop acquired UDT later in childhood, the 'ascending' testis often needs surgery between 5 years and 10 years, so all boys should be screened again for UDT at school entry.

INTRODUCTION: Variations of the renal arteries have been studied and published across various population groups, but similar information for the ethnically diverse nation of Australia is lacking. This study describes the pattern of renal artery anomalies in a section of the Australian population based on computed tomography (CT) angiograms of the abdomen and cadaveric dissection. METHODS: The renal arterial vasculature of 594 kidneys from 300 subjects (28 cadavers, 272 CT) was studied. The number and pattern of renal arteries were categorised on the basis of laterality, point of origin and termination in the kidney (superior pole, hilum and inferior pole), symmetry and sex. RESULTS: Multiple renal arteries were discovered in 22% of subjects and 12.12% of kidneys. The most common pattern observed was the presence of one variant renal artery (93.1%), compared to the finding of two (5.6%) and three (1.4%) multiple arteries. The aorta was the most frequent site of origin for anomalous vessels, while the hilum was the predominant point of entry. No significant difference was established between left- and right-sided kidneys (13.8% vs. 12.5%; P = 0.627); however, unilateral distribution was more common than bilateral additional renal arteries (16.7% vs. 3.4%; P < 0.01), and variations among males were more than females (27.2% vs. 15.2%; P < 0.05). A higher rate of multiple renal arteries was noted in cadaveric dissections compared to CT images (46.4% vs. 19.5%; P < 0.01). CONCLUSION: These findings provide application of an evidence-based teaching tool that facilitates education regarding renal arterial variations in Australia.

Referral to a clinical radiologist is the prime means of communication between the referrer and the radiologist. Current Australian and New Zealand government regulations do not prescribe what clinical information should be included in a referral. This work presents a qualitative compilation of clinical radiologist opinion, relevant professional recommendations, governmental regulatory positions and prior work on diagnostic error to synthesise recommendations on what clinical information should be included in a referral. Recommended requirements on what clinical information should be included in a referral to a clinical radiologist are as follows: an unambiguous referral; identity of the patient; identity of the referrer; and sufficient clinical detail to justify performance of the diagnostic imaging examination and to confirm appropriate choice of the examination and modality. Recommended guideline on the content of clinical detail clarifies when the information provided in a referral meets these requirements. High-quality information provided in a referral allows the clinical radiologist to ensure that exposure of patients to medical radiation is justified. It also minimises the incidence of perceptual and interpretational diagnostic error. Recommended requirements and guideline on the clinical detail to be provided in a referral to a clinical radiologist have been formulated for professional debate and adoption.

AIM: Relapsed/refractory (R/R) aggressive lymphoma outcomes are poor. There is no standard treatment. PACEBOM (prednisolone, doxorubicin, cyclophosphamide, etoposide, bleomycin, vincristine and methotrexate) has shown efficacy for several lymphoma subtypes in published reports. We evaluate PACEBOM+/-rituximab for R/R aggressive lymphomas in this millennium. METHODS: In this retrospective, single-center study, R/R aggressive lymphoma patients who received PACEBOM or its derivatives were identified from the pharmacy database. Demographic, treatment, toxicity and survival data were collected. RESULTS: A total of 37 eligible patients were identified. Histological subtypes included 20 Diffuse Large B-Cell Lymphoma (DLBCL), 10 T-Cell Lymphoma (TCL) and 7 Hodgkin lymphoma. All DLBCL patients had received prior rituximab. Thirty-one (84%) received second-line PACEBOM. Median number of cycles was six (1-6). Eighteen out of 20 B-cell lymphoma patients received R-PACEBOM. Overall response rate was 65%, 70% and 71% in patients with DLBCL, TCL and Hodgkin lymphoma respectively. Thirteen patients underwent autologous stem cell transplant post-PACEBOM. Median follow-up was 49 months (3-201). Most common grade 3-4 toxicities were neutropenia (46%), anemia (24%) and thrombocytopenia (16%). No additional toxicity was seen in patients who received rituximab. CONCLUSION: In this cohort, PACEBOM is active in R/R aggressive lymphoma with manageable toxicity and can be safely combined with rituximab. Outcomes were similar to reports of other salvage regimens. PACEBOM remains a suitable option for R/R aggressive lymphoma, in patients exposed to prior rituximab and those planned for autologous stem cell transplant.

BACKGROUND: Debate continues regarding the benefits versus risks of initial resection of the primary tumor in metastatic colorectal cancer (mCRC) patients with an asymptomatic primary tumor. Although the benefit of the anti-vascular endothelial growth factor agent bevacizumab alongside first-line chemotherapy in mCRC is established, the impact of bevacizumab on the intact primary tumor (IPT) is less well understood. METHODS: Data from an Australian mCRC registry were used to assess the impact of bevacizumab-based regimens in the presence of an IPT, to see if this differs from effects in resected primary tumor (RPT) patients and to understand the safety profile of bevacizumab in patients with IPT. Progression-free survival (PFS), overall survival (OS) and safety endpoints were analyzed. RESULTS: Of 1204 mCRC patients, 826 (69%) were eligible for inclusion. Bevacizumab use was similar in both arms (IPT (64%) versus RPT (70%)); compared with chemotherapy alone, bevacizumab use was associated with significantly longer PFS (IPT: 8.5 months vs 4.7 months, P = 0.017; RPT: 10.8 months vs 5.8 months, P < 0.001) and OS (IPT: 20 months vs 14.8 months, P = 0.005; RPT: 24.4 months vs 17.3 months, P = 0.004)).1 Bevacizumab use in an IPT was associated with more GI perforations (4.5% vs 1.8%, P = 0.210) but less frequent bleeding (1.5% vs 5.3%, P = 0.050) and thrombosis (1.5% vs 2.7%, P = 0.470), versus chemotherapy alone. Median survival was equivalent between patients that did or did not experience bevacizumab-related adverse events - 20.0 months versus 19.9 months, hazard ratio = 0.98, P = 0.623.1 CONCLUSIONS: The addition of bevacizumab significantly improved survival outcomes in mCRC with an IPT. The occurrence of bevacizumab-related adverse events did not significantly impact survival outcomes.

AIM: The aim of the study is to investigate the effectiveness of Peristeen retrograde continence enema (RCE) in the management of faecal incontinence in children with spina bifida. METHODS: We identified a homogenous group of spina bifida patients in whom RCE was initiated (Jan 2006-July 2013). Confidential assessments included (i) Fecal Incontinence Quality Of Life (FIQOL), (ii) St Marks Faecal Incontinence score, (iii) Cleveland Clinic Constipation score and (iv) Neurogenic Bowel Dysfunction score. RESULTS: Of 20 patients, 11 (mean age 14.5 ± 5.3 years) were male. Of 20 patients, nine were still using RCE (mean follow-up 4.1 years). Three patients ceased RCE within 10 days, six after 4-12 months and two after 36-48 months. Reasons for cessation included balloon difficulties (n = 4), procedure deemed too difficult (n = 4) and pain (n = 3). There were no differences between the groups in length of training time for technique, instillate fluid/volume used and time taken to perform RCE. There were no differences between the groups for quality of life, faecal incontinence or constipation scores. CONCLUSIONS: We demonstrated a high rate of cessation with RCE in patients with spina bifida. This could not be explained by associated conditions, or by enema-related parameters. One possible explanation is the lack of ongoing outpatient support for the children and their families.

CONTEXT: Longitudinal integrated clerkships (LICs) represent a model of the structural redesign of clinical education that is growing in the USA, Canada, Australia and South Africa. By contrast with time-limited traditional block rotations, medical students in LICs provide comprehensive care of patients and populations in continuing learning relationships over time and across disciplines and venues. The evidence base for LICs reveals transformational professional and workforce outcomes derived from a number of small institution-specific studies. OBJECTIVES: This study is the first from an international collaborative formed to study the processes and outcomes of LICs across multiple institutions in different countries. It aims to establish a baseline reference typology to inform further research in this field. METHODS: Data on all LIC and LIC-like programmes known to the members of the international Consortium of Longitudinal Integrated Clerkships were collected using a survey tool developed through a Delphi process and subsequently analysed. Data were collected from 54 programmes, 44 medical schools, seven countries and over 15 000 student-years of LIC-like curricula. RESULTS: Wide variation in programme length, student numbers, health care settings and principal supervision was found. Three distinct typological programme clusters were identified and named according to programme length and discipline coverage: Comprehensive LICs; Blended LICs, and LIC-like Amalgamative Clerkships. Two major approaches emerged in terms of the sizes of communities and types of clinical supervision. These referred to programmes based in smaller communities with mainly family physicians or general practitioners as clinical supervisors, and those in more urban settings in which subspecialists were more prevalent. CONCLUSIONS: Three distinct LIC clusters are classified. These provide a foundational reference point for future studies on the processes and outcomes of LICs. The study also exemplifies a collaborative approach to medical education research that focuses on typology rather than on individual programme or context.

Prisoners are a priority group for hepatitis C (HCV) treatment. Although treatment durations will become shorter using directly acting antivirals (DAAs), nearly half of prison sentences in Scotland are too short to allow completion of DAA therapy prior to release. The purpose of this study was to compare treatment outcomes between prison- and community-based patients and to examine the impact of prison release or transfer during therapy. A national database was used to compare treatment outcomes between prison treatment initiates and a matched community sample. Additional data were collected to investigate the impact of release or transfer on treatment outcomes. Treatment-naïve patients infected with genotype 1/2/3/4 and treated between 2009 and 2012 were eligible for inclusion. 291 prison initiates were matched with 1137 community initiates: SVRs were 61% (95% CI 55%-66%) and 63% (95% CI 60%-66%), respectively. Odds of achieving a SVR were not significantly associated with prisoner status (P=.33). SVRs were 74% (95% CI 65%-81%), 59% (95% CI 42%-75%) and 45% (95% CI 29%-62%) among those not released or transferred, transferred during treatment, or released during treatment, respectively. Odds of achieving a SVR were significantly associated with release (P<.01), but not transfer (P=.18). Prison-based HCV treatment achieves similar outcomes to community-based treatment, with those not released or transferred during treatment doing particularly well. Transfer or release during therapy should be avoided whenever possible, using anticipatory planning and medical holds where appropriate.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a complex therapeutic procedure that is complicated by pancreatitis in 3-5% of cases. The aim of this study is to determine whether a 4-h post-ERCP serum lipase level is superior to the serum amylase level in predicting the occurrence of post-ERCP pancreatitis (PEP). METHODS: We performed a retrospective review of prospectively collected data on 543 consecutive patients undergoing therapeutic ERCP at a single centre. Serum lipase and amylase levels were measured at 4-h post-procedure and were recorded as a factor of the upper limit of normal: amylase factor (AF) and lipase factor (LF). Sensitivity and specificity were compared using receiver-operating characteristics and the Youden index (YI). RESULTS: A total of 506 procedures were considered for analysis. PEP occurred in 19 patients (3.8%). A LF of <10 was useful for the exclusion of PEP with a sensitivity of 100% and a specificity of 94%, YI = 0.94. In contrast, an AF <3 yielded a sensitivity of 79% and specificity of 94%, YI = 0.73. CONCLUSION: Serum lipase measured at 4-h post-ERCP better excludes PEP than serum amylase measured at the same time point. Patients with a LF <10 may be safely considered for same-day discharge.

OBJECTIVE: General practitioners (GPs) fail to identify more than 50% of dementia cases using the existing passive case-finding approach. Using data from the "Ageing in General Practice" study, we sought to establish the additional benefit of screening all patients over the age of 75 for dementia beyond those patients already identified by passive case-finding. METHOD: Patients were classified as "case-finding" (n = 425) or "screening" (n = 1006) based on their answers to four subjective memory related questions or their GP's clinical judgement of their dementia status. Cognitive status of each patient was formally assessed by a research nurse using the Cambridge Cognition Examination (CAMCOG-R). Patients then attended their usual GP for administration of the GP assessment of Cognition (GPCOG) dementia screening instrument, and follow-up care and/or referral as necessary in light of the outcome. RESULTS: The prevalence of dementia was significantly higher in the case-finding group (13.6%) compared to the screening group (4.6%; p < 0.01). The GPCOG had a positive predictive value (PPV) of 61% in the case-finding group and 39% in the screening group; negative predictive value was >95% in both groups. GPs and their patients both found the GPCOG to be an acceptable cognitive assessment tool. The dementia cases missed via case-finding were younger (p = 0.024) and less cognitively impaired (p = 0.020) than those detected. CONCLUSION: There is a very limited benefit of screening for dementia, as most people with dementia could be detected using a case-finding approach, and considerable potential for social and economic harm because of the low PPV associated with screening.

AIMS: To understand the barriers and enablers to fertility-awareness education in general practice. BACKGROUND: Most women along with their primary care practitioners - general practitioners and practice nurses - believe that women should be educated about fertility-awareness when first reporting trouble conceiving. To date, no in-depth study has examined the enablers and challenges of this type of education in general practice. DESIGN: A descriptive exploratory qualitative study using deductive content analysis. METHODS: General practitioners (N = 11) and practice nurses (N = 20) were recruited from general practices in three socioculturally diverse areas in Victoria, Australia. Data were collected through semistructured interviews based on the 12 domains of a theoretical behaviour change framework from April-August 2012. The participants' responses were organized into themes that fall under the framework domains. FINDINGS: The biggest barriers to fertility-awareness education in general practice were short consultations and time constraints faced by general practitioners together with a lack of patient educational materials and remuneration to support its delivery. The biggest enablers were a greater use of nurses trained in fertility-awareness in a collaborative team care arrangement with general practitioners. CONCLUSION: This study has identified several important barriers and enablers to fertility-awareness education in general practice. Translation into practice of our findings is imperative as the first step in establishing a primary care model in fertility-awareness. This would fill an important gap in the primary care of infertile women and build capacity in general practice to reduce infertility through women's enhanced fertility knowledge.

OBJECTIVE: Restricted pulmonary function is found among people with diabetes. This study aimed to investigate the dose-response relationship between pulmonary function measurements [forced expiratory volume in one second (FEV1) and forced vital capacity (FVC)] and risk of metabolic syndrome (MS)/type 2 diabetes. METHODS: A total of 1454 adults in rural Victoria, Australia, and 5824 adults in Nanjing, China, from randomly selected households provided clinical history, oral glucose tolerance test, lipids, anthropometric, blood pressure and spirometric measurements. MS was defined by International Diabetes Federation criteria. Adjusted odds ratios for MS and type 2 diabetes with lung capacity measurements were estimated using logistic regression. Dose-response relationships were explored using the restricted cubic spline models. RESULTS: There was a nonlinear relationship between FEV1 and the risk of type 2 diabetes and MS (both P < 0·0001) in both the Australian and Chinese populations. The FEV1 associated with the lowest risk of type 2 diabetes and MS was above 2·70 l (95%CI: 2·68 to 2·72 l and 2·65 to 2·76 l in Chinese and Australian populations, respectively). The discrimination of the model could be significantly improved using the FEV1 threshold in both the Australian and Chinese populations. CONCLUSIONS: In both the Australian and Chinese populations, the risk of type 2 diabetes and MS is lowest with a FEV1 of 2·65-2·76 l. This might be used in clinical practice in different countries as a prompt to screen for type 2 diabetes and MS in patients with obstructive lung disease and to ensure there was no abnormal glucose metabolism before the commencement of steroids if indicated.

OBJECTIVES: To determine the prevalence of sporting injuries in a regional Australian setting and readiness of the rural health systems to combat the overall impact. DESIGN, SETTING AND PARTICIPANTS: Five years of data between 2008 and 2012 from the Victorian Emergency Minimal Dataset showing sports injuries presenting to Goulburn Valley Base Hospital Emergency Department (ED) were analysed. MAIN OUTCOME MEASURES: Prevalence of overall sporting injuries including different types and location of injury in the body, seasonal variation for emergency presentation, mechanism of injury and hospital admissions. RESULTS: We observed a total of 4537 Emergency presentations and 235 hospitalisations between 2008 and 2012 with sporting injuries. About 78% of injuries presented in the winter sporting months; the rate of injury was higher in the month of 'May' across the most data reviewing years. Also, there was a higher proportion of hospital admissions recorded in winter sporting months. We reported that those who played sports in winter were significantly younger than those in summer (P < 0.05). Sprains and strains due to different sporting activities were the commonest cause of ED presentations, while falls and collisions were the mostly reported mechanism for sporting injuries. CONCLUSION: It might be extrapolated from the data that within a regional setting, there is a need to optimise emergency departments and hospital bed availability with emphasis on orthopaedic involvements during the winter sporting months. Many of these sports injuries are preventable and community risk reduction strategies should be applied to reduce the burden to the regional hospitals.

In the context of persisting health inequities within many multicultural and socially diverse countries like Australia, there is a call for health services to implement culturally inclusive systems and practices. Nowhere is this more important than in regional, rural and remote Australia where consumers are diverse, health services are scarce, and services designed for particular groups of the population are lacking. Drawing on interviews with 20 staff of a rurally-based, mainstream community health service, this article examines the role of discourse in the transition to a culturally inclusive health centre. In doing so, the power struggles inherent in such a process are highlighted. The article contends that improvements in the health outcomes of First Nation and culturally Other groups within the Australian population is contingent upon systematic resistances that disrupt and re-arrange existing dominant discourses. This calls for a disruption of current race relations in both broader social fields as well as those supporting biomedical assumptions about the delivery of healthcare in the mainstream health sector. Alternative discourses must be promoted in both these fields.

Although health services in Australia have an aim to provide inclusive care for their patients/clients, this study highlights how barriers to care can lie at the centre of patient-provider interactions. Racial microaggression is a subtle form of racism that can occur in health settings, leading to further exclusion for First Nations Australians, immigrants and refugees. This paper is guided by Derrida's approach to deconstructionism by unpacking how language is used by health professionals - as holders of organisational power - and how they construct 'truths' or discourses about clients that historically have been marginalised by health services and system. Data comprise 21 interviews with staff from two rural health services. It identified three racial microaggressions were used to justify the challenges of providing care to people from First Nations, immigrant and refugee backgrounds: (1) Participants problematised culture(s) of service users; (2) participants implied cultural superiority in their conceptualisation of 'other' cultures; and (3) participants shared stories of inactions, discomfort and relegating of responsibility. The findings identified these discourses as forms of racial microaggression that can potentially lead to further exclusion of people seeking services and support.

Across the globe, people are not equitably included or respected by health services. This results in some people being 'hardly reached' and having less access to safe and appropriate care. While some health services have adopted specific agendas to increase inclusion, these services can struggle to implement such strategies because the underlying reasons for exclusion have not been addressed. This calls for preparation prior to implementation of inclusion approaches that deconstructs discourses and practices of exclusion. This paper presents a pre-inclusion framework that seeks to deconstruct exclusion in health services. Authors developed this framework from action research in four 'mainstream' regional health services in southeast Australia over five years. Research identified dominant discourses of exclusion among staff in these services. The study also identified common experiences of residents hardly reached by these services. Following, a range of change activities were undertaken within these services to deconstruct exclusion. Researchers also kept journals, reflected on their impact, and identified lessons learned from trying to deconstruct exclusion. Triangulating these analyses, researchers developed an interdisciplinary framework that weaves together Foucauldian theory on power/discourse with continuous quality improvement processes to embed cultural humility and voices of the hardly reached in health care. The framework outlines five foundational concepts (power as productive, deconstruction, use of continuous quality improvement processes, cultural humility and voices of service users), followed by six principles (a journey, expect resistance, whole of service approach, make visible the reasons for change, we are all cultural beings and people centred care) and six actions undertaken within health services (commitment, assessment of exclusion, action plans, structural change, reflective discussions and engagement). Until such approaches to deconstruct exclusion are implemented, inclusive agendas are likely to be ineffective.

BACKGROUND: Mental health policies outline the need for codesign of services and quality improvement in partnership with service users and staff (and sometimes carers), and yet, evidence of systematic implementation and the impacts on healthcare outcomes is limited. OBJECTIVE: The aim of this study was to test whether an adapted mental health experience codesign intervention to improve recovery-orientation of services led to greater psychosocial recovery outcomes for service users. DESIGN: A stepped wedge cluster randomized-controlled trial was conducted. SETTING AND PARTICIPANTS: Four Mental Health Community Support Services providers, 287 people living with severe mental illnesses, 61 carers and 120 staff were recruited across Victoria, Australia. MAIN OUTCOME MEASURES: The 24-item Revised Recovery Assessment Scale (RAS-R) measured individual psychosocial recovery. RESULTS: A total of 841 observations were completed with 287 service users. The intention-to-treat analysis found RAS-R scores to be similar between the intervention (mean = 84.7, SD= 15.6) and control (mean = 86.5, SD= 15.3) phases; the adjusted estimated difference in the mean RAS-R score was -1.70 (95% confidence interval: -3.81 to 0.40; p = .11). DISCUSSION: This first trial of an adapted mental health experience codesign intervention for psychosocial recovery outcomes found no difference between the intervention and control arms. CONCLUSIONS: More attention to the conditions that are required for eight essential mechanisms of change to support codesign processes and implementation is needed. PATIENT AND PUBLIC INVOLVEMENT: The State consumer (Victorian Mental Illness Awareness Council) and carer peak bodies (Tandem representing mental health carers) codeveloped the intervention. The adapted intervention was facilitated by coinvestigators with lived-experiences who were coauthors for the trial and process evaluation protocols, the engagement model and explanatory model of change for the trial.

PURPOSE: To understand how frequently exercise is discussed and/or prescribed as a supportive care measure and the barriers and facilitators to exercise uptake for men with prostate cancer receiving androgen deprivation therapy (ADT) at a regional cancer centre. METHODS: An observational, cross-sectional study was conducted at a regional cancer centre in three stages: (1) Retrospective chart review of men with prostate cancer undergoing ADT to identify the frequency of discussion and/or prescription of supportive care measures; (2) prospective patient survey exploring barriers and facilitators to exercise; and (3) prospective clinician survey exploring barriers, facilitators and awareness of exercise guidelines in men with prostate cancer. RESULTS: Files of 100 men receiving ADT (mean age 73 years; mean ADT duration =12 months) in the medical oncology (n = 50) and radiation oncology (n = 50) clinics were reviewed. Exercise was discussed with 16% of patients and prescribed directly to 5%. Patient survey (n = 49). 44.2% of patients reported participating in exercise at a high level. Common barriers to exercise participation included fatigue (51.0%), cancer/treatment-related weakness (46.9%) and joint stiffness (44.9%). 36.7% of patients reported interest in a supervised exercise program. Clinician survey (n = 22). 36.4% identified one or more exercise guidelines, and 40.9% correctly identified national exercise guidelines. Clinicians reported low knowledge of referral pathways to a supervised exercise program (27.3%). Clinicians believe physiotherapists (95.5%) are most suited to exercise prescription and 72.7% stated that exercise counselling should be part of supportive care. Limited time (63.6%) and patient safety (59.1%) were the two most common barriers to discussing exercise with patients. Clinicians reported that only 21.9% of their patients asked about exercise. The most endorsed facilitators to increase exercise uptake were patient handouts (90.9%) and integration of exercise specialists into the clinical team (86.4%). CONCLUSION: Despite a third of patient respondents indicating an interest in a supervised exercise program, only 16% of patients with prostate cancer undergoing ADT at a regional cancer centre engaged in a discussion about exercise with their treating clinicians. Physical limitations and fatigue were the greatest barriers for patients. Clinicians indicated a need for more clinician education and better integration of exercise specialists into clinical care. A tailored, integrated approach is needed to improve the uptake of exercise in men with prostate cancer.

Background: Hypertension, as one of the main predisposing factors of many non-communicable diseases, is generally underdiagnosed among women with a significant uncontrolled rate. This study explores the understanding, management practice and challenges related to hypertension among hypertensive women in rural Bangladesh. Methods: A qualitative study was conducted among hypertensive rural women at Kumarkhali Upazilla, Kushtia, Bangladesh, using purposive and snowball sampling technique. Data was collected through in-depth interviews among twenty-three hypertensive women until they reached saturation. Data were analyzed thematically. Results: Findings of the study found that a small number of participants perceived the symptoms, risk factors, management and treatment of hypertension based on biomedical understanding. Also, their awareness level and adherence to preventive practices reflected a significant gap between biomedical preventive practices and local practices. A substantial number of participants preferred home management and alternative treatment for hypertension over the medication adherence and hospital treatment. This investigation revealed that poor socio-economic conditions, such as financial insufficiency, and, gender-based negligence impacted women's perception of and practice for hypertension and resulted in risky hypertension management behaviors. Conclusion: Based on the study, formulation of a comprehensive health education program for creating awareness, provisioning of significant interventions services related to hypertensive care are needed. Further intensive research is needed at the community-level to manage this chronic disease.

OBJECTIVE: Prior to coronavirus disease (COVID-19), many Australians experienced extreme bushfires, droughts, and floods. A history of experiencing these events might be a risk factor for increased psychological distress during COVID-19. This study aimed to provide insight into the mental health of Australian workers during the initial COVID-19 outbreak, with an additional focus on whether previous disaster exposure and impact from that disaster is a risk factor for increased psychological distress. METHODS: A snowball recruitment strategy was used. Participants (n = 596) completed an online survey, which included the Depression Anxiety Stress Scales-21, and questions related to mental health and disaster exposure. RESULTS: Overall, 19.2%, 13.4%, and 16.8% of participants were experiencing moderate to extremely severe depression, anxiety, and stress symptoms, respectively. Multiple regression found that higher depression, anxiety, and stress symptoms were associated with a pre-existing mental health diagnosis; only higher stress symptoms were associated with having experienced a disaster, with impact, in addition to COVID-19. CONCLUSIONS: People who have experienced impact from an additional disaster might need additional support to protect their mental health during COVID-19. A focus on the cumulative mental health impacts of multiple disasters and the implications for organizational communities where recovery work is undertaken, such as schools and workplaces, is needed.

Selective digestive decontamination (SDD) regimens, variously constituted with topical antibiotic prophylaxis (TAP) and protocolized parenteral antibiotic prophylaxis (PPAP), appear highly effective for preventing ICU-acquired infections but only within randomized concurrent control trials (RCCT's). Confusingly, SDD is also a concept which, if true, implies population benefit. The SDD concept can finally be reified  in humans using the broad accumulated evidence base, including studies of TAP and PPAP that used non-concurrent controls (NCC), as a natural experiment. However, this test implicates overall population harm with higher event rates associated with SDD use within the ICU context.

INTRODUCTION: Access to high-quality primary healthcare is limited for remote residents in Australia. Increasingly, remote health services are reliant on short-term or 'fly-in, fly-out/drive-in, drive-out' health workforce to deliver primary healthcare. A key strategy to achieving health service access equity, particularly evident in remote Australia, has been the development of Aboriginal Community Controlled Health Services (ACCHSs). This study aims to generate new knowledge about (1) the impact of short-term staffing in remote and rural ACCHSs on Aboriginal and Torres Strait Islander communities; (2) the potential mitigating effect of community control; and (3) effective, context-specific evidence-based retention strategies. METHODS AND ANALYSIS: This paper describes a 3-year, mixed methods study involving 12 ACCHSs across three states. The methods are situated within an evidence-based programme logic framework for rural and remote primary healthcare services. Quantitative data will be used to describe staffing stability and turnover, with multiple regression analyses to determine associations between independent variables (population size, geographical remoteness, resident staff turnover and socioeconomic status) and dependent variables related to patient care, service cost, quality and effectiveness. Qualitative assessment will include interviews and focus groups with clinical staff, clinic users, regionally-based retrieval staff and representatives of jurisdictional peak bodies for the ACCHS sector, to understand the impact of short-term staff on quality and continuity of patient care, as well as satisfaction and acceptability of services. ETHICS AND DISSEMINATION: The study has ethics approval from the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research (project number DR03171), Central Australian Human Research Ethics Committee (CA-19-3493), Western Australian Aboriginal Health Ethics Committee (WAAHEC-938) and Far North Queensland Human Research Ethics Committee (HREC/2019/QCH/56393). Results will be disseminated through peer-reviewed journals, the project steering committee and community/stakeholder engagement activities to be determined by each ACCHS.

OBJECTIVE: High-quality data regarding the prevalence of chronic disease in rural areas are essential in understanding the challenges faced by rural populations and for informing strategies to address health care needs. This study compared the prevalence of a range of self-reported chronic conditions and utilisation of GP services and emergency department in a regional Victorian setting between two studies conducted in the same region in 2001-2003 and 2014. DESIGN: Repeat cross-sectional studies conducted over a decade apart. SETTING: The projects were conducted in the Goulburn Valley in regional Victoria. PARTICIPANTS: The earlier study randomly selected households from local government lists. The later study randomly selected householders from the telephone directory. MAIN OUTCOME MEASURES: Participants were asked whether they had been diagnosed with a range of chronic health conditions and how often they had visited a general practitioner or emergency department in the past 12 months. RESULTS: The age-standardised prevalence of depression was higher in the 2014 study than the 2001-2003 study in men (increased by 8.0% (95% CI 4.5, 11.5%)) and women (increased by 13.7% (95% CI 8.4, 19.0%)). Similarly, the prevalence of age-standardised diabetes and hypertension was higher in 2014 than 2001-2003 (men increased by 3.6% (95% CI 0.7, 6.5% (diabetes)) and 13.6% (95% CI 8.6, 18.6% (hypertension)), women increased by 3.1% (95% CI 0.3, 6.5% (diabetes)) and 8.4% (95% CI 2.3, 14.5% (hypertension))). CONCLUSION: The results of this study indicate that the prevalence of self-reported depression, diabetes and hypertension has increased in this regional Victorian area over the past 13 years. The reasons for these observed increases and the subsequent impact on the health care needs of regional communities warrants further investigation.

BACKGROUND: Anorectal malformations (ARM) are common congenital abnormalities of the terminal hindgut. Ideally, ARM should be diagnosed at, or shortly following, birth by careful physical examination of the perineum. Delayed diagnosis has been implicated as a risk factor for complications, including intestinal perforation. This study aimed to determine the rate of delayed diagnosis and associated intestinal perforation in ARM. METHODS: A retrospective review was performed for all ARM patients managed at The Royal Children's Hospital over a 16-year period (2000-2015). Data collected included ARM type, timing of diagnosis and complications. Delayed diagnosis was defined as being at more than 24 h of age. RESULTS: A total of 243 ARM patients (male 146/243, 60%) were included. The most frequent ARM types were perineal fistula (83/243, 34%) and rectovestibular fistula (40/243, 16%). Diagnosis was delayed beyond 24 h of age in 92 of 243 (38%) patients. The ARM type most commonly delayed in diagnosis was perineal fistula (37/83, 45%). Two patients in whom diagnosis was delayed suffered an intestinal perforation. CONCLUSION: Delayed diagnosis in ARM patients remains a common, and potentially fatal, occurrence. Improved assessment of newborns is required to ensure timely diagnosis of ARM, and avoidance of complications associated with delayed diagnosis.

AIM: Current International Association of the Diabetes and Pregnancy Study Groups/World Health Organization gestational diabetes mellitus (GDM) diagnostic thresholds are based on a landmark study in which the pre-analytical plasma glucose sampling methodology is unclear. Worldwide, plasma glucose pre-analytical sampling methodology practices are divergent. We considered the effects of pre-analytical plasma glucose sampling methodology on GDM prevalence and gestational outcomes. METHODS: This is a retrospective observational cohort study of 1178 pregnant women undergoing an oral glucose tolerance test (OGTT). Of the 1178 pregnant women, a subset of 892 non-GDM women with singleton births undergoing OGTT between 24 and 28 weeks' gestation were investigated for large for gestation age (LGA) outcomes. OGTT were determined using traditional methods (sodium fluoride tubes batched at roomed temperature). We modelled the potential effects of using a recommended pre-analytical plasma glucose methodology (lyophilized citrate tubes) on GDM prevalence. RESULTS: The GDM prevalence in our cohort was 13.5%. The incidence of LGA showed a linear association with maternal plasma glucose that was similar to the association observed in the Hyperglycemia and Adverse Pregnancy Outcome study. Frequency of LGA exceeded 10% at HAPO glucose category 4 (fasting, 4.8 to 4.9 mmol/l; 1-h, 8.7 to 9.5 mmol/l) for fasting and 1-h plasma glucose. The use of a recommended pre-analytical method is projected to increase the prevalence of GDM to 39.2%. CONCLUSION: We challenge the consensus that recommended pre-analytical plasma glucose methodologies are optimal for the accurate diagnosis of GDM. Recommended pre-analytical plasma glucose methods may profoundly over-diagnose GDM. Centres using recommended pre-analytical plasma glucose methodologies may need to reappraise their diagnostic thresholds.

BACKGROUND: Pertuzumab, when combined with trastuzumab and chemotherapy, is a highly active human epidermal growth factor receptor 2 (HER2), targeting agent in the neoadjuvant, adjuvant and first-line metastatic HER2-positive breast cancer setting. The efficacy of late-line (after first/second-line) pertuzumab in combination with trastuzumab and chemotherapy is unknown. AIMS: To establish pertuzumab efficacy by performing an audit of patients who received pertuzumab after first-line HER2 directed therapy. We sought to establish whether efficacy differed by clinicopathological factors. METHODS: The primary endpoint was progression-free survival (PFS) and the secondary endpoint, overall survival (OS). Clinicopathological factors, PFS and OS data were collated and clinicopathological factors associated with PFS were evaluated using Cox regression models. RESULTS: Fourteen women were identified. Six (43%) had hormone receptor (HR) negative and eight (57%) had HR-positive, metastatic HER2-positive breast cancer. Median follow up was 22.8 months, median prior lines of therapy were 5 (range: 1-9). Median time from diagnosis of metastatic disease to receiving pertuzumab was 4.5 years (range: 4.2-5.8). All patients received initial chemotherapy with pertuzumab and trastuzumab (taxane-based 71%). Median PFS was 9 months (95% confidence interval [CI]: 7-not estimable [NE]) and median OS was not reached (95% CI, 16 months-NE). Univariable analysis demonstrated that HR-negative patients had a significantly longer PFS than HR-positive patients (hazard ratio = 0.11; 95% CI, 0.01-0.88; P = 0.04). CONCLUSION: This small cases series reports a favorable PFS and OS for pertuzumab with trastuzumab and chemotherapy in the later line metastatic setting. This finding warrants further study.

OBJECTIVE: The need for more Remote Area Nurses in the Northern Territory is clear. This paper investigates the perspectives of Remote Area Nurse workforce issues among multiple stakeholders. The aim is to identify how Remote Area Nurse staffing issues are perceived by clinic managers, Remote Area Nurses themselves, Aboriginal colleagues and community members in seven remote communities in the Northern Territory. DESIGN: This is a qualitative study that uses interviews and focus groups to identify key messages of local stakeholders about Remote Area Nurse workforce issues. A content analysis was used for data analysis. SETTING: Seven diverse remote Aboriginal communities in the Northern Territory with government-run health clinics were visited. PARTICIPANTS: Non-random sampling techniques were used to target staff at the clinics at the time of field work. Staff and community members, who agreed to participate, were interviewed either individually or in groups. Interviews were conducted with 5 Managers, 29 Remote Area Nurses, 12 Aboriginal staff (some clinics did not have Aboriginal staff) and 56 community residents. Twelve focus groups were conducted with community members. RESULTS: Content analysis revealed that participants thought having the "right" nurse was more important than having more nurses. Participants highlighted the need for Remote Area Nurses to have advanced clinical and cultural skills. While managers and, to a lesser extent, Remote Area Nurses prioritised clinical skills, Aboriginal staff and community residents prioritised cultural skills. CONCLUSIONS: Participants identified the importance of clinical and cultural skills and reiterated that getting the "right" Remote Area Nurse was more important than simply recruiting more nurses. Thus, retention strategies need to be more targeted and cultural skills prioritised in recruitment.

BACKGROUND: Anorectal malformations (ARM) are common congenital abnormalities of the terminal hindgut. The high incidence of associated anomalies necessitates systematic screening, which should include renal and spinal ultrasonography, spinal radiography and an echocardiogram. This study aimed to determine the incidence of associated anomalies in ARM, and whether screening protocols were appropriately applied. METHODS: A retrospective review was performed of all ARM patients managed at The Royal Children's Hospital, Melbourne over a 16-year period (2000-2015). Data collected included ARM type, presence of associated anomalies, as well as utilization of renal and spinal ultrasonography, spinal radiography and echocardiography. RESULTS: A total of 243 patients (male 146/243, 60%) were reviewed. The most frequent ARM types were perineal fistula (83/243, 34%) and rectovestibular fistula (40/243, 16%). Full screening was performed in 153/243 (63%), while 18/243 (7%) received no screening. In fully screened patients, associated anomalies were diagnosed in 143/153 (93%), with cardiovascular, renal and musculoskeletal anomalies being most frequent. CONCLUSIONS: The high incidence of associated anomalies identified in fully screened ARM patients highlights the importance of systematic screening. Clinically significant anomalies may have been overlooked in the more than one-third of ARM patients in whom screening was absent or incomplete. Standardized screening protocols for ARM patients have now been implemented.

BACKGROUND: Emerging evidence on the optimal use of chemotherapy and biologics in patients with metastatic colorectal cancer should impact management in routine care. Recent studies have demonstrated benefits for initial triplet chemotherapy (5-fluorouracil, oxaliplatin and irinotecan, FOLFOXIRI) and for initial treatment with an epidermal growth factor receptor inhibitor (EGFRi) in patients with a RAS wild-type tumour and a left-sided primary tumour. AIM: To explore evolving pattern of metastatic colorectal cancer care over time in Australia. METHODS: We analysed data from the Treatment of Recurrent and Advanced Colorectal Cancer registry. RESULTS: From July 2009 to December 2017, 2552 metastatic colorectal cancer patients were entered into the Treatment of Recurrent and Advanced Colorectal Cancer registry. Of 1585 patients who initially underwent chemotherapy, treatment was with a doublet in 76%. FOLFOXIRI was given to 22 patients (1.4%), mostly young patients and those with potentially resectable disease. Along with first-line chemotherapy, 61% received bevacizumab, while 3.3% received an EGFRi, predominantly over the last 2 years. Within the KRAS wild-type left-sided tumour cohort, EGFRi use increased from 9% in 2015 to 37% in 2017. Across treatment sites, there was a wide variation in the utilisation of FOLFOXIRI and EGFRi therapy; bevacizumab use was more consistent. A clear impact on survival outcomes from these regimens is not evident, potentially due to multiple confounders. CONCLUSION: Doublet chemotherapy + bevacizumab remains the dominant initial strategy, with limited uptake of triplet chemotherapy and of EGFRi. Potential explanations include uncertainty about the significance of post hoc analyses for EGFRi and concerns regarding adverse events for both strategies.

OBJECTIVE: The quality of acute stroke care in a regional Victorian hospital (study hospital) was assessed by comparing with selected standard indicators of Acute Stroke Clinical Care. DESIGN: A retrospective review of records of patients with stroke was performed manually and by reviewing electronic database. SETTING: The study was carried out in Goulburn Valley Health, one of the five regional referral and teaching hospitals in Victoria, Australia. PARTICIPANTS: Patients with stroke who were discharged from the study hospital between October 2015 and March 2016. MAIN OUTCOME MEASURES: Timeliness of brain imaging, proportion of patients thrombolysed if arrived within 4.5 hours of stroke and timeliness of thrombolysis. RESULTS: A total of 66 patients' records was found. Brain imaging was completed for 45%, compared to 25.8% nationally, if arrived to the study hospital within 1 hour of stroke and 100% imaging completed within 24 hours of arrival, compared to 75.6% nationally. When patients arrived to the emergency department within 4.5 hours of stroke, 37.5% (23.6% nationally and 18.6% in similar- sized hospitals) of them were thrombolysed, while none was thrombolysed within 60 minutes of arrival. Door-to-thrombolysis time was 85 minutes, 7 minutes longer than national standard. Symptoms onset to thrombolysis time was 225 minutes, 55 minutes longer than national standard. CONCLUSION: The timeliness of brain imaging and thrombolysis was comparable in the study hospital to that of the national standard, while other stroke management indicators still require improvement. Continuing efforts for improvement and revisiting possible areas of delay are warranted.

INTRODUCTION: Rural and remote populations experience the greatest burden of chronic obstructive pulmonary disease (COPD), the fifth leading cause of death in Australia. Currently there is a need to prioritise health services to improve health outcomes among those at higher risk of COPD. OBJECTIVES: To investigate the differences in COPD hospitalisation between rural and urban populations and determine predictive factors contributing to COPD hospitalisation. METHODS: Statewide hospitalisation data from 2010 to 2015 were obtained through the Victorian Admitted Episodes Dataset and other key data sets. The rates of hospitalisation were analysed using hierarchical multiple regression to examine the association between COPD hospitalisations and a number of predictor variables. RESULTS: The highest COPD incidence occurred in metropolitan males aged 85 years of age and older (35.092 hospitalisations per 1000 population). Among metropolitan residents, smoking, population density and household income had a significant association with COPD hospitalisations for both sexes. Among rural males, smoking rates, household income and rural land use (farming) were significant predictors of COPD hospitalisations. There was an overall stability in statewide COPD hospitalisation over the 5 years to 2015, P = 0.420. CONCLUSION: This investigation highlights many rural and regional areas have much lower COPD hospitalisation rates than metropolitan areas. Between males and females, there are heterogenetic factors that contribute to the significant variation associated with COPD hospitalisation in metropolitan and rural areas, such as rural land use among rural males. This indicates that risk factor assessments, beyond smoking alone, need to be individualised and prioritised in practice to optimise care.

A retrospective observational study of 21 patients admitted to the Intensive Care Unit (ICU) of Frankston Hospital with acute asthma between 2011 and 2014 was undertaken. We report the outcomes for three groups of patients; those that did (n = 7) or did not (n = 6) receive initial therapy with non-invasive ventilation (NIV) together with those that received invasive ventilation (n = 8). Patients successfully managed with NIV alone experienced a shorter ICU and hospital stay versus those who required invasive ventilation.

INTRODUCTION: Integrity is one of the core values in nursing that needs to be maintained by nurses in practice. However, the complexity in the nursing milieu can pose threats to integrity. An understanding of the common threats and coping strategies might assist nurses in preserving integrity in everyday practice. AIMS AND OBJECTIVES: To review and synthesis the concept of integrity in nursing and identify common threats and coping strategies. METHODS: Whittemore and Knafl's integrative review method was implemented. A search was performed in Scopus, Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Proquest Health and Medical electronic databases published in English between 2000-2017. Two reviewers independently assessed eligibility for inclusion. Methodological appropriateness for the included studies was assessed using the critical appraisal skills programme. The constant comparative method of grounded theory was used to analyse and synthesise data from seven peer-reviewed articles. RESULTS: Two major conceptions of integrity were identified. These included the sense of wholeness with regard to personal-professional concerns and ethical-moral conducts. Five entities, self, patients, teamwork and work culture, the nature of work, and organisation, were identified as interweaving elements that may induce threats to integrity. When integrity is threatened, nurses use two key strategies to survive: adjusting and compensating. An emergent framework to facilitate understanding of nurses' threats to integrity is discussed. CONCLUSIONS: A threat to nurses' integrity takes form when there is an unmitigated gap between a nurse's expectation and reality. While the expectation comes from within the nurse, the reality materialises out of the complex interplays that occur in the healthcare workforce. Maintaining integrity demands a continual strive to balance personal expectations, professional concerns and nursing realities.

Progressive aged care reforms are shifting dementia care into the community. These efforts have been shown to prevent transition to residential aged care facilities and hospitals. There is a paucity of studies examining the utilisation of home care services for people living with dementia. This study aims to address the current knowledge gap by providing a comprehensive summary of older adults receiving home care and comparing service use for people with and without dementia. A retrospective secondary data analysis was conducted using routine data prospectively collected from a cohort (n = 2,703 with dementia matched to 9,224 without dementia; total 11,927) using a community home nursing service in metropolitan Melbourne, Australia, in 2014. Descriptive statistics compared individuals with and without dementia on client-level demographics and their episode of home care service use. A comparative analysis on select variables was also performed using a conditional Poisson regression to estimate relative risk (RR). Compared to older adults without dementia, people with dementia were more likely to be born overseas (RR 1.10, 95% CI [1.03-1.19]), require an interpreter (RR 1.41, 95% CI [1.26-1.59]), and live with family (RR 1.09 [1.01-1.16]). When examining an individual's episode of care, people with dementia were more likely to require acute care (RR 1.07, 95% CI [1.01-1.14]) and be discharged from home care with personal care services (RR 1.46, 95% CI [1.24-1.72]). People with dementia were less likely to be referred from a hospital (RR 0.73, 95% CI [0.69-0.77]), achieve their home care goals (RR 0.91, 95% CI [0.87-0.94]), or die while in receipt of home care services (RR 0.82, 95% CI [0.72-0.94]). Our findings suggest that people with dementia have different socio-demographic characteristics and interactions with home care services compared to people without dementia.

BACKGROUND: Paperwork is a key tool that transforms organizational intentions into actions in group homes, although prescriptive procedures may limit how frontline staff use it in practice. The aim of this study was to explore how frontline staff use paperwork in group homes for people with intellectual disability and identify practice implications. METHOD: Constructivist grounded theory methodology guided the research. Data collection included semi-structured interviews and participant observations. Coding, comparison and sorting methods were adopted to analyse how staff used paperwork. RESULTS: Staff followed organizational paperwork rules when they aligned with their resident-focused approach to work. When they perceived rules to misalign with this approach, they managed paperwork by adjusting the time and place of completion, managing content, creating alternative tools and refusing completion. CONCLUSIONS: Staff purposefully managed paperwork rather than simply following procedures. Disability service organizations could develop flexible paperwork procedures and include frontline perspectives in paperwork development.

AIM: To increase understanding of strategies graduate nurses use on a day-to-day basis to integrate themselves into pre-existing social frameworks. BACKGROUND: Being a graduate nurse and transitioning from a novice to beginner in the first year of clinical practice is stressful, challenging and overwhelming due to steep learning curves and adjusting to working in professional environments. How graduate nurses socially adapt and fit into ward cultures is a hurdle to successful transition and can be difficult. DESIGN: A qualitative constructivist grounded theory methodology was used. METHODS: Seven adult, Registered Nurses were recruited using a purposive sampling technique. Participants were undertaking a graduate nurse transition programme, in one of two acute care, adult public hospitals in South Australia. Data collection conducted in 2016 used individual interviews consisting of open-ended questions in an unstructured format. Transcripts were transcribed verbatim. Data analysis processes included initial and focused coding, theory building, memo-writing and theoretical sampling. RESULTS: Three main categories: self-embodiment and self-consciousness, navigating the social constructs and raising consciousness, supported by subcategories describe the main strategies graduate nurses use to facilitate adaptation into complex clinical environments and ward cultures. Subsequent concept and theory development explains how graduate nurses find the social and professional balance to fit in. CONCLUSIONS: Understanding the graduates' adaptation strategies can inform improvements in graduate nurse transition programmes. Facilitating and enhancing graduate nurse adaptation is the precursor in creating more resilient nurses ready to face the challenges that exist in today's work environments.

As many patients' sole point of contact with the health care system, primary health care physicians (general practitioners [GPs] in Australia) are often positioned as key players in responding to rates of overweight and obesity in dominant public discourse. However, research from Western industrialised countries suggests that GPs may not be prepared for, or confident in, having conversations about overweight and obesity with patients. Little attention has been given to this topic in Australia, particularly in the context of rural health. The aim of this study was to understand how GPs in two rural settings in Victoria, Australia talk about overweight and obesity with patients. Working from a multidisciplinary perspective, a qualitative study design was adopted, and semi-structured interviews were conducted with seven GPs and seven GP patients living in two rural communities between January and April, 2016. Data was coded manually and thematic analysis was used to explore the data. The findings of this study support the argument that, in contrast to dominant messages within public health discourses, GPs may not be best placed to act as the primary actors in responding to overweight and obesity as they are constructed in epidemiological terms. In fact, the perspectives of GP study participants suggest that to do so would compromise important dimensions of general medical practice that make it simultaneously a human practice. Instead, more balanced, holistic approaches to discussing and responding to overweight and obesity with patients could be taken up in local, interdisciplinary collaborations between different health professionals and patients, which utilise broader social supports. Focussing on long-term, incremental programs that consider the whole person within their particular socio-cultural environment would be a productive means of working with the complexities of overweight and obesity. However, structural level changes are required to ensure such initiatives are sustainable in rural practice.

OBJECTIVE: To examine the effects of dominant knowledge in rural health, including how they shape issues central to rural health. In particular, this article examines the roles of: (i) deficit knowledge of rural health workforce; (ii) dominant portrayals of generalism; and (iii) perceptions of inferiority about rural communities in maintaining health disparities between rural- and metropolitan-based Australians. DESIGN: A Foucauldian framework is applied to literature, evidence, case studies and key messages in rural health. Three scenarios are used to provide practical examples of specific knowledge that is prioritised or marginalised. RESULTS: The analysis of three areas in rural health identifies how deficit knowledge is privileged despite it undermining the purpose of rural health. First, deficit knowledge highlights the workforce shortage rather than the type of work in rural practice or the oversupply of workforce in metropolitan areas. Second, the construction of generalist practice as less skilled and more monotonous undermines other knowledge that it is diverse and challenging. Third, dominant negative stereotypes of rural communities discourage rural careers and highlight undesirable aspects of rural practice. CONCLUSION: The privileging of deficit knowledge pertaining to rural health workforce, broader dominant discourses of generalism and the nature of rural Australian communities reproduces many of the key challenges in rural health today, including persisting health disparities between rural- and metropolitan-based Australians. To disrupt the operations of power that highlight deficit knowledge and undermine other knowledge, we need to change the way in which rural health is currently constructed and understood.

INTRODUCTION: The need to measure reporting workload in teaching departments remains a current pertinent need. In Australia, the Pitman-Jones reporting RVUs have been in the public domain since 2003 (revised in 2009). These are expressed in arbitrary units. In New Zealand, single-site Christchurch Hospital reporting times have been validated and placed in the public domain. Concurrently, the RANZCR has been developing a formulaic descriptor lexicon for imaging studies (the Body System Framework). There is a need to bring these three strands of work together into a common public resource. In 2015, under the auspices of the Chief Accreditation Officer, RANZCR convened the Radiologist Workload Working Group. The goal of the group was to develop a robust method of measuring radiologist workload in teaching departments in Australia and New Zealand for the RANZCR accreditation processes of teaching departments as training sites. This paper concerns itself with one aspect of the group's work, namely reaching a consensus on radiologist study ascribable times for common imaging studies. METHOD: The BSF examination descriptors were reduced to a smaller, generic dataset of descriptors at the expense of loss of specificity. BSF study ascribable times had been previously obtained by stopwatch observation. The dataset was harmonized with the Christchurch descriptors to ensure commonality of case mix. The two lead authors reached an approximate consensus study ascribable time for each descriptor in agreement with the BSF and Christchurch data. Specifically, the Christchurch reporting times were relied on extensively to validate the new dataset's study ascribable times. The first draft of descriptors and times was tabled at the meetings of the RANZCR Radiologist Workload Working Group, and was progressively refined by iterative consensus. RESULTS: The output of the Radiologist Workload Working Group comprises a simplified modality-based table of robust descriptors and 'best estimate' corresponding study ascribable times. These can be used with the extant Pitman-Jones methodology in order to estimate the reporting workload of a medical imaging teaching department in units of time. As a first for Australia and New Zealand, nuclear medicine and PET study ascribable times have been incorporated and balanced against radiology study ascribable times. CONCLUSION: The RANZCR 2016 study ascribable times are ready for use by the Australian and New Zealand radiologist and nuclear medicine specialist community. We hope these times will also stimulate further data collection in our two countries towards a robust, bi-national study ascribable times database.

BACKGROUND: The sickest Australians are often those belonging to non-privileged groups, including Indigenous Australians, gay, lesbian, bisexual, transsexual, intersex and queer people, people from culturally and linguistically diverse backgrounds, socioeconomically disadvantaged groups, and people with disabilities and low English literacy. These consumers are not always engaged by, or included within, mainstream health services, particularly in rural Australia where health services are limited in number and tend to be generalist in nature. OBJECTIVE: The aim of this study was to present a new approach for improving the sociocultural inclusivity of mainstream, generalist, rural, health care organisations. DESIGN: This approach combines a modified Continuous Quality Improvement framework with Participatory Action Research principles and Foucault's concepts of power, discourse and resistance to develop a change process that deconstructs the power relations that currently exclude marginalised rural health consumers from mainstream health services. It sets up processes for continuous learning and consumer responsiveness. RESULTS: The approach proposed could provide a Continuous Quality Improvement process for creating more inclusive mainstream health institutions and fostering better engagement with many marginalised groups in rural communities to improve their access to health care. CONCLUSION: The approach to improving cultural inclusion in mainstream rural health services presented in this article builds on existing initiatives. This approach focuses on engaging on-the-ground staff in the need for change and preparing the service for genuine community consultation and responsive change. It is currently being trialled and evaluated.

BACKGROUND: Transcutaneous electrical stimulation (TES) using interferential current (IFC) is a new therapeutic treatment for constipation. Clinical studies show that TES-IFC for 3-6 months improves colonic transit, but it is not clear if short-term stimulation affects transit or the effect requires longer to develop. The aim of this study was to determine if TES-IFC for only four days affects oral-rectal transit time in healthy pigs. METHODS: Twenty-two 4-5-week old large white female piglets had transit studies during week 4 and week 5 by placing a capsule containing 18 radiopaque plastic markers in the esophagus under anesthetic followed by x-rays at 6, 30, 54, and 78 hours. Animals were randomly assigned to active or control groups. The active group received TES for 30 min daily for four days. Interferential current was applied through four electrodes (4 × 4 cm), with two para-spinal just below the last rib and two on the belly at the same level. Stimulation was at 4000 Hz and 4080-4160 Hz with currents crossing through the abdominal cavity. RESULTS: Whole bowel transit times ranged from 7.7 to 72.2 hours, stomach transit from <1 to 63 hours, and bowel with rectum transit time from 5 to 53 hours. Transit times were the same for the control (median 28.4 hours) and TES-IFC (23.0 hours) groups in the prestimulation and stimulation weeks (control 23.0, TES-IFC 19.8 hours) with no change within or between groups. CONCLUSION: Four days of half-hour TES-IFC daily in healthy 5-week-old piglets did not change oral-rectal transit time.

BACKGROUND: Docetaxel is an effective therapy for metastatic castration-resistant prostate cancer (mCRPC); however, many patients experience febrile neutropenia (FN) and cease treatment early due to toxicity. It is not known whether lower dose (LD) q3-weekly docetaxel impacts toxicity or efficacy. METHODS: Multicenter retrospective study included 166 patients with mCRPC who received q3-weekly docetaxel between 2010 and 2015. Demographic, disease, chemotherapy (standard dose, SD > 60 mg/m2 vs LD ≤ 60 mg/m2 ) and toxicity data were collected. Univariable and multivariable logistic and competing risk regression models evaluated docetaxel-dose association with FN and early treatment cessation (ETC) due to toxicity. Associations between dose and efficacy end points were also evaluated. Analyses were repeated employing inverse propensity score weights. RESULTS: Patients who received LD docetaxel (28.9%) were older with poorer Eastern Cooperative Oncology Group (ECOG) status. Fifteen percent of patients experienced FN, with a nonsignificant trend to lower incidence in the LD group (multiple adjusted odds ratio [OR] = 0.42; P = 0.21). Neither baseline patient nor prior treatment factors were predictive of FN. ETC due to toxicity occurred in 35%, with risk associated with increasing age, comorbidity count and poorer ECOG. There was no difference between LD and SD with respect to ETC due to toxicity, in unweighted and weighted analyses (LD vs SD, multivariable weighted hazard ratio [HR] = 1.47; P = 0.08). LD was associated with reduced prostate-specific antigen (PSA) response (50% vs 66.1%, multivariable weighted HR = 0.54; P = 0.03) and overall survival (median 7.9 vs 13.8 months, multivariable weighted HR = 2.19; P < 0.0001). CONCLUSIONS: LD docetaxel for mCRPC did not mitigate the risk of FN or ETC due to toxicity. Dose reduction may result in poorer PSA response and survival.

Antenatal anxiety symptoms are not only a health problem for the expectant mother. Research has found that maternal anxiety may also have an impact on the developing baby. Therefore, it is important to estimate the prevalence of maternal anxiety and associated factors. The current study aims to estimate the prevalence of anxiety symptoms during the first trimester of pregnancy and to identify associated risk factors. Secondly, to investigate other factors associated with anxiety during early pregnancy including fear of childbirth and a preference for cesarean section. In a population-based community sample of 1,175 pregnant women, 916 women (78%) were investigated in the first trimester (gestation week 8-12). The Hospital Anxiety Depression Scale (HADS-A) was used to measure anxiety symptoms. The prevalence of anxiety symptoms (HADS-A scores≥8 during pregnancy) was 15.6% in early pregnancy. Women under 25 years of age were at an increased risk of anxiety symptoms during early pregnancy (OR 2.6, CI 1.7-4.0). Women who reported a language other than Swedish as their native language (OR 4.2, CI 2.7-7.0), reported high school as their highest level of education (OR 1.6, CI 1.1-2.3), were unemployed (OR 3.5, CI 2.1-5.8), used nicotine before pregnancy (OR 1.7, CI 1.1-2.5), and had a self-reported psychiatric history of either depression (OR 3.8, CI 2.6-5.6) or anxiety (OR 5.2, CI 3.5-7.9) before their current pregnancy were all at an increased risk of anxiety symptoms during early pregnancy. Anxiety symptoms during pregnancy increased the rate of fear of birth (OR 3.0, CI 1.9-4.7) and a preference for cesarean section (OR 1.7, CI 1.0-2.8). Caregivers should pay careful attention to history of mental illness to be able to identify women with symptoms of anxiety during early pregnancy. When presenting with symptoms of anxiety, the women might need counseling and or treatment in order to decrease her anxiety.

Background and objective: By adopting a trauma-informed approach to care at the organisational and clinical levels, health care systems and providers can enhance the quality of care that they deliver and improve health outcomes for individuals with a trauma history. This study aimed to explore the trauma-related knowledge, attitudes awareness, practice, competence and confidence of health service staff from three small rural health services in Victoria, Australia, and examine their self-reported capacity to respond to clients with a trauma history.Methods: Staff from each site were invited to complete a paper-based survey. The survey included demographic information and questions related to knowledge and understanding of trauma, experience of trauma-informed care and confidence engaging in, and perceived importance of, trauma-informed practices. Results: The respondents were predominately nurses. Results showed that 16% of respondents had undertaken training in trauma-informed care and 44% disagreed that they had an understanding of trauma-informed practices. There were high levels of agreement for statements related to knowledge and understanding of trauma and low levels of agreement with statements related to experience of trauma-informed care. More than 70% of respondents reported that they had little knowledge of the principals of trauma-informed care, and little experiencing with practicing trauma-informed care.Discussion and conclusions: Overall, the survey results showed that staff were trauma-aware, but supported the need for more education and training in trauma-informed practices and improved organisational approaches to support trauma-informed approaches. It is important for organisations to shift from being trauma aware to being trauma-informed, by building foundational awareness of these practices and reinforcement through continuing education.

There are several antiseptic, antibiotic and non-decontamination-based interventions for preventing intensive care unit (ICU) acquired infection. These have been evaluated in &gt;200 studies. Infection prevention using topical antibiotic prophylaxis (TAP) appears to be the most effective. Whether antibiotic use in the ICU may influence the risk of infection among concurrent control patients within the same ICU and result in asymmetrical herd effects cannot be resolved with individual studies examined in isolation. The collective observations within control and intervention groups from numerous ICU infection prevention studies simulates a multi-center natural experiment enabling the herd effects of antibiotics to be evaluated. Among the TAP control groups, the incidences for both ventilator associated pneumonia (VAP) and mortality are unusually high in comparison to literature-derived benchmarks. Paradoxically, amongst the TAP intervention groups, the incidences of mortality are also unusually high and the VAP incidences are similar (i.e., not lower) compared to the incidences among studies of other interventions. By contrast, the mortality incidences among the intervention groups of other studies are similar to those among the intervention groups of TAP studies. Using topical antibiotics to prevent infections acquired within the ICU environment may result in profoundly asymmetrical effects.

Background: Complex, ongoing social factors have led to a context where metabolic syndrome (MetS) is disproportionately high in Aboriginal Australians. MetS is characterised by insulin resistance, abdominal obesity, hypertension, hypertriglyceridemia, high blood-sugar and low HDL-C. This descriptive study aimed to document physical activity levels, including domains and intensity and sedentary behaviour, and MetS risk factors in the Perth Aboriginal (predominately Noongar) community. Methods: The Global Physical Activity Questionnaire (GPAQ), together with a questionnaire on self-reported MetS risk factors, was circulated to community members for completion during 2014 (n = 129). Results: Data were analysed using chi-squared tests. The average (SD) age was 37.8 years (14) and BMI of 31.4 (8.2) kg/m2. Occupational, transport-related and leisure-time physical activity (PA) and sedentary intensities were reported across age categories. The median (interquartile range) daily sedentary time was 200 (78, 435), 240 (120, 420) and 180 (60, 300) minutes for the 18-25, 26-44 and 45+ year-olds, respectively (p = 0.973). Conclusions: An in-depth understanding of the types, frequencies and intensities of PA reported for the Perth Aboriginal community is important to implementing targeted strategies to reduce the prevalence of chronic disease in this context. Future efforts collaborating with community should aim to reduce the risk factors associated with MetS and improve quality of life.

OBJECTIVE: To explore the complex factors influencing the implementation of cultural competency frameworks for Aboriginal and Torres Strait Islander peoples within rural, Victorian, mainstream health and community service organisations. METHODS: Semi-structured telephone interviews were conducted with key individuals from 20 public health and community services in rural Victoria who had participated in the Koolin Balit Aboriginal Health Cultural Competence Project (KB-AHCC project). Interviews were recorded and transcribed verbatim and a content analysis was undertaken. The findings informed the selection of six case study sites for more in-depth analysis. Following this, an expert reference group provided feedback on the findings. Findings from the different data were triangulated to identify eight factors. RESULTS: Key factors acting as barriers and/or enablers to implementing cultural competence frameworks were: comprehensive, structured tools; project workers; communication; organisational responsibility for implementation; prioritising organisational cultural competence resourcing; resistance to focussing on one group of people; and accountability. CONCLUSIONS: Embedding cultural competence frameworks within rural, mainstream health and community services requires sustained government resourcing, prioritisation and formal accountability structures. Implications for public health: Findings will inform and guide the future development, implementation and evaluation of organisational cultural competence projects for rural public health and community services.

BACKGROUND: Febrile neutropenia is a serious complication of chemotherapy. The Multinational Association for Supportive Care in Cancer (MASCC) risk index score identifies patients at low risk of serious complications. Outpatient management programs have been successfully piloted in other Australian metropolitan cancer centers. AIM: To assess current management of febrile neutropenia at our regional cancer center and determine potential impacts of an outpatient management program. METHOD: We performed a retrospective review of medical records for all patients admitted at our regional institution with febrile neutropenia between 1 January 2016, and 31 December 2018. We collected information regarding patient characteristics, determined the MASCC risk index score, and if low risk, we determined the eligibility for outpatient care and potential reduction in length of stay and cost benefit. RESULTS: A total of 98 hospital admissions were identified. Of these, 66 had a MASCC low-risk index score. Fifty-eight patients met the eligibility criteria for outpatient management. Seventy-one percent were female. The most common tumor type was breast cancer. Forty-eight percent were treated with curative intent. The median length of stay was 3 days. The median potential reduction in length of stay for each admission was 2 days. The total potential reduction in length of stay was 198 days. No admission resulted in serious complications. CONCLUSION: This review demonstrates a significant number of hospital admission days can be avoided. We intend to conduct a prospective pilot study at our center to institute an outpatient management program for such low-risk patients with potential reduction in hospital length of stay. This will have significant implications on health resource usage, service provision planning, and patient quality of life.

BACKGROUND: Effective person-centred interventions are needed to support people living with mental-physical multimorbidity to achieve better health and wellbeing outcomes. Depression is identified as the most common mental health condition co-occurring with a physical health condition and is the focus of this intervention development study. The aim of this study is to identify the key components needed for an effective intervention based on a clear theoretical foundation, consideration of how motivational interviewing can inform the intervention, clinical guidelines to date, and the insights of primary care nurses. METHODS: A multimethod approach to intervention development involving review and integration of the theoretical principles of Theory of Planned Behavior and the patient-centred clinical skills of motivational interviewing, review of the expert consensus clinical guidelines for multimorbidity, and incorporation of a thematic analysis of group interviews with Australian nurses about their perspectives of what is needed in intervention to support people living with mental-physical multimorbidity. RESULTS: Three mechanisms emerged from the review of theory, guidelines and practitioner perspective; the intervention needs to actively 'engage' patients through the development of a collaborative and empathic relationship, 'focus' on the patient's priorities, and 'empower' people to make behaviour change. CONCLUSION: The outcome of the present study is a fully described primary care intervention for people living with mental-physical multimorbidity, with a particular focus on people living with depression and a physical health condition. It builds on theory, expert consensus guidelines and clinician perspective, and is to be tested in a clinical trial.

This is the full version of the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 guideline for pre-existing diabetes and pregnancy. The guideline encompasses the management of women with pre-existing type 1 diabetes and type 2 diabetes in relation to pregnancy, including preconception, antepartum, intrapartum and postpartum care. The management of women with monogenic diabetes or cystic fibrosis-related diabetes in relation to pregnancy is also discussed.

BACKGROUND: In response to the challenges of assessing fetal growth in obese women, guidelines recommend routine third trimester ultrasound scans. AIM: The aim of this study was to assess the diagnostic performance of this routine scan in obese women (body mass index (BMI) ≥ 35 kg/m2 ). METHODS: A retrospective cohort study of 1008 pregnancies with maternal BMI ≥ 35 kg/m2 born after 37 weeks gestation at a Victorian hospital from 2015 to 2017. Multiple pregnancies and those affected by diabetes were excluded. Growth ultrasounds were performed between 34 + 0 and 36 + 6 weeks gestation. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the detection of large for gestational age (LGA > 90%) and small for gestational age (SGA < 10%) were calculated using ultrasound estimated fetal weight (EFW) or abdominal circumference (AC) and compared with gestational age and gender-based birthweight percentiles. RESULTS: Using EFW, sensitivity for detecting SGA at birth was 8.1% (six of 74) with a PPV of 100%. Sensitivity for detecting LGA at birth was 61.0% (119 of 195), PPV 54.8%. Sensitivity, specificity, PPV and NPV percentages were all lower using AC. Only 40% of actual birthweight percentiles (405/1008) were within ±10 percentiles of their growth ultrasound EFW percentile. CONCLUSION: The performance of a routine third trimester ultrasound in women with BMI ≥ 35 kg/m2 suggests limited utility in helping identify aberrant fetal growth. This has important implications for the management of obese pregnant women.

The Northern Territory (NT) government operates remote clinics which are primarily staffed by Aboriginal Health Practitioners and Remote Area Nurses (RANs). RAN practice has been described as particularly complex due to high health needs, workforce shortages and high levels of turnover in remote Aboriginal communities. While individual incentives are offered, there has been little examination of the role and why the work takes such a toll on RANs. This study aims to identify dominant discourses underpinning RAN practice and how these discourses reflect tensions and reinforce power relations that impact on the RAN role. Discourses were identified from a Foucauldian-inspired discourse analysis of 29 interviews with RANs in six remote NT communities. Five dominant discourses were identified, namely, that permanent RANs are preferred to agency RANs, RANs portray themselves as experienced and certain, RANs use autonomous clinical judgement, Aboriginal staff are important and RAN's belief in making a difference. However, the experience of RANs suggested that there are many types of employment that learning from was also important, RANs often struggled to work with Aboriginal staff and they were unsure if they were making a difference. Furthermore, these discourses created tensions between RANs who were permanent-agency, older-younger, experienced-newer and certain-reflexive. Deconstructing these rigid discourses could allow the RAN role to be reconstructed in ways that lead to better retention, job satisfaction and health outcomes.

AIM: Optimal treatment for newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC) has evolved, with many patients deriving benefit from the addition of docetaxel to androgen deprivation therapy (D-ADT). This study sought to define the therapy used and associated activity following D-ADT. METHODS: Retrospective analysis of patients with mHSPC treated with one or more cycles of D-ADT who were identified from a prospectively maintained multisite prostate cancer database of patients treated in a community or academic center setting in Australia. The primary endpoint of this study was first-line time to treatment failure (1L TTF) for subsequent treatment of metastatic Castrate Resistant Prostate Cancer (mCRPC), with secondary endpoints of prostate-specific antigen (PSA) reduction >50% and time from 1L to second-line (2L) treatment initiation. RESULTS: A total of 93 patients received D-ADT for mHSPC, 85 (91%) had subsequent treatment for mCRPC. Median time to mCRPC (biochemical, clinical or radiographic) had been 14.8 months (95% confidence interval [CI], 11.9-16.5). 1L treatment was enzalutamide 47 patients (55%), abiraterone 23 (27%), cabazitaxel 7 (8%), docetaxel 4 (5%) and other therapies 4 (5%). Median 1L TTF was 6.3 months (95% CI, 4.9-7.6), PSA > 50% reduction was achieved in 32 of 89 patients (36%), median time from 1L to second-line treatment was 7.3 months (1.3-27.4), which did not differ significantly between treatment groups. CONCLUSIONS: Abiraterone, enzalutamide, cabazitaxel and docetaxel all demonstrate activity following progression on D-ADT. No difference in efficacy was detected between treatment options for mCRPC. Prospective trials investigating the optimal treatment sequence for prostate cancer following progression on D-ADT needed.

Objectives To examine associations of education and occupation with handgrip strength (HGS), lower limb strength (LLS) and appendicular lean mass (ALM). Methods Measures of HGS, LLS and ALM (dual‐energy X‐ray absorptiometry) were ascertained at baseline in 1090 adults (50‐80 years, 51% women), ~3 and 5 years. Education and occupation were self‐reported, the latter categorised as high‐skilled white collar (HSWC), low‐skilled white collar (LSWC) or blue collar. Separate general estimating equations were performed. Results The highest education group had greater HGS than the middle (0.33 psi) and lowest (0.48 psi) education groups, and 0.34 kg greater ALM than the lowest education group. HGS was 0.46 psi greater for HSWC than LSWC groups. Compared to LSWC groups, LLS was 5.38 and 7.08 kg greater in HSWC and blue‐collar groups. Blue‐collar and HSWC groups each had ~ 0.60‐0.80kg greater ALM than LSWC. Conclusion Progressive muscle loss can be prevented by targeted intervention; thus, we suggest clinical attention be directed towards specific social groups.

This paper contributes to scholarship on the medicalisation of mental health support for young people through a case study of a multidisciplinary mental health service in rural Australia. All staff (n = 13) working at the service participated in semi-structured, individual interviews. Transcripts of interview data were read and selectively coded and interpreted in relation to the overarching question of how participants view and experience mental health care provision to a diverse range of young people. Following analytical reflection, codes pertaining to engagement, accessibility and care provision were re-examined using the concept of medicalisation to understand the biomedical underpinning of mental healthcare and how this plays out in the experiences and perceived challenges participants talked about in responding to the mental health concerns of diverse young people. The resulting analysis is presented under five theme headings: (a) privileging clinical expertise and priorities within service provision, which was an important source of conflict for some participants; (b) 'multidisciplinary' teams-a 'difficult kind of culture at times'; (c) articulations of where cultural barriers lie; (d) the tracks along which young people are directed to 'engage' with 'mental health'; and (e) a clinical 'feel' to space. We suggest that service and system investment needs to be given to alternative ways of thinking about and approaching mental health and care provision that are cognisant of, and engage with, the inherent connections between individual circumstance and social, place, cultural, economic and political contexts. This is particularly relevant to the provision of care in rural contexts because of limited service options and the complexities of access and providing care to a diverse range of young people living in isolated environments. Interdisciplinary frameworks need to be enacted and services must acknowledge their own cultural positions for alternative ways of working to become possibilities.

BACKGROUND: Anti-HER2 therapy-related cardiotoxicity is well described in the context of clinical trials, particularly in the setting of early stage disease, but there is more limited data in advanced breast cancer and in the real world setting. MATERIAL AND METHODS: A prospectively-maintained registry database with 312 consecutive patients diagnosed with HER2 positive advanced breast cancer in Australia was analysed. RESULTS: 287 patients (92%) received anti-HER2 therapy, 17 (6%) experienced anti-HER2 therapy-related cardiotoxicity. Patients who experienced cardiotoxicity were more likely to have ≥2 risk factors for cardiotoxicity (OR 3.9 95% CI 1.4-11.3 p = 0.01). A prior diagnosis of cardiovascular disease was significantly associated with cardiotoxicity (OR 7.1 95% CI 1.3-39.5). Cardiotoxicity resolved on imaging in 65% of patients; there was no association between severity and resolution. 11 patients (65%) received cardiologist input. Of the patients who developed cardiotoxicity, 12 patients (71%) received further anti-HER2 therapy in the first- or second-line setting without recurrent cardiotoxicity. DISCUSSION AND CONCLUSION: Therapy-related cardiotoxicity is an uncommon complication of anti-HER2 therapy in the real world setting. Cardiac toxicity resolved in the majority of affected patients, and further anti-HER2 therapy was administered without recurrence of cardiac issues. Our data suggests anti-HER2 therapy can be safely given in routine care, even in patients with risk factors for toxicity.

OBJECTIVE: To probe health practitioner perceptions of Australian First Nations' Peoples' health and to compare these with reported burden of disease, social determinants and culturally safe health systems data. DESIGN: An online survey tool was used to collect self-reported responses from health practitioners to answer literature-derived questions regarding underlying issues in Australian First Nations' Peoples' health. SETTING: Responses to the survey were sought from rural and urban health service locations across all Australian states and territories. PARTICIPANTS: Allied health, nursing, pharmacy, psychology, social work and related discipline students and practitioners currently working or studying in Australia. MAIN OUTCOME MEASURE(S): Degrees of correspondence between health discipline student and practitioner perceptions on 'major health issues' and 'health systems issues' and published population health and health systems data. Metrics for 'connectedness to' and 'preparedness to engage with' Australian First Nations' Peoples were also reported. RESULTS: Significant differences between practitioner perceptions of 'major health issues' and the disease burden/social determinants published evidence, and with the 'culturally safe health systems' published evidence, were noted. Positive impacts of social and professional relationships (connectedness) between practitioners and First Nations' Peoples were demonstrated. CONCLUSIONS: The inclusion of basic population health and culturally safe health systems training in curricula for all genres of health practitioners appears to be indicated by these findings. Further, a meaningful role for the intentional nurture of social and professional relationships with Australian First Nations' Peoples across all health disciplines is suggested as part of efforts to address health systems and equity issues.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is an incurable, chronic condition that leads to significant morbidity and mortality, with most patients dying in hospital. While diagnostic tests are important for actively managing patients during hospital admissions, the balance between benefit and harm should always be considered. This is particularly important when patients reach the end of life, when the focus is to reduce burdensome interventions. AIMS: To examine the use of diagnostic testing in a cohort of people with COPD who died in hospital. METHODS: Retrospective medical record audits were completed at two Australian hospitals (Royal Melbourne Hospital and Northeast Health Wangaratta), with all patients who died from COPD over 12 years between 1 January 2004 and 31 December 2015 included. RESULTS: Three hundred and forty-three patients were included, with a median of 11 diagnostic testing episodes per patient. Undergoing higher numbers of diagnostic tests was associated with younger age, intensive care unit admission and non-invasive ventilation use. Reduced testing was associated with recent hospital admission for COPD, domiciliary oxygen use and a prior admission with documentation limiting medical treatment. Most patients underwent diagnostic tests in the last 2 days of life, and 12% of patients had ongoing diagnostic tests performed after a documented decision was made to change the goal of care to provide comfort care only. CONCLUSION: There were missed opportunities to reduce the burden of diagnostic tests and focus on comfort at the end of life. Increased physician education regarding communication and end-of-life care, including recognising active dying may address these issues.

BACKGROUND: There is no universally accepted age cut-off for defining young strokes. AIMS: We aimed to determine, based on the profile of young stroke patients in our regional centre, an appropriate age cut-off for young strokes. METHODS: A retrospective analysis of all ischaemic stroke patients admitted to our centre from 2015 to 2017. We identified 391 ischaemic stroke patients; 30 patients between the ages of ≤50, 40 between 51-60 inclusive and 321 ≥ 61 years of age. We collected data on demographic profiles, risk factors and stroke classification using the Trial of Org 10 172 in Acute Stroke Treatment criteria. RESULTS: We found significant differences between the ≤50 and ≥61 age groups for most of the risk factors and similarities between the 51-60 inclusive and ≥ 61 age groups. At least one of the six risk factors assessed in the study was present in 86.7% of the youngest group, 97.5% of the intermediate age group and 97.2% in the oldest group. In terms of the mechanisms of stroke, the youngest and oldest age groups in our study differed in the prevalence of cryptogenic, cardioembolic and other causes of stroke. The middle and older age groups had similar mechanisms of stroke. CONCLUSIONS: The prevalence of vascular risk factors and mechanisms of stroke likewise differed significantly across age groups. This study suggests that 50 years is an appropriate age cut-off for defining young strokes and reinforces the importance of primary prevention in all age groups.

OBJECTIVES: To assess the clinical outcomes of patients presenting with ST-elevation myocardial infarction (STEMI) secondary to stent thrombosis (ST) compared to those presenting with STEMI secondary to a de novo culprit lesion and treated by percutaneous coronary intervention (PCI). BACKGROUND: ST is an infrequent but serious complication of PCI with substantial associated morbidity and mortality, however with limited data. METHODS: We studied consecutive patients who underwent PCI for STEMI from 2005 to 2013 enrolled prospectively in the Melbourne Interventional Group registry. Patients were divided into two groups: the ST group comprised patients where the STEMI was due to ST and the de novo group formed the remainder of the STEMI cohort and all patients were treated by PCI. The primary endpoint was 30-day all-cause mortality. RESULTS: Compared to the de novo group (n = 3,835), the ST group (n = 128; 3.2% of STEMI) had higher rates of diabetes, hypertension and dyslipidemia, established cardiovascular diseases, myocardial infarction, and peripheral vascular disease, all p < .01. Within the ST group, very-late ST was the most common form of ST, followed by late and early ST (64, 19, and 17%, respectively). There was no significant difference in the primary outcome between the ST group and the de novo group (4.7 vs. 7.1%, p = .29). On multivariate analysis, ST was not an independent predictor of 30-day mortality (odds ratio: 0.62, 95% confidence interval: 0.07-1.09, p = .068). CONCLUSION: The short-term prognosis of patients with STEMI secondary to ST who were treated by PCI was comparable to that of patients with STEMI due to de novo lesions.

The critical importance of primary health care in maintaining a healthy population is well established internationally. Nevertheless, general practitioner care is not always easily accessible for some patients in Australia, particularly in rural regions. This is partly due to an insufficient number of medical graduates entering and being retained in the rural general practitioner workforce. Key elements of international and national programs designed to address this shortfall are discussed and include the use of entry requirements that preferentially select for applicants from a rural residence background, and immersion of medical students for a large share, or entire duration, of their training in rural communities. In addition, other factors that can influence decisions to enter and stay in rural practice are discussed.

INTRODUCTION: Longstanding gaps in physiotherapy service delivery exist in rural areas across Australia. In response to this, a large public rural health organisation contracted a private physiotherapy business to implement a public-private partnership (PPP) to supply physiotherapy to hospital inpatients, aged care facility residents and outpatients in four outer regional Australian towns. Treatment rooms were provided by the health organisation for the private physiotherapists to see clients. This study explored how stakeholders defined the success of a PPP model of service delivery in a rural setting and examined if the model was successful according to stakeholder definitions. Barriers and enablers (mechanisms) were identified and linked to stakeholder-defined success measures. METHODS: A qualitative study was conducted using a constructive inquiry design. Participants were purposively recruited, via email invitation and telephone follow-up. Participants comprised managers and clinicians from the rural public health organisation and the private physiotherapy business involved in setting up, working within or alongside the partnership. Semi-structured interviews were undertaken with all participants. Data were transcribed verbatim and analysed using framework analysis. Program logic was used to synthesise all information. RESULTS: Individual interviews were conducted with five staff from each partnering organisation, including managers and clinicians (total n=10). Two main themes and three subthemes were identified. All participants described the model as being successful. Elements of success included improved access to local services, and satisfied stakeholders. There were three mechanisms identified to successfully implement the service delivery model. The first mechanism was the provision of human and several other resources, which included the workforce model and the use of several resources for the partnership. The second mechanism was stakeholder engagement, which included having motivated stakeholders and consistent stakeholders. The third mechanism was streamlined processes, which included the content of the contract and referral schedule, streamlined administration processes for contracting and accounting, having processes for managing private therapists in a public setting as well as processes for communication. CONCLUSION: This study demonstrates that an innovative physiotherapy PPP model of service delivery can be a successful way to improve access to physiotherapy services in rural areas. Success of service models varies depending on the viewpoint of the stakeholder and achieving success for all stakeholders is contingent on mechanisms such as those identified in this study. PPPs have potential to address service gaps in hospitals, residential aged care and primary care in rural areas.

Objective The aim of this study was to understand, from the perspective of policy makers, who holds the responsibility for driving evidence-based policy to reduce the high burden of cardiovascular disease (CVD) in rural Australia. Methods Qualitative interviews were conducted with policy makers at the local, state and federal government levels in Australia (n=21). Analysis was conducted using the Conceptual Framework for Understanding Rural and Remote Health to understand perceptions of policy makers around who holds the key responsibility in driving evidence-based policy. Results At all levels of government, there were multiple examples of disconnect in the understanding of who is responsible for driving the generation of evidence-based policy to reduce CVD in rural areas. Policy makers suggested that the rural communities themselves, health services, health professionals, researchers and the health sector as a whole hold large responsibilities in driving evidence-based policy to address CVD in rural areas. Within government, there was also a noticeable disconnect, with local participants feeling it was the federal government that held this responsibility; however, federal government participants suggested this was largely a local government issue. Overall, there seemed to be a lack of responsibility for CVD policy, which is reflected in a lack of action in rural areas. Conclusion There was a lack of clarity about who is responsible for driving evidence-based policy generation to address the high burden of CVD in Australia, providing one possible explanation for the lack of policy action. Clarity among policy makers over shared roles and leadership for policy making must be addressed to overcome the current burden of CVD in rural communities. What is known about the topic? Rural health inequalities, such as the increased burden of CVD in rural Australia are persistent. Such health inequalities are unjust, with global theory suggesting political processes have facilitated, in part, the inequalities. With similar examples observed internationally in rural areas, little is known about the influence of the perspectives of policy makers regarding who is responsible for addressing health issues in rural areas, in the government context. What does this paper add? This paper provides empirical evidence, for all levels of government in Australia, that there is a lack of clarity in policy roles and responsibilities to address the unequal burden of CVD in rural Australia, at all levels of government. The paper provides evidence to support the urgent need for clarity within government around policy stakeholder roles. Without such clarity, it is unlikely that national-level progress in addressing rural health inequalities will be achieved in the near future. What are the implications for practitioners? Addressing ambiguity around who is responsible for the development of evidence-based policy to address the high burden of CVD in rural areas must be a high priority to ensure health disparities do not persist for future Australian generations. The results reported here are highly relevant to the Australian context, but also reflect similar findings internationally, namely that a lack of clarity among policy stakeholders appears to contribute to reduced action in addressing preventable health inequalities in disadvantaged populations. This paper provides evidence for policy makers and public health professionals to advocate for clear policy roles and direction in rural Australia.

Infectious disease (ID) physicians and ID pharmacists commonly confront therapeutic questions relating to antibiotic resistance. Randomized controlled trial data are few and meta-analytic-based approaches to develop the evidence-base from several small studies that might relate to an antibiotic resistance question are not simple. The overriding challenge is the sparsity of data which is problematic for traditional frequentist methods, being the paradigm underlying the derivation of 'P value' inferential statistics. In other sparse data contexts, simulation methods enable answers to key questions that are meaningful, quantitative and potentially relevant. How these simulation methods 'work' and how Bayesian-based methods, being not 'P value based', can facilitate simulation are reviewed. These methods are becoming increasingly accessible. This review highlights why sparse data is less of an issue within Bayesian versus frequentist paradigms. A fictional pharmacokinetic study with sparse data illustrates a simplistic application of Bayesian and simulation methods to antibiotic dosing. Whether within epidemiological projections or clinical studies, simulation methods are likely to play an increasing role in antimicrobial resistance research within both hospital and community studies of either rare infectious disease or infections within specific population groups.