Dandenong Hospital

Moral injury—emerging from actions, inactions, or witnessed events that transgress deeply held moral beliefs—remains an often overlooked yet profoundly consequential health condition. While initially described among military personnel, it now spans health care workers, first responders, educators, and countless others navigating ethically fraught environments. Unlike PTSD, moral injury’s core is spiritual, ethical, and emotional dissonance rather than fear. It manifests as shame, guilt, betrayal, and loss of meaning, undermining psychological well-being and professional longevity. Yet public health systems and workplaces rarely recognize or treat it with the seriousness it deserves. This opinion article argues that ignoring moral injury not only harms individuals but weakens institutions, erodes trust, and accelerates burnout. Addressing it requires cultural change, leadership accountability, trauma-informed practices, and integration of moral repair into mainstream health care. Moral injury is a public health problem hiding in plain sight, demanding urgent attention, empathy, and structural reform.

Abstract. Narulita E, Utami DAW, Izzaturrohmah L, Arrachmi HI, Febrianti RA, Ludfillah RZ, Widianto AH, Addy HS, Utami BR, Kuswati, Fikri K. 2025. Genomic and evolutionary perspectives on bacteriophage ?Afa-NA1 targeting MDR Gram-negative bacteria in diabetic ulcer. Biodiversitas 26: 6014-6024. The rise of Multidrug-Resistant (MDR) bacterial infections poses a significant challenge in clinical settings, particularly for diabetic ulcer patients who are highly susceptible to persistent infections. This study reports the isolation, characterization, and genomic analysis of a novel lytic bacteriophage, ?Afa-NA1, specifically targeting MDR Gram-negative bacteria associated with diabetic ulcers in Indonesia. The bacteriophage was isolated from wound dressings and tested against four clinical isolates: Alcaligenes faecalis T17, Pseudomonas sp. FP1911, and the Gram-positive control Streptomyces violaceoruber S21. ?Afa-NA1 exhibited strong lytic activity against three Gram-negative isolates but none against the Gram-positive control, confirming host specificity. ?Afa-NA1 produced clear plaques with an average diameter of 3.0±0.5 mm on Alcaligenes faecalis T17, indicative of its potent lytic activity. Stability tests showed the phage retained >90% infective titer after 24 hours at -20°C and 4°C, and exhibited robust stability across a wide pH range (pH 6 to 11). One-step growth analysis revealed a short latent period of 21.7±8.1 minutes and a burst size of 27.7±1.5 PFU per infected cell. Genomic analysis showed ?Afa-NA1 possesses a 78,105 bp double-stranded DNA genome with 45.8% G+C content encoding 83 predicted open reading frames. Comparative genomics and phylogenetic reconstruction confirmed its placement among T7-like Podoviruses, consistent with its obligate lytic lifecycle and genomic architecture. However, the potential for therapeutic application remains preliminary, as host range testing was conducted on a limited panel of single clinical isolates, and all assays were performed in vitro.

• The intervention did not reduce homelessness for most participants. • Aboriginal participants experienced worse outcomes than non-Aboriginal participants. • Previously homeless youth benefited more than peers without such history. • Participants found intervention more acceptable than support they received during OOHC. • Aftercare planning practice was a major barrier to implementation. Young people transitioning from out-of-home care (OOHC) face elevated risks of adverse outcomes across multiple domains. Existing interventions have shown small or null effects when rigorously evaluated, highlighting the need to identify effective approaches to supporting care leavers. Evaluate the impact of the Premier’s Youth Initiative (PYI), an accommodation and support intervention, on homelessness outcomes for care leavers and explore its implementation. 295 eligible care leavers who received PYI in New South Wales, Australia between 2017–2020 and a matched comparison group drawn from locations where PYI was unavailable. We undertook a hybrid type-1 implementation-effectiveness study that used linked administrative data from child welfare and homelessness services. Propensity score methods were applied to estimate the average treatment effect on the treated on ten measures of homelessness between ages 18–19. Implementation was explored through focus groups with participants, service providers and the funder to explore intervention acceptability as well as barriers and facilitators. Overall PYI had no impact on any assessed homelessness measures—with treatment effects consistently near zero. Subgroup analyses showed that Aboriginal participants experienced worse outcomes than non-Aboriginal peers. Participants who experienced homelessness during OOHC appeared to benefit more from PYI, relative to those who did not, but estimates were inconsistent. Implementation analysis identified high acceptability among participants but revealed substantial barriers, particularly inadequate planning for leaving care. Interventions like PYI may need to commence earlier, be provided at greater intensity, or be targeted more effectively to the most vulnerable care leavers.

This paper examines how exchange rate regime flexibility impacts the allocation of labor across firms. Specifically, we investigate how differences in labor-intensity or capital-intensity in production affect employment decisions under various degrees of exchange rate regime flexibility. In a simple theoretical model, we show that firms utilizing more labor-intensive production technologies are more likely to expand their employment when the exchange rate they face becomes less flexible. In contrast, firms employing more capital-intensive technology tend to hire more workers when the exchange rate is more flexible. We test our theory using granular firm-level data from China and provide robust evidence supporting the theoretical predictions. • We shift focus from exchange rate levels to how regime flexibility influences firms’ employment decisions. • Capital-intensive firms gain from flexible exchange rates, while labor-intensive firms prefer fixed regimes to reduce uncertainty. • After China’s 2005 move to a managed float, labor-intensive firms increase employment more when FX flexibility is lower. • Firm characteristics, particularly labor intensity in production, are crucial drivers of how companies respond to exchange rate regime changes.

BackgroundWhile recovery orientation is national policy in many countries, evidence remains limited for the effectiveness at a service level. This paper describes the protocol for implementing a pro-recovery training intervention (REFOCUS-RETAFORM) in specialist mental health services across France. The aim is to evaluate whether REFOCUS-RETAFORM plus usual care leads to improved outcomes for adolescent and adult mental health service users compared with usual care alone.MethodsA two-step stepped wedge cluster randomised controlled trial will be conducted, with a nested qualitative sub-study exploring stakeholders’ views on changes in staff-user relationships and implementation influences. The REFOCUS-RETAFORM intervention is a training intervention for mental health staff, to develop recovery-promoting relationships and pro-recovery working practices. Clusters are services, which transition sequentially from control to intervention condition in a randomised order. Eight clusters are randomised to deliver REFOCUS-RETAFORM in year one and eight clusters in year two. Each cluster delivers REFOCUS-RETAFORM to two teams from their organisation (32 teams in total). Participants are a) service users aged 13–65 years attending services implementing REFOCUS-RETAFORM, and b) staff receiving the intervention. The primary outcome is the Questionnaire about the Process of Recovery. Secondary outcomes include perceived stigma and coercion, self-stigma and wellbeing for service users, and recovery-orientation for staff. Data will be collected from 540 service users (180 at baseline, 180 at month 12, 180 at month 24) and 220 staff. We will use multilevel mixed-effects models, adjusting for secular trends and thematic analysis for the qualitative interview data.DiscussionFindings will inform the continued transformation of French specialist mental health services toward a recovery orientation.Trial registrationClinical Trials NCT05824234, registered 21 April 2023.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12888-025-07253-w.

Abstract This commentary argues the need to prioritize regulation and abstinence-based prevention and recovery as critical services in efforts to maximize the reduction of substance-related harm and the promotion of mental health at a population-level. Treatment and harm reduction for those experiencing mental health and or substance use problems tends to be poorly integrated with regulatory and prevention approaches, which seek to reduce the development of these problems. This commentary examines evidence from Australia to argue the benefits of more deliberate service system integration based on life-course science. Harm reduction programs dominated the substance use prevention field in Australia until 2009 and were associated with high levels of youth substance use. The introduction of abstinence-based prevention programs and policies effectively reduced adolescent substance use and these reductions have flowed to generational reductions in adult substance use. The potential benefits of Australia’s movement to abstinence-based prevention continue to be disrupted by conflicting harm reduction treatment messages. This commentary outlines the argument to maximize substance use intervention effectiveness and mental health promotion by increasing investment in abstinence-based substance use regulation and prevention and then restructuring treatment and recovery services to more deliberately integrate with this emphasis. The benefits of this approach are argued to include reduction of substance use harm and mental health burden.

Primary diffuse large B-cell lymphoma (DLBCL) of the colon, particularly involving the caecum, is rare and often poses a diagnostic challenge due to its non-specific presentation and the low incidence of colorectal involvement. Early recognition is crucial, as timely diagnosis and multidisciplinary management can significantly improve patient outcomes. A 29-year-old female presented with a two-week history of intermittent lower abdominal pain, progressive abdominal bloating, weight loss, night sweats, and bilateral ankle swelling over the last four weeks. Initial ultrasonography revealed a large soft tissue mass within the abdomen, initially reported as an ovarian mass; however, further evaluation, including CT imaging and colonoscopy, revealed an ulcerated, partially obstructing caecal mass. Histopathological examination of endoscopic biopsies confirmed DLBCL, non-germinal-centre B-cell subtype. PET imaging revealed multiple large, intensely fluorodeoxyglucose (FDG)-avid lymph nodes below the diaphragm forming a bulky nodal mass, along with a similarly FDG-avid caecal mass, strongly suggesting extra-nodal lymphoma involvement. The patient was subsequently managed with R-CHOP (rituximab, cyclophosphamide, doxorubicin hydrochloride (hydroxydaunorubicin), vincristine sulfate (Oncovin), and prednisone) chemotherapy under the guidance of a multidisciplinary team. Primary colonic DLBCL is rare, accounting for a small fraction of colorectal malignancies. Its non-specific symptoms, including abdominal pain, altered bowel habits, and constitutional complaints, can mimic more common gastrointestinal conditions. This case highlights the importance of maintaining a broad differential diagnosis, especially in younger patients. While imaging modalities, endoscopic assessment, and histopathology are critical for accurate diagnosis, prompt oncologic consultation and chemotherapy remain central to management. A multidisciplinary treatment approach is vital in improving patient prognosis.