Mona Vale Hospital

Severe, refractory lower limb oedema can be a significant burden for patients with advanced metastatic malignancy. Despite this challenge, management strategies are often limited to analgesia, as well as pressure care and nursing care with positioning and dressings. The evidence for subcutaneous drainage in this setting largely consists of case reports, and it is infrequently practised in palliative care units (PCUs). In this case report, a patient with advanced metastatic ovarian cancer in her final weeks of life is discussed. Her severe lower limb oedema resulted in frequent pain and severe limitations on her mobility. The symptoms resulted in a multidisciplinary approach from the palliative care team, part of which included the use of subcutaneous drainage. The process of initiating this procedure in the PCU, details of the procedure and the benefit from it are described.

A videira é uma planta da família Vitaceae, e originária da Ásia. Devido ser a principal cultura de importância econômica do Vale do Submédio do São Francisco, faz-se necessário a utilização de práticas de manejo e monitoramento fitossanitário para auxiliar o produtor na prevenção e controle, visando reduzir os danos econômicos à videira. Assim sendo, o objetivo deste trabalho foi verificar o percentual de infestação das principais pragas e doenças que acometem a videira, cultivar BRS Vitória. O trabalho foi desenvolvido em uma área comercial, em Petrolina-PE. Vinte plantas foram amostradas semanalmente, no período de agosto/2021 a maio/2022, utilizando-se a metodologia e nível de ação da Produção Integrada de Uvas Finas de Mesa (PI Uva). Para a ferrugem, podridão-da-uva-madura, ácaro-vermelho, cigarrinhas e traça-da-videira-sul-americana, utilizou-se uma metodologia adaptada da PI Uva. No monitoramento foi detectado, em folhas, a incidência do oídio, míldio, ferrugem, lagarta-das-folhas e cigarrinhas; em inflorescência, observou-se a presença de tripes, e em cachos, oídio e a traça-dos-cachos. A precipitação pluviométrica e umidade relativa do ar influenciaram a incidência de oídio, ferrugem e lagarta-das-folhas. Na fase de repouso foram detectados os maiores índices de oídio, ferrugem, lagarta-das-folhas e cigarrinhas. Os níveis de incidência para oídio, míldio e traça-dos-cachos estão dentro dos valores recomendados pela PI Uva. Para ferrugem e cigarrinhas, os níveis adotados podem ser utilizados como indicador para a tomada de decisão no controle químico. Espera-se com esses resultados fornecer aos produtores subsídios para a melhoria no Manejo das Pragas e Doenças da Videira.

Many gastrointestinal diseases affect the mucosal layer, suggesting that on computed tomography (CT) examination, detection of consistent inner wall layering of the gastrointestinal tract may aid in detection of disease. Changes in wall enhancement can also characterise specific diseases and provide prognostic information. The objectives of this mixed retrospective and prospective analytical study were therefore to identify the scan delays for peak detection of canine stomach and small intestinal inner wall layering and enhancement when using a 20 s fixed‐injection‐duration and bolus tracking technique. For each patient, 700 mg I/kg iohexol was administered intravenously. Bolus tracking was used to determine aortic arrival. Diagnostic scans were performed after a post‐aortic arrival scan delay. Postcontrast CT series were grouped according to post‐aortic arrival scan delay: 5 s (n = 17), 10 s (n = 18), 15 s (n = 23), 20 s (n = 10), 25 s (n = 6), 30 s (n = 14), 35 s (n = 17), 40 s (n = 24), and 180 s (n = 60). The stomach and small intestine were assessed for the presence of a contrast‐enhancing inner wall layer and wall enhancement. Statistical modeling showed that the scan delays for peak inner wall layering and enhancement were 10 and 15 s for the small intestine, respectively, and 40 s for the stomach. For the injection protocol used in this study, assessment of the canine gastrointestinal tract may use scan delays of 10–15 s and 40 s.

Successive suicide prevention frameworks and action plans in Australia and internationally have called for improvements to mental health services and enhancement of workforce capacity. However, there is debate regarding the priorities for resource allocation and the optimal combination of mental health services to best prevent suicidal behaviour. This study investigates the potential impacts of service capacity improvements on the incidence of suicidal behaviour in the Australian context. A system dynamics model was developed to investigate the optimal combination of (1) secondary (acute) mental health service capacity, (2) non-secondary (non-acute) mental health service capacity and (3) resources to re-engage those lost to services on the incidence of suicidal behaviour over the period 2018-2028 for the Greater Western Sydney (Australia) population catchment. The model captured population and behavioural dynamics and mental health service referral pathways and was validated using population survey and administrative data, evidence syntheses and an expert stakeholder group. Findings suggest that 28% of attempted suicide and 29% of suicides could be averted over the forecast period based on a combination of increases in (1) hospital staffing (with training in trauma-informed care), (2) non-secondary health service capacity, (3) expansion of mental health assessment capacity and (4) re-engagement of at least 45% of individuals lost to services. Reduction in the number of available psychiatric beds by 15% had no substantial impact on the incidence of attempted suicide and suicide over the forecast period. This study suggests that more than one-quarter of suicides and attempted suicides in the Greater Western Sydney population catchment could potentially be averted with a combination of increases to hospital staffing and non-secondary (non-acute) mental health care. Reductions in tertiary care services (e.g. psychiatric hospital beds) in combination with these increases would not adversely affect subsequent incidence of suicidal behaviour.

To reduce the number of paediatric respiratory viral swabs (locally referred to as a FLOQ) performed across the authors clinical centre from a baseline of over 800 ($38 000) per year by 25% over 4 months from 6 February 2017 to 31 May 2017. A quality improvement project 'What the FLOQ?' (WTF) was instigated from 6 February 2017 to complement the Emergency Department (ED) 'Sensible Test Ordering Process' project from 1 April 2017. Stakeholder engagement across ED and general paediatric staff was sought. Alterations in practice included education of staff, targeted feedback to groups frequently ordering a FLOQ and rationalising patients appropriate for testing. Monthly requests were tallied on a run chart for FLOQs ordered in ED and the paediatric ward. A monthly audit of FLOQs performed on ED-discharged patients was conducted with feedback. Total FLOQ swabs decreased by 55% from 336 (February to May 2016) to 151 (February to May 2017). ED performed 66% less FLOQs from 237 (February to May 2016) to 82 (February to May 2017). There was no increase in the number of FLOQs performed on the paediatric ward February to May 2017. Monthly auditing of ED discharged patients under 2 years with a FLOQ went from 40 to 3%. Rationalising patient groups appropriate for testing with targeted feedback and broad stakeholder engagement successfully reduced FLOQs performed by 55%. This has projected savings of over $21 000 by 12 months. WTF has reduced the number of invasive patient procedures performed, benefitting staff and patients. Sustaining this change will be achieved through ongoing staff education on rationalisation criteria and consultant only requests outside of these parameters.

Circadian clocks regulate the daily timing of many of our physiological, metabolic and biochemical functions. The immune system also displays circadian oscillations in immune cell count, synthesis and cytokine release, clock gene expression in cells and organs of the immune system as well as clock-controlled genes that regulate immune function. Circadian disruption leads to dysregulation of immune responses and inflammation which can further disrupt circadian rhythms. The response of organisms to immune challenges, such as allergic reactions also vary depending on time of the day, which can lead to detrimental responses particularly during the rest and early active periods. This review evaluates what is currently known in terms of circadian biology of immune response and the cross-talk between circadian and immune system. We discuss the circadian pattern of three respiratory-related inflammatory diseases, chronic obstructive pulmonary disease, allergic rhinitis and asthma. Increasing our knowledge on circadian patterns of immune responses and developing chronotherapeutic studies in inflammatory diseases with strong circadian patterns will lead to preventive measures as well as improved therapies focussing on the circadian rhythms of symptoms and the daily variation of the patients’ responses to medication.

The name ‘Norfolk Island’ has long been synonymous with its use between 1825 and 1855 as a harsh punishment station for recidivist British convicts. Much of its previous archaeological investigation has focused on the conservation and management of standing structures from that period, to the detriment of an overall understanding of the archaeology of the island. This paper reviews the several phases of post-1788 occupation of this tiny and remote outpost of the British Empire and considers the archaeological potential of each of these distinct phases of free and unfree habitation. New directions and themes for further archaeological research are considered, including broader comparison with contemporary mainland Australian free and convict settlements and a focus on processes of adaptation and re-appropriation of buildings, sites and landscape by successive colonist groups.

We conducted an educational intervention emphasizing rational antibiotic prescribing in early-career General Practitioners (GP) in vocational training (trainees). The intervention consisted of an online introduction module, an online communication training module, face-to-face workshops, and cases to be discussed one-on-one by the trainee-supervisor dyad during regular scheduled education sessions. To explore the participants' experiences with the intervention. A qualitative study of 14 GP trainees and supervisors. Interviews followed a semi-structured interview guide, were transcribed and analysed using concurrent thematic analysis. Overall, the intervention was well received. Resources were not often used in practice, but GP trainees used the information in communicating with patients. The intervention improved trainees' confidence and provided new communication strategies, e.g. explicitly asking about patients' expectations and talking patients through the examination to form an overall clinical picture. Trainees seemed eager to learn and adapt their practice, whereas GP supervisors rather commented that the intervention was reinforcing. None of the participants reported prescribing conflicts between trainee and supervisor. However, most participants identified conflicts within the GP practice or with specialists: other doctors who prescribe more antibiotics perpetuate patients' ideas that antibiotics will fix everything, which in turn causes conflict with the patient and undermines attempts to improve antibiotic prescribing. The educational intervention was received positively. Early-career GPs thought it influenced their prescribing behaviour and improved their confidence in non-prescribing. Interventions that target teams (e.g. entire practice) could minimize conflict, ensure consistency of messages and support overall antibiotic stewardship in primary care.