Tweed Shire Council

This paper demonstrates that fine‐grained (2–3 μm), transparent Nd:YAG can be achieved at SiO 2 doping levels as low as 0.02 wt% by the sinter plus hot isostatic pressing (HIP) approach. Fine grain size is assured by sintering to 98% density, in order to limit grain growth, followed by HIP. Unlike dry‐pressed samples, tape‐cast samples were free of large, agglomerate‐related pores after sintering, and thus high transparency (i.e., >80% transmission at 1064 nm) could be achieved by HIP at <1750°C along with lower silica levels, thereby avoiding conditions shown to cause exaggerated grain growth. Grain growth was substantially limited at lower SiO 2 levels because silica is soluble in the YAG lattice up to ∼0.02–0.1 wt% at 1750°C, thus allowing sintering and grain growth to occur by solid‐state diffusional processes. In contrast, liquid phase enhanced densification and grain growth occur at ∼0.08–0.14 wt% SiO 2 , especially at higher temperatures, because the SiO 2 solubility limit is exceeded.

RATIONALE: Intrapleural tissue plasminogen activator (tPA)/deoxyribonuclease (DNase) therapy for pleural infection given at the time of diagnosis has been shown to significantly improve radiological outcomes. Published cases are limited to only a single randomized controlled trial and a few case reports. OBJECTIVES: Multinational observation series to evaluate the pragmatic "real-life" application of tPA/DNase treatment for pleural infection in a large cohort of unselected patients. METHODS: All patients from eight centers who received intrapleural tPA/DNase for pleural infection between January 2010 and September 2013 were included. Measured outcomes included treatment success at 30 days, volume of pleural fluid drained, improvement in radiographic pleural opacity and inflammatory markers, need for surgery, and adverse events. MEASUREMENTS AND MAIN RESULTS: Of 107 patients treated, the majority (92.3%) were successfully managed without the need for surgical intervention. No patients died as a result of pleural infection. Most patients (84%) received tPA/DNase more than 24 hours after failing to respond to initial conservative management with antibiotics and thoracostomy. tPA/DNase increased fluid drained from a median of 250 ml (interquartile range [IQR], 100-654) in the 24 hours preceding commencement of intrapleural therapy to 2,475 ml (IQR 1,800-3,585) in the 72 hours following treatment initiation (P < 0.05). We observed a corresponding clearance of pleural opacity on chest radiographs from a median of 35% (IQR 25-31) to 14% (7-28) of the hemithorax (P < 0.001), as well as significant reduction in C-reactive protein (P < 0.05). Pain necessitating escalation of analgesia occurred in 19.6% patients, and nonfatal bleeding occurred in 1.8%. CONCLUSIONS: This large series of patients who received intrapleural tPA/DNase therapy provides important evidence that the treatment is effective and safe, especially as a "rescue therapy" in patients who do not initially respond to antibiotics and thoracostomy drainage.

We measured cerebral oxygen extraction, cerebral blood flow(CBF), and cerebral metabolic rate (CMRO2) in comatose patients during the first 60 hours after resuscitation from cardiac arrest. Each patient was studied 2 or 3 times. CBF was determined by a modification of the Kety-Schmidt method using inhaled Xenon133. Over the study period jugular venous oxygen tension and saturation rose, while the oxygen content difference between arterial and jugular venous blood fell, indicating a progressive increase in the ratio of CBF to metabolism CBF and CMRO2 measurements confirmed this. Between 2 and 6 hours after resuscitation both measurements were severely but proportionately depressed to less than 50% of normal. After 6 hours CBF was increased disproportionately to CMRO2 so that a relative hyperemia developed and persisted for the duration of the study. Although regional inhomogeneity of flow and regional ischemia cannot be ruled out, we have found no evidence for global cerebral ischemia between 2 and 60 hours post-resuscitation as an explanation for failure of recovery. In man following cardiac arrest restoration of levels of global cerebral blood flow, which can be considered adequate relative to the depressed metabolic state of the tissue, is achieved within 2 hours of resuscitation.

Objective: Family physicians in Canada receive little training in chronic pain management; concomitantly, they face increasing pressure to reduce their prescribing of opioids. Project ECHO Ontario Chronic Pain/Opioid Stewardship (ECHO) is a telementoring intervention for primary care practitioners that enhances their pain management skills. This qualitative study reports participants' experiences and assessment of ECHO. Design: An opportunistic sample of multidisciplinary primary care providers attending one of three residential weekend workshops participated in focus group discussions. Setting: University or hospital facilities in Toronto, Thunder Bay, and Kingston, Ontario, Canada. Subjects: Seventeen physicians and 20 allied health professionals. Methods: Six focus group discussions were conducted at three different sites during 2014 and 2015. Transcripts were analyzed using a qualitative-descriptive approach involving analytic immersion in the data, reflection, and achieving consensus around themes discerned from transcribed discussions. Results: Findings resolved into five main themes: 1) challenges of managing chronic pain in primary care; 2) ECHO participation and improvement in patient-provider interaction and participant knowledge; 3) the diffusion of knowledge gained through ECHO to participants' colleagues and patients; 4) ECHO participation generating a sense of community; and 5) disadvantages associated with participating in ECHO. Conclusions: Managing patients with chronic pain in primary care can be difficult, particularly in remote or underserved practices. Project ECHO offers guidance to primary care practitioners for their most challenging patients, promotes knowledge acquisition and diffusion, and stimulates the development of a "community of practice."

The October 8, 2005 earthquake in Northern Pakistan had widespread destructive effects throughout the northern subcontinent. Large numbers of people were killed or severely injured and many medical services destroyed. This report describes the experience of the only standing surgical hospital in the Kashmir region of Bagh District. More than 1,500 people were triaged in 72 hours, many critically injured; 78.4% of patients had upper or lower limb injuries; 50.3% of patients had fractures, mainly closed; 37% of patients required extensive wound debridements. A total of 149 patients received emergency surgery using ketamine anaesthesia with benzodiazepine premedication. This was found to be safe, effective and with a low incidence of major adverse effects. We recommend that ketamine anaesthesia be encouraged in disaster area surgery, particularly in under-resourced regional centres.

These guidelines are a consensus document developed by a working party of the Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) to provide an approach to the investigation of perioperative anaphylaxis. They focus primarily on the use of skin testing as it is the investigation with the greatest clinical utility for the identification of the likely causative agent and potentially safer alternatives. The practicalities and process of skin testing, its limitations, and the place of other tests are discussed. These guidelines also address the roles of graded challenge and in vitro testing. The implications of anaphylaxis associated with neuromuscular blocking agents, beta-lactam antibiotics, local anaesthetic agents and chlorhexidine are discussed. Evidence for the recommendations is derived from literature searches using the words skin test, allergy, anaphylaxis, anaesthesia, and each of the individual agents listed in these guidelines. The individual articles were then reviewed for suitability for inclusion in these guidelines. Where evidence was not strong, as is the situation for many perioperative agents, expert consensus from the ANZAAG working party was used. These guidelines are intended for use by specialists involved in the investigation of perioperative allergy. They have been approved following peer review by members of ANZAAG and are available on the ANZAAG website: http://www.anzaag.com/anaphylaxis-management/testing-guidelines.pdf.

Compositions of Carboniferous and Lower Permian mafic and felsic magmatic rocks from the southern New England Fold Belt, combined with a time‐space evaluation of appropriate regional geological elements, indicate that Late Palaeozoic tectonic events can be simply explained in terms of ongoing west‐dipping subduction. The diversity of igneous rock types and tectonostratigraphic assemblages are interpreted to reflect sequential development of a stationary (Carboniferous), retreating (Early Permian) and advancing (Late Permian) subduction boundary along the active continental margin of East Gondwana. The stationary Carboniferous subduction boundary is expressed as a dual magmatic chain comprising a volcanic arc front of intermediate‐felsic volcanic rocks in the Tamworth Belt and a subparallel rear‐arc chain of granitoids and rare high‐K gabbroic rocks represented by the Bathurst Batholith and satellite plutons. Waning of arc‐front magmatism at ca 330 Ma corresponded to climactic activity in the rear‐arc between 330 Ma and 320 Ma. Subduction boundary retreat is reflected by outboard migration of magmatism into the former accretionary prism of the Tablelands Complex, represented by the ca 300 Ma S‐type Hillgrove Suite granites and coeval Bakers Creek Suite gabbros. Trace‐element chemistry of these gabbros, and of Lower Permian basalts in the nascent Sydney Basin, suggests generation in a backarc setting. The 290–270 Ma Sydney Basin basalts record a transition from steep to flat, N‐MORB normalised chemical trends, which suggests progressive upper plate (Gondwanan) lithospheric thinning during ongoing subduction boundary retreat. The S‐type Bundarra and I‐type Barrington Tops granite suites formed from contrasting crustal sources in this Early Permian extensional backarc setting. A reversal to compressional deformation is recorded by the Late Permian Hunter‐Bowen Orogeny, which placed the Sydney‐Bowen Basin in a foreland setting. An increasing volume of volcanic material, coincident with an increase in the proportion and thickness of conglomeratic units in the Late Permian foreland deposits, is considered to represent the westward translation of the orogenic front and magmatic arc back toward the old Carboniferous continental margin, reflecting an advancing subduction boundary. Voluminous post‐tectonic, high‐K calc‐alkaline plutonism in the New England Batholith indicates establishment of the main magmatic arc in the New England Fold Belt, during the latest Permian ‐ Early Triassic. It completes the cycle of subduction boundary retreat and advancement in the Late Palaeozoic.

Although many studies have attempted to define appropriate nursing staff levels, allocation and patient dependency, minimal data is available on the effect of nursing staff shortage (NSS) on quality of care provided in intensive care. This study aimed to identify incidents associated with staff shortage as reported to the Australian Incident Monitoring Study-ICU (AIMS-ICU) project and to assess their estimated effect on patient outcome. A search of narrative keywords and contributing factors identified 89 nursing staff shortage incidents (NSS-INCIDENTS) and 373 incidents involving nursing staff shortage contributing factors (NSS-CF). NSS resulted from inappropriate rostering for current patient load (81%) and inability to respond to increased unit activity (19%). Most frequent associated incidents included problems with: drug administration/documentation (47), patient supervision (20), set-up of ventilators/equipment (16), and accidental extubation (14). Undesirable patient outcomes included: major physiological change (22%), patient/relative dissatisfaction (12%), and physical injury (3%). This study suggests that inadequate staffing results in incidents and compromised patient safety.

OBJECTIVE: To review the evidence that buffering of local anaesthetics with sodium bicarbonate reduces the pain of injection whilst not affecting efficacy. METHODS: Medline search from 1966 to December 2001. Articles in all languages were included. Bibliographies were examined for papers. RESULTS: The search identified 63 publications. All were retrieved. Of these, 22 were human prospective randomized controlled trials directly assessing the pain of infiltration. Three papers were based on observations. No case series, case reports, or retrospective studies were identified. One animal study was found. CONCLUSION: The evidence is that buffering with sodium bicarbonate significantly reduces the pain of local anaesthetic injection. The buffered solutions retain the efficacy of local anaesthetics and are stable in the mixtures used in the trials. Adrenaline-containing buffered solutions need refrigeration in closed containers for storage. Buffering will be particularly useful where pain of local anaesthetic injection may not be well tolerated such as in large areas of infiltration, sensitive areas such as the face and in children. It is recommended that sodium bicarbonate and tables of stable dilutions are readily available in the emergency department to facilitate this.

A common symptom of eutrophication in temperate estuaries is the proliferation of ephemeral, floating macroalgae. Information on the effects of blooms on underlying assemblages mostly originates from non-vegetated intertidal and subtidal habitats. Blooms also often settle in large aggregations over seagrasses, where they decompose. To test hypotheses concerning the effect of dense mats on underlying assemblages of benthic invertebrates within a seagrass meadow, biomass of the green macroalga Enteromorpha intestinalis was experimentally manipulated in the Tuggerah Lakes estuary, New South Wales, Australia. Algae, equivalent to a naturally occurring bloom (~4.5 kg wet wt m -2 ), were added to caged plots (1 m 2 ) at 2 sites in the seagrass meadow. After 3 mo, the E. intestinalis population began to decompose in the treatment plots and in shallow habitats adjacent to the foreshore. Dramatic declines in the biomass of seagrass and components of the infauna were detected in plots containing decomposing macroalgae. The results have implications for managing estuaries, since assemblages of seagrasses and macrobenthic organisms are considered to be important in nutrient-cycling and food-webs.

PURPOSE: This study was designed to review the results of laparoscopic lavage for the management of perforated sigmoid diverticulitis. METHODS: A 10-year retrospective review was conducted of 78 consecutive cases of sigmoid diverticulitis warranting emergency surgical intervention (1999-2008). RESULTS: Hinchey grades were I (12 patients), II (31 patients), III (29 patients), and IV (6 patients). The patients' mean age was 72 years. Procedures performed were laparoscopic washout (35), Hartmann procedure (31), percutaneous drainage of abscess (4), and resection and primary anastomosis (8). Overall mortality was 5 of 78 (7%); all of these patients were in the Hartmann group. Washout was successful in 27 of 35 cases, meaning recovery from the initial episode of peritonitis without resection. The short-term failures of washout in 8 patients were because of perforated cancer (1), fecal fistula formation (2), and inadequate washout and ongoing sepsis (5). In long-term follow-up, 8 patients in the washout group developed symptoms of recurrent complicated diverticulitis, including painful phlegmon (3), stricture (1), fistulas (3), and repeat perforation (1); all 8 patients underwent delayed resection. Eight patients underwent early planned resection without experiencing further symptoms. Eleven patients were observed without further symptoms with a mean follow-up of 20 months (range, 6-60 mo). CONCLUSIONS: Laparoscopic washout is an emerging technique that is particularly applicable to the management of Hinchey III perforated peritonitis. Short- and long-term problems exist with the technique that may be overcome with further improvement in technique and case selection. Resection and radiological drainage remain widely used in managing perforated sigmoid diverticulitis.

Corticosteroids are synthetic analogues of human hormones normally produced by the adrenal cortex. They have both glucocorticoid and mineralocorticoid properties. The glucocortoid components are anti-inflammatory, immunosuppressive, anti-proliferative and vasoconstrictive. They influence the metabolism of carbohydrate and protein, in addition to playing a key role in the body's stress response. Mineralocorticoid's main significance is in the balance of salt and water concentrations. Due to the combination of these effects, corticosteroids can cause many adverse effects. Oral corticosteroids are absorbed systemically and are therefore more likely to cause adverse effects than topical or inhaled corticosteroids. Furthermore, it is assumed that greater duration of treatment will lead to a greater number of adverse effects, and therefore the most at risk group are those taking high dose, long-term oral corticosteroids (LTOC). High dose is defined as a prescription of >5 mg oral prednisolone and long term as duration of treatment >1 month (based on National Institute for Health and Care Excellence guidance for patient's 'at risk' of systemic side effects). Parameters to be monitored in primary care include weight, blood pressure, triglycerides, glucose and urea and electrolytes. From clinical experience within the general practice setting, the authors propose that these patients do not receive adequate baseline monitoring before starting corticosteroids nor are these markers monitored consistently thereafter. This project intended to evidence this claim, evaluate the adverse effect profile and improve monitoring in this patient group. The initial audit of 22 patients, within a single general practice, detected at least one documented adverse effect in 64% of patients, while 41% reported more than one adverse effect. 45% had recorded weight gain, 18% had recorded osteoporosis, 18% had at least one recorded cataract, 14% had recorded Hypertension, 14% had recorded diabetes mellitus, 9% had recorded dyspepsia and 5% had a recorded psychiatric complaint. All of these recorded conditions were either directly attributed to steroid medication or occurred since LTOC were prescribed. The aim of this project was to increase the percentage of patients on LTOC with complete baseline monitoring to 100%. 'Baseline monitoring' was defined as a measurement taken within the previous 5 years. Although somewhat arbitrary, 5 years was felt to be the maximum timeframe in which monitoring would still be relevant for comparison following introduction of LTOC. Quality improvement methodology was used throughout this project with multiple PDSA (Plan, Study, Do and Act) cycles. Through this, a monitoring system and protocol for patients taking LTOC was developed. As a result of this project, five adverse effects were detected in five different patients. These included two cases of secondary hypertension, one case of diabetes mellitus, one cataract and one case of adrenal insufficiency. 12 out of 20 patients achieved complete baseline monitoring. While this study did not fully achieve its aim, the aim was deliberately ambitious. As not all patients in this study attended for monitoring, a figure of 100% was impossible to achieve. The remaining 'incompletely monitored patients' had some but not all parameters measured. The creation of a staff protocol and increased clinical experience will ensure that complete monitoring takes place in the future. In conclusion, this project has shown that adverse effects from LTOC are prevalent in a single general practice population. It is also shown that monitoring for LTOC adverse effects is inadequate but can be improved relatively easily as skills and competencies from other medication monitoring systems already exist within healthcare settings and are immediately transferable.

BACKGROUND: Endometriosis is a chronic inflammatory condition defined as endometrial-like tissue proliferating outside the uterus. It is a common yet frequently under-recognised condition affecting one in nine Australian women. OBJECTIVE: This paper aims to provide a summary of the recommendations for the diagnosis and management of endometriosis-associated pain and infertility from the most recent evidence-based guidelines on endometriosis by the European Society of Human Reproduction and Embryology, the Royal Australian College of Obstetricians and Gynaecologists and the National Institute for Health and Care Excellence. DISCUSSION: Effective management of endometriosis requires prompt diagnosis to enable early multidisciplinary intervention that aligns with patient needs and priorities. Assessment includes a thorough history, pelvic examination where appropriate and referral for transvaginal ultrasound and/or magnetic resonance imaging. If endometriosis is suspected based on clinical symptoms but imaging is negative or empirical treatment is ineffective, individuals should be referred to a gynaecologist for further assessment and consideration of laparoscopy. Management options include hormonal and surgical therapies.

Anaphylaxis is an uncommon but important cause of serious morbidity and even mortality in the perioperative period. The Australian and New Zealand College of Anaesthetists (ANZCA) with the Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) have developed clinical management guidelines that include six crisis management cards. The content of the guidelines and cards is based on published literature and other international guidelines for the management of anaesthesia-related and non-anaesthesia-related anaphylaxis. The evidence is summarised in the associated background paper (Perioperative Anaphylaxis Management Guidelines [2016] www.anzca.edu.au/resources/endorsed-guidelines and www.anzaag.com/Mgmt%20Resources.aspx). These guidelines are intended to apply to anaphylaxis occurring only during the perioperative period. They are not intended to apply to anaphylaxis outside the setting of dedicated monitoring and management by an anaesthetist. In this paper guidelines will be presented along with a brief background to their development.

Global warming is increasing mean temperatures and altering temperature variability at multiple temporal scales. To better understand the consequences of changes in thermal variability for ectotherms it is necessary to consider thermal variation at different time scales (i.e., acute, diel, and annual) and the responses of organisms within and across generations. Thermodynamics constrain acute responses to temperature, but within these constraints and over longer time periods, organisms have the scope to adaptively acclimate or evolve. Yet, hypotheses and predictions about responses to future warming tend not to explicitly consider the temporal scale at which temperature varies. Here, focusing on multicellular ectothermic animals, we argue that consideration of multiple processes and constraints associated with various timescales is necessary to better understand how altered thermal variability because of climate change will affect ectotherms.

Arterial cannulation is frequently used in the critical care environment. Literaturefocuses on insertion techniques and complications. This report utilized data from the Australian Incident Monitoring Study (AIMS-ICU) national database to identify common problems and contributing factors associated with the use and maintenance of arterial lines. A review of narratives, keywords and contributing factors yielded 251 reports outlining 376 incidents. Of these, 15% describing line insertion problems, 66% line use and maintenance problems and 19% patient injuries. Inadequate line securing, accidental line dislodgement, incorrect set-up, distal ischaemia and infection featured prominently. As a result of the incident, 49% of patients involved suffered no ill effect, 28% minor physiological complications and 15% suffered major adverse effects. Multiple contributing factors were selected for each report, with lack of knowledge, rule-based errors, high unit activity, and lack of support staff or supervision selected most frequently. This study highlights the need to employ meticulous insertion technique, line set-up, securing, frequent line assessment and the early removal of lines no longer essential to patient care. Support and education of staff as well as the development of protocols are important for the safe use of arterial lines.

Abstract Aim This pilot study aimed to explore the impact of Smart Home technology to support older people’s quality of life, particularly for those who live alone. Background There has been an increased interest in using innovative technologies and artificial intelligence to enable Smart Home technology to support older people to age independently in their own homes. Methods This study used a pre‐and post‐test design. The seven item Personal Wellbeing Index was used to measure participants’ subjective quality of life across seven quality of life domains. Participants ( n = 60) aged between 68 and 90 years ( M = 80.10, SD = 5.56) completed a 12‐week personalised Smart Home technology program. Results Approximately half of the participants lived alone (48.3%). Participants’ quality of life significantly increased ( p = 0.010) after Smart Home use. Two domains, “achieving in life” ( p = 0.026) and “future security” ( p = 0.004), were also significantly improved after participating in the Smart Home technology program. Improvements in quality of life did not vary as a function of living arrangement (all p s &gt; .152, all &gt; .00). Conclusion The current study provides preliminary evidence for the role of Smart Home technology in supporting older people’s quality of life, particularly their sense of achieving in life and future security.

We report a clinical pregnancy occurring in a 31 year old patient following intracytoplasmic sperm injection (ICSI) of cryopreserved spermatozoa obtained from a testicular biopsy. This was the couple's second attempt at an ovarian stimulated cycle resulting in the collection of 17 metaphase II ova which were all injected with progressively motile spermatozoa. A fertilization rate of 58% and a cleavage rate of 90% were achieved. This report is our first case of ICSI using cryopreserved testicular spermatozoa which resulted in normal fertilization, embryo development and an on-going singleton pregnancy.

This report constitutes a prospectively planned meta-analysis combining two almost identical trials undertaken in Australasia and Canada to study the effect of starting chemotherapy immediately in asymptomatic patients with metastatic colorectal cancer. Patients (n=168) were randomised to receive either immediate or delayed treatment (at onset of predefined symptoms). Australasian patients received either weekly 5-fluorouracil and leucovorin (500 and 20 mg m(-2), respectively) (n=59) or the daily x 5 Mayo Clinic schedule (425 and 20 mg m(-2), respectively) (n=42). Canadian patients were treated with the Mayo schedule (n=67). Otherwise, the two studies were almost identical in design and each used the European Organisation for the Research and Treatment of Cancer (EORTC) QLQ-C30 instrument for measuring quality of life (QoL). Treatment was continued until 6 months had elapsed or disease progression occurred. Low accrual led to trial suspension before the predetermined sample size for either study was reached. Median survival was not significantly better with immediate treatment (median 13.0 vs 11.0 months; hazard ratio, 1.15; 95% confidence interval (CI) 0.79-1.72; P=0.49). There was no statistically significant difference in progression-free survival (time from randomisation until first evidence of progression after chemotherapy, 10.2 vs 10.8 months; hazard ratio, 1.08; 95% CI 0.71-1.64; P=0.73). There was no difference in overall QoL or its individual domains between the two treatment strategies at baseline or at any subsequent time point. Early treatment of asymptomatic patients with metastatic colorectal cancer did not provide a survival benefit or improved QoL compared to withholding treatment until symptoms occurred.

Acute right heart failure in a young person is an unusual presentation and drug overdose is a rare cause. A case is described where the patient presented with striking clinical signs of acute pulmonary hypertension and right heart failure, which were confirmed by transthoracic echocardiography. The precipitating event appeared to be poisoning by tramadol. There were features in keeping with tramadol toxicity and serotonin syndrome. The possible pathophysiology behind the process is discussed.