"Quite simply they don't communicate": a case study of a National Health Service response to staff suicide.

Workplace suicide can have significant knock-on effects within an organisation, yet research has shown within the healthcare profession, not all staff receive suicide prevention training, and few employers take the time to reflect on the need to change workplace policies or practices following the death of a staff member to suicide. How staff suicide is communicated across an organisation and to family members is important. Effective crisis communication is critical for effective management for a timely and sensitive response to a staff suicide within an organisation. By doing so, workplaces can help to reduce the significant emotional trauma suicide can have on an employee, and support good mental health across its workforce. This study aimed to explore and understand the communication processes around staff suicide across a National Health Service (NHS) Trust and to provide recommendations based on these findings. Semi-structured interviews were conducted with 29 participants, each lasting approximately 90 min. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were followed. Thematic analysis was used to analyse the data, resulting in seven themes being identified based on communication. Findings indicated that the Trust had no clear communication strategy in place for tackling staff suicide. Each suicide was handled differently, training across staff roles was lacking and operational procedures were deemed insensitive. This paper aimed to provide insight into the communication strategies used in the aftermath of a staff suicide. These findings highlight the inconsistency of the communication, lack of clear policy and guidance and the negative impact this had on staff. Further research is needed across NHS Trusts nationwide to gain insight into the current communication strategies in place to develop a national approach to clear communication following the death of an NHS worker to suicide. Tweetable abstract: Effective communication is critical in the aftermath of an NHS staff suicide. By doing so, NHS Trusts can help to reduce the trauma suicide can have on an employee and support good mental health across its workforce @stann2.

Is use of opioid agonist treatment associated with broader primary healthcare use among men with recent injecting drug use histories following release from prison? A prospective cohort study.

BACKGROUND: A precipitous decline in health status among people recently released from prison is common. In Victoria, Australia, opioid agonist treatment (OAT) in the community involves frequent contact with primary care, potentially facilitating broader use of primary healthcare services. Among a cohort of men who injected drugs regularly pre-imprisonment, we estimated differences in rates of primary healthcare use and medication dispensation between people who did and did not receive OAT post-release. METHODS: Data came from the Prison and Transition Health Cohort Study. Three-month post-release follow-up interviews were linked with primary care and medication dispensation records. Generalised linear models were fit with one exposure (OAT: none/partial/complete) for 13 outcomes relating to primary healthcare use, pathology testing, and medication dispensation, adjusted for other covariates. Coefficients were reported as adjusted incidence rate ratios (AIRR). RESULTS: Analyses included 255 participants. Compared to no OAT use, both partial and complete OAT use were associated with increased rates of standard (AIRR: 3.02, 95%CI: 1.88-4.86; AIRR: 3.66, 95%CI: 2.57-5.23), extended (AIRR: 2.56, 95%CI: 1.41-4.67; AIRR: 2.55, 95%CI: 1.60-4.07) and mental health-related (AIRR: 2.71, 95%CI: 1.42-5.20; AIRR: 2.27, 95%CI: 1.33-3.87) general practitioner (GP) consultations, total medication (AIRR: 1.88, 95%CI: 1.19-2.98; AIRR: 2.40, 95%CI: 1.71-3.37), benzodiazepine (AIRR: 4.99, 95%CI: 2.81-8.85; AIRR: 8.30, 95%CI: 5.28-13.04) and gabapentinoid (AIRR: 6.78, 95%CI: 3.34-13.77; AIRR: 4.34, 95%CI: 2.37-7.94) dispensations, respectively. Partial OAT use was also associated with increased after-hours GP consultations (AIRR: 4.61, 95%CI: 2.24-9.48) and complete OAT use? with increased pathology utilisation (e.g. haematological, chemical, microbiological or immunological tissue/sample testing; AIRR: 2.30, 95%CI: 1.52-3.48). CONCLUSION: We observed higher rates of primary healthcare use and medication dispensation among people who reported partial and complete OAT use post-release. Findings suggest that access to OAT post-release may have a collateral benefit in supporting broader health service utilisation, underscoring the importance of retention in OAT after release from prison.

Criminal Justice Involvement after Release from Prison following Exposure to Community Mental Health Services among People Who Use Illicit Drugs and Have Mental Illness: a Systematic Review.

Illicit drug use and mental illness are common among people in prison and are associated with higher rates of reoffending and reimprisonment. We conducted a systematic review, searching MEDLINE, Embase, and PsycINFO to January 10, 2022, for studies reporting criminal justice involvement following exposure to community mental health services among people released from jail or prison who use illicit drugs and have mental illness. Our search identified 6954 studies; 13 were eligible for inclusion in this review. Studies were separated into three broad categories based on community mental health service type. Eleven of 13 studies reported a reduction in criminal justice involvement among participants exposed to community mental health services compared to a comparison group. Findings indicate a need to expand and improve integration and referral mechanisms linking people to community mental health services after jail or prison release, alongside a need for tailored programs for individuals with complex illicit drug use and mental health morbidities.

Torque- and Muscle-Driven Flexion Induce Disparate Risks of In Vitro Herniation: A Multiscale and Multiphasic Structure-Based Finite Element Study.

The intervertebral disc is a complex structure that experiences multiaxial stresses regularly. Disc failure through herniation is a common cause of lower back pain, which causes reduced mobility and debilitating pain, resulting in heavy socioeconomic burdens. Unfortunately, herniation etiology is not well understood, partially due to challenges in replicating herniation in vitro. Previous studies suggest that flexion elevated risks of herniation. Thus, the objective of this study was to use a multiscale and multiphasic finite element model to evaluate the risk of failure under torque- or muscle-driven flexion. Models were developed to represent torque-driven flexion with the instantaneous center of rotation (ICR) located on the disc, and the more physiologically representative muscle-driven flexion with the ICR located anterior of the disc. Model predictions highlighted disparate disc mechanics regarding bulk deformation, stress-bearing mechanisms, and intradiscal stress-strain distributions. Specifically, failure was predicted to initiate at the bone-disc boundary under torque-driven flexion, which may explain why endplate junction failure, instead of herniation, has been the more common failure mode observed in vitro. By contrast, failure was predicted to initiate in the posterolateral annulus fibrosus under muscle-driven flexion, resulting in consistent herniation. Our findings also suggested that muscle-driven flexion combined with axial compression could be sufficient for provoking herniation in vitro and in silico. In conclusion, this study provided a computational framework for designing in vitro testing protocols that can advance the assessment of disc failure behavior and the performance of engineered disc implants.

Analysis of four syringe dispensing machine point-of-access data 2017-2020 in Melbourne, Australia: machine utilisation and client demographics.

BACKGROUND: Australian needle and syringe distribution occurs via a mix of modalities, including syringe dispensing machines (SDMs). SDMs are electronic vending machines providing (often) 24-h access to needles/syringes and may attract greater numbers of people who are younger, female, and/or have limited connection to health care services compared to individuals accessing fixed-site needle and syringe programs (NSPs). However, validating the demographic characteristics of SDM clients has proven difficult in previous research. METHODS: In this paper, we analyse SDM order and client demographic data from four SDMs located in South-East Melbourne, Australia, and compare this against the managing fixed-site NSP between May 2017 and December 2020. SDM data were collected via a novel 0-9 numeric keypad input tool. Via the tool, SDM clients were requested to input their categorised age, gender and postcode. Given the novelty of the tool, we evaluate the feasibility of the data collection method. We analysed data according to: (1) total SDM orders made, (2) estimated 'unique SDM presentations' and (3) describing the demographics of unique SDM clients. Importantly, we noted substantial invalid demographic data, and consequently, severely restricted data for analysis. RESULTS: There were 180,989 SDM orders made across the four SDMs to an estimated 90,488 unique SDM presentations. There was little variation in unique presentations across days of the week, but 69% occurred out of NSP operating hours. Across the study period, the SDMs distributed 66% of the number of syringes distributed by the fixed-site NSP. Due to invalid demographic data, our restriction method provided only 10,914 (6% of all data) unique presentations for analysis. There were some demographic differences between SDM and NSP client, but these should be treated with caution. CONCLUSIONS: The data collection tool provides a novel means of comparing SDM and fixed-site presentations, demonstrating the substantial expansion of service via the SDMs. However, the validity of the demographic data was highly questionable and requires significant data coding, meaning it is not feasible for community NSPs. While we recommend the inclusion of automatically collected SDM order data, the use of a 0-9 numeric keypad to collect demographic data-while an innovation-requires alteration to support NSP data.

Time-series analysis of presentations to four syringe dispensing machines and a needle and syringe programme during COVID-19 lockdowns in Melbourne, Australia.

BACKGROUND: Australian harm reduction services are provided via a mix of modalities, including fixed-site needle and syringe programmes (NSP) and syringe-dispensing machines (SDMs). SDMs are cost-effective and provide 24-h anonymous access to needles/syringes, often to underserved geographic areas, and can attract clientele who may choose not to use NSPs. The introduction of COVID-19 control measures saw disruptions and adaptations to the provision of harm reduction services. It is possible that SDMs filled the gap in otherwise disrupted harm reduction services in Melbourne. In this paper, we use data from four SDMs and an NSP to explore changes to harm reduction usage during periods of COVID-19 lockdowns in Melbourne, Australia, in 2020. METHODS: Our data span September 2017-December 2020. We analysed daily counts of SDM use and monthly counts of NSP use, according to unique presentations to both. Auto-regressive integrated moving average (ARIMA) time-series models were fitted to the data with the effects of lockdowns estimated via a step function. RESULTS: Across the study period, we estimated 85,851 SDM presentations and 29,051 NSP presentations. Usage across both the SDMs and the NSP declined during the COVID-19 lockdowns, but only the decline in SDM usage was significant in ARIMA analysis. CONCLUSIONS: The slight, but significant decline in SDM use suggests barriers to access, though this may have been mitigated by SDM users acquiring needles/syringes from other sources. The decline, however, may be a concern if it led to lowered needle/syringe coverage and a subsequent increase in injecting risk. Further work is needed to properly explore potential changes in preference for needle/syringe acquisition site and associated barriers. Importantly, this work adds to the body of literature around the impacts of COVID-19 on harm reduction provision and potential areas of improvement.

Unusual Alternating Crystallization-Induced Emission Enhancement Behavior in Nonconjugated ω-Phenylalkyl Tropylium Salts.

The alternating physical properties, especially melting points, of α,ω-disubstituted n-alkanes and their parent n-alkanes had been known since Baeyer's report in 1877. There is, however, no general and comprehensive explanation for such a phenomenon. Herein, we report the synthesis and examination of a series of novel ω-phenyl n-alkyl tropylium tetrafluoroborates, which also display alternation in their physicochemical characters. Despite being organic salts, the compounds with odd numbers of carbons in the alkyl bridge exist as room temperature ionic liquids. In stark contrast to this, the analogues with even numbers of carbons in the linker are crystalline solids. These solid nonconjugated molecules exhibit curious photoluminescent properties, which can be attributed to their ability to form through-space charge-transfer complexes to cause crystallization-induced emission enhancement. Most notably, the compound with the highest photoluminescent quantum yield in this series showed an unusual arrangement of carbocationic dimer in the solid state. A combination of XRD analysis and ab initio calculations revealed interesting insights into these systems.

A principle-based framework for improving health equity in the Champlain region of Ontario, Canada.

The purpose of this column is to present an action-oriented health equity framework derived from Beauchamp and Childress' four ethical principles (ie, autonomy, beneficence, nonmaleficence, and justice) and centred around the specific needs of marginalized and excluded communities of the Champlain region of Ontario. It describes the conceptual underpinnings of the framework, defines its components, and demonstrates how it can be applied. The principle-based health equity framework is a useful tool to reduce health disparities within healthcare organizations; it is designed to promote the incorporation of health equity objectives, strategies, principles, and measurements into healthcare organizations' strategic planning processes and operations.

Virtual care and the pursuit of the quadruple aim: A case example.

Many healthcare organizations have adopted the quadruple aim to create system-level improvements for delivering enhanced experience and outcomes to patients, healthier populations, reduced per-capita costs, and better provider experiences. With a maturing health technology sector, virtual care is gradually being adopted in Canada and proving to be a viable tactic for achieving the quadruple aim. Despite increased acceptance of virtual innovations and their related benefits to patients and providers, implementation of virtual care can be challenging in a Canadian healthcare system. The Ottawa Hospital developed an innovation strategy to guide the adoption and maturity of virtual care as a means of supporting the pursuit of the quadruple aim and achievement of the organization's mission and vision. A case example presenting the strategy and recommendations for health leaders and providers considering implementation of virtual care is discussed.

Therapeutic efficacy of intra-articular delivery of encapsulated human mesenchymal stem cells on early stage osteoarthritis.

Mesenchymal stem cells (MSCs) represent a great therapeutic promise in pre-clinical models of osteoarthritis (OA), but many questions remain as to their therapeutic mechanism of action: engraftment versus paracrine action. Encapsulation of human MSCs (hMSCs) in sodium alginate microspheres allowed for the paracrine signaling properties of these cells to be isolated and studied independently of direct cellular engraftment. The objective of the present study was to quantitatively assess the efficacy of encapsulated hMSCs as a disease-modifying therapeutic for OA, using a medial meniscal tear (MMT) rat model. It was hypothesized that encapsulated hMSCs would have a therapeutic effect, through paracrine-mediated action, on early OA development. Lewis rats underwent MMT surgery to induce OA. 1 d post-surgery, rats received intra-articular injections of encapsulated hMSCs or controls (i.e., saline, empty capsules, non-encapsulated hMSCs). Microstructural changes in the knee joint were quantified using equilibrium partitioning of a ionic contrast agent based micro-computed tomography (EPIC-µCT) at 3 weeks post-surgery, an established time point for early OA. Encapsulated hMSCs significantly attenuated MMT-induced increases in articular cartilage swelling and surface roughness and augmented cartilaginous and mineralized osteophyte volumes. Cellular encapsulation allowed to isolate the hMSC paracrine signaling effects and demonstrated that hMSCs could exert a chondroprotective therapeutic role on early stage OA through paracrine signaling alone. In addition to this chondroprotective role, encapsulated hMSCs augmented the compensatory increases in osteophyte formation. The latter should be taken into strong consideration as many clinical trials using MSCs for OA are currently ongoing.

Contrast enhanced µCT imaging of early articular changes in a pre-clinical model of osteoarthritis.

OBJECTIVE: The objective of this study was to characterize early osteoarthritis (OA) development in cartilage and bone tissues in the rat medial meniscus transection (MMT) model using non-destructive equilibrium partitioning of an ionic contrast agent micro-computed tomography (EPIC-µCT) imaging. Cartilage fibrillation, one of the first physiological developments in OA, was quantified in the rat tibial plateau as three-dimensional (3D) cartilage surface roughness using a custom surface-rendering algorithm. METHODS: Male Lewis rats underwent MMT or sham-operation in the left leg. At 1- and 3-weeks post-surgery, the animals (n = 7-8 per group) were euthanized and the left legs were scanned using EPIC-µCT imaging to quantify cartilage and bone parameters. In addition, a custom algorithm was developed to measure the roughness of 3D surfaces. This algorithm was validated and used to quantify cartilage surface roughness changes as a function of time post-surgery. RESULTS: MMT surgery resulted in significantly greater cartilage damage and subchondral bone sclerosis with the damage increasing in both severity and area from 1- to 3-weeks post-surgery. Analysis of rendered 3D surfaces could accurately distinguish early changes in joints developing OA, detecting significant increases of 45% and 124% in surface roughness at 1- and 3-weeks post-surgery respectively. CONCLUSION: Disease progression in the MMT model progresses sequentially through changes in the cartilage articular surface, extracellular matrix composition, and then osteophyte mineralization and subchondral bone sclerosis. Cartilage surface roughness is a quantitative, early indicator of degenerative joint disease in small animal OA models and can potentially be used to evaluate therapeutic strategies.

Long-distance flights and high-risk breeding by nomadic waterbirds on desert salt lakes.

Understanding and conserving mobile species presents complex challenges, especially for animals in stochastic or changing environments. Nomadic waterbirds must locate temporary water in arid biomes where rainfall is highly unpredictable in space and time. To achieve this they need to travel over vast spatial scales and time arrival to exploit pulses in food resources. How they achieve this is an enduring mystery.  We investigated these challenges in the colonial-nesting Banded Stilt (Cladorhynchus leucocephalus), a nomadic shorebird of conservation concern. Hitherto, Banded Stilts were hypothesized to have only 1-2 chances to breed during their long lifetime, when flooding rain fills desert salt lakes, triggering mass-hatching of brine shrimp. Over 6 years, we satellite tagged 57 individuals, conducted 21 aerial surveys to detect nesting colonies on 14 Australian desert salt lakes, and analyzed 3 decades of Landsat and MODIS satellite imagery to quantify salt-lake flood frequency and extent. Within days of distant inland rainfall, Banded Stilts flew 1,000-2,000 km to reach flooded salt lakes. On arrival, females laid over half their body weight in eggs. We detected nesting episodes across the species' range at 7 times the frequency reported during the previous 80 years. Nesting colonies of thousands formed following minor floods, yet most were subsequently abandoned when the water rapidly evaporated prior to egg hatching. Satellite imagery revealed twice as many flood events sufficient for breeding-colony initiation as recorded colonies, suggesting that nesting at remote sites has been underdetected. Individuals took risk on uncertain breeding opportunities by responding to frequent minor flood events between infrequent extensive flooding, exemplifying the extreme adaptability and trade-offs of species exploiting unstable environments. The conservation challenges of nest predation by overabundant native gulls and anthropogenic modifications to salt lakes filling frequencies require investigation, as do the physiological and navigational mechanisms that enable such extreme strategies.

Effect of Caffeine on Sprint Cycling in Experienced Cyclists.

Anderson, DE, LeGrand, SE, and McCart, RD. Effect of caffeine on sprint cycling in experienced cyclists. J Strength Cond Res 32(8): 2221-2226, 2018-Research regarding the ergogenic effects of caffeine (CAF) in anaerobic activity remains inconclusive. However, some researchers have found significant improvements in anaerobic performance when testing specifically trained athletes. A double-blind, placebo-controlled, counterbalanced, cross-over design was implemented to assess the impact of CAF on a 30-second Wingate Anaerobic Test (WAnT) in experienced cyclists. Nine experienced cyclists volunteered to participate in this study (men, n = 7 and women, n = 2). The subjects completed 2 separate experimental trials consisting of a 30-second WAnT at a resistance of 9% body mass. In a random order, 1 hour before each WAnT, subjects ingested either a CAF (∼280 mg) or placebo (PLAC) coffee. For each trial, heart rate (HR) and blood lactate (BL) values were recorded at rest, pre-WAnT, post-WAnT, and 5 minutes post-WAnT. After each trial, the subjects recorded their perception of which treatment they received. Heart rate and BL responses were not significantly different between the CAF and PLAC conditions. The ingestion of CAF did not significantly improve peak anaerobic power, mean anaerobic power, nor fatigue index. In at least 1 of the 2 trials, 44% of the subjects incorrectly guessed which substance they had ingested. The findings of this study do not show a significant correlation between CAF ingestion and improved anaerobic performance in experienced cyclists. However, performance enhancements may depend on varying individual responses to CAF. Athletes who are positive CAF responders may consider using coffee before competition to improve anaerobic performance.

NHC-Catalyzed Metathesis and Phosphorylation Reactions of Disulfides: Development and Mechanistic Insights.

The development of efficient methods for the metathesis and phosphorylation reactions of disulfide compounds is of widespread interest due to their important synthetic utility in polymer, biological, medicinal and agricultural chemistry. Herein, we demonstrate the use of N-heterocyclic carbenes (NHCs) as versatile organocatalysts to promote these challenging reactions under mild conditions. This metal- and oxidant-free protocol is operationally simple with very short reaction times. The interplay between the nucleophilicity and basicity of NHCs in these reactions were also elucidated by NMR studies and high-level ab initio calculations.

Pomalidomide desensitization in a patient hypersensitive to immunomodulating agents.

Despite progressive treatments with tandem stem-cell transplantation, patients with incurable myeloma eventually succumb to relapsed or refractory disease if left untreated. Promising agents such as proteasome inhibitors and immunomodulating imide drugs (imids), including the newer-generation agent pomalidomide, in combination with lower-dose dexamethasone, have been shown to be effective and to significantly improve and prolong survival in pretreated patients. Although the incidence of pomalidomide hypersensitivity reaction (hsr) in this class of drugs is not as well known, we have documented cutaneous toxicity (grade 3 by the Common Terminology Criteria for Adverse Events, version 4) in 2 separate cases (not yet published). Because the imids are chemically, structurally, and pharmacologically similar, it is not unreasonable to consider possible cross-reactivity in pomalidomide recipients who developed hsr when receiving previous lines of imids. As a patient's advocate, it is only prudent to provide a responsible, and yet practical, means to better address cross-sensitivity for patients. Intervention with the use of a rapid desensitization program (rdp) as a preventive measure should be introduced before initiating pomalidomide. Such a proactive measure for the patient's safety will ensure a smooth transition into pomalidomide treatment. A hsr can be either related or non-related to immunoglobulin E. As imids become an essential treatment backbone for myeloma and other plasma-cell diseases, an increasing number of patients could experience skin and other life-threatening toxicities, resulting in unnecessary discontinuation of these life-prolonging agents. An extemporaneously prepared pomalidomide suspension developed at our centre enables patients to undergo rdp safely. Patients enjoy a good quality of life and clinical response after the rdp procedure.

Promotion of Organic Reactions by Non-Benzenoid Carbocyclic Aromatic Ions.

The first three primary members of the non-benzenoid carbocyclic aromatic ion family, namely cyclopropenium, cyclopentadienide, and cycloheptatrienium (tropylium) ions, have planar cyclic structures with (4n+2)π electrons in fully conjugated systems. They fulfill Hückel's rule for aromaticity and hence possess extraordinary stability. Since the historic discovery of tropylium bromide in the late 19th Century, these non-benzenoid aromatic ions have attracted a lot of attention because of their unique combination of stability and reactivity. The charge on the aromatic ions makes them more prone to nucleophilic/electrophilic reactions than the neutral benzenoid counterparts. Within the last seven years, there has been a large number of investigations in utilizing aromatic ions to mediate organic reactions. This Review highlights these recent developments and discusses the potential of aromatic ions in promoting synthetically useful organic transformations.

The Resurgence of the Highly Ylidic N-Heterocyclic Olefins as a New Class of Organocatalysts.

In recent decades, N-heterocyclic carbenes have become established as a prevalent family of organocatalysts. N-Heterocyclic olefins, the alkylidene derivatives of N-heterocyclic carbenes, have recently also emerged as efficient promoters for CO2 fixation and polymerization reactions. Their extraordinarily strong Lewis/Brønsted basicity suggests great potential as a new class of organocatalysts for a broad range of reactions in synthetic chemistry.

Rabbit biocontrol and landscape-scale recovery of threatened desert mammals.

Funding for species conservation is insufficient to meet the current challenges facing global biodiversity, yet many programs use expensive single-species recovery actions and neglect broader management that addresses threatening processes. Arid Australia has the world's worst modern mammalian extinction record, largely attributable to competition from introduced herbivores, particularly European rabbits (Oryctolagus cuniculus) and predation by feral cats (Felis catus) and foxes (Vulpes vulpes). The biological control agent rabbit hemorrhagic disease virus (RHDV) was introduced to Australia in 1995 and resulted in dramatic, widespread rabbit suppression. We compared the area of occupancy and extent of occurrence of 4 extant species of small mammals before and after RHDV outbreak, relative to rainfall, sampling effort, and rabbit and predator populations. Despite low rainfall during the first 14 years after RHDV, 2 native rodents listed by the International Union for Conservation of Nature (IUCN), the dusky hopping-mouse (Notomys fuscus) and plains mouse (Pseudomys australis), increased their extent of occurrence by 241-365%. A threatened marsupial micropredator, the crest-tailed mulgara (Dasycercus cristicauda), underwent a 70-fold increase in extent of occurrence and a 20-fold increase in area of occupancy. Both bottom-up and top-down trophic effects were attributed to RHDV, namely decreased competition for food resources and declines in rabbit-dependent predators. Based on these sustained increases, these 3 previously threatened species now qualify for threat-category downgrading on the IUCN Red List. These recoveries are on a scale rarely documented in mammals and give impetus to programs aimed at targeted use of RHDV in Australia, rather than simply employing top-down threat-based management of arid ecosystems. Conservation programs that take big-picture approaches to addressing threatening processes over large spatial scales should be prioritized to maximize return from scarce conservation funding. Further, these should be coupled with long-term ecological monitoring, a critical tool in detecting and understanding complex ecosystem change.

Bortezomib in multiple myeloma: systematic review and clinical considerations.

We conducted a systematic review to determine the appropriate use of bortezomib alone or in combination with other agents in patients with multiple myeloma (mm). We searched medline, embase, the Cochrane Library, conference proceedings, and the reference lists of included studies. We analyzed randomized controlled trials and systematic reviews if they involved adult mm patients treated with bortezomib and if they reported on survival, disease control, response, quality of life, or adverse effects. Twenty-six unique studies met the inclusion criteria. For patients with previously untreated mm and for candidates for transplantation, we found a statistically significant benefit in time to progression [hazard ratio (hr): 0.48, p < 0.001; and hr: 0.63, p = 0.006, respectively] and a better response with a bortezomib than with a non-bortezomib regimen (p < 0.001). Progression-free survival was longer with bortezomib and thalidomide than with thalidomide alone (p = 0.01). In non-candidates for transplantation, a significant benefit in overall survival was observed with a bortezomib regimen (hr compared with a non-bortezomib regimen: 0.61; p = 0.008), and in transplantation candidates receiving bortezomib, the response rate was improved after induction (p = 0.004) and after a first transplant (p = 0.016). In relapsed or refractory mm, overall survival (p = 0.03), time to progression (hr: 1.82; p = 0.000004), and progression-free survival (hr: 1.69; p = 0.000026) were significantly improved with bortezomib and pegylated liposomal doxorubicin (compared with bortezomib alone), and bortezomib monotherapy was better than dexamethasone alone (hr: 0.77; p = 0.027). Bortezomib combined with thalidomide and dexamethasone was better than either bortezomib monotherapy or thalidomide with dexamethasone (p < 0.001). In previously untreated or in relapsed or refractory mm patients, bortezomib-based therapy has improved disease control and, in some patients, overall survival.

A single-centre retrospective study of the utility of routine chest X-ray post intrathoracic drain removal in cardiothoracic surgical patients.

Routine chest X-ray (CXR) post intrathoracic drain removal in cardiac surgical patients is common practice to identify the presence of a pneumothorax following drain removal. Such pneumothoraces occur infrequently and rarely require intervention. We investigated the utility of routine CXR post drain removal and hypothesised that the practice is unnecessary and a possible area for significant cost saving. We conducted a single-centre, retrospective study of 390 patients who underwent cardiac surgery over a one-year period. Routine CXR post drain removal was reviewed for the presence of a pneumothorax. Rates of intervention post routine CXR were analysed to assess for clinical benefit obtained from this practice. Potential cost savings were calculated by the cost of a mobile CXR and by considering the radiographer's time. There were 15 pneumothoraces detected on routine CXR post drain removal. All pneumothoraces detected on routine post drain removal CXR were defined as small. No patients had a clinically significant pneumothorax requiring re-insertion of a chest drain. The potential cost saved by omitting routine CXR post drain removal was estimated to be approximately A$7750 per year. This study did not detect any clinically significant pneumothoraces requiring intervention. It also suggests that routine CXR post drain removal does not provide any clinical benefit and indicates that current practice should be reviewed.