Parenteral nutrition insecurity: ASPEN survey to assess the extent and severity of parenteral nutrition access and reimbursement issues.

BACKGROUND: Parenteral nutrition (PN) shortages and lack of qualified professional staff to manage PN impact safe, efficacious care and costs of PN. This American Society for Parenteral and Enteral Nutrition (ASPEN)-sponsored survey assessed the frequency and extent to which PN access affects PN delivery to patients. METHODS: Healthcare professionals involved with PN were surveyed. Questions were developed to characterize the respondent population and determine the extent and severity of PN access issues to components, devices, and healthcare professionals, as well as their effects on discharge and transfer issues. Reimbursement issues included cost, adequacy of therapy, and healthcare professional reimbursement. Burdens were types and frequency of errors, adverse events, and nutrition problems resulting from PN access issues. Impact on professionals and organizations was determined. RESULTS: Respondents (N = 350) worked in hospitals (75%) and home infusion (25%). Per day, clinicians cared for <15 patients receiving PN. All age populations were represented. Respondents reported shortages of macronutrients (72%, 233 of 324) and micronutrients (91%, 297 of 324). Issues with access to healthcare workers were observed. PN access issues contribute to increased costs of PN, and knowledge regarding the current rate of PN reimbursement is limited. Respondents (75%, 197 of 261) observed an error due to PN access issues. Adverse events (57%, 149 of 259) were observed leading to temporary or permanent harm (24%, 61 of 259) as well as near death (4%, 9 of 259) and death (1%, 2 of 259). Providers reported time away from other job responsibilities and workplace stress. CONCLUSION: PN access issues result in "PN insecurity" that negatively impacts patients and healthcare providers and leads to adverse events including death in patients receiving PN.

Time to embrace sepsis pathways and antibiotic prescribing decision support in the emergency department: Observations from a retrospective single site clinical audit.

OBJECTIVE: To compare clinician documentation of sepsis for infective presentations in the ED against a formal sepsis pathway in the ED and to assess appropriateness of the initial parenteral antibiotic prescription for adult patients in ED. METHODS: A retrospective, clinical audit of adult patients who received at least one parenteral antibiotic in ED over a 10-week period in 2018. Documented initial clinical impression was compared with an approved sepsis pathway. Antibiotic appropriateness was assessed using National Antimicrobial Prescribing Survey definitions. Assessment was carried out by an infectious diseases pharmacist, with input from an infectious diseases physician. RESULTS: Two hundred and nineteen infective presentations were included in the analysis. There was a discordance between the initial documented clinical impression compared with the classification when a sepsis pathway was applied. An initial documented clinical impression of sepsis and septic shock was present in 38 (60.3%) of the presentations compared to 63 presentations when a formal sepsis pathway was applied as a screening tool. There was a significant difference in the proportion of patients in each diagnostic group (infection, sepsis and septic shock) according to documented clinical impression versus sepsis pathway classification (P = 0.0002). There were 386 prescriptions for antibiotics as part of the initial management. Antibiotic appropriateness for the initial prescription was assessed as 63.7% appropriate, 27.2% inappropriate and 9.1% not assessable. CONCLUSION: Our observations demonstrate that use of a formal sepsis pathway may improve the screening and early diagnosis of sepsis and septic shock and that there is a need for antibiotic prescribing guidance in the ED.

Beyond the 'big smoke': Enabling supervision of ophthalmology trainees in regional, rural and remote Australia.

OBJECTIVE: Expansion of opportunities for ophthalmology training beyond the 'big smoke' is anticipated to support the future distribution of ophthalmologists in regional, rural and remote areas of Australia. However, little is known about what enables supervision outside of metropolitan tertiary hospital settings that would contribute to positive training experiences for specialist medical trainees and encourage them to leave the 'big smoke' once qualified. The aim of this study was therefore to explore the perceived enablers of ophthalmology trainee supervision in regional, rural and remote health settings across Australia. SETTING: Australia. PARTICIPANTS: Ophthalmologists working in regional, rural or remote health settings with experience and/or interest in supervising ophthalmology trainees (n = 16). DESIGN: Qualitative design involving semistructured interviews. RESULTS: Seven key enablers of ophthalmology trainee supervision in regional, rural and remote health settings were identified: adequate physical infrastructure, resources and funding to host a trainee; availability of online curriculum and teaching resources so as to ensure equity of training opportunities; pre-established training posts, driven by supervision 'champions'; a critical mass of ophthalmologists to help share the supervisory load; relationships and support between training posts, the training network and the Specialist Medical College; alignment of trainee competence and attitude with the needs of the training setting; and the recognition of reciprocal benefits for supervisors through supporting trainees, including workforce support and renewal. CONCLUSION: With training experiences beyond the 'big smoke' anticipated to influence future ophthalmology workforce distribution, implementation of enablers of trainee supervision should occur in regional, rural and remote health settings wherever possible.

Benefits and challenges to ophthalmology training via the Specialist Training Program.

INTRODUCTION: The Specialist Training Program (STP) is a commonwealth funding initiative to support specialist medical training positions in regional, rural and remote areas, and in private settings. The program helps to improve the skills and distribution of the specialist medical workforce by providing trainees experience of a broader range of healthcare settings. OBJECTIVE: To examine the benefits and challenges of ophthalmology training delivered by the STP in regional, rural, remote, and/or private settings across Australia. DESIGN: Qualitative design involving semi-structured in-depth interviews with thirty-two participants experienced in the delivery of ophthalmology training at STP posts including ophthalmology trainees (n = 8), STP supervisors and clinical tutors (n = 16), and other stakeholders (n = 8). FINDINGS: Training delivered at STP posts was reportedly beneficial for ophthalmology trainees, their supervisors and the broader community given it enabled exposure to regional, rural, remote and private settings, access to unique learning opportunities, provided workforce support and renewal, and affordable ophthalmic care. However, all participants also reported challenges including difficulties achieving work/life balance, unmet training expectations, a lack of professional support, and financial and administrative burden. Malalignment between trainee preferences for STP posts, low STP literacy and limited regional, rural and remote training experiences were also seen as missed opportunities to foster future rural ophthalmic workforce development. DISCUSSION: The STP improves access to ophthalmic care in underserved populations while enabling valuable rural and/or private practice exposure for medical specialist trainees and workforce support for supervising ophthalmologists. CONCLUSION: Efforts are needed to improve the quality of training experiences provided at STP posts and post sustainability. Although research is needed to investigate the longer-term benefits of the STP to rural and/or private workforce recruitment and retention, RANZCO should develop further regional, rural and remote STP posts to help realise future rural practice intention amongst ophthalmology trainees.

Impact of the COVID-19 pandemic on student experiences during rural placements in Australia: findings from a national multi-centre survey.

BACKGROUND: The aim of this national study was to explore the learning experiences of Australia's medical students who trained rurally during the COVID-19 pandemic in 2020. METHODS: A cross-sectional, national multi-centre survey was conducted in 2020, through the Federation of Rural Australian Medical Educators (FRAME). Participants were medical students who had completed an extended Rural Clinical School (RCS) training placement (≥ 12 months). A bespoke set of COVID-19 impact questions were incorporated into the annual FRAME survey, to capture COVID-19-related student experiences in 2020. Pre-pandemic (2019 FRAME survey data) comparisons were also explored. RESULTS: FRAME survey data were obtained from 464 students in 2020 (51.7% response rate), compared with available data from 668 students in 2019 (75.6% response rate). Most students expressed concern regarding the pandemic's impact on the quality of their learning (80%) or missed clinical learning (58%); however, students reported being well-supported by the various learning and support strategies implemented by the RCSs across Australia. Notably, comparisons to pre-pandemic (2019) participants of the general RCS experience found higher levels of student support (strongly agree 58.9% vs 42.4%, p < 0.001) and wellbeing (strongly agree 49.6% vs 42.4%, p = 0.008) amongst the 2020 participants. Students with more than one year of RCS experience compared to one RCS year felt better supported with clinical skills learning opportunities (p = 0.015) and less affected by COVID-19 in their exam performance (p = 0.009). CONCLUSIONS: This study has provided evidence of both the level of concern relating to learning quality as well as the positive impact of the various learning and support strategies implemented by the RCSs during the pandemic in 2020. RCSs should further evaluate the strategies implemented to identify those that are worth sustaining into the post-pandemic period.

Considerations for Training and Workforce Development to Enhance Rural and Remote Ophthalmology Practise in Australia: A Scoping Review.

Australia has one of the lowest per capita numbers of ophthalmologists among OECD countries, and they predominantly practise in metropolitan centres of the country. Increasing the size and distribution of the ophthalmology workforce is of critical importance. The objective of this review was to investigate the context of rural ophthalmology training and practise in Australia and how they relate to future ophthalmology workforce development. This scoping review was informed by Arksey and O'Malley's framework and the methodology described by Coloqhuon et al. The search yielded 428 articles, of which 261 were screened for eligibility. Following the screening, a total of 75 articles were included in the study. Themes identified relating to rural ophthalmology training and practise included: Indigenous eye health; access and utilisation of ophthalmology-related services; service delivery models for ophthalmic care; ophthalmology workforce demographics; and ophthalmology workforce education and training for rural and remote practise. With an anticipated undersupply and maldistribution of ophthalmologists in the coming decade, efforts to improve training must focus on how to build a sizeable, fit-for-purpose workforce to address eye health needs across Australia. More research focusing on ophthalmology workforce distribution is needed to help identify evidence-based solutions for workforce maldistribution. Several strategies to better prepare the future ophthalmology workforce for rural practise were identified, including incorporating telehealth into ophthalmology training settings; collaborating with other health workers, especially optometrists and specialist nurses in eyecare delivery; and exposing trainees to more patients of Indigenous background.

Influence of rural clinical school experience and rural origin on practising in rural communities five and eight years after graduation.

OBJECTIVE: To examine associations between extended medical graduates' rural clinical school (RCS) experience and geographic origins with practising in rural communities five and eight years after graduation. DESIGN, PARTICIPANTS: Cohort study of 2011 domestic medical graduates from ten Australian medical schools with rural clinical or regional medical schools. MAIN OUTCOME MEASURES: Practice location types eight years after graduation (2019/2020) as recorded by the Australian Health Practitioner Regulation Agency, classified as rural or metropolitan according to the 2015 Modified Monash Model; changes in practice location type between postgraduate years 5 (2016/2017) and 8 (2019/2020). RESULTS: Data were available for 1321 graduates from ten universities; 696 were women (52.7%), 259 had rural backgrounds (19.6%), and 413 had extended RCS experience (31.3%). Eight years after graduation, rural origin graduates with extended RCS experience were more likely than metropolitan origin graduates without this experience to practise in regional (relative risk [RR], 3.6; 95% CI, 1.8-7.1) or rural communities (RR, 4.8; 95% CI, 3.1-7.5). Concordance of location type five and eight years after graduation was 92.6% for metropolitan practice (84 of 1136 graduates had moved to regional/rural practice, 7.4%), 26% for regional practice (56 of 95 had moved to metropolitan practice, 59%), and 73% for rural practice (20 of 100 had moved to metropolitan practice, 20%). Metropolitan origin graduates with extended RCS experience were more likely than those without it to remain in rural practice (RR, 2.0; 95% CI, 1.3-2.9) or to move to rural practice (RR, 1.9; 95% CI, 1.2-3.1). CONCLUSION: The distribution of graduates by practice location type was similar five and eight years after graduation. Recruitment to and retention in rural practice were higher among graduates with extended RCS experience. Our findings reinforce the importance of longitudinal rural and regional training pathways, and the role of RCSs, regional training hubs, and the rural generalist training program in coordinating these initiatives.

Distribution and Location Stability of the Australian Ophthalmology Workforce: 2014-2019.

OBJECTIVE: To investigate the ophthalmology workforce distribution and location stability using Modified Monash Model category of remoteness. METHODS: Whole of ophthalmologist workforce analysis using Australian Health Practitioner Registration Agency (AHPRA) data. Modified Monash Model (MMM) category was mapped to postcode of primary work location over a six-year period (2014 to 2019). MMM stability was investigated using survival analysis and competing risks regression. DESIGN: Retrospective cohort study. SETTING: Australia. PARTICIPANTS: Ophthalmologists registered with AHPRA. MAIN OUTCOME MEASURES: Retention within MMM category of primary work location. RESULTS: A total of 948 ophthalmologists were identified (767 males, 181 females). Survival estimates indicate 84% of ophthalmologists remained working in MMM1, while 79% of ophthalmologists working in MMM2-MMM7remained in these regions during the six-year period. CONCLUSION: The Australian ophthalmology workforce shows a high level of location stability and is concentrated in metropolitan areas of Australia. Investment in policy initiatives designed to train, recruit and retain ophthalmologists in regional, rural and remote areas is needed to improve workforce distribution outside of metropolitan areas.

The impact of health information management professionals on patient safety: A systematic review.

BACKGROUND: The importance of high-quality health information for patient safety has been established in the literature, yet the impact of the professionals who are the custodians of health information is absent. OBJECTIVES: This article presents the results of a systematic literature review examining the impact of the Health Information Management (HIM) profession on patient safety. METHODS: A PRISMA approach was adopted for the review of selected databases and specific journals. Titles identified as relating to HIM and patient quality were screened using Covidence ® by title and abstract, followed by full text. The quality of selected articles was assessed and thematically analysed. RESULTS: Analysis of the 8 included articles found that the key themes from the non-empirical research were data quality, information governance, corporate governance, skills and knowledge required for HIM professionals. DISCUSSION: Most publications focussed on HIM professional involvement in maintaining standards for data quality and health records, but not the professional qualifications themselves. CONCLUSIONS: There are links between patient safety and health records, and between health records and HIM professional work. More empirical research is needed to demonstrate how qualified HIM professionals contribute to patient safety.

Mortality benefit of crystalloids administered in 1-6 hours in septic adults in the ED: systematic review with narrative synthesis.

BACKGROUND: Based on the 2018 update of the Surviving Sepsis Campaign, the Committee for Quality Improvement of the NHSs of England recommended the instigation of the elements of the 'Sepsis-6 bundle' within 1 hour to adult patients screened positive for sepsis. This bundle includes a bolus infusion of 30 mL/kg crystalloids in the ED. Besides the UK, both in the USA and Australia, compliance with similar 1-hour targets became an important quality indicator. However, the supporting evidence may neither be contemporaneous nor necessarily valid for emergency medicine settings. METHOD: A systematic review was designed and registered at PROSPERO to assess available emergency medicine/prehospital evidence published between 2012 and 2020, investigating the clinical benefits associated with a bolus infusion of a minimum 30 mL/kg crystalloids within 1 hour to adult patients screened positive for sepsis. Due to the small number of papers that addressed this volume of fluids in 1 hour, we expanded the search to include studies looking at 1-6 hours. RESULTS: Seven full-text articles were identified, which investigated various aspects of the fluid resuscitation in adult sepsis. However, none answered completely to the original research question aimed to determine either the effect of time-to-crystalloids or the optimal fluid volume of resuscitation. Our findings demonstrated that in the USA/UK/Australia/Canada, adult ED septic patients receive 23-43 mL/kg of crystalloids during the first 6 hours of resuscitation without significant differences either in mortality or in adverse effects. CONCLUSION: This systematic review did not find high-quality evidence supporting the administration of 30 mL/kg crystalloid bolus to adult septic patients within 1 hour of presentation in the ED. Future research must investigate both the benefits and the potential harms of the recommended intervention.

Escape to the country: Lessons from interviews with rural general practice interns.

METHOD: Semi-structured interviews were conducted with 12 rural general practice interns. RESULTS: Six main themes emerged: the social experience of rural/remote placements, the intern role, skill acquisition, challenges experienced by interns, placements reinforcing ideas of rural general practice and advice to future interns. Rural interns were positive about the program, reporting intensive learning experiences from a range of clinical environments. There were some challenges initially implementing the wave consulting model. The main difficulty faced by interns was isolation from peers/social support. DISCUSSION: Rural general practice intern terms support rural career pathways. Practice staff need to be mindful of the integration of interns into the practice environment, and programs need to provide training and support for the role.

Recipe for a Healthy Gut: Intake of Unpasteurised Milk Is Associated with Increased Lactobacillus Abundance in the Human Gut Microbiome.

INTRODUCTION: The gut microbiota plays a role in gut-brain communication and can influence psychological functioning. Diet is one of the major determinants of gut microbiota composition. The impact of unpasteurised dairy products on the microbiota is unknown. In this observational study, we investigated the effect of a dietary change involving intake of unpasteurised dairy on gut microbiome composition and psychological status in participants undertaking a residential 12-week cookery course on an organic farm. METHODS: Twenty-four participants completed the study. The majority of food consumed during their stay originated from the organic farm itself and included unpasteurised milk and dairy products. At the beginning and end of the course, participants provided faecal samples and completed self-report questionnaires on a variety of parameters including mood, anxiety and sleep. Nutrient intake was monitored with a food frequency questionnaire. Gut microbiota analysis was performed with 16S rRNA gene sequencing. Additionally, faecal short chain fatty acids (SCFAs) were measured. RESULTS: Relative abundance of the genus Lactobacillus increased significantly between pre- and post-course time points. This increase was associated with participants intake of unpasteurised milk and dairy products. An increase in the faecal SCFA, valerate, was observed along with an increase in the functional richness of the microbiome profile, as determined by measuring the predictive neuroactive potential using a gut-brain module approach. CONCLUSIONS: While concerns in relation to safety need to be considered, intake of unpasteurised milk and dairy products appear to be associated with the growth of the probiotic bacterial genus, Lactobacillus, in the human gut. More research is needed on the effect of dietary changes on gut microbiome composition, in particular in relation to the promotion of bacterial genera, such as Lactobacillus, which are recognised as being beneficial for a range of physical and mental health outcomes.

'It's mostly about the job' - putting the lens on specialist rural retention.

INTRODUCTION: Rural health services throughout the world face considerable challenges in the recruitment and retention of medical specialists. This research set out to describe the factors that contribute to specialist workforce retention and attrition in a health service in rural Tasmania, Australia. METHODS: This qualitative study utilised in-depth interviews with 22 medical specialists: 12 currently employed by the service and 10 who had left or intended to leave. Interview transcripts were thematically analysed to identify professional, social and location factors influencing retention decision-making. RESULTS: Professional and workplace factors were more important than social or location factors in retention decision-making. Tipping points were excessive workloads, particularly on-call work, difficult collegial relationships, conflict with management, offers of more appealing positions elsewhere, family pressure to live in a metropolitan area, educational opportunities for children and a lack of contract flexibility. Inequitable workload distribution and the absence of senior registrars contributed to burnout. Financial remuneration was not a primary factor in retention decision-making, however, there was acknowledgement of the need to ensure equitable pay scales, flexible employment contracts including statewide positions and increased CPD payments/leave. Specialists who had autonomy in determining their preferred work balance tended to stay, as did those who had family or developed social connections within the area, rural backgrounds and a preference for rural living. CONCLUSION: To improve specialist workforce retention, rural health services should ensure a professionally rewarding, harmonious work environment, without onerous out-of-hours demands and where specialists feel valued. Specialists should have autonomy over workloads, flexible contracts, appropriate financial remuneration and enhanced access to CPD. New specialists and their families should have additional support to assist with social integration.

Antibiotics administered within 1 hour to adult emergency department patients screened positive for sepsis: a systematic review.

OBJECTIVE: The 2018 Surviving Sepsis Campaign update recommended instigating the Sepsis-6 bundle within 1 h; however, the supporting evidence is weak. The objective was to systematically review the literature to determine whether there is mortality benefit (hospital or 28/30-day survival) associated with administration of antibiotics <1 h to adult emergency department (ED) patients screened positive for sepsis using systemic inflammatory response system criteria. METHODS: A systematic review and meta-analysis were conducted. Embase, CINAHL, Medline, Pubmed, Cochrane Library and grey literature were searched for articles published between 2012 and 2019. RESULTS: From 232 identified articles, seven met the inclusion criteria. Due to the small number of articles that fit the inclusion criteria and the considerable heterogeneity (I = 92.6%, P < 0.001), only the results of the systematic review are reported. Three of the seven studies demonstrated survival benefit for patients who screened positive for sepsis who were administered antibiotics ≤1 h after presentation to the ED. Four studies reported no statistically significant improvement in survival associated with administration of antibiotics within 1 h of ED presentation. Interestingly, two studies reported worse outcomes associated with early administration of antibiotics in patients with low acuity sepsis. CONCLUSION: There is equivocal evidence of in-hospital or 28/30-day survival benefit associated with antibiotics administered ≤1 h after presentation to the ED for patients who screened positive for sepsis. Further research is needed to identify the exact patient group, which would truly benefit from initiation of antibiotics <1 h after ED presentation.

The foot-health of people with diabetes in regional and rural Australia: baseline results from an observational cohort study.

BACKGROUND: There is limited Australian epidemiological research that reports on the foot-health characteristics of people with diabetes, especially within rural and regional settings. The objective of this study was to explore the associations between demographic, socio-economic and diabetes-related variables with diabetes-related foot morbidity in people residing in regional and rural Australia. METHODS: Adults with diabetes were recruited from non-metropolitan Australian publicly-funded podiatry services. The primary variable of interest was the University of Texas diabetic foot risk classification designated to each participant at baseline. Independent risk factors for diabetes-related foot morbidity were identified using multivariable analysis. RESULTS: Eight-hundred and ninety-nine participants enrolled, 443 (49.3%) in Tasmania and 456 (50.7%) in Victoria. Mean age was 67 years (SD 12.7), 9.2% had type 1 diabetes, 506 (56.3%) were male, 498 (55.4%) had diabetes for longer than 10 years and 550 (61.2%) either did not know the ideal HbA1c target or reported that it was ≥7.0. A majority had peripheral neuropathy or worse foot morbidity (61.0%). Foot morbidity was associated with male sex (OR 2.42, 95% CI 1.82-3.22), duration of diabetes > 20 years (OR 3.25, 95% CI 2.22-4.75), and Tasmanian residence (OR 3.38, 95% CI 2.35-4.86). CONCLUSIONS: A high proportion of the regional Australian clinical population with diabetes seen by the publicly-funded podiatric services in this study were at high risk of future limb threatening foot morbidity, and participants residing in Northern Tasmania are more likely to have worse diabetes-related foot morbidity than those from regional Victoria. Service models should be reviewed to ensure that diabetes-related foot services are appropriately developed and resourced to deliver interdisciplinary evidence-based care.

Geographical variation in preventable hospital admissions for dental conditions: An Australia-wide analysis.

OBJECTIVE: To describe the characteristics of hospital admissions for dental conditions, by Australian Statistical Geography Standard remoteness area for the 5 years 2010/2011 to 2014/2015. DESIGN: Retrospective analysis of preventable hospital admissions due to dental conditions. SETTING: National data set provided by the Australian Institute of Health and Welfare. PARTICIPANTS: Every hospital admission for patients who were admitted for dental conditions over five financial years, from 2010/2011 to 2014/2015. MAIN OUTCOME MEASURES: The number (and rate per 1000 population) of hospital admissions due to dental conditions in each Australian Statistical Geography Standard remoteness area (major city, inner regional, outer regional, remote and very remote). RESULTS: There were 316 937 hospital admissions for dental conditions over the 5-year period. The rate of potentially preventable dental hospital admissions ranged from an average of 2.5 per 1000 population in major cities to 3.2 in inner regional areas, 3.1 in outer regional areas, and 4.1 per 1000 in remote and very remote areas. The rate of admissions was highest among those aged 0-14 years living in remote (9.0-10.0 per 1000) and very remote (9.8-12.5 per 1000) areas. Dental caries was the most common reason for admissions. CONCLUSIONS: There is an urgent need to address the social determinants of oral health in children aged 0-14 years living in remote and very remote Australia. The delivery of mobile primary dental care services needs to be expanded in remote and very remote areas to prevent and treat dental caries.

Minimally invasive glaucoma surgery: Comparison of iStent with iStent inject in primary open angle glaucoma.

IMPORTANCE: Minimally invasive glaucoma surgery has gained significant traction in recent years. This study evaluates the first- and second-generation trabecular micro-bypass stents "iStent" and "iStent inject". BACKGROUND: To evaluate and compare the effect of a single iStent and double iStent inject in primary open angle glaucoma. DESIGN: Prospective comparative case series. PARTICIPANTS: Primary open angle glaucoma patients undergoing trabecular micro-bypass stent insertion combined with cataract surgery. METHODS: Baseline demographic information, preoperative, intraoperative and postoperative outcomes including intraocular pressure (IOP), visual acuity, reliance on glaucoma medication and complications were collected and analysed. MAIN OUTCOME MEASURES: Primary, secondary and tertiary outcome measures were consecutively defined as an IOP of ≤18 mmHg with zero medications, an IOP of ≤18 mmHg with reduced medications or a 20% reduction in IOP with or without medication. RESULTS: The study comprised 145 eyes in the iStent and 100 eyes in the iStent inject group. At 12 months, 56.0% of the iStent and 51.3% of the iStent inject eyes had achieved primary success and 63.1% and 57.7% secondary success. The mean postoperative IOP was 16.6 mmHg in iStent and 16.9 mmHg in iStent inject. Survival analysis demonstrated a greater incidence of failure in the iStent inject beyond 5 months. CONCLUSIONS AND RELEVANCE: Both trabecular micro-bypass stents in this study were effective in reducing IOP and the burden of medication when combined with cataract surgery. There was no statistically significant difference between the two groups across our outcome measures although the iStent inject required earlier recommencement of medications for optimal IOP control.

Small aperture IC-8 intraocular lens in cataract patients: achieving extended depth of focus through small aperture optics.

BACKGROUND: To investigate visual outcomes following cataract surgery in patients who were implanted monocularly with an extended range of focus IC-8 IOL. METHODS: A multicentre, non-randomised, retrospective case series of 126 consecutive patients implanted with the IC-8 IOL. Data were collected and pooled from six centres across Australia. Uncorrected distance visual acuity (UDVA), uncorrected intermediate visual acuity (UIVA) at 80 cm and uncorrected near visual acuity (UNVA) at 40 cm were measured in eyes implanted with the IC-8 IOL. Adverse events, spectacle independence, visual symptoms and patient satisfaction were assessed at final follow-up. RESULTS: Over 90% of the patients without pre-existing ocular pathology (n = 109) achieved UDVA, UIVA and UNVA of 6/12 or better in the IC-8 eye. Binocularly, in this group, 98% achieved UDVA of 6/9, 94% UIVA of 6/12 and 91% UNVA of 6/12 or better. By final follow-up, over 50% of patients reported complete spectacle independence for distance, intermediate and near visual activity, with the remainder only using spectacles for specific tasks such as near-vision hobbies and reading in dim light. CONCLUSIONS: The IC-8 IOL is capable of providing extended depth of focus following cataract surgery. It allows complete spectacle independence in more than half of the patients implanted with the IC-8 IOL.

Building a medical workforce in Tasmania: A profile of medical student intake.

OBJECTIVE: To identify under-represented groups in a medical school intake. DESIGN: Descriptive analysis of student demographic characteristics. SETTING: One state-wide medical school. PARTICIPANTS: All students enrolled between 2010 and 2016. MAIN OUTCOME MEASURE(S): Proportion of students from regional and rural areas, state versus independent schools, highest parental qualification, Aboriginal or Torres Strait Islander students. RESULTS: Of 819 students, 472 (57.6%) were from Tasmania, five (1.1%) identified as Aboriginal or Torres Strait Islanders, 335 (71.0%) completed their secondary education at independent schools and 137 (29.0%) at government schools. The overall median Modified Monash Model was 2 (range 1-6) and median Australia Statistical Geography Standard Remoteness Area was 2 (inner regional: range 1-4), reflecting that a majority came from one of the two main cities. Over two-thirds (69.5%) had a parent with a Bachelor degree or higher qualification, regardless of the school attended. Just under half (225, 47.7%) of all Tasmanian students attended a secondary school with a parental contribution of ≥$5000 per annum. These students attended a small number of independent schools, with the proportion relatively stable over the period from 2010 to 2016. CONCLUSION: Widening participation and widening access initiatives to graduate doctors who understand and want to work in communities in need might not be working as well in Tasmania as elsewhere in Australia. Social accountability might be improved by adapting a rural classification that reflects the demographic profile of Tasmania.

Transfusion rates with intravenous tranexamic acid in total hip arthroplasty performed using the direct anterior approach.

INTRODUCTION: Tranexamic acid (TXA) has been shown to reduce blood loss and transfusion requirements in patients undergoing total hip arthroplasty (THA). Most studies have focused on TXA in THA performed using a posterior approach (PA) or lateral approach. The aim of this study was to analyse the efficacy of TXA in patients undergoing THA using the direct anterior approach (DAA). PATIENTS AND METHODS: Using our institutional database, a retrospective analysis was conducted on consecutive primary THA performed for osteoarthritis to determine transfusion rates in patients undergoing THA with the DAA with and without TXA. RESULTS: 146 consecutive THA were performed using DAA: 83 (56.8%) patients had TXA and 63 (43.2%) did not have TXA. Among patients who had TXA, 1 patient required a blood transfusion compared to 7 patients among those who did not have TXA (1.2% vs. 11.12%, p = 0.02). The relative risk of 0.11 (95% confidence interval 0.01-0.86) indicates an 89% reduction in the risk of requiring blood transfusion with TXA administration compared to no TXA. CONCLUSION: TXA is effective in reducing blood transfusion requirements for patients undergoing DAA THA.