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Background Preoperative assessment of mental health rarely occurs within routine surgery. Any screening tool selected to form part of this process must be deemed practical, acceptable and valid by clinicians and consumers alike. This study aims to assess the acceptability and face validity of two existing mental health screening tools to select one for further development and use in the routine surgical setting. Methods A survey of clinicians and consumers was conducted from October 2020 to March 2021 at a tertiary hospital in Sydney, Australia. Using a Likert scale (1–5, lowest to highest rating), the clinicians evaluated four domains for acceptability and two for validity (six overall) and the consumers four domains for acceptability and one for validity (five overall) on the preoperative use of the amended Kessler Psychological Distress Scale (K10) and the Somatic and Psychological Health Report-12 (SPHERE-12). Consensus was achieved through a rating of 4 or 5 being given by 70% or more of participants with domains able to remain unchanged. Free text responses were analysed into themes. Results A total of 73 participants (51 clinicians; 22 consumers) were included. The K10 received consensus scores (≥ 70%) in four out of six domains for clinicians (4/4 acceptability; 0/2 validity), and all five domains for consumers (4/4 acceptability; 1/1 validity). The SPHERE-12 received consensus scores (≥ 70%) in three domains for clinicians (3/4 acceptability; 0/2 validity), and three domains for consumers (3/4 acceptability; 0/1 validity). Six qualitative themes were described including (1) amendments to tool structure and language; (2) scale response options; (3) difficulty with somatic questions; (4) practicality and familiarity with K10; (5) challenges for specific patient cohorts and (6) timing considerations for patients. Conclusion Adequate acceptability was established for the K10. However further development is required to strengthen its validity for this specific surgical cohort and purpose. Future research to determine the feasibility and acceptability of implementing and using the K10 in the routine surgical setting is now needed.

Robotic-assisted total knee arthroplasty (TKA) may improve the precision of bone preparation and component alignment when compared to the conventional surgical approach; however, the detailed cost analysis of robotic-assisted TKA is lacking. This study aims to compare in-hospital costs between robotic-assisted and computer-navigated TKA. Patients undergoing primary TKA at a public hospital in Sydney between October 2018 and June 2019 were included. Patient demographics, surgical outcomes and in-hospital cost variables including, staff, critical care, emergency department, diagnostic, prosthesis, operating room, ward and other related costs until the discharge to the community were collected. Differences across in-hospital costs between robotic-assisted and computer-navigated TKA were compared using independent Student’s t-tests. Of the 258 primary TKAs, 181 (70.2%) were computer-navigated and 77 (29.8%) robotic-assisted. Surgical time (p

Background Despite relatively few COVID‐19 cases within New South Wales, the uncertainty surrounding the pandemic has prevented a return to business as usual for the delivery of surgical services. This study aims to describe the evolving impact of COVID‐19 on surgical activity and patient outcomes at a major public tertiary referral hospital. Methods A retrospective cohort study involving adult surgical patients treated at a large public tertiary referral hospital in Sydney, Australia. Surgical activity, surgical outcomes and patient demographics were compared across two time periods, including the ‘first wave’ (February–May 2020 vs. February–May 2019) and the ‘perseverance phase’ (June–September 2020 vs. June–September 2019). Variables across both groups were compared using an independent t test or chi‐squared test. Results A −32% reduction in surgical separations was observed in the ‘first wave’, including −20% emergency and −37% elective. In the ‘perseverance phase’, there was a −19% reduction in surgical activity, including 0% emergency and −27% elective. The average length of stay, intensive care admissions, postoperative complications and in‐hospital costs significantly increased in the ‘first wave’. The proportion of public patients increased marginally (3%) in the ‘first wave’. Conclusion The impact of COVID‐19 was most severely experienced in the initial months of the pandemic and observed in the number of patients treated. Although there was an initial effect on surgical outcomes, overall, the standard of care remained safe. The delivery of elective surgery remains a challenge and reflects the ongoing system‐wide changes that are required to manage the COVID‐19 pandemic., The ongoing uncertainty surrounding the COVID‐19 pandemic has prevented a return to business as usual for the delivery of surgical services. The impact of COVID‐19 was most severely experienced in the initial ‘first wave’ of the pandemic (February to May 2020) and observed in the number of surgical patients treated. There was an initial effect on patient outcomes, however, overall the standard of care remained comparable and safe. The delivery of elective surgery remains a challenge and reflects the ongoing system‐wide changes that are required to manage the COVID‐19 pandemic.

Objectives The use of robotic-assisted surgery (RAS) remains predominantly in the private sector. In the public sector, the effect of the implementation of RAS on theatre staff is unknown. The aim of this study was to examine the knowledge and attitudes of theatre staff before and after implementation of RAS in the public sector. Methods In all, 250 theatre staff, including nursing, medical and support staff, were invited to participate in the study. A survey investigating the benefits of RAS for patients and staff, concerns towards the workplace environment and facilitators towards the implementation of new technology was administered before (June 2016) and after (February 2019) the implementation of a comprehensive RAS program. Results The survey was completed by 164 (65.6%) staff before and 200 (80.0%) staff after the implementation of RAS. With time, most nursing (P = 0.002) and medical staff (P = 0.003) indicated that RAS may benefit patients by reducing intraoperative complications, whereas support staff remained uncertain about this benefit (P = 0.594). Before the implementation, most medical staff indicated that RAS would benefit staff, although after they were unsure about this benefit. Overall, before RAS implementation, theatre staff were mostly concerned about workplace safety, but this concern was significantly reduced after RAS implementation (P

This study aimed to describe short- and medium-term longitudinal quality-of-life (QoL) outcomes after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Consecutive patients undergoing CRS and HIPEC were recruited. The primary outcome was QoL, measured using the short-form 36 questionnaire and expressed as a physical component score (PCS) and a mental component score (MCS), with higher scores representing better QoL. Data were collected prospectively at baseline and before discharge, then 3, 6, and 12 months postoperatively. Trajectories of the PCS and MCS were described for the study period and grouped according to a peritoneal carcinomatosis index (PCI) (≤ 12 vs. ≥ 13) and a completeness of cytoreduction (CC) score (CC0 vs. CC1–CC3). Overall, 117 patients underwent CRS and HIPEC and 115 (98.3%) of the 117 patients participated in the study. The main primary pathology was colorectal in 52 (45%) of the 115 patients and appendiceal in 27 (23.5%) of the 115 patients. The median baseline PCS [48.16; interquartile range (IQR), 38.6–54.9] had decreased at pre-discharge (35.34; IQR, 28.7–41.8), then increased slightly at 3 months (42.54; IQR, 37.6–51.6), before returning to baseline within 6 months (48.35; IQR, 39.1–52.5) and remaining unchanged 12 months after surgery (48.55; IQR, 40.8–55.5). The MCS remained unchanged during the study period. The patients with a PCI of 13 or higher had worse PCS and MCS during the postoperative period than the patients with a PCI of 12 or lower. The CRS and HIPEC procedures impaired PCS, with scores returning to baseline within 6 months after surgery, whereas MCS remained unchanged. The patients with a lower PCI had better postoperative QoL outcomes. For patients with peritoneal malignancy, CRS and HIPEC can be performed with acceptable short- to medium-term QoL outcomes.

Background: As the number of people living with obesity increases, the maintenance of treatment outcomes is especially pertinent. Treatment at tertiary obesity services have proven to be successful, but patients need to be transitioned out of these services to community-based care to accommodate the influx of new patients. Little is known about the support needs of patients after transition from acute tertiary obesity services. It is important to establish the supports needed by these patients, especially in the context of maintaining treatment outcomes and ensuring continuity of care. Methods: A qualitative study was conducted to identify the support needs of people with obesity as they transition to community care. Patients and clinicians recruited from a tertiary obesity clinic participated in semi-structured interviews and focus groups to explore factors influencing transition and supports needed in the community. Data was collected through audio recordings, transcribed verbatim and analysed thematically. Results: A total of 16 patients and 7 clinicians involved in the care of these patients participated between July 2020 and July 2021. Themes identified included the influence of clinic and individual factors on transition, the benefits of phased transition, patient-centred communication, and the role of social support. It was found that dependency and lack of self-efficacy, as well as low social support, hindered transition efforts. It was also identified that patients required substantial integrated professional and social support structures in the community to adequately address their care needs both during and following transition. Conclusion: Interventions are needed to provide social community services following transition to ensure adequate community care that can support the maintenance of treatment outcomes. Such services should be integrated and address the social needs of people living with obesity.

Background The Māori & Pasifika population experience high rates of health inequity, with a greater prevalence of obesity and the associated, life diminishing comorbidities. This is in part attributable to higher socioeconomic disadvantage, low health literacy and a lack of culturally tailored health services. Currently no validated tool exists to assess health behaviour change among Māori & Pasifika populations or success of tailored health interventions to tackle chronic disease. Methods The project incorporates a comprehensive validation and pilot testing process, including 1) cognitive interviewing and 2) test-retest reproducibility. Participants will include a representative sample of Māori & Pasifika young people and their parents/guardians. All research methodology is guided by cultural experts, specific to the Māori & Pasifika population. Results Qualitative data collected via cognitive interviewing will provide feedback regarding the readability, comprehension and content validity of the questionnaire items. Thematic analysis will inform improvements, optimising participant understandability. Cronbach’s alpha will be used to assess internal consistency and Pearson’s r will determine questionnaire test-retest reproducibility. Conclusions A validated questionnaire articulating with cultural values will provide meaningful data to researchers, health practitioners and government bodies regarding the lifestyle decisions of Māori & Pasifika peoples. Enhanced monitoring will determine the success of health initiatives to improve health outcomes of a priority population, across Australia and internationally. Key messages Lifestyle programs aiming to improve health outcomes are increasingly adapted to incorporate and acknowledge cultural values. Reliable measurement tools, including questionnaires, are fundamental to advancing future health research and tackling health inequity among priority populations.

Due to the higher incidence of hormone responsive tumours in women >50, the safety of hormone replacement therapy (HRT) in older breast cancer survivors may differ from younger age groups. The primary outcome in this review was the risk of tumour recurrence and secondary outcome the relationship with breast cancer-related mortality. Medline, CINAHL, Cochrane, Google Scholar and EMBASE databases were searched through August 2018 for studies reporting exposure to HRT in survivors ≥50 at primary diagnosis. Random effects models were used to estimate the combined relative risk (RR) of tumour recurrence and breast cancer-related mortality using the Mantel-Haenszel method and the quality of evidence determined for the primary outcome. Overall, nine studies (four cohort, one case-control, four RCTs; n = 16,002) were included. Very low quality evidence from observational studies demonstrated no adverse effect on tumour recurrence with HRT use (RR 0.80, 95% CI 0.53 to 1.19; I2 = 66%; n = 11,984), while moderate quality evidence from RCTS demonstrated an adverse effect (RR 1.46, 95% CI 1.20 to 1.77; I2 = 17%; n = 4108). Similarly, observational studies demonstrated no adverse effect on breast cancer-related mortality (RR 0.32, 95% CI 0.21 to 1.49; I2 = 0%, n = 2182), while RCTs demonstrated a non-significant higher risk (RR 1.07, 95% CI 0.77 to 1.49; I2 = 0%; n = 3918). Ultimately, despite conflicting findings, evidence of sufficient quality suggests that HRT may increase the risk of tumour recurrence in older survivors. However, adverse effect on mortality is unlikely. Caution with HRT use in survivors is further advised.

Pasifika populations experience high incidence and prevalence of obesity and T2DM. However, no international review of lifestyle intervention studies amongst Pasifika communities exists. This study seeks to identify the effect and translatability of lifestyle strategies on weight amongst Pasifika populations.Lifestyle studies involving ≥90% adult Pasifika participants measuring weight change were eligible for inclusion. Database searching was carried out up to December 2021. Databases searched were MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCOhost) and ProQuest Central. Risk of bias was assessed using RoB2 (RCTs) and the National Heart, Lung and Blood Institute (NHLBI) quality assessment tool. Meta-analysis and meta-regression used a bivariate random-effects model. Strategies were coded against pre-identified components of the newly proposed Cultural and Sustainability Assessment of Intervention (CSAI) framework.Twenty-three studies (Qualitative and quantitative analysis show tailored lifestyle interventions has had an estimated small but beneficial effect on WL amongst Pasifika communities. Potential for tailored interventions design to incorporate psychosocial and behavioural considerations. The CSAI has the potential for systematically identifying cultural and sustainability components of efficacy in interventions.This review was funded under Western Sydney University's Postgraduate Research Scholarship.

Breast cancer is the most common cause of cancer amongst Australian women and the second most common cause of cancer mortality. Despite the proven effectiveness of early intervention, screening rates remain subpar across many regions in New South Wales (NSW). Screening rates are particularly low within the culturally and linguistically diverse (CALD) area of South Western Sydney (SWS). The objective of this study was to qualitatively explore barriers and facilitators to breast screening from the perspectives of CALD women from SWS. CALD women aged ≥40 who resided in SWS were invited to participate in a semi-structured interview to explore barriers and facilitators to breast cancer screening. Interviews were recorded, transcribed verbatim and analysed thematically to identify recurring patterns in the data. Sixteen women from CALD backgrounds participated. Women in this study reported absence of symptoms, fatalistic beliefs and embarrassment during the procedure to be the primary reasons for reluctance to screen. Lack of general practitioner (GP) endorsement, transport issues and pain associated with the procedure were also reported as additional barriers to screening. Common facilitators to screening included encouragement from family and friends, family history of cancer and media adverts. CALD women have distinctive barriers to mammography, which lead to poor breast screening participation rates. Opportunistic health promotion in this area is warranted and may lead to better health outcomes amongst this population.

Background: Lack of effective treatments for chronic conditions is associated with high rates of complementary medicine (CM) use. However, little is known about CM use for dementia. Aims and Objectives: The aim of this study was to explore the experiences, motivations, and attitudes towards CM use by people living with dementia in an Australian setting. Design: This study had a qualitative research design; quantitative demographic information was also collected. Methods: In-depth interviews were conducted with people living with dementia and their caregivers (N = 18). A thematic (inductive) analysis approach was taken to interpret data. Results: Three in four participants used CM for dementia, spending ~AUD$100/month (USD$70/month). Within three overarching themes, a range of sub-themes was identified: (1) CM knowledge and use: people living with dementia and caregivers understanding of CM, types of CM used, and CM usage patterns; (2) Self-determined reasons for use/non-use: maintain or improve quality of life, hope, management of dementia symptoms, level of awareness, willingness and evidence, perceptions on efficacy and safety of CM, experiences of conventional medicine, and holistic approach to wellness; (3) External determinants of use: information on CM, relationship influences on CM use, and experiences with General Practitioners (GPs) and CM. Conclusion: Findings highlight that CM use is widespread and positively viewed by people living with dementia and their caregivers. Decisions regarding CM use were based on personal opinions. Findings have important implications for conversations with health professionals regarding CM use by people living with dementia to improve communication, health literacy, and reduce the risk of adverse effects through polypharmacy. Implications for Practice: This study showed that CM is a valued approach for dementia management by people living with dementia, their families, and healthcare providers. Future international research is required to evaluate the efficacy and safety of these approaches and promote accurate advice in nursing care.

Background People with serious mental illness (SMI) have significantly worse surgical outcomes compared to the general population. There are many contributing factors to this complex issue, however consideration of the surgical experience from the patient’s own perspective has never been undertaken. This lack of understanding prevents the provision of truly patient centred care and may limit the impact of potential improvement initiatives. Therefore this study aims to describe and better understand the surgical experience from the perspective of patients with SMI. Methods Within this qualitative study, semi-structured, audio-recorded interviews were conducted between August 2019 – June 2020, with 10 consenting participants with SMI who had surgery in the previous 2 years. A thematic analysis approach was used to explore both the positive and negative aspects of the participant’s surgical experience commencing from pre-operative consultation to hospital discharge and follow-up. Results Four main themes and related subthemes emerged including i) the perceived lack of mental ill health recognition, ii) highly variable patient and clinician interactions, iii) the impact of healthcare services, and iv) strategies for improvement. Conclusion Surgical patients with SMI want to be treated like everyone else whilst still having their mental ill health acknowledged and proactively managed despite this rarely occurring, which is valuable information for all surgical teams to consider and learn from. Participants were able to describe several readily implementable strategies to potentially improve their care and overall surgical experience, and as such highlight considerable opportunities for these to be tested and evaluated for this underserved patient group.

Objective To assess the association between having a serious mental illness and surgical outcomes for adults, including in-hospital and 30-day mortality, post-operative complications, and hospital length of stay. Study design Systematic review and meta-analysis of publications in English to 30 July 2018 of studies that examined associations between having a serious mental illness and surgical outcomes for adults who underwent elective surgery. Primary outcomes were in-hospital and 30-day mortality, post-operative complications, and length of hospital stay. Risk of bias was assessed with the Quality in Prognosis Studies (QUIPS) tool. Studies were grouped by serious mental illness diagnosis and outcome measures. Odds ratios (ORs) or mean differences (MDs), with 95% confidence intervals (CIs), were calculated in random effects models to provide pooled effect estimates. Data sources MEDLINE, EMBASE, PsychINFO, and the Cochrane Library. Data synthesis Of the 3824 publications identified by our search, 26 (including 6 129 806 unique patients) were included in our analysis. The associations between having any serious mental illness diagnosis and having any post-operative complication (ten studies, 125 624 patients; pooled effect: OR, 1.44; 95% CI, 1.15-1.79) and a longer stay in hospital (ten studies, 5 385 970 patients; MD, 2.6 days; 95% CI, 0.8-4.4 days) were statistically significant, but not those for in-hospital mortality (three studies, 42 926 patients; OR, 1.21; 95% CI, 0.69-2.12) or 30-day mortality (six studies, 83 013 patients; OR, 1.85; 95% CI, 0.86-3.99). Conclusions Having a serious mental illness is associated with higher rates of post-operative complications and longer stays in hospital, but not with higher in-hospital or 30-day mortality. Targeted pre-operative interventions may improve surgical outcomes for these vulnerable patients. Systematic review registration PROSPERO, CRD42018080114 (prospective).

Background A barrier to the uptake of robotic-assisted surgery (RAS) continues to be the perceived high costs. A lack of detailed costing information has made it difficult for public hospitals in particular to determine whether use of the technology is justified. This study aims to provide a detailed description of the patient episode costs and the contribution of RAS specific costs for multiple specialties in the public sector. Methods A retrospective descriptive costing review of all RAS cases undertaken at a large public tertiary referral hospital in Sydney, Australia from August 2016 to December 2018 was completed. This included RAS cases within benign gynaecology, cardiothoracic, colorectal and urology, with the total costs described utilizing various inpatient costing data, and RAS specific implementation, maintenance and consumable costs. Results Of 211 RAS patients, substantial variation was found between specialties with the overall median cost per patient being $19,269 (Interquartile range (IQR): $15,445 to $32,199). The RAS specific costs were $8828 (46%) made up of fixed costs including $4691 (24%) implementation and $2290 (12%) maintenance, both of which are volume dependent; and $1848 (10%) RAS consumable costs. This was in the context of 37% robotic theatre utilisation. Conclusions There is considerable variation across surgical specialties for the cost of RAS. It is important to highlight the different cost components and drivers associated with a RAS program including its dependence on volume and how it fits within funding systems in the public sector.

Cost-effective cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for treatment of patients with peritoneal malignancy remains an ongoing financial challenge for healthcare systems, hospitals and patients. This study aims to describe the detailed in-hospital costs of CRS and HIPEC compared with an Australian Activity Based Funding (ABF) system, and to evaluate how the learning curve, disease entities and surgical outcomes influence in-hospital costs.A retrospective descriptive costing review of all CRS and HIPEC cases undertaken at a large public tertiary referral hospital in Sydney, Australia from April 2017 to June 2019. In-hospital cost variables included staff, critical care, diagnosis, operating theatre, and other costs. Univariate and multivariate analyses were conducted to investigate the differences between actual cost and the provision of funding, and potential factors associated with these costs.Of the 118 CRS and HIPEC procedures included in the analyses, the median total cost was AU$130,804 (IQR: 105,744 to 153,972). Provision of funding via the ABF system was approximately one-third of the total CRS and HIPEC costs (p 0.001). Surgical staff proficiency seems to reduce the total CRS and HIPEC costs. Surgical time, length of intensive care unit and hospital stay are the main predictors of total CRS and HIPEC costs.Delivery of CRS and HIPEC is expensive with high variability. A standard ABF system grossly underestimates the specific CRS and HIPEC funding required with supplementation essential to sustaining this complex highly specialised service.

Background Breast cancer is the second most common cancer among Australian women. In 2019, an estimated 19,000 women in Australia were diagnosed with breast cancer, with around 3,058 women dying from the disease in the same year. Although many qualitative studies published in Australia exist which examine breast cancer from various perspectives, only limited literature is available which addresses Australian women's lived experience of breast cancer from diagnosis, treatment and beyond. Method Meta-synthesis of qualitative studies. Participants who took part in either semi-structured interviews or surveys with open-ended questions were included. A thematic synthesis analysis approach was used. Results Five themes and 13 sub themes emerged from the data analysis which illustrated the lived experience of Australian women diagnosed with breast cancer. Emotional burden and women's response towards their breast cancer diagnosis were key themes. Experience of decision- making , social distress, symptoms beyond changes in their body, fertility considerations and their role as mothers were some of the challenges during their treatment. Women coped and adjusted with these challenges through the support of their family, and healthcare providers. Women developed greater empowerment by making their life choices after treatment. Life choices such as getting into a new relationship was challenging for single women. Conclusion Although most women were emotionally supported following their diagnosis, there are still areas where women could be better supported such as when having to break the news of their breast cancer diagnosis to their children, provision of ongoing emotional support for caregivers of women with breast cancer, providing constant emotional and informational support at the point of diagnosis and during their treatment, tailoring treatments according to different stages of pregnancy, and discussion of fertility treatments in timely manner by healthcare professionals.

The evolving coronavirus disease 2019 (COVID‐19) pandemic represents an unprecedented and largely unanticipated challenge to the delivery of surgical care in Australia and New Zealand. The first confirmed COVID‐19 case in Australia occurred on 25 January 2020. Since then, 2675 patients have been diagnosed nationally, resulting in 12 deaths (at the time of writing). New South Wales has been the most affected state based on case volume, with 1219 documented cases. During the initial response in New South Wales, all patients with confirmed COVID‐19 requiring hospitalization were managed at a nominated COVID‐19 centre (Westmead Hospital). As the pandemic evolved and the confirmed cases increased, a second COVID‐19 centre was established at Royal Prince Alfred (RPA) Hospital on 4 March 2020. RPA is a 900‐bed teaching hospital located in metropolitan Sydney, which provides surgical care for the local community but also serves as a quaternary referral centre for complex surgical services including advanced gastrointestinal malignancy, complex cardiovascular and neurosurgery, and renal and liver transplantation. As the third week of the response period at RPA comes to an end, this article aims to share our initial experience as a dedicated COVID‐19 centre by describing the issues faced in providing acute and elective surgical care, the broad impacts on staff and the early strategies adopted to address these challenges.

Background Timely diagnosis of dementia has a wide range of benefits including reduced hospital emergency department presentations, admissions and inpatient length of stay, and improved quality of life for patients and their carers by facilitating access to treatments that reduce symptoms, and allow time to plan for the future. Memory clinics can provide such services, however there is no 'gold standard' model of care. This study involved the co-creation of a model of care for a new multidisciplinary memory clinic with local community members, General Practitioners (GPs), policy-makers, community aged care workers, and service providers. Methods Data collection comprised semi-structured interviews (N = 98) with 20 GPs, and three 2-h community forums involving 53 seniors and community/local government representatives, and 25 community healthcare workers. Interviews and community forums were audio-recorded, transcribed verbatim, and coded by thematic analysis using Quirkos. Results GPs’ attitudes towards their role in assessing people with dementia varied. Many GPs reported that they found it useful for patients to have a diagnosis of dementia, but required support from secondary care to make the diagnosis and assist with subsequent management. Community forum participants felt they had a good knowledge of available dementia resources and services, but noted that these were highly fragmented and needed to be easier to navigate for the patient/carer via a 'one-stop-shop' and the provision of a dementia key worker. Expectations for the services and features of a new memory clinic included diagnostic services, rapid referrals, case management, education, legal services, culturally sensitive and appropriate services, allied health, research participation opportunities, and clear communication with GPs. Participants described several barriers to memory clinic utilisation including transportation access, funding, awareness, and costs. Conclusion This study demonstrates the importance of working with stakeholders to co-design models of care for people with dementia that take into account the local communities’ needs. Findings pave the way for the development of a potential new “gold standard” memory clinic model of care and operationalise new national clinical guidelines.

Background People with comorbid mental illness have poorer health status and disparate access to healthcare. Several studies internationally have reported mixed findings regarding the association between mental illness and surgical patient outcomes. This study examines the surgical outcomes in people with decompensated serious mental illness (SMI) within the setting of the Australian universal healthcare system. Methods Retrospective cohort study involving elective overnight surgical patients aged 18 years and above who attended a large public tertiary referral hospital in Sydney, Australia, between 2010 and 2014. Patients were identified using ICD-10-AM diagnosis codes. Outcomes measure including in-hospital mortality, post-operative complications, morbidity, admission and time in intensive care, length and cost of hospitalization, discharge destination and 28-day re-admission rates were examined. Results Of 23 343 surgical patient admissions, 451 (2%) patients had decompensated comorbid SMI with a subset of 47 (0.2%) having a specific psychotic illness. Patients with SMI comorbidity had significantly higher in-hospital mortality (2% versus 0%), post-operative complications (22% versus 8%), total comorbidity (7.6 versus 3.4 secondary codes), admissions (29% versus 9%) and time in intensive care (34.6 h versus 5.0 h), stay in hospital (12.2 days versus 4.6 days), admission costs ($24 162 versus $12 336), re-admission within 28 days (14% versus 10%) and discharges to another facility (11% versus 3%). Conclusion Patients with comorbid SMI had significantly worse surgical outcomes and incur much higher costs compared with the general surgical population. These results strongly highlight that specific perioperative interventions are needed to proactively improve the identification, management and outcomes for these disadvantaged patients.

Pasifika communities bear a disproportionate burden of diabetes compared to the general Australian population. Community-based participatory research (CBPR), which involves working in partnership with researchers and communities to address local health needs, has gained prominence as a model of working with underserved communities. This paper describes how Le Taeao Afua (LTA) Samoan diabetes prevention program was underpinned by two CBPR frameworks to develop a culturally tailored church-based lifestyle intervention to prevent diabetes and its complications in the Australian Samoan community. The name LTA, which means ‘a new dawn,’ was chosen by the community to signify a new dawn without diabetes in the Australian Samoan community. Strategies for engaging with the Australian Samoan community in South Western Sydney are discussed mapped to the key principles from the CBPR frameworks. In particular, this paper highlights the steps involved in building relationships with Samoan community leaders and the vital role of community activators and peer support facilitators in the success of delivering the program. Lessons learnt, such as the importance of church and maintaining a Samoan way of life in daily activities, and processes to build effective partnerships and maintain long-term relationships with the Australian Samoan community, are also discussed. Our paper, through providing a case example of how to apply CBPR frameworks, will help guide future community-based health promotion programs for underserved communities.

To systematically review studies of health promotion intervention in the police force. Four databases were searched for articles reporting on prepost single and multigroup studies in police officers and trainees. Data were extracted and bias assessed to evaluate study characteristics, intervention design and the impact of interventions on health. Database searching identified 25 articles reporting on 21 studies relevant to the aims of this review. Few studies (n=3) were of long duration (≥6 months). Nine of 21 studies evaluated structured physical activity and/or diet programmes only, 5 studies used education and behaviour change support-only interventions, 5 combined structured programmes with education and behaviour change support, and 2 studies used computer prompts to minimise sedentary behaviour. A wide array of lifestyle behaviour and health outcomes was measured, with 11/13 multigroup and 8/8 single-group studies reporting beneficial impacts on outcomes. High risk of bias was evident across most studies. In those with the lowest risk of bias (n=2), a large effect on blood pressure and small effects on diet, sleep quality, stress and tobacco use, were reported. Health promotion interventions can impact beneficially on health of the police force, particularly blood pressure, diet, sleep, stress and tobacco use. Limited reporting made comparison of findings challenging. Combined structured programmes with education and behaviour change support and programmes including peer support resulted in the most impact on health-related outcomes.

Distributive justice refers to the fair and appropriate distribution of benefits, risks and costs within a society. In a medical context, this requires patients with similar cases to be treated in a similar manner, and for there to be overarching equality of access to finite health resources. Distributive justice is a derivative of the broader principle of justice, which is one of the four biomedical ethics pillars described by Beauchamp and Childress as underpinning modern medical practice, along with beneficence, non‐maleficence and autonomy.1 The concept of distributive justice as it relates to the delivery of surgical care requires attention in the context of the coronavirus disease 2019 (COVID‐19) pandemic. Significant measures have been taken by our governments, health ministries and public and private hospitals in an effort to prepare the Australian healthcare system for high volumes of patients with COVID‐19. In the Australian context where a relatively low societal burden of disease has emerged, a question arises about the opportunity cost of these unprecedented interventions and restrictions, which have resulted in significant disruptions to the delivery of emergency and elective medical treatment – are we upholding the principle of distributive justice during the present pandemic?

Objectives To describe the current prevalence of type 2 diabetes (diabetes) and readiness to change diet and physical activity among Samoans associated with churches in Sydney. Methods Residents aged ≥18 years attending four Samoan churches in Sydney were invited to participate in a church-wide lifestyle intervention. Participants completed questionnaires, anthropometric measurements, provided a non-fasting blood sample for HbA1c and random blood glucose (RBG) measurement, and performed a 6-minute walk test. Obesity was defined using a Pacific body mass index (BMI) threshold ≥32 kg/m2 and diabetes if HbA1c was ≥6.5%. Results In total, 131/187 (70%) of Samoans (mean age of 44.1 ± 15 years; Female 52%) participated. Diabetes was present in 33% of the population which included 20% previously diagnosed diabetes, duration 13.4 ± 6.7 years, (HbA1c 8.3 ± 2.5% and RBG 10.2 ± 4.1 mmol/L) and 13% had undiagnosed diabetes (HbA1c 8.1 ± 2.7% and RBG 10.3 ± 4.7 mmol/L). The overall baseline prevalence of obesity, high blood pressure and meeting the physical activity recommendation of ≥150 min/wk were 77%, 44% and 38% respectively. Over 90% of participants were contemplating, if not already taking action towards healthier diet choices and increasing physical activity. Conclusions Prevalence of diabetes and its risk factors were high among Samoans in Sydney with a high proportion with undiagnosed diabetes. SO WHAT?: These findings highlight the need to prioritise the delivery of culturally appropriate interventions tailored to the needs of the Samoan community. The high level of healthy lifestyle contemplation suggests that the community would be receptive to such interventions.

Objectives: Samoan people are susceptible to early onset of type 2 diabetes and have low primary care participation. We have evaluated the effectiveness of a culturally adapted, church-based intervention delivered by Samoan coaches and Peer Support Facilitators to prevent and manage type 2 diabetes in Samoans associated with 3 churches in South Western Sydney (SWS). Methods: This pre-post study included Samoans ≥18 years and involved the delivery of 12 lifestyle messages and 10 diabetes messages. Participants completed questionnaires, the diabetes knowledge and behavior questionnaire, anthropometric measurements and provided a non-fasting blood sample (‘new’ diabetes diagnosis was defined if HbA1c or random blood glucose was ≥6.5% (48 mmol/mol) or ≥11.1mmol/l respectively). Obesity was defined using a Pacific body mass index (BMI) threshold ≥32kg/m2. Results: One hundred participants (70%) participated with 68 (mean age 49.6±14.2 years; female 57.4%) completing data collection 3-8 months after commencing the intervention. The prevalence of obesity was 73% and diabetes was 32.8% (19.8% previously diagnosed; 13% undiagnosed). Overall, HbA1c fell from baseline to follow-up (mean±SD; 6.4±1.7% (46 mmol/mol) vs. 6.0±1.4% (42 mmol/mol); p Conclusion: There is a high prevalence of diabetes and its risk factors among Samoans living in SWS. A structured church-based culturally tailored lifestyle intervention showed promise in reducing their diabetes risks. Disclosure D. Ndwiga: None. F. MacMillan: None. K. McBride: None. O. Alofivae-Doorbinnia: None. J. Reath: None. P.A. Abbott: None. D. Simmons: Speaker's Bureau; Self; Sanofi-Aventis. Other Relationship; Self; Medtronic. Funding South Western Sydney Local Health District; South Western Sydney Primary Health Network; WentWest Health Care; Western Sydney University

BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an accepted therapeutic approach in selected patients with peritoneal malignancy. The aim of this study was to describe early outcomes in the first 50 patients managed with CRS and HIPEC in a newly established peritoneal malignancy centre in Sydney, Australia, under the guidance of an experienced peritoneal malignancy mentor. METHODS This is a retrospective review of a prospective maintained database of early outcomes in the first 50 patients who underwent CRS and HIPEC between April 2017 and April 2018 at a newly established peritoneal malignancy centre. Type of primary, surgery time, length of hospital stay, blood loss, peritoneal carcinomatosis index, completeness of surgery, complications, recurrence rate and 30-day mortality were reviewed. RESULTS A total of 135 patients were referred and reviewed at the multidisciplinary team meeting with 50 (26 male) patients undergoing CRS and HIPEC. Of these 50 patients, 47 (94%) underwent complete cytoreduction while three (6%) had maximal tumour debulking surgery. Tumour pathology was of appendix origin (44%) and colorectal peritoneal metastases (44%). Median surgical time was 7.4 h (interquartile range 5.7-10.0). Median length of hospital stay was 13 days (interquartile range 9.7-19.0). Six (12%) patients experienced a grade III or IV Clavien-Dindo complication. There was no 30-day mortality. CONCLUSION This study reports the successful establishment of a peritoneal malignancy centre under the guidance of an experienced peritoneal malignancy mentor. The short-term surgical outcomes observed in the first 50 cases are promising and comparable to other more experienced centres.

Germline TP53 mutation carriers are at high risk of developing a range of cancers. Effective cancer risk management is an important issue for these individuals. We assessed the psychosocial impact in TP53 mutation carriers of WB-MRI screening as part of the Surveillance in Multi-Organ Cancer (SMOC+) protocol, measuring their unmet needs, anxiety and depression levels as well as cancer worry using psychological questionnaires and in-depth interviews about their experiences of screening. We present preliminary psychosocial findings from 17 participants during their first 12 months on the trial. We found a significant reduction in participants' mean anxiety from baseline to two weeks post WB-MRI (1.2, 95% CI 0.17 to 2.23 p = 0.025), indicative of some benefit. Emerging qualitative themes show most participants are emotionally supported and contained by the screening program and are motivated by their immediate concern about staying alive, despite being informed about the current lack of evidence around efficacy of screening for people with TP53 mutations in terms of cancer morbidity or mortality. For those that do gain emotional reassurance from participating in the screening study, feelings of abandonment by the research team are a risk when the study ends. For others, screening was seen as a burden, consistent with the relentless nature of cancer risk associated with Li-Fraumeni syndrome, though these patients still declared they wished to participate due to their concern with staying alive. Families with TP53 mutations need ongoing support due to the impact on the whole family system. These findings suggest a comprehensive multi-organ screening program for people with TP53 mutations provides psychological benefit independent of an impact on cancer morbidity and mortality associated with the syndrome. The benefits of a multi-organ screening program will be greater still if the screening tests additionally reduce the cancer morbidity and mortality associated with the syndrome. These findings may also inform the care of individuals and families with other multi-organ cancer predisposition syndromes.

BACKGROUND To undertake a comprehensive needs assessment to determine the baseline of surgical research activity at a tertiary referral hospital in Sydney, Australia. METHOD The comprehensive needs assessment comprised three components: a retrospective audit of the hospital ethics committee records to identify surgical research activity; a survey of all 17 surgical departments about the availability of 10 potential research resources and a survey of surgical staff to ascertain perceptions of research culture at the organizational, team and individual levels. RESULTS Of all research studies submitted to the hospital ethics committee in a 2-year period, only 9% were identified as surgical studies. Among the 17 surgical departments, there was wide variation in activity with only four defined as being 'research active'. On average, 52% of potential resources for surgical research were found to be in place within surgical departments. Only five departments were considered to be adequately research resourced (≥75% potential resources in place). Surgical research culture was rated 'moderate' at the organizational and team level, and 'low' at the individual level. Medical staff rated research capacity significantly higher at the team and individual levels compared to nursing staff. CONCLUSION Collectively, the baseline results indicate there is considerable opportunity to enhance surgical research at the hospital level and to use this information to guide new and innovative approaches in the future.

Objective: Australia has implemented a nation-wide programme providing a human papillomavirus (HPV) vaccine to girls and boys through school-based programmes. Previous research has identified three distinct areas for attention: (1) lack of understanding about HPV and HPV vaccination, (2) young people’s desire for involvement in decision-making about HPV vaccination and (3) fear of HPV vaccination. We aimed to develop an intervention to address young people’s low levels of understanding, to promote their involvement in consent and reduce vaccination-related fear and anxiety. Design, Setting, Methods: Formative qualitative research was conducted in six public, private and Catholic schools in the Sydney metropolitan area. Girls who were offered the vaccine in a school programme and aged 12–13 years were interviewed in focus groups. Piloting of materials was conducted in three private schools across Sydney with both girls and boys, and changes and additions were made to the materials in accordance with feedback. Results: We developed an educational intervention aimed at addressing gaps in young people’s knowledge and understanding, and offering strategies to improve confidence with vaccination and reduce needle-related anxiety. Components of the final intervention include film chapters, a magazine, a website, an app and teacher support materials. The intervention is designed for teachers and/or nurses to deliver and is linked to the school-based HPV vaccination programme. Conclusions: This is the first educational intervention designed for young people in HPV school-based vaccination, to be developed from empirical data with the involvement of young people themselves.

Aim Integration of clinical genetics into oncology is variable. Sarcomas have a strong genetic component, with up to 1/30 patients carrying germline TP53 mutations. This study aimed to define genetic risk awareness among sarcoma physicians. Outcomes were attitudes toward genetic testing, level of cancer risk and awareness of risk reduction measures. Methods An online survey was administered to members of the Connective Tissue Oncology Society and the Australasian Sarcoma Study Group. Results Sarcoma physicians (N = 124) from 21 countries participated, 40% of whom favored TP53 mutation testing in children regardless of family history, increasing to ∼83% for all age groups if a family history was present and ∼85% if multiple primary cancers were present. However, 33% were not aware that risk reduction strategies might identify some cancers at a more curable stage in carriers. Conclusion Clinical genetics is not yet standard of care for multidisciplinary management of sarcoma. Awareness of genetic risk is important among sarcoma physicians. Attitudes among the sarcoma community were generally positive, but education on genetic risk in sarcoma patients and collaboration with clinical genetics services might improve quality of care. Sarcoma physicians need routine access to clinical genetics services so that potential germline TP53 mutation carriers are recognized.

Obesity in Australia is rapidly rising, and is a major public health concern. Obesity increases risk of breast cancer and worse associated outcomes, yet breast screening participation rates in Australia are suboptimal and can be lower in higher risk, obese women. This study qualitatively explored barriers to breast screening participation in obese women in Australia. In-depth interviews (n=29), were conducted with obese women (BMI 30) and key health stakeholders. A disconnect between stakeholders’ and women’s perceptions was found. For women, low knowledge around a heightened need to screen existed, they reported limited desire to prioritize personal health needs, reluctance to screen due to poor body image and prior negative mammographic experiences due to issues with weight. Stakeholders perceived few issues in screening obese women beyond equipment limitations, and health and safety issues. Overall, weight was a taboo topic among our interviewees, indicating that a lack of discourse around this issue may be putting obese women at increased risk of breast cancer morbidity and mortality. Consideration of breast screening policy in obese women is warranted. Targeted health promotion on increased breast cancer risk in obese women is required as is a need to address body image issues and encourage screening participation.

Obesity in Australia is rising rapidly, and is a major public health concern. Obesity increases the risk of breast cancer and worsens associated outcomes, yet breast screening participation rates in Australia are suboptimal and can be lower in higher risk, obese women. This study qualitatively explored barriers to breast screening participation in obese women in Australia. In-depth interviews (n = 29), were conducted with obese women (body mass index &ge, 30) and key health providers. A disconnect between providers&rsquo, and women&rsquo, s perceptions was found. For women, low knowledge around a heightened need to screen existed, they also reported limited desire to prioritize personal health needs, reluctance to screen due to poor body image and prior negative mammographic experiences due to issues with weight. Providers perceived few issues in screening obese women beyond equipment limitations, and health and safety issues. Overall, weight was a taboo topic among our interviewees, indicating that a lack of discourse around this issue may be putting obese women at increased risk of breast cancer morbidity and mortality. Consideration of breast screening policy in obese women is warranted. Targeted health promotion on increased breast cancer risk in obese women is required as is a need to address body image issues and encourage screening participation.

Aims To evaluate the effectiveness of a culturally adapted, church-based lifestyle intervention among Australian Samoans living in Sydney. Methods This was a prospective, pre-post study of a church-wide education and support programme delivered by Community Coach Facilitators and Peer Support Facilitators to prevent, and promote self-management of, Type 2 diabetes. Participants completed questionnaires, anthropometric and HbA1c measurements before and 3–8 months after the intervention. The primary outcome was HbA1c. Results Overall, 68/107(63.5%) participants completed both before and after intervention data collection (mean age 48.9 ± 14.2 years; 57.2% female). HbA1c dropped significantly between baseline and follow-up among participants with known diabetes (8.1 ± 2.4% (65 mmol/mol) vs 7.4 ± 1.8% (57 mmol/mol); p = 0.040) and non-significantly among participants with newly diagnosed diabetes (8.0 ± 2.1% (64 mmol/mol) vs 7.1 ± 2.3 (54 mmol/mol); p = 0.131). Participants with no diabetes increased their weekly moderate and vigorous physical activity (316.1 ± 291.6mins vs 562.4 ± 486.6mins; p = 0.007) and their diabetes knowledge also improved post-intervention (42.0 ± 13.5% to 61.3 ± 20.2%; p < 0.001). There were no significant reductions in blood pressure, BMI or waist circumference at follow-up. Conclusions A structured, church-based, culturally tailored lifestyle intervention showed a number of improvements in diabetes risk among Samoans in Sydney. The intervention however, requires a more rigorous testing in a larger randomised controlled trial over a longer time period.

Issue addressed: The Samoan community in Australia has one of the highest rates of diabetes in Australia. We explored the experiences and perceptions of Samoan patients living with diabetes and their family members. Methods: Semi-structured interviews were conducted with adults from a Samoan background living in Australia who had diabetes and their family members. Participants were recruited from a single general practice with a high proportion of Pacific Islander patients, through self-response to waiting room flyers. Inductive thematic analysis was conducted using a constructivist-grounded theory approach. This qualitative project was part of the developmental phase of a larger project aiming to promote healthy lifestyles and decrease diabetes in the Samoan community in Sydney, Australia. Results: Twenty participants, aged 36-67 years, were interviewed. The majority was men (n = 13) and all were migrants to Australia. Participants reported a range of barriers to early detection and self-management of diabetes, including dietary practices common within their culture and the role of church and religion. They identified that pride in their heritage and role within families could be a barrier to care but also provided an opportunity for health promotion. Conclusions: The cultural factors which influence the risk and management of diabetes in the Samoan community in Australia can be the barriers to health change but also provide opportunities for culturally targeted diabetes education and health promotion. So what?: These findings will inform the development of approaches for the prevention and management of diabetes within the Samoan-Australian community. These include health-promotion initiatives which take into account the role of cultural dietary practices, diabetes stigma, cultural pride and working with churches.

General consensus exists that clinically significant germline genetic research results should be fed back to research participants. A body of literature is emerging about Australian research participants’ experiences of feedback of genetic research results and factors that influence a participant’s actions after receiving such information. This exploratory qualitative study conducted interviews with 11 participants from the International Sarcoma Kindred Study, four probands and seven of their relatives. They had been informed by letter of the availability of clinically significant germline TP53 mutations identified through research. We examined the participants’ views about the feedback of these genetic test results. Thematic (inductive) analysis was used to analyse the data. A number of factors influenced participants’ responses following notification. This included participants’ understanding of the notification letter and their perception of the relevance of the information for them and/or their family. Most notably, timing of the letter in the context of an individual’s current life experiences was important. Timing and context are novel factors identified that may impact on research participants’ understanding or their ability to access clinically significant research results. We outline strategies for disseminating results to research participants and their next of kin that may reduce their uncertainty around the receipt of research results.

The International Menopause Society defines menopause as the permanent cessation of menstruation resulting from the loss of ovarian follicular activity. It is recognised to have occurred after 12 consecutive months of amenorrhoea, for which there is no obvious physiological or pathological cause. This article will outline, and evaluate the evidence for, the range of non-hormonal options available for managing the menopause.

People with comorbid mental illness have poorer health status and disparate access to healthcare. Several studies internationally have reported mixed findings regarding the association between mental illness and surgical patient outcomes. This study examines the surgical outcomes in people with decompensated serious mental illness (SMI) within the setting of the Australian universal healthcare system.Retrospective cohort study involving elective overnight surgical patients aged 18 years and above who attended a large public tertiary referral hospital in Sydney, Australia, between 2010 and 2014. Patients were identified using ICD-10-AM diagnosis codes. Outcomes measure including in-hospital mortality, post-operative complications, morbidity, admission and time in intensive care, length and cost of hospitalization, discharge destination and 28-day re-admission rates were examined.Of 23 343 surgical patient admissions, 451 (2%) patients had decompensated comorbid SMI with a subset of 47 (0.2%) having a specific psychotic illness. Patients with SMI comorbidity had significantly higher in-hospital mortality (2% versus 0%), post-operative complications (22% versus 8%), total comorbidity (7.6 versus 3.4 secondary codes), admissions (29% versus 9%) and time in intensive care (34.6 h versus 5.0 h), stay in hospital (12.2 days versus 4.6 days), admission costs ($24 162 versus $12 336), re-admission within 28 days (14% versus 10%) and discharges to another facility (11% versus 3%).Patients with comorbid SMI had significantly worse surgical outcomes and incur much higher costs compared with the general surgical population. These results strongly highlight that specific perioperative interventions are needed to proactively improve the identification, management and outcomes for these disadvantaged patients.

Carriers of germline mutations in the TP53 gene, encoding the cell-cycle regulator and tumour suppressor p53, have a markedly increased risk of cancer-related morbidity and mortality during both childhood and adulthood, and thus require appropriate and effective cancer risk management. However, the predisposition of such patients to multiorgan tumorigenesis presents a specific challenge for cancer risk management programmes. Herein, we review the clinical implications of germline mutations in TP53 and the evidence for cancer screening and prevention strategies in individuals carrying such mutations, as well as examining the potential psychosocial implications of lifelong management for a ubiquitous cancer risk. In addition, we propose an evidence-based framework for the clinical management of TP53 mutation carriers and provide a platform for addressing the management of other cancer predisposition syndromes that can affect multiple organs.

Rates of diabetes are high in many communities of Pacific Island peoples, including people from Fiji. This qualitative study explores knowledge and attitudes towards diabetes among i-Taukei Fijians to facilitate the cultural tailoring of diabetes prevention and management programs for this community. Fijians aged 26 to 71 years (n = 15), residing in Australia, participated in semi-structured interviews, 53% (n = 8) were male. Interviews were audio-recorded, transcribed verbatim, then thematically analyzed. Diabetes is recognized as an important and increasing health problem requiring action in the i-Taukei Fijian community. Widespread support for culturally appropriate lifestyle interventions utilizing existing societal structures, like family networks and church groups, was apparent. These structures were also seen as a crucial motivator for health action. Intervention content suggestions included diabetes risk awareness and education, as well as skills development to improve lifestyle behaviors. Leveraging existing social structures and both faith and family experiences of diabetes within the Fijian community may help convert increased awareness and understanding into lifestyle change. Ongoing in-community support to prevent and manage diabetes was also regarded as important. We recommend building upon experience from prior community-based interventions in other high-risk populations, alongside our findings, to assist in developing tailored diabetes programs for Fijians.

BackgroundThe use of robotic-assisted surgery (RAS) is becoming increasingly prevalent across a range of surgical specialties within public hospitals around Australia. As a result, it is critical that organisations consider workplace factors such as staff knowledge, attitudes and behaviours prior to the implementation of such new technology. This study aimed to describe the knowledge and attitudes of operating theatre staff from a large public tertiary referral hospital prior to the commencement of an RAS program.MethodsA cross-sectional survey of nursing, medical and support staff working in the operating theatre complex of a large public tertiary referral hospital was completed over a one-week period in June 2016. A 23-item questionnaire was utilised for data collection.Results164 (66%) theatre staff returned the surveys and were included in this study. The majority of medical staff reported being knowledgeable about RAS, whilst the majority of nursing and support staff did not. Overall the theatre staff were neutral about the potential benefits of RAS to patients. The majority of medical staff believed the implementation of RAS will increase the value of staff roles and job satisfaction, while nursing and support staff were uncertain about these benefits. All three staff groups were concerned about the impact of an RAS program on Workplace Health and Safety, and care and handling.ConclusionOperating theatre staff presented different knowledge and attitudes prior to the introduction of RAS. Whilst theatre staff were more favourable towards RAS than negative, they largely reserved their judgement about the new system prior to their own experiences. Collectively, these findings should be taken into consideration for training and support strategies prior to the implementation of a RAS program.

Recurrent miscarriage is defined as three or more consecutive pregnancy losses prior to the 24th week of gestation. The condition affects 1% of couples attempting to conceive and in the majority of cases no cause is identified. It can be an anxious and worrying time for those involved, and our role as GPs is made up of reassurance, support and tertiary referral where necessary. Fortunately, many couples proceed to having a successful pregnancy without the need for medical intervention. This article aims to discuss the aetiology, investigation and subsequent evidence-based management of recurrent pregnancy loss.