Journal articles on the topic 'Alfred Hospital (Melbourne, Vic )'

IntroductionThe advent of direct acting antiviral therapy for hepatitis C virus (HCV) means the elimination of HCV is possible but requires sustained effort to achieve. Between 2016 and 2019, 44% of those living with HCV were treated in Australia. However, treatment uptake has declined significantly. In Australia, people who inject drugs (PWID) are the population most at risk of HCV acquisition. Eliminating HCV in Australia will require nuanced understanding of the barriers to HCV treatment experienced by PWID and tailored interventions to address these barriers. The EC-Experience Cohort study aims to explore the barriers and enablers reported by PWID to engagement in HCV care.Methods and analysisThe EC-Experience Cohort study is a prospective cohort of PWID, established in Melbourne, Australia in 2018. Participants are assigned into three study groups: (1) those not currently engaged in HCV testing; (2) those diagnosed with HCV but not currently engaged in treatment and (3) those completed treatment. Participants complete a total of four interviews every 6 months across an 18-month study period. Predictors of experience of key outcome events along the HCV care cascade will be explored over time.Ethics and disseminationEthical approval for the EC-Experience Cohort study was obtained by the Alfred Hospital Ethics Committee in Melbourne, Australia (Project Number: HREC/16/Alfred/164). All eligible participants are assessed for capacity to consent and partake in a thorough informed consent process. Results from the EC-Experience Cohort study will be disseminated via national and international scientific and public health conferences and peer-reviewed journal publications. Data from the EC-Experience Cohort study will improve the current understanding of the barriers to HCV care for PWID and guide the tailoring of service provision for specific subgroups. Understanding the barriers and how to increase engagement in care of PWID is critical to achieve HCV elimination goals.

(Scarff CW, Lippmann J, Fock AW. A review of diving practices and outcomes following the diagnosis of a persistent (patent) foramen ovale in compressed air divers with a documented episode of decompression sickness. Diving and Hyperbaric Medicine. 2020 December 20;50(4):363–369. doi: 10.28920/dhm50.4.363-369. PMID: 33325017.) Introduction: The presence of a persistent (patent) foramen ovale (PFO) increases the risk of decompression sickness (DCS) whilst diving with pressurised air. After the diagnosis of a PFO, divers will be offered a number of options for risk mitigation. The aim of this study was to review the management choices and modifications to diving practices following PFO diagnosis in the era preceding the 2015 joint position statement (JPS) on PFO and diving. Methods: A retrospective study was conducted of divers sourced from both the Alfred Hospital, Melbourne and the Divers Alert Network Asia-Pacific during the period 2005–2015. Divers were contacted via a combination of phone, text, mail and email. Data collected included: diving habits (years, style and depths); DCS symptoms, signs and treatment; return to diving and modifications of dive practices; history of migraine and echocardiography (ECHO) pre- and post-intervention; ECHO technique(s) used, and success or failure of PFO closure (PFOC). Analyses were performed to compare the incidence of DCS pre- and post-PFO diagnosis. Results: Seventy-three divers were interviewed. Sixty-eight of these returned to diving following the diagnosis of PFO. Thirty-eight underwent PFOC and chose to adopt conservative diving practices (CDPs); 15 chose PFOC with no modification to practices; 15 adopted CDPs alone; and five have discontinued diving. The incidence of DCS decreased significantly following PFOC and/or adoption of conservative diving practices. Of interest, migraine with aura resolved in almost all those who underwent PFOC. Conclusions: Many divers had already adopted practices consistent with the 2015 JPS permitting the resumption of scuba diving with a lowering of the incidence of DCS to that of the general diving population. These results support the recommendations of the JPS.

Background A number of studies have shown promising performance of artificial intelligence (AI) algorithms for diagnosis of lesions in skin cancer. To date, none of these have assessed algorithm performance in the real-world setting. Objective The aim of this project is to evaluate practical issues of implementing a convolutional neural network developed by MoleMap Ltd and Monash University eResearch in the clinical setting. Methods Participants were recruited from the Alfred Hospital and Skin Health Institute, Melbourne, Australia, from November 1, 2019, to May 30, 2021. Any skin lesions of concern and at least two additional lesions were imaged using a proprietary dermoscopic camera. Images were uploaded directly to the study database by the research nurse via a custom interface installed on a clinic laptop. Doctors recorded their diagnosis and management plan for each lesion in real time. A pre-post study design was used. In the preintervention period, participating doctors were blinded to AI lesion assessment. An interim safety analysis for AI accuracy was then performed. In the postintervention period, the AI algorithm classified lesions as benign, malignant, or uncertain after the doctors’ initial assessment had been made. Doctors then had the opportunity to record an updated diagnosis and management plan. After discussing the AI diagnosis with the patient, a final management plan was agreed upon. Results Participants at both sites were high risk (for example, having a history of melanoma or being transplant recipients). 743 lesions were imaged in 214 participants. In total, 28 dermatology trainees and 17 consultant dermatologists provided diagnoses and management decisions, and 3 experienced teledermatologists provided remote assessments. A dedicated research nurse was essential to oversee study processes, maintain study documents, and assist with clinical workflow. In cases where AI algorithm and consultant dermatologist diagnoses were discordant, participant anxiety was an important factor in the final agreed management plan to biopsy or not. Conclusions Although AI algorithms are likely to be of most use in the primary care setting, higher event rates in specialist settings are important for the initial assessment of algorithm safety and accuracy. This study highlighted the importance of considering workflow issues and doctor-patient-AI interactions prior to larger-scale trials in community-based practices. Acknowledgments This research was supported by the Victorian Medical Research Acceleration Fund, with 1:1 contribution from MoleMap Ltd. VM is supported by the National Health and Medical Research Council Early Career Fellowship. CF is supported by the Monash University Research Training Program Scholarship. Conflicts of Interest SM is head of clinical research and regulatory affairs at Kahu.ai Ltd, a subsidiary of MoleMap Ltd. MH was the chief medical officer and a director of MoleMap Ltd, and holds shares in MoleMap Ltd. Trial Registration ClinicalTrials.gov NCT04040114; https://clinicaltrials.gov/ct2/show/NCT04040114

In May 1994 the Physiotherapy Department at John Hunter Hospital received a Commonwealth Best Practice in the Health Sector grant to design a critical pathway for the treatment of stroke.The implementation of the pathway at John Hunter Hospital and the introduction of the methodology to secondary sites (The Alfred Healthcare Group, Melbourne, and Royal Hobart & Repatriation General Hospitals, Hobart) resulted in the development of a Benchmarking Consortium.This paper will discuss the importance of benchmarking in understanding clinical processes, and the methodology employed to ensure that meaningful benchmarks wereachieved.

Abstract Aim/Background: The outcomes of high risk multiple myeloma (HR-MM) remain poor. As per the revised international staging system (R-ISS), high risk patients, defined by International Staging System (ISS) stage 3 plus high risk chromosomal abnormality and/or high Lactate Dehydrogenase (LDH), have particularly poor outcomes with 5 year progression free survival (PFS) and overall survival (OS) of 24% and 40% respectively.1 Tandem autologous - non-myeloablative allogeneic stem cell transplantation (ASCT-NMA AlloSCT), when used as upfront consolidation may improve the outcome via a graft versus myeloma effect. We performed a retrospective analysis comparing patients who had upfront tandem ASCT-NMA allo SCT for HR-MM with a HR-MM control group who were conventionally treated with upfront ASCT alone. Method: From May 2008 to June 2015, 29 HR-MM patients were treated at the Alfred Hospital Melbourne, with upfront tandem ASCT-NMA alloSCT. HR-MM was defined by the presence of at least 2 of 5 high risk features including International Staging System (ISS) score III, adverse cytogenetics [t(4;14 and/or 17p- identified on FISH and/or complex karyotype on metaphase analysis], elevated lactate dehydrogenase (LDH), plasma cell leukemia (all at diagnosis) or induction failure (less than partial remission (PR)) with proteosome inhibitor (PI) or immunomodulator (IMID) based combination chemotherapy. Outcomes for these patients were compared with 12 HR-MM patients contemporaneously treated at the Royal Adelaide hospital, Adelaide with upfront ASCT alone. All ASCT were conditioned with melphalan 200mg/m2; NMA were conditioned with oral fludarabine 48mg/m2 on days -4 to -2 and 2Gy TBI on day 0. All tandem ASCT-NMA allo SCT patients received cyclosporine and mycophenylate mofetil for graft versus host disease prophylaxis. Results: Median age of the tandem cohort was 52 years (range: 22-66 years) whereas the ASCT cohort was older with a median age of 59 years (range: 51-72 years; p=0.01). 44.8% of the tandem group and 50% of the ASCT group were male (p=0.77). 18 patients (62.1%) of the tandem cohort were transplanted from unrelated donors. Within the tandem cohort 24.1% developed grade II-IV acute graft versus host disease (GVHD) and 44.8% had extensive chronic GVHD. After a median follow up of 48.9 months, progression free survival (PFS) was significantly superior for tandem group compared to ASCT group (median PFS=1166 days versus 399 days; p=0.001) (Fig:1). The 3-year cumulative incidence of relapse was 31.9% for tandem group against 79.8% for ASCT group (p=0.005). The 5-year overall survival of tandem and ASCT groups were 59.84% and 44.56%, respectively (p=0.38). Transplant related mortality was not significantly different between the groups (20.7% for tandem group and 8.3% for ASCT group; p=0.32). To avoid any age bias, we then compared the ASCT cohort with an older subgroup of the tandem cohort (17 patients with a median age of 58 years, range: 51-66 years, p=0.61 when compared with ASCT cohort) and demonstrated that the PFS was still significantly superior for the tandem approach (median PFS=1179 days for tandem cohort versus 399 days for ASCT cohort; p=0.009). Minimal residual disease (MRD) analysis by 8-colour Euroflow (sensitivity at 10-5) was negative in 12 of 17 tandem patients tested. Conclusion: Upfront tandem ASCT-NMA AlloSCT for HR-MM results in superior PFS and an emerging OS benefit with acceptable toxicity when compared to conventional ASCT. High-resolution MRD negativity in a significant proportion of tandem patients predicts for extended disease free survival. Ref: 1. Palumbo A, Avet-Loiseau H, Oliva S, et al. Revised International Staging System for Multiple Myeloma: A Report From International Myeloma Working Group. J Clin Oncol. 2015 Sep 10;33(26):2863-69. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

In 1983 a patient at The Alfred Hospital, Melbourne died during general anaesthesia for emergency surgery, in the weeks following maintenance to the operating theatre gas supply. In the ensuing investigation, it was revealed that he had been given 100% nitrous oxide throughout the anaesthetic due to the inadvertent crossing of the nitrous oxide and oxygen pipelines during the repair work. In this article we review the published literature on the delivery of hypoxic and anoxic gas mixtures, and the associated morbidity and mortality. We explore the developments that took place in the delivery of anaesthetic gases, and the unforeseen dangers associated with these advances. We consider the risks to patient safety when technological advances outpaced the implementation of essential safety standards. We investigate the events that pushed the development of safer standards of anaesthetic practice and patient monitoring, which have contributed to modern day theatre practice. Finally, we consider the risks that still exist in the hospital environment, and the need for on-going vigilance.

IntroductionConvolutional neural networks (CNNs) can diagnose skin cancers with impressive accuracy in experimental settings, however, their performance in the real-world clinical setting, including comparison to teledermatology services, has not been validated in prospective clinical studies.Methods and analysisParticipants will be recruited from dermatology clinics at the Alfred Hospital and Skin Health Institute, Melbourne. Skin lesions will be imaged using a proprietary dermoscopic camera. The artificial intelligence (AI) algorithm, a CNN developed by MoleMap Ltd and Monash eResearch, classifies lesions as benign, malignant or uncertain. This is a preintervention/postintervention study. In the preintervention period, treating doctors are blinded to AI lesion assessment. In the postintervention period, treating doctors review the AI lesion assessment in real time, and have the opportunity to then change their diagnosis and management. Any skin lesions of concern and at least two benign lesions will be selected for imaging. Each participant’s lesions will be examined by a registrar, the treating consultant dermatologist and later by a teledermatologist. At the conclusion of the preintervention period, the safety of the AI algorithm will be evaluated in a primary analysis by measuring its sensitivity, specificity and agreement with histopathology where available, or the treating consultant dermatologists’ classification. At trial completion, AI classifications will be compared with those of the teledermatologist, registrar, treating dermatologist and histopathology. The impact of the AI algorithm on diagnostic and management decisions will be evaluated by: (1) comparing the initial management decision of the registrar with their AI-assisted decision and (2) comparing the benign to malignant ratio (for lesions biopsied) between the preintervention and postintervention periods.Ethics and disseminationHuman Research Ethics Committee (HREC) approval received from the Alfred Hospital Ethics Committee on 14 February 2019 (HREC/48865/Alfred-2018). Findings from this study will be disseminated through peer-reviewed publications, non-peer reviewed media and conferences.Trial registration numberNCT04040114.

Contact precautions (CPs) may lead to adverse psychological effects, delays in access to services, and compromises in the quality of care and patient safety. These need to be balanced with the benefits in preventing transmission of resistant microorganisms. In this study, we aimed to quantify the effect of CPs on reported patient safety incidents.The Alfred hospital is a tertiary referral hospital in Melbourne, Australia. Previous studies have shown that colonization with vancomycin-resistant enterococcus (VRE) is endemic in our hospital. Patients found to be colonized with VRE are placed in CPs immediately and during each subsequent admission. At our facility, modified CPs practiced during the study period include isolation in single rooms with a dedicated toilet, use of gloves when entering the room, and gloves and gown if contact with body fluids is anticipated. The hospital has a computerized risk management system where relevant patient safety incidents are reported to facilitate institutional review and response. We conducted a retrospective cohort study using these routinely collected data, comparing the incidence rate of documented adverse events in patients prior and subsequent to initiation of CPs among patients colonized or infected with VRE. Patients with incident VRE detection between January 2009 and October 2010 were included.

IntroductionContinuous EEG (cEEG) monitoring is essential for the optimal diagnosis and management of non-convulsive seizures. We audited the use of cEEG across two major metropolitan hospitals in Melbourne, Australia as part of a new combined epilepsy program. There are no reported case series of cEEG in Australia.MethodsData was collected retrospectively from consecutive patients who underwent cEEG monitoring as part of their acute inpatient care between Jan 2018 to Dec 2018 at the Alfred and Royal Melbourne Hospitals. All inpatient EEG studies over 1 hr were included. Elective cases from the epilepsy monitoring unit were excluded. Demographic and clinical information regarding their admission was collected. Descriptive statistics, and comparative analysis was performed.ResultsThere were 94 patients identified that underwent cEEG. 50% were male and 50% female, with an average age of 51.3 yrs. 45% were performed in the ICU, and 55% on the acute medical ward. The average duration of recording per patient was 86.2 hrs or 3.6 days. Of 89 of 94 available cEEG reports, seizures were seen in 55%, the majority being non-convulsive. Interictal discharges were seen in 60%. 19% (13/67 of available records) were dead at the time of the audit.ConclusionNon-convulsive seizures and non-convulsive status epilepticus is common and widely underrecognized without cEEG. We present 94 cases as part of our newly expanding cEEG program across two major Australian hospitals over a one year period, 55% with seizures which were predominantly non-convulsive. A prospective database will be designed for further quality improvement and future research.

There is limited evidence suggesting the underlying reasons for the use of complementary and alternative medicines (CAMs) by people with HIV/AIDS, or individual attitudes and beliefs about the use of CAMs. Using focus groups and a survey with 151 individuals attending the HIV Clinics at The Alfred Hospital, Melbourne, we aimed to provide insights into factors that influence the use of CAMs among people living with HIV/AIDS. Roughly half (49%) of the participants had used CAMs to manage their HIV/AIDs. Users of CAMs utilized a wide range of treatments in managing their condition, but costs of the CAMs meant that users were not necessarily able to use them as much as they might have liked. Use of CAMs was based on a desire to find something beneficial rather than on being dissatisfied with conventional medicine. Further research is needed into (a) the effects of CAMs and (b) the enhancement of communication and collaboration between patients, doctors and complementary medicine practitioners.

To present-day astronomers the name of Robert Ellery, by which our newly established lectureship is to be known, means little. A century ago it was a different story. Ellery was then one of the most respected scientists in the country, a leading astronomer who had been director of the Melbourne Observatory since it was founded in 1853, and who had taken it to a prominent position in international astronomy. Besides this he was a man of parts who spread his talents widely. He was a founder and long-term president of the Royal Society of Victoria, treasurer of the University Council, chairman of the committee of the Alfred Hospital, Trustee of the Public Library, the Art Gallery and the Museum, and he was an active member, latterly commander, of the local Torpedo and Signal Corps, a coastal defence unit manned by citizen soldiers. Late in life he became the first president of the Beekeepers’ Club. He was elected to the Royal Society and awarded a CMG: all in all, a man of character and achievement.

Objectives. To describe a model that matches electronic patient care records within a given case to one or more patients within that case. Method. This retrospective study included data from all metropolitan Ambulance Victoria electronic patient care records (n = 445 576) for the time period 1 January 2009–31 May 2010. Data were captured via VACIS (Ambulance Victoria, Melbourne, Vic., Australia), an in-field electronic data capture system linked to an integrated data warehouse database. The case patient algorithm included ‘Jaro–Winkler’, ‘Soundex’ and ‘weight matching’ conditions. Results. The case patient matching algorithm has a sensitivity of 99.98%, a specificity of 99.91% and an overall accuracy of 99.98%. Conclusions. The case patient algorithm provides Ambulance Victoria with a sophisticated, efficient and highly accurate method of matching patient records within a given case. This method has applicability to other emergency services where unique identifiers are case based rather than patient based. What is known about the topic? Accurate pre-hospital data that can be linked to patient outcomes is widely accepted as critical to support pre-hospital patient care and system performance. What does this paper add? There is a paucity of literature describing electronic matching of patient care records at the patient level rather than the case level. Ambulance Victoria has developed a complex yet efficient and highly accurate method for electronically matching patient records, in the absence of a patient-specific unique identifier. Linkage of patient information from multiple patient care records to determine if the records are for the same individual defines the ‘case patient’. What are the implications for practitioners? This paper describes a model of record linkage where patients are matched within a given case at the patient level as opposed to the case level. This methodology is applicable to other emergency services where unique identifiers are case based.

Introduction: Burns fuelled by petrol are a major cause of injury in Australia and New Zealand. The same quality of explosive ignition that makes petrol so valuable as a fuel can cause injuries when handled carelessly or used for a purpose for which it was not intended. Methods: This was a retrospective cohort study that examined the epidemiology of patients admitted to the Victorian Adult Burns Service (VABS) based at the Alfred Hospital, Melbourne. Data were extracted from the VABS Database on patients presenting over a seven-year period, between 1st July 2009 to 30th June 2016. Results: During the study period, 378 out of 1927 burns (19.6%) admissions were related to petrol use. Males aged 20 – 29 years were most at risk, contributing to 25.4% of petrol related burn injuries. A large portion of burns, 31.0%, occurred during a leisure activity. The mean total body surface area burnt in this cohort was 19.3% and surgery was required in 70.4% of cases. Petrol related burns injuries is estimated to cost AU$ 5,484,834 annually and had a mortality rate of 7.4%. Conclusion: Misuse of petrol contributed to a substantial injury burden to Victorians. Raising community awareness through preventive strategies targeted at high-risk groups of at-risk behaviours is warranted to reduce the incidence of petrol related burn injuries.

Abstract Background Current guidelines recommend empiric antibiotics be used only for severe cases of coronavirus disease 2019 (COVID-19) or in cases where there is high clinical suspicion for bacterial co-infection. Level of adherence to guideline-recommended prescribing is unknown and high rates of antimicrobial prescribing may lead to increased development of resistance. Methods We reviewed antimicrobial prescribing patterns for patients with COVID-19 managed at The Alfred Hospital in Melbourne, Australia in 2020. Adherence to World Health Organization (WHO) guideline-based prescribing was assessed by manual review of case notes. Monthly hospital-wide antibacterial consumption April-Dec 2020 (post-pandemic period) was compared to Jan 2019-Mar 2020 (pre-pandemic period), measured as days of therapy (DOT) per 1000 patient-days. Rates of multi-drug resistant organisms (MRO) (including MRSA, VRE, CPE, ESBL) were compared between months in 2019 and 2020 after pandemic onset (April 2020) and expressed as isolates per 1000 patient-days. Results 147 patients were managed for COVID-19 in 2020 at our centre. 101 patients required hospital admission and 58 (39%) were classified as either severe or critical in severity. 80 (54%) patients received empiric antimicrobial treatment, including 78/101 (77%) of hospital inpatients and 24/26 (92%) of ICU-admitted patients. 59 (73%) of antimicrobial prescriptions were adherent to WHO guidelines. Monthly antibacterial consumption was significantly lower post-pandemic than in the pre-pandemic period (mean 853 vs 902 DOT/1000 patient-days, P=0.0065). Antimicrobial use patterns varied, with significant decreases in commonly used antibiotics such as ceftriaxone, piperacillin-tazobactam, azithromycin and ciprofloxacin but no change in vancomycin or meropenem (Figure 1). There was a mean decrease of 0.77 MRO isolates/1000 patient-days (P=0.026) when each month in 2020 was compared with the corresponding month in 2019 (Figure 2). Antibacterial consumption in 2019 and 2020 by month, expressed as days of therapy/1000 patient-days. Rates of isolated multi-drug resistant organisms in 2019 and 2020 by month, expressed as isolates/1000 patient-days. Conclusion A high proportion of admitted patients with COVID-19 received empiric antibiotics. In spite of this, we observed a significant reduction in total antimicrobial consumption and reduced rates of MRO isolation in the post-pandemic period. Disclosures All Authors: No reported disclosures

Barlow JW, Crowe TC, Cowen NL, Raggatt LE, Topliss DJ, Stockigt JR. Stimulation of sex hormone-binding globulin mRNA and attenuation of corticosteroid-binding globulin mRNA by triiodothyronine in human hepatoma cells. Eur J Endocrinol 1994;130:166–70. ISSN 0804–4643 We examined the time course and dose response of the triiodothyronine (T3) effect on mRNAs for sex hormone-binding globulin (SHBG) and corticosteroid-binding globulin (CBG) in cells of the human hepatoma line HepG2. After 7 h of exposure to a saturating dose of T3, SHBG mRNA was unchanged but increased to 1.5±0.1 times the unstimulated control at 22 h. Maximal stimulation (2.3±0.6) was observed at 2–3 days. Corticosteroid-binding globulin mRNA was unchanged for 22 h after exposure to T3 but diminished thereafter to 64% by day 3. At 3–4 days of exposure, the changes in both SHBG mRNA and CBG mRNA were dose-responsive to the T3 concentration. For both mRNAs, half-maximal response occurred between 10 and 20 pmol/l bioavailable T3. Cortisol-binding proteins secreted by HepG2 cells after 3 days in culture also were T3 dose-responsive. No re-uptake of secreted CBG by the cells was observed, suggesting that the T3 effect on CBG secretion occurs during production of the mature protein. These data suggest that T3 stimulates the expression of the SHBG gene and attenuates the expression of the CBG gene. The effects of T3 on these genes are consistent with the increase in circulating SHBG and decrease in circulating CBG observed in hyperthyroidism. The HepG2 cells may be a useful human cell line in which to study the diversity of the molecular mechanisms of T3 action. JW Barlow, Ewen Downie Metabolic Unit, Alfred Hospital, Commercial Rd. Melbourne, Victoria 3181, Australia

Aims Acetabular fractures in older adults lead to a high risk of mortality and morbidity. However, only limited data have been published documenting functional outcomes in such patients. The aims of this study were to describe outcomes in patients aged 60 years and older with operatively managed acetabular fractures, and to establish predictors of conversion to total hip arthroplasty (THA). Methods We conducted a retrospective, registry-based study of 80 patients aged 60 years and older with acetabular fractures treated surgically at The Alfred and Royal Melbourne Hospital. We reviewed charts and radiological investigations and performed patient interviews/examinations and functional outcome scoring. Data were provided by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Survival analysis was used to describe conversion to THA in the group of patients who initially underwent open reduction and internal fixation (ORIF). Multivariate regression analyses were performed to identify factors associated with conversion to THA. Results Seven patients (8.8%) had died at a median follow-up of 18 months (interquartile range (IQR) 12 to 25), of whom four were in the acute THA group. Eight patients (10%) underwent acute THA. Of the patients who underwent ORIF, 17/72 (23.6%) required conversion to THA at a median of 10.5 months (IQR 4.0 to 32.0) . After controlling for other factors, transport-related cases had an 88% lower rate of conversion to THA (hazard ratio (HR) 0.12, 95% confidence interval (CI) 0.02 to 0.91). Mean standardized Physical Component Summary Score (PCS-12) of the 12-Item Short Form Health Survey (SF-12) was comparable with the general population (age-/sex-matched) by 12 to 24 months. Over half of patients working prior to injury (14/26) returned to work by six months and two-thirds of patients (19/27) by 12 months. Conclusion Patients over 60 years of age managed operatively for displaced acetabular fractures had a relatively high mortality rate and a high conversion rate to THA in the ORIF group but, overall, patients who survived had mean PCS-12 scores that improved over two years and were comparable with controls. Cite this article: Bone Joint J 2020;102-B(12):1735–1742.

Introduction: The malignant clonal cell proliferation in multiple myeloma (MM) results in significant immune dysregulation through clonal specific T cell expansion, elevated levels of CD4+ CD25+FOXP3+ T regulator cells, downregulation of NK cells, high levels of IL-6 and activation of immunosuppressive tumour associated macrophages (TAM) . However, the mechanisms underlying the hypercoagulable state in MM and predisposing to venous thromboembolic (VTE) complications is unclear. Confounding disease factors is the use of immunomodulatory drugs (IMiDs) such as Lenalidomide, Thalidomide and Pomalidomide causing ubiquitination and degradation of the Ikaros Family Zinc Finger Protein (IKZF)1 and 3 by cereblon which also contributes to the prothrombotic effect despite thromboprophylaxis. Aims: The aim of this study was to analyse the changes in the coagulation profile and plasma cell disease burden with treatment, including Lenalidomide, in patients with MM to help define potential underlying mechanisms for hypercoagulability and thrombosis. Methods: Coagulation profiles and disease markers were retrospectively analysed in 16 MM patients receiving treatment with Daratumumab, Lenalidomide and Dexamethasone (DRd) at The Alfred Hospital, Melbourne from April 2019 to August 2020. Patients enrolled were transplant eligible with MM that was refractory to initial induction therapy with Velcade, Cyclophosphamide and Dexamethasone (VCD). This study was approved by The Alfred Hospital ethics committee. Statistical analysis was performed using descriptive statistics and the Wilcoxon Sign Rank Test to compare the median coagulation profiles and disease markers after 1-2 cycles of DRd and 3-4 cycles of DRd. Biomarkers included Prothrombin Time (PT), Partial Thromboplastin Time (PTT), Fibrinogen, Thrombin Clotting Time (TCT), serum paraprotein (SPEP) and serum free light chain (SFLC) with a p value of <0.05 indicating statistical significance. Results: A total 7 patients had coagulation profiles at the two time points i) post 1-2 cycles and ii) post 3-4 cycles of DRd (Table 1). 9 patients had coagulation profiles only after 3-4 cycles of DRd. A separate analysis was performed using Wilcoxon Sign Rank with imputed median differences to allow the inclusion of the 9 additional patients subsequently increasing the sample size to a total of 16 (Table 2). All patients were on anticoagulation with aspirin (n=14), rivaroxaban (n=1) or clopidogrel (n=1) at the time of the analysis. The analysis showed a statistically significant reduction in PT from median 13.6s (11.9-16.6) to 12.7s (11.7-14.1) with 3-4 cycles DRd in both analysis (p=0.006 and p= 0.027). Fibrinogen levels reduced from median of 5.4 g/L (2.8-8) to 3.98 g/L (2.3- 5.1) after 3-4 cycles (p=0.001). TCT increased after 3-4 cycles of DRd (p=0.005). Serum paraprotein demonstrated statistically significant reduction from 10.8g/L (6 -13) to 7.6 g/L (2-13) after 3-4 cycles (p=0.007). Serum free light chain assay also demonstrated reduction in median values from 82.8mg/L (8.1 - 415.7) to 54.6mg/L (0.8 - 338.6) but was not statistically significant (p=0.084). Discussion: All the patients in this study either responded to treatment or had stable disease after treatment with DRd. The data demonstrate a coagulation response to treatment. The median fibrinogen level that was above the upper limit of normal declined on treatment, the TCT increased and the PT decreased, all coinciding with the statistically significant decline in paraprotein level. A larger study is required to confirm these findings. However, this study has demonstrated that the hypercoagulable state in MM improves with disease response. Disclosures Spencer: Roche: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Pharmamar: Other; Secura Bio: Consultancy, Honoraria; Sanofi: Consultancy, Honoraria; Servier: Consultancy, Other: Grant/Research Support; Janssen: Consultancy, Honoraria, Other: Grant/Research Support, Speakers Bureau; Haemalogix: Consultancy, Honoraria, Other: Grant/Research Support; BMS: Honoraria, Other: Grant/Research Support, Research Funding, Speakers Bureau; TheraMyc: Consultancy, Honoraria; Amgen: Consultancy, Honoraria, Other: Grant/Research Support; Takeda: Honoraria, Other, Speakers Bureau; Antegene: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria, Other: Grant/Research Support.

Barlow JW, Curtis AJ, Raggatt LE, Loidl NM, Topliss DJ. Stockigt JR. Drug competition for intracellular triiodothyronine-binding sites. Eur J Endocrinol 1944;130:417–21. ISSN 0804–4643 A variety of substances, including frusemide, non-esterified fatty acids (NEFAs) and non-steroidal antiinflammatory drugs (NSAIDs), can compete for triiodothyronine (T3)-binding sites in serum and at the cell surface. We examined the competitive potency of these agents at intracellular T3-binding sites in order to assess their potential to act as T3 antagonists. Competition for [125I]T3 binding was determined using hydroxyapatite separation in cytosols and nuclear extracts prepared from livers of Macaca fascicularis. The T3 affinities were 15.8 ± 1.2 nmol/l in cytosol and 0.23 ± 0.02 nmol/l in nuclear extract. Does–response curves were analysed by a four-parameter sigmoid curve-fitting program to determine competitor potency. The nineteen agents tested included various NSAIDs, NEFAs, non-bile acid cholephils (NBACs), frusemide, amiodarone and the flavonoid EMD 21388. In nuclear extract the most active competitors were linoleic acid (8.5 μmol/l) and linolenic acid (7.8 μmol/l), Potencies of NSAIDs varied between 66 μmol/l (meclofenamic acid) and 525 μmol/l (diclofenac). In cytosol, NEFAs were less potent but NSAIDs were stronger competitors than in nuclear extract. Half-inhibitory potencies in cytosol were between 13.2 μmol/l (meclofenamic acid) and 63.1 μmol/l (flufenamic acid). The NBAC bromosulphthalein was one of the most potent inhibitors in both cytosol and nuclear extract. When expressed relative to T3, diclofenac was a more effective competitor in cytosol than it was in nuclear extract. Amiodarone and EMD 21388 were without effect both in cytosol and nuclear extract. Frusemide (759 μmol/l) was weakly active in cytosol only. The action of T3 was assessed by measuring secretion of sex hormone-binding globulin (SHBG) in Hep-G2 cells. After 3 days with total T3 (0.1 μmol/l), SHBG was 155 ± 15% of the control. Amiodarone (100 μmol/l) and meclofenamic acid (100 μmol/l) were cytotoxic. Bromosulphthalein (10 μmol/l), one of the most potent competitors at both the cytoplasmic and the nuclear level, did not influence the T3-induced rise in SHBG secretion. None of the drugs tested affected the magnitude of maximal induction of SHBG by T3. Substances that compete for serum and cell surface T3-binding sites are also weak competitors for intracellular T3-binding proteins, although the heirarchy of potency differs. Frusemide and diclofenac, with a greater relative potency for cytosolic binding than nuclear binding, may have potential use in investigating the function of cytosolic T3-binding. Amiodarone shows no binding activity and is not a hormone antagonist in primate hepatic tissue. John W Barlow, Ewen Downie Metabolic Unit, Alfred Hospital, Commercial Road, Melbourne, Victoria 3181, Australia

Background Relapse remains an unresolved issue in smoking cessation. Extended stop smoking medication use can help, but uptake is low and several behavioural relapse prevention interventions have been found to be ineffective. However, opportunistic ‘emergency’ use of fast-acting nicotine replacement treatment or electronic cigarettes may be more attractive and effective, and an online behavioural Structured Planning and Prompting Protocol has shown promise. The present trial aimed to evaluate the clinical effectiveness and cost-effectiveness of these two interventions. Design A randomised controlled trial. Setting English stop smoking services and Australian quitlines, Australian social media and St Vincent’s Hospital Melbourne, Fitzroy, VIC. Participants Ex-smokers abstinent for at least 4 weeks, with some participants in Australia also recruited from 1 week post quit date. The planned sample size was 1400, but the trial was curtailed when 235 participants were recruited. Interventions Participants were randomised in permuted blocks of random sizes to (1) oral nicotine replacement treatment/electronic cigarettes to use if at risk of relapse, plus static text messages (n = 60), (2) the Structured Planning and Prompting Protocol and interactive text messages (n = 57), (3) oral nicotine replacement treatment/electronic cigarettes plus the Structured Planning and Prompting Protocol with interactive text messages (n = 58) or (4) usual care plus static text messages (n = 59). Outcome measures Owing to delays in study set-up and recruitment issues, the study was curtailed and the primary outcome was revised. The original objective was to determine whether or not the two interventions, together or separately, reduced relapse rates at 12 months compared with usual care. The revised primary objective was to determine whether or not number of interventions received (i.e. none, one or two) affects relapse rate at 6 months (not biochemically validated because of study curtailment). Relapse was defined as smoking on at least 7 consecutive days, or any smoking in the last month at final follow-up for both the original and curtailed outcomes. Participants with missing outcome data were included as smokers. Secondary outcomes included sustained abstinence (i.e. no more than five cigarettes smoked over the 6 months), nicotine product preferences (e.g. electronic cigarettes or nicotine replacement treatment) and Structured Planning and Prompting Protocol coping strategies used. Two substudies assessed reactions to interventions quantitatively and qualitatively. The trial statistician remained blinded until analysis was complete. Results The 6-month relapse rates were 60.0%, 43.5% and 49.2% in the usual-care arm, one-intervention arm and the two-intervention arm, respectively (p = 0.11). Sustained abstinence rates were 41.7%, 54.8% and 50.9%, respectively (p = 0.17). Electronic cigarettes were chosen more frequently than nicotine replacement treatment in Australia (71.1% vs. 29.0%; p = 0.001), but not in England (54.0% vs. 46.0%; p = 0.57). Of participants allocated to nicotine products, 23.1% were using them daily at 6 months. The online intervention received positive ratings from 63% of participants at 6 months, but the majority of participants (72%) completed one assessment only. Coping strategies taught in the Structured Planning and Prompting Protocol were used with similar frequency in all study arms, suggesting that these are strategies people had already acquired. Only one participant used the interactive texting, and interactive and static messages received virtually identical ratings. Limitations The inability to recruit sufficient participants resulted in a lack of power to detect clinically relevant differences. Self-reported abstinence was not biochemically validated in the curtailed trial, and the ecological momentary assessment substudy was perceived by some as an intervention. Conclusions Recruiting recent ex-smokers into an interventional study proved problematic. Both interventions were well received and safe. Combining the interventions did not surpass the effects of each intervention alone. There was a trend in favour of single interventions reducing relapse, but it did not reach significance and there are reasons to interpret the trend with caution. Future work Further studies of both interventions are warranted, using simpler study designs. Trial registration Current Controlled Trials ISRCTN11111428. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 68. See the NIHR Journals Library website for further project information. Funding was also provided by the National Health and Medical Research Council, Canberra, ACT, Australia (NHMRC APP1095880). Public Health England provided the funds to purchase the nicotine products in England.

Abstract Introduction The CHaDOx1 nCov-19 AstraZeneca (AZ) vaccination has been associated with an antibody-mediated prothrombotic syndrome, termed "Thrombosis with Thrombocytopenia Syndrome" (TTS)[1-3]. The current diagnostic criteria for TTS are thrombosis (venous or arterial) within 4-42 days of AZ vaccine, thrombocytopenia and presence of an antibody to platelet factor 4 (PF4)[4, 5]. TTS commonly presents with cerebral venous sinus thrombosis (CVST) or splanchnic vessel thrombosis (SVT), but outside of TTS, CVST and SVT are uncommon, with an overall incidence of less than 0.5 per 100,000 [5-7]. Deep vein thrombosis (DVT) and pulmonary embolism (PE) are also associated with TTS, however the background incidence of venous thromboembolism (VTE) is much higher, with 1-2 events per 1000 patients per year[7, 8]. Therefore, many patients will present with new VTE and a recent exposure to the AZ vaccine, requiring consideration of investigation for TTS. Recent data suggests that PF4 antibodies can be seen in up to 8% of patients without thrombosis but following AZ vaccination[9]. We hypothesised in patients with recent AZ vaccination, new VTE but with a normal platelet count, that the incidence of a PF4 antibody is similar to this background rate of PF4 positivity. If confirmed, then presence of a normal platelet count despite new VTE and recent vaccination may exclude TTS without the need for PF4 antibody testing. We present our preliminary data on the rates of PF4 antibody positivity amongst patients with VTE, recent AZ vaccination and a normal platelet count at presentation. Aim and Methods To assess the incidence of PF4 ELISA positive results in patients with confirmed VTE, recent vaccination (within 4-42 days) with the first dose of AZ vaccine, and platelet count greater than 150x10 9/L. A retrospective audit of cases referred with suspected TTS to Monash Pathology, Melbourne, Victoria, and New South Wales Health Pathology at Royal Prince Alfred Hospital and St George Hospital sites Sydney, New South Wales, Australia, for testing for anti PF4 antibodies from 1 st April to 31 st July 2021. Patient sera were tested for the Anti-PF4 antibody using the STAGO Asserachrom HPIA IgG ELISA (Asnières sur Seine, France). For patients with a positive PF4 antibody test additional testing was sought for either the presence of platelet activating antibodies with a flow cytometry-based assay or the presence of spontaneous serotonin release without heparin in the serotonin release assay. Results From April 1 st to July 31 st 350 tests were run on 332 patients. 91 patients met our criteria, of whom 51 were female and 40 male, with a median age of 73 years. Median platelet count at presentation was 226x10 9/L, and median D dimer values were 10 times the upper limit of normal. 86 patients had either DVT, PE or both, including 2 with upper limb DVT, and 5 patients had PE with concurrent arterial events (1 axillary artery thrombosis, 3 arterial strokes, 1 coronary artery thrombosis). Further details are presented in table 1. 82 patient samples tested negative for anti-PF4 antibodies by ELISA, 5 were positive, and were 4 weak positive/equivocal (see table 2 for further details). Of the positive results, 3 had functional testing available, of which 2 were negative, and 1 showed discordant results, with a positive SRA but negative flow cytometry. None of the weak positive/equivocal cases had functional testing results available. Of the negative ELISA results, 5 patients had functional testing results available, of which 4 were negative. One of these cases had positive testing by flow cytometry, but negative by SRA (case included in table 2). Conclusion In our Australian cohort of patients with their first dose of AZ vaccine and new VTE within 4-42days, but a normal platelet count (therefore not fulfilling the clinical criteria of TTS), the incidence of a positive PF4 antibody test was 9/91 (9.9%, 95% CI 3.7-15.9%) and only one had evidence of platelet activating antibodies. This observed rate is similar to that observed in healthy patients without thrombosis who received AZ vaccination as described by Thiele et. al., 2021. Further confirmation in a larger cohort of VTE patients is required, but if confirmed, then PF4 ELISA testing in patients with VTE and normal platelet count post AZ vaccine may not be required, and should give clinicians confidence to institute routine management. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Abstract BACKGROUND: We have previously shown that one target of hyper-methylation in AML is the promoter of the tumour suppressor and stress-response mediator Growth Arrest and DNA Damage inducible 45A (GADD45A) (GADD45AmeHI; 42% of AML). In mice Gadd45a has recently been shown to play a critical role in HSC stress responses. Gadd45a deficiency leads to enhanced HSC self-renewal, DNA damage accumulation in HSC, increased susceptibility to leukemogenesis, and impairment in HSC apoptosis after genotoxic exposure (Chen et al, Blood 2014). These findings suggest that hypermethylation of the GADD45A gene may play an important role in the altered properties of HSC, leukaemic initiation and progression. Promoter hypermethylation of this gene defines a patient group with poor survival on standard therapy (Perugini et al, Leukaemia 2012). To explore further the molecular basis of the GADD45AmeHI patient group weperformed genetic profiling of diagnosis samples using a Sequenom multiplex mutation panel, or using whole exome sequencing for broader coverage (n=95 patients).Sequenom MassARRAY was used for quantitative detection of GADD45A promoter methylation in patient samples. For a cohort of matched diagnosis and relapse samples we used CpG methylation data for GADD45A determined by ERRBS (Akalin et al, PLoSGenetics 2012). Response to cytotoxic drugs and assessment of drug combinations with 5-Aza-deoxycytidine (decitabine, DAC) and anthracycline (Daunorubicin, DNR) was performed in AML cell lines, and with primary leukemic cell populations. RESULTS: The association of the GADD45AmeHI patient group with poor outcome was validated in an independent AML patient cohort of 48 patients from the Alfred Hospital, Melbourne, Australia (p=0.003; HR3.35). Whole exome sequencing and Sequenom multiplex analysis of 95 AML patients revealed a striking co-occurrence of the GADD45AmeHI phenotype with mutations in IDH1, IDH2, and TET2 (p<0.0001, Fisher’s exact test, Fig. 1). To test the prediction that GADD45A hypermethylation may be an important factor for relapse we investigated GADD45A promoter DNA methylation levels in paired diagnosis and relapse samples. In a paired analysis of 39 patients we show that relapse samples display a significant increase in GADD45A promoter CpG methylation (p=0.035, paired t-test). This is consistent with emergence in many patients following chemotherapy of a chemoresistant clone that has increased GADD45A methylation and reduced GADD45A activity. We next tested whether reactivation of GADD45A expression in GADD45AmeHI patient samples could be achieved through the use of hypo-methylation agents, and whether this is beneficial for response to chemotherapy. DAC treatment has been reported to induce DNA demethylation and GADD45A reactivation in primary AML samples (Klco et al, Blood 2013), and we observe reduced GADD45A promoter methylation and increased expression following DAC treatment of the GADD45AmeHI AML cell line (Mv4;11), consistent with DNA methylation-induced gene silencing of GADD45A. DAC pre-treatment of the GADD45AmeHI AML cell lines MOLM13 and Mv4;11, and three primary AML samples (GADD45AmeHI), resulted in increased GADD45A expression and increased DNR sensitivity. CONCLUSIONS: DNA methylation of the GADD45A proximal promoter marks a large percentage of AML patients at diagnosis including the majority of those with IDH1/2 and TET2 mutations (collectively these occur in 28% of AML (Network CGAR, N Engl J Med, 2013)), and is an independent predictor of poor outcome in two independent patient cohorts. Our data shows that silencing of GADD45A through increased promoter CpG methylation maybe an important early event in leukaemogenesis associated with impaired TET2 activity. Based on recent studies describing the properties of Gadd45a-deficient murine HSC we suggest reduced GADD45A activity in this subset of patients may contribute to the properties of pre-leukaemic HSC that have been associated with IDH1/2 mutation and reported to display clonal expansion, resistance to chemotherapy, and ultimately a high risk of relapse. In vitro drug experiments suggest that a priming schedule of DAC followed by DNR may provide a successful tailored treatment strategy for GADD45AmeHI patients, in combination with GADD45A expression as a biomarker predicting increased DNR sensitivity. Fig 1: Co-association of GADD45AmeHI with IDH1/2 and TET2 mutations in 95 AML patients Fig 1:. Co-association of GADD45AmeHI with IDH1/2 and TET2 mutations in 95 AML patients Disclosures No relevant conflicts of interest to declare.

Abstract Aim/Background: Multiple myeloma (MM) is a malignant plasma cell disorder predominantly of the elderly. Current treatment modalities, including newer drug combinations and autologous stem cell transplantation (ASCT) offer longer and deeper responses, but none of them are curative. Furthermore, a subgroup of patients (approximately 20%) with high risk features manifest aggressive disease at onset with only short term or no response with available therapies. Non-myeloablative allogeneic stem cell transplantation (NMA) is a therapeutic option in these settings and maybe potentially curative. We undertook a retrospective analysis of MM patients who underwent tandem ASCT-NMA at our centre. Primary objectives were to evaluate the disease outcomes and treatment related complications experienced by these patients Method: Between May 2008 and March 2015, 55 patients referred to the Alfred Hospital, Melbourne with MM underwent either 'upfront' or 'deferred' tandem autologous (ASCT) /nonmyeloblative (NMA) transplantation procedure as part of their disease management. The decision for upfront tandem transplant was based on the presence of at least 2 of 5 high risk features exhibited by the patients, these included ISS score 3, plasma cell leukemia, elevated LDH, adverse cytogenetics [t(4;14),17p- or complex karyotype] and induction failure (<PR) with bortezomib or immunomodulatory agent containing therapy. ASCT were conditioned with melphalan 200mg/m2; NMA were conditioned with oral fludarabine 48mg/m2 on days -4 to -2 and 2Gy TBI on day 0. Forty seven patients received their allografts as outpatients. All patients received cyclosporine and mycophenylate mofetil for graft versus host disease prophylaxis. Results: Twenty seven patients underwent upfront tandem ASCT/NMA transplantation - median age 51 years (range, 22-62 years) and 28 patients underwent deferred ASCT/NMA transplantation - median age 57 years (range, 47-67 years). Thirty four patients were males. Median follow up was 862 days (115-2659 days). Median time between ASCT and NMA was 98 days (50 - 336 days). 23 patients had matched sibling donors and 32 had matched unrelated donors. All patients engrafted with neutrophils never below 0.5 x 109/l in 42% patients and platelets never below 20 x 109/l in 93% patients. Median neutrophil recovery occurred on day 11 (range 0-26 days). Acute GVHD occurred in 49% of patients. Incidence of Grade II-IV AGVHD was 29% (22% upfront patients and 35% deferred patients (p=0.27)). CGVHD occurred in 67% of evaluable patients (68% upfront patients and 67% deferred patients p=0.92). The proportion of patients who required ongoing treatment for active chronic GVHD at 1yr, 2yrs and 3yrs was 51%, 29% and 18%, respectively. Transplant related mortality (5 GVHD; 2 infection) was 12.7% (5 [19%] upfront patients and 2 [7%] deferred patients). Twenty two patients (40%) progressed post allograft (30% upfront patients and 50% deferred patients [p=0.12]). Twelve patients died from primary disease (3 upfront patients and 9 deferred patients). Progression free survival (PFS) and overall survival (OS) of the whole group at 5yrs were 46.5% and 54.3% respectively.Comparing the two cohorts at 3 and 5 years, OS was higher, although not statistically significant, in the upfront cohort (75% vs 52% at 3 years, p=0.13 and 63% vs 42% at 5 years, p=0.22).Patients who achieved VGPR or better prior to transplant had a better PFS (median PFS 1922 days versus 686 days, p=0.01) compared to the rest but no OS benefit is yet evident for this group. However, patients who achieved stringent CR post transplant had significantly superior PFS and OS compared to those who did not (median PFS; sCR versus CR versus <CR= not reached versus 1922 days versus 474 days, respectively,p=0.0008; and, median OS; sCR versus CR versus <CR= not reached versus not reached versus 581 days, respectively, p=0.0004). There was no significant difference in outcome between matched sibling and VUD donor transplants. Conclusion: Tandem ASCT-NMA transplantation is an effective approach as an upfront treatment for appropriately selected poor risk MM patients and for salvaging relapsed patients, with acceptable treatment related morbidity and mortality. Response status achieved post transplantation has a highly significant impact on long-term survival. Figure 1. Figure 1. Figure 2. Figure 2. Figure 3. Figure 3. Disclosures Off Label Use: Fludarabine was used as part of conditioning regimen for allogeneic stem cell transplantation.

Abstract Background/Aim: Despite recent advances in the management of ALL, alloHSCT remains standard of care for younger adults with high-risk features. The optimum conditioning regimen for adults is not yet established. There is evidence for usage of Etoposide or higher-dose TBI in advanced disease transplants for ALL in a mixture of adult and paediatric patients (Marks et al, Biol BMT, 2006) We undertook a retrospective analysis of adult ALL patients who underwent allogeneic stem cell transplantation at our centre to find out factors influencing outcome and early treatment related complications. We also compared between Cyclophosphosphamide and Total Body Irradiation (Cy/TBI) and Etoposide and Total Body Irradiation (Etop/TBI). Method: Patients were identified from a transplant database search from January 2000 to May 2015 at the Alfred Hospital Melbourne, Australia. Decision to transplant the patients were based on high risk factors such as adverse cytogenetics (Ph+, MLL, complex karyotype), high presenting WBC count, delayed blast clearance with induction treatment and relapsed and refractory disease. Patients were compared based on transplant conditioning, disease factors and analysed for disease outcomes and complications. We also stratified the patients based on EBMT risk score and investigated the applicability of the score to predict outcome. High EBMT score was defined as >3. Results: 69 patients identified (34 Cy/TBI, 35 Etop/TBI) with median age of 33 years (range 17 - 59 years). Age was comparable for each group (Cy/TBI 35 years, Etop/TBI 31 years, p=0.84). 52 patients were males. The diagnoses were B ALL(49),T ALL(15), Bilineage Leukemia(1) and ambiguous lineage leukemia(1). 27 sibling and 42 non-sibling transplants, similar proportion for each conditioning (p=0.14). T-cell depletion with antithymocytic globulin used in 43 cases (all non-sibling and 1 sibling). High EBMT scores seen in 22 patients, with significantly higher numbers in Cy/TBI group (47% vs. 17%, p=0.01). 43 transplants done in CR1, 8 in CR2 and 18 in active-disease. There were significantly higher non-CR transplants in the Cy/TBI group (55% vs. 20%,p=0.003). Stem cell source was bone marrow in 10 patients (6 in CyTBI, 4 in Etop/TBI, p=0.5). 18 patients developed grade 3-4 acute GVHD and 13 of them were from Etop/TBI group (p=0.09). 28 patients developed extensive chronic GVHD and 20 of them received Etop/TBI conditioning(p=0.006). TRM was similar in both groups (38% vs. 31%, p=0.62). TRM was lower in patients transplanted in CR1 versus non-CR1 (25% vs. 50%, p=0.04). Median overall survival (OS) was 263 days in the Cy/TBI group versus not reached in the Etop/TBI group (p=0.08). In patients transplanted in CR1, OS was similar (NR, p=0.59) with a predicted 3-year OS of 77% and 62% in Cy/TBI and Etop/TBI groups respectively. OS was superior in CR1 transplants compared to the rest (NR vs 174 days, p<0.001). There was no difference in outcome between sibling and matched unrelated transplants (p=0.12). Patients with a high EBMT score had inferior OS (99 days vs NR, p<0.001) and TRM (63% vs 21%, p<0.001). Discussion: Outcomes for allogeneic stem cell transplant are similar for Cy/TBI and Etop/TBI for transplants performed in first remission, with equivalent outcomes for sibling and unrelated donor transplants. The rates of chronic graft vs. host disease are higher in Etop/TBI conditioned transplants. The EBMT score was highly predictive of outcome in ALL transplants, with high transplant related and disease related mortality. While long-term survivors are seen with Etop/TBI conditioning in non-CR1 transplants, the outcome in this patient group are very poor, highlighting the need for better prediction of relapse risk to aid appropriate patient selection for allografts in CR1. Figure 1. Figure 1. Figure 2. Figure 2. Figure 3. Figure 3. Disclosures Wei: Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees; Servier: Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Membership on an entity's Board of Directors or advisory committees, Research Funding; Agios: Membership on an entity's Board of Directors or advisory committees; Astra Zeneca: Membership on an entity's Board of Directors or advisory committees; Bayer: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees.

Abstract Introduction: The management of patients with treatment resistant AML (failure to achieve complete remission, CR; or CR with incomplete blood count recovery; CRi) after intensive chemotherapy is an important clinical consideration. Anticipating the benefit of intensive salvage therapy facilitates patient management decisions and counseling. The UK Medical Research Council (MRC) has associated morphologic partial remission (PRm; defined as 5-15% bone marrow blasts) after course 1 of standard-dose cytarabine (SDAC) based induction, with 5yr overall survival (OS) outcomes comparable to achieving CR (42 vs 51%). In contrast, failure to achieve PRm was linked to 5-year OS of 20% (Wheatley, et al 1999). In an MD Anderson study, patients failing initial high-dose cytarabine (HiDAC) based induction had a 6-month OS expectation of only 7% (Ravandi, et al 2010). Less than 1% of patients in this study achieved PR using International Working Group (IWG) criteria (treatment related decrease in marrow blasts to 5-25% with a >50% reduction from baseline and blood count recovery. We therefore sought to verify the prognostic relevance of PRm in patients with treatment resistant AML (no CR/CRi). Patients and treatment: A retrospective cohort of 104 patients failing intensive chemotherapy at 3 Australian hospitals (Alfred Hospital, Melbourne, Princess Alexandra and Royal Brisbane and Women's Hospitals, Brisbane) was identified. Prior therapy was standard-dose ara-C (SDAC) 100mg/m2 d1-7 in 73% or high-dose ara-C (HiDAC)(³1g/m2 cytarabine per dose for 5-8 doses) in 28% combined with idarubicin 9-12mg/m2 D1-3 as part of induction. For salvage after SDAC failure, the commonest regimens were HiDAC based, fludarabine and cytarabine (FLAG) variants or a second cycle of 7 + 3, the HiDAC group received further HiDAC based therapy, or FLAG based regimens. Outcomes were compared to a contemporaneously treated AML population (n=128) achieving CR/CRi. Results: OS was stratified according to the level of residual bone marrow blasts after induction. Patients with 5-15% residual blasts (PRm) had a median OS of 20.6 mo, compared to only 5.0 mo for patients with a residual blast count >15% (p<0.0001). Outcome was superior in patients achieving a marrow blast reduction of ³50% or greater after induction (median OS 18.7m, vs 5.5m if blast reduction was <50%; p >0.0001). The proportion of patients with treatment resistant AML (no CR/CRi) achieving PRm was 41%. CR/CRi rates from salvage chemotherapy were 64% for those failing SDAC and 52% for those failing prior HiDAC-based induction (p=0.37). The likelihood of attaining subsequent remission SDAC-based induction failure was not related to PRm status after cycle 1 of therapy (CR/CRi 73%, compared to 66% without prior mPR; p=0.85). In contrast, the response to subsequent salvage chemotherapy was more common after attainment of prior PRm in cycle 1 for those receiving HiDAC-based induction (CR/CRi 83%, compared to 14% without prior PRm; p=0.01). For patients receiving prior SDAC-based induction, median OS was not reached for patients with PRm, compared to only 8 mo for those not achieving PRm (p=0.0006) (Fig 1A). For patients receiving prior HiDAC-based induction, median OS was 45.5 mo for patients with PRm, compared to only 3.3 mo for those not achieving PRm (p<0.0001) (Fig 1). If PRm was achieved after cycle 1 of induction, outcomes were not improved by subsequent HSCT (median OS 45.5 mo with HSCT, compared to 48.8 mo without HSCT [p=0.2]) (Fig 1B). In contrast, the benefit of HSCT was greater for resistant patients failing to achieve PRm (median OS 10.5 mo with HSCT, compared to 3.2 mo without [p=0.006]) (Fig 1B). Conclusion: in patients with AML failing initial chemotherapy, good long-term outcomes are still achievable, especially if a PRm was achieved after the first course of induction chemotherapy, regardless of whether SDAC or HiDAC induction was delivered. In contrast, patients refractory (no CR or PRm) to induction chemotherapy have a very poor prognosis and should be considered candidates for experimental therapies or allogeneic stem cell transplantation. Assessment for PRm may be a useful prognostic factor when clinical decisions regarding adults with AML failing to achieve CR/CRi after induction therapy are being considered. Figure 1. Ð Survival by response, by induction intensity Figure 1. Ð Survival by response, by induction intensity Figure 2. Ð Survival after induction failure and by prior PRm status and subsequent allograft Figure 2. Ð Survival after induction failure and by prior PRm status and subsequent allograft Disclosures Mollee: Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Onyx: Membership on an entity's Board of Directors or advisory committees. Wei:Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees; Servier: Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Membership on an entity's Board of Directors or advisory committees, Research Funding; Agios: Membership on an entity's Board of Directors or advisory committees; Astra Zeneca: Membership on an entity's Board of Directors or advisory committees; Bayer: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees.

Dr Himson Tamur Mulas was born on the Gazelle Peninsula of East New Britain, New Guinea, on 13 March 1934. After finishing his schooling, he was selected to go to Fiji to undertake a medical course at Fiji Central Medical School in 1953, returning to New Guinea in 1958. He successfully completed residency posts and after a period of training in anaesthesia in Port Moresby, was sent to the Alfred Hospital in Melbourne, Australia, in 1966–1967 to further his anaesthetic career. After returning to New Guinea he undertook several administrative posts as well as continuing his anaesthetic career before settling at Nonga Hospital in Rabaul, East New Britain Province. He was first registered as a specialist anaesthetist in 1972. He went on to complete a Diploma in Public Health in New Zealand in 1974, and in 1976 completed a Diploma in Tropical Health and Hygiene at the University of Sydney. He left public hospital anaesthetic practice in 1980. He is recognised as the first New Guinean to be a specialist anaesthetist. He died on 28 July 2000 aged 66 years.

In this paper, we present a case study of a decision-support system deployment at The Alfred Hospital, in Melbourne, Australia. This work outlines Information and Communications Technology (ICT) affordances and their actualisations in time-critical clinical practices to enable better information processing. From our study findings, we present a stage-wise model describing the role played by ICT in the context of the Trauma Centre practices. This addresses a knowledge gap surrounding the role and impact of ICT in the delivery of quality improvements to processes and culture in time-critical environments, amid increasing expenditure on ICT globally. Our model has implications for research and practice, such that we observe for the first time how information standards, synergy and renewal are developed between the system and its users in order to reduce error rates in the healthcare context. Through the study findings, we demonstrate that healthcare quality can be further refined as ICT allows for knowledge dissemination and informs existing practices.

Background: Lentigo maligna (LM) characteristically has an ill-defined margin and may require multiple excisions to achieve complete excision with 5mm margins. In vivo reflectance confocal microscopy (RCM) is a non-invasive tool recognised as useful in the management of LM. The authors aimed to determine whether the use of RCM prior to surgical excision reliably increased the rate of complete excision when compared with standard surgical excision. Methods: This prospective pilot study included patients with biopsy-proven LM of head and neck region who sought consultation for surgical management from May 2017 to May 2019 at the Victorian Melanoma Service, Melbourne. Patients were randomised to two groups based on the availability of RCM — Group 1, RCM-guided surgical excision, and Group 2, standard surgical excision. Outcomes were measured based on clinical markings and histopathological margins achieved and reported as RCM or surgical margin excess or deficit. Ethics approval for the study was obtained from the Research Governance Unit of The Alfred Hospital, Melbourne. Results: Results demonstrated that RCM marking of lesion margins was in excess in 69 percent of cases, in deficit in 22 per cent and accurate in nine per cent after histopathological analysis of the specimens. In comparison, lesions that were surgically marked were removed with margins in excess in 43 per cent of cases, in deficit in 11 per cent and accurate in 46 per cent. Conclusion: This pilot study demonstrates that RCM did not increase the accuracy of LM surgical excision in comparison with standard surgically marked excisions.

Background Patients with a single ventricle who experience early life growth failure suffer high morbidity and mortality in the perisurgical period. However, long‐term implications of poor infant growth, as well as associations between body mass index (BMI) and outcome in adulthood, remain unclear. We aimed to model BMI trajectories of patients with a single ventricle undergoing a Fontan procedure to determine trajectory‐based differences in baseline characteristics and long‐term clinical outcomes. Methods and Results We performed a retrospective analysis of medical records from patients in the Australia and New Zealand Fontan Registry receiving treatment at the Royal Children's Hospital, The Children's Hospital at Westmead, Royal Melbourne Hospital, and Royal Prince Alfred Hospital from 1981 to 2018. BMI trajectories were modeled in 496 patients using latent class growth analysis from 0 to 6 months, 6 to 60 months, and 5 to 16 years. Trajectories were compared regarding long‐term incidence of severe Fontan failure (defined as mortality, heart transplantation, Fontan takedown, or New York Heart Association class III/IV heart failure). Three trajectories were found for male and female subjects at each age group—lower, middle, higher. Subjects in the lower trajectory at 0 to 6 months were more likely to have an atriopulmonary Fontan and experienced increased mortality long term. No association was found between higher BMI trajectory, current BMI, and long‐term outcome. Conclusions Poor growth in early life correlates with increased long‐term severe Fontan failure. Delineation of distinct BMI trajectories can be used in larger and older cohorts to find optimal BMI targets for patient outcome.

Abstract Background Climate change has led to increased interest in studying adverse health effects relating to ambient temperatures. It is unclear whether incident chest pain is associated with non-optimal temperatures and how chest pain presentation rates might be affected by climate change. Methods The study included ambulance data of chest pain presentations in Melbourne, Australia from 1/1/2015 to 30/6/2019 with linkage to hospital and emergency discharge diagnosis data. A time series quasi-Poisson regression with a distributed lag nonlinear model was fitted to assess the temperature-chest pain presentation associations, after adjusting for season, day of the week and long-term trend. Future excess chest pain presentations associated with cold and heat were projected under six general circulation models under medium and high emission scenarios. Results In 206,789 chest pain presentations, mean (SD) age was 61.2 (18.9) years and 50.3% were female. Significant heat- and cold-related increased risk of chest pain presentations were observed for mean air temperatures above and below 20.8°C, respectively (Figure 1). Excess chest pain presentations related to heat were observed in all subgroups, but appeared to be attenuated for older patients (≥70 years) and patients of higher socioeconomic status (SES). We projected no significant change in net temperature-related chest pain presentations with climate change under medium- and high-emission scenarios, with increases in heat-related chest pain presentations offset by decreases in chest pain presentations related to cold temperatures. Conclusions Heat- and cold-exposure appear to increase risk of chest pain presentations, especially among younger patients and patients of lower SES. In Melbourne, Australia, chest pain presentations overall were not projected to increase with climate change, but increases in heat-related chest pain presentations highlight the importance of risk mitigation strategies to minimise adverse health impacts on hotter days. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Alfred Health.

Objective: Guidelines stipulate that baseline prolactin be ordered prior to commencing antipsychotic treatment to facilitate investigation of any subsequent hyperprolactinaemic symptoms. The aim was to observe when and why prolactin levels are ordered for psychiatry inpatients commencing or continuing antipsychotics and how this alters clinical management. Methods: Psychiatry inpatients admitted to the Alfred Hospital, Melbourne, Australia, in 2018 with the diagnoses of psychosis, schizophrenia, schizo-affective disorder or bipolar affective disorder were retrospectively analysed. Results and clinical history data were collected in patients in whom prolactin was ordered during or within 12 months of the relevant admission. Results: Of 592 patients admitted during this period, 90 had prolactin ordered. Eight (8.9%) of the 90 tests were for hyperprolactinaemic symptoms, while the remainder were routine blood work. The results altered clinical management in 10 of the 90 (11.1%) patients. Of these 10, 8 were symptomatic. In the six patients with first episode psychosis, only one had prolactin ordered prior to antipsychotic commencement. Conclusions: Adherence to guideline recommendations of baseline prolactin testing was poor. When established on antipsychotics, measuring prolactin rarely changed management in asymptomatic patients; however, it did in those with hyperprolactinaemic symptoms. Measuring prolactin in asymptomatic patients on antipsychotics appears unhelpful.

Abstract Background In patients with prior CABG requiring subsequent PCI there is uncertainty whether bypass grafts or native coronary arteries should be targeted. Methods We analysed data from 2,764 patients with prior CABG in the Melbourne Interventional Group registry (2005–2018), divided into two groups: those undergoing PCI to a native vessel (n=1,928) and those with PCI to a graft vessel (n=836). Results Patients with a graft vessel PCI were older, had more high-risk clinical characteristics (prior MI, heart failure, ejection fraction &lt;50%, renal impairment, peripheral and cerebrovascular disease), and high-risk procedural features (ACC/AHA types B2/C lesions). However, patients in the native vessel group were more likely to have PCI to a chronic total occlusion. The majority of graft PCI were to saphenous vein grafts (84%), with 10% to radial and 6% to LIMA/RIMA grafts. Distal embolic protection devices were used in 30% of graft PCI. Patients with graft PCI had higher rates of no reflow (6.3% vs. 1.5%; p&lt;0.001), coronary perforation (p=0.016) and inpatient stent thrombosis (p=0.028). However, 30-day mortality and major adverse cardiovascular and cerebrovascular events (MACCE) were similar. Unadjusted long-term mortality (median follow up 4.8 years) was higher in patients who had undergone a graft PCI (44% vs. 32%, p&lt;0.001), but following Cox proportional hazards modelling, PCI vessel type was not a predictor of long-term mortality (HR 1.13; 95% CI 0.96–1.33, p=0.14). Conclusions Early clinical outcomes and risk-adjusted long-term mortality are similar for patients with prior CABG undergoing PCI to a native vessel or a bypass graft. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): The Alfred Hospital

At the start of the twentieth century, many young Australian artists travelled abroad to expand their art education and to gain exposure to the modern art movements of Europe. Most of these artists were active members of artist associations such as the Victorian Artists Society or the New South Wales Society of Artists. Male artists from Victoria were generally also members of the Melbourne Savage Club, a club with a strong association with the arts.This paper investigates the dual function of the club, as a space where the artists felt “at home” in the familiar environment that the club offered whilst they were abroad and, at the same time, a meeting space where they could engage in a stimulating artistic environment and gain introductions to leading figures in the art world. For those artists who chose England, London’s arts clubs played a large role, for it was in these establishments that they discussed, exhibited, shared, and met with their English counterparts. The club environment in London would have a significant impact on male Australian artists, as it offered a space where they were integrated into the English art world, which enhanced their experience whilst abroad.Artists were seldom members of Australia’s early gentlemen’s clubs, however, in the late nineteenth century Melbourne, artists formed less formal social groupings with exotic names such as the Prehistoric Order of Cannibals, the Buonarotti Club, and the Ishmael Club (Mead). Melbourne artists congregated in these clubs until the Melbourne Savage Club, modelled on the London Savage Club (1857)—a club whose membership was restricted to practitioners in the performing and visual arts—opened its doors in 1894.The Melbourne Savage Club had its origins in the Metropolitan Music Club, established in the late 1880s by a group of professional and amateur musicians and music lovers. The club initially admitted musicians and people from the dramatic professions free-of-charge, however, author Randolph Bedford (1868–1941) and artist Alf Vincent (1874–1915) were not content to be treated on a different basis to the musicians and actors, and two months after Vincent joined the club, at a Special General Meeting, the club resolved to vary Rule 6, “to admit landscape or portrait painters and sculptors without entrance fee” (Melbourne Savage Club). At another Special General Meeting, a year later, the rule was altered to admit “recognised members of the musical, dramatic and artistic professions and sculptors without payment of entrance fee” (Melbourne Savage Club).This resulted in an immediate influx of prominent Victorian male artists (Williams) and the Melbourne Savage Club became their place of choice to gather and enjoy the fellowship the club offered and to share ideas in a convivial atmosphere. When the opportunity arose for them to travel to London in the early twentieth century, they met in London’s famous art clubs. Membership of the Melbourne Savage Club not only conferred rights to visit reciprocal clubs whilst in London, but also facilitated introductions to potential patrons. The London clubs were the venue of choice for visiting artists to meet their fellow artist expatriates and to share experiences and, importantly, to meet with their British counterparts, exhibit their works, and establish valuable contacts.The London Savage Club attracted many Australian expatriates. Not only is it the grandfather of London’s bohemian clubs but also it was the model for arts clubs the world over. Founded in 1857, the qualification for admission was (and still is) to be, “a working man in literature or art, and a good fellow” (Halliday vii). If a candidate met these requirements, he would be cordially received “come whence he may.” This was embodied in the club’s first rules which required applicants for membership to be from a restricted range of pursuits relating to the arts thought to be commensurate with its bohemian ideals, namely art, literature, drama, or music.The second London arts club that attracted expatriate Australian artists was the New English Arts Club, founded in 1886 by young English artists returning from studying art in Paris. Members of The New English Arts Club were influenced by the Impressionist style as opposed to the academic art shown at the Royal Academy. As a meeting place for Australia’s expatriate artists, the New English Arts Club had a particular influence, as it exposed them to significant early Modern artist members such as John Singer Sargent (1856–1925), Walter Sickert (1860–1942), William Orpen (1878–1931) and Augustus John (1878–1961) (Corbett and Perry; Thornton; Melbourne Savage Club).The third, and arguably the most popular with the expatriate Australian artists’ club, was the Chelsea Arts Club, a bohemian club formed in 1891 by local working artists looking for a place to go to “meet, talk, eat and drink” (Cross).Apart from the American-born founding member, James McNeill Whistler (1834–1903), amongst the biggest Chelsea names at the time of the influx of travelling young Australian artists were modernists Sir William Orpen, Augustus John, and John Sargent. The opportunity to mix with these leading British contemporary artists was irresistible to these antipodean artists (55).When Melbourne artist, Miles Evergood (1871–1939) arrived in London from America in 1910, he had been an active exhibiting member of the Salmagundi Club, a New York artists’ club. Almost immediately he joined the New English Arts Club and the Chelsea Arts Club. Hammer tells of him associating with “writer Israel Zangwill, sculptor Jacob Epstein, and anti-academic artists including Walter Sickert, Augustus John, John Lavery, John Singer Sargent and C.R.W. Nevison, who challenged art values in Britain at the beginning of the century” (Hammer 41).Arthur Streeton (1867–1943) used the Chelsea Arts Club as his postal address, as did many expatriate artists. The Melbourne Savage Club archives contain letters and greetings, with news from abroad, written from artist members back to their “Brother Savages” (Various).In late 1902, Streeton wrote to fellow artist and Savage Club member Tom Roberts (1856–1931) from London:I belong to the Chelsea Arts Club now, & meet the artists – MacKennel says it’s about the most artistic club (speaking in the real sense) in England. … They all seem to be here – McKennal, Longstaff, Mahony, Fullwood, Norman, Minns, Fox, Plataganet Tudor St. George Tucker, Quinn, Coates, Bunny, Alston, K, Sonny Pole, other minor lights and your old friend and admirer Smike – within 100 yards of here – there must be 30 different studios. (Streeton 94)Whilst some of the artists whom Streeton mentioned were studying at either the Royal Academy or the Slade School, it was the clubs like the Chelsea Arts Club where they were most likely to encounter fellow Australian artists. Tom Roberts was obviously attentive to Streeton’s enthusiastic account and, when he returned to London the following year to work on his commission for The Big Picture of the 1901 opening of the first Commonwealth Parliament, he soon joined. Roberts, through his expansive personality, became particularly active in London’s Australian expatriate artistic community and later became Vice-President of the Chelsea Arts Club. Along with Streeton and Roberts, other visiting Melbourne Savage Club artists joined the Chelsea Arts Club. They included, John Longstaff (1861–1941), James Quinn (1869–1951), George Coates (1869–1930), and Will Dyson (1880–1938), along with Sydney artists Henry Fullwood (1863–1930), George Lambert (1873–1930), and Will Ashton (1881–1963) (Croll 95). Smith describes the exodus to London and Paris: “It was the Chelsea Arts Club that the Heidelberg School established its last and least distinguished camp” (Smith, Smith and Heathcote 152).Streeton, who retained his Chelsea Arts Club membership when he returned for a while to Australia, wrote to Roberts in 1907, “I miss Chelsea & the Club-boys” (Streeton 107). In relation to Frederick McCubbin’s pending visit he wrote: “Prof McCubbin left here a week ago by German ‘Prinz Heinrich.’ … You’ll introduce him at the Chelsea Club and I hope they make him an Hon. Member, etc” (Streeton et al. 85). McCubbin wrote, after an evening at the Chelsea Arts Club, following a visit to the Royal Academy: “Tonight, I am dining with Australian artists in Soho, and shall be there to greet my old friends. How glad I am! Longstaff will be there, and Frank Stuart, Roberts, Fullwood, Pontin, Coates, Quinn, and Tucker’s brother, and many others from all around” (MacDonald, McCubbin and McCubbin 75). Impressed by the work of Turner he wrote to his wife Annie, following avisit to the Tate Gallery:I went yesterday with Fullwood and G. Coates and Tom Roberts for a ramble … to the Tate Gallery – a beautiful freestone building facing the river through a portico into the gallery where the lately found turners are exhibited – these are not like the greater number of pictures in the National Gallery – they represent his different periods, but are mostly in his latest style, when he had realised the quality of light (McCubbin).Clearly Turner’s paintings had a profound impression on him. In the same letter he wrote:they are mostly unfinished but they are divine – such dreams of colour – a dozen of them are like pearls … mist and cloud and sea and land, drenched in light … They glow with tender brilliancy that radiates from these canvases – how he loved the dazzling brilliancy of morning or evening – these gems with their opal colour – you feel how he gloried in these tender visions of light and air. He worked from darkness into light.The Chelsea Arts Club also served as a venue for artists to entertain and host distinguished visitors from home. These guests included; Melbourne Savage Club artist member Alf Vincent (Joske 112), National Gallery of Victoria (NGV) Trustee and popular patron of the arts, Professor Baldwin Spencer (1860–1929), Professor Frederick S. Delmer (1864–1931) and conductor George Marshall-Hall (1862–1915) (Mulvaney and Calaby 329; Streeton 111).Artist Miles Evergood arrived in London in 1910, and visited the Chelsea Arts Club. He mentions expatriate Australian artists gathering at the Club, including Will Dyson, Fred Leist (1873–1945), David Davies (1864–1939), Will Ashton (1881–1963), and Henry Fullwood (Hammer 41).Most of the Melbourne Savage Club artist members were active in the London Savage Club. On one occasion, in November 1908, Roberts, with fellow artist MacKennal in the Chair, attended the Australian Artists’ Dinner held there. This event attracted twenty-five expatriate Australian artists, all residing in London at the time (McQueen 532).These London arts clubs had a significant influence on the expatriate Australian artists for they became the “glue” that held them together whilst abroad. Although some artists travelled abroad specifically to take up places at the Royal Academy School or the Slade School, only a minority of artists arriving in London from Australia and other British colonies were offered positions at these prestigious schools. Many artists travelled to “try their luck.” The arts clubs of London, whilst similarly discerning in their membership criteria, generally offered a visiting “brother-of-the-brush” a warm welcome as a professional courtesy. They featured the familiar rollicking all-male “Smoke Nights” a feature of the Melbourne Savage Club. With a greater “artist” membership than the clubs in Australia, expatriate artists were not only able to catch up with their friends from Australia, but also they could associate with England’s finest and most progressive artists in a familiar congenial environment. The clubs were a “home away from home” and described by Underhill as, “an artistic Earl’s Court” (Underhill 99). Most importantly, the clubs were a centre for discourse, arguably even more so than were the teaching academies. Britain’s leading modernist artists were members of the Chelsea Arts Club and the New English Arts Club and mixed freely with the visiting Australian artists.Many Australian artists, such as Miles Evergood and George Bell (1878–1966), held anti-academic views similar to English club members and embraced the new artistic trends, which they would bring back to Australia. Streeton had no illusions about the relative worth of the famed institutions and the exhibitions held by clubs such as the New English. Writing to Roberts before he joins him in London, he describes the Royal Academy as having, “an inartistic atmosphere” and claims he “hasn’t the least desire to go again” (Streeton 77). His preference lay with a concurrent “International Exhibition”, which featured works by Rodin, Whistler, Condor, Degas, and others who were setting the pace rather than merely continuing the academic traditions.Architect Hardy Wilson (1881–1955) served as secretary of The Chelsea Arts Club. When he returned to Australia he brought back with him a number of British works by Streeton and Lambert for an exhibition at the Guild Hall Melbourne (Underhill 92). Artists and Bohemians, a history of the Chelsea Arts Club, makes special reference of its world-wide contacts and singles out many of its prominent Australian members for specific mention including; Sir John William (Will) Ashton OBE, later Director of the Art Gallery of New South Wales, and Will Dyson, whose illustrious career as an Australian war artist was described in some detail. Dyson’s popularity led to his later appointment as Chairman of the Chelsea Arts Club where he initiated an ambitious rebuilding program, improving staff accommodation, refurbishing the members’ areas, and adding five bedrooms for visiting members (Bross 87-90).Whilst the influence of travel abroad on Australian artists has been noted, the importance of the London Clubs has not been fully explored. These clubs offered artists a space where they felt “at home” and a familiar environment whilst they were abroad. The clubs functioned as a meeting space where they could engage in a stimulating artistic environment and gain introductions to leading figures in the art world. For those artists who chose England, London’s arts clubs played a large role, for it was in these establishments that they discussed, exhibited, shared, and met with their English counterparts. The club environment in London had a significant impact on male Australian artists as it offered a space where they were integrated into the English art world which enhanced their experience whilst abroad and influenced the direction of their art.ReferencesCorbett, David Peters, and Lara Perry, eds. English Art, 1860–1914: Modern Artists and Identity. Manchester: Manchester University Press, 2000.Croll, Robert Henderson. Tom Roberts: Father of Australian Landscape Painting. Melbourne: Robertson & Mullens, 1935.Cross, Tom. Artists and Bohemians: 100 Years with the Chelsea Arts Club. 1992. 1st ed. London: Quiller Press, 1992.Gray, Anne, and National Gallery of Australia. McCubbin: Last Impressions 1907–17. 1st ed. Parkes, A.C.T.: National Gallery of Australia, 2009.Halliday, Andrew, ed. The Savage Papers. 1867. 1st ed. London: Tinsley Brothers, 1867.Hammer, Gael. Miles Evergood: No End of Passion. Willoughby, NSW: Phillip Mathews, 2013.Joske, Prue. Debonair Jack: A Biography of Sir John Longstaff. 1st ed. Melbourne: Claremont Publishing, 1994.MacDonald, James S., Frederick McCubbin, and Alexander McCubbin. The Art of F. McCubbin. Melbourne: Lothian Book Publishing, 1916.McCaughy, Patrick. Strange Country: Why Australian Painting Matters. Ed. Paige Amor. The Miegunyah Press, 2014.McCubbin, Frederick. Papers, Ca. 1900–Ca. 1915. Melbourne.McQueen, Humphrey. Tom Roberts. Sydney: Macmillan, 1996.Mead, Stephen. "Bohemia in Melbourne: An Investigation of the Writer Marcus Clarke and Four Artistic Clubs during the Late 1860s – 1901.” PhD thesis. Melbourne: University of Melbourne, 2009.Melbourne Savage Club. Secretary. Minute Book: Melbourne Savage Club. Club Minutes (General Committee). Melbourne: Savage Archives.Mulvaney, Derek John, and J.H. Calaby. So Much That Is New: Baldwin Spencer, 1860–1929, a Biography. Carlton, Vic.: Melbourne University Press, 1985.Smith, Bernard, Terry Smith, and Christopher Heathcote. Australian Painting, 1788–2000. 4th ed. South Melbourne, Vic.: Oxford University Press, 2001.Streeton, Arthur, et al. Smike to Bulldog: Letters from Sir Arthur Streeton to Tom Roberts. Sydney: Ure Smith, 1946.Streeton, Arthur, ed. Letters from Smike: The Letters of Arthur Streeton, 1890–1943. Melbourne: Oxford University Press, 1989.Thornton, Alfred, and New English Art Club. Fifty Years of the New English Art Club, 1886–1935. London: New English Art Club, Curwen Press 1935.Underhill, Nancy D.H. Making Australian Art 1916–49: Sydney Ure Smith Patron and Publisher. South Melbourne: Oxford University Press, 1991.Various. Melbourne Savage Club Correspondence Book: 1902–1916. Melbourne: Melbourne Savage Club.Williams, Graeme Henry. "A Socio-Cultural Reading: The Melbourne Savage Club through Its Collections." Masters of Arts thesis. Melbourne: Deakin University, 2013.

Abstract Background Multiple screening Duplex ultrasound scans (DUS) are performed in trauma patients at high risk of deep vein thrombosis (DVT) in the intensive care unit (ICU). Intensive care physician performed compression ultrasound (IP-CUS) has shown promise as a diagnostic test for DVT in a non-trauma setting. Whether IP-CUS can be used as a screening test in trauma patients is unknown. Our study aimed to assess the agreement between IP-CUS and vascular sonographer performed DUS for proximal lower extremity deep vein thrombosis (PLEDVT) screening in high-risk trauma patients in ICU. Methods A prospective observational study was conducted at the ICU of Alfred Hospital, a major trauma center in Melbourne, Australia, between Feb and Nov 2015. All adult major trauma patients admitted with high risk for DVT were eligible for inclusion. IP-CUS was performed immediately before or after DUS for PLEDVT screening. The paired studies were repeated twice weekly until the DVT diagnosis, death or ICU discharge. Written informed consent from the patient, or person responsible, or procedural authorisation, was obtained. The individuals performing the scans were blinded to the others’ results. The agreement analysis was performed using Cohen’s Kappa statistics and intraclass correlation coefficient for repeated binary measurements. Results During the study period, 117 patients had 193 pairs of scans, and 45 (39%) patients had more than one pair of scans. The median age (IQR) was 47 (28–68) years with 77% males, mean (SD) injury severity score 27.5 (9.53), and a median (IQR) ICU length of stay 7 (3.2–11.6) days. There were 16 cases (13.6%) of PLEDVT with an incidence rate of 2.6 (1.6–4.2) cases per 100 patient-days in ICU. The overall agreement was 96.7% (95% CI 94.15–99.33). The Cohen’s Kappa between the IP-CUS and DUS was 0.77 (95% CI 0.59–0.95), and the intraclass correlation coefficient for repeated binary measures was 0.75 (95% CI 0.67–0.81). Conclusions There is a substantial agreement between IP-CUS and DUS for PLEDVT screening in trauma patients in ICU with high risk for DVT. Large multicentre studies are needed to confirm this finding.

Australian suburbia, historically and culturally, has been viewed as a feminised domain, associated with the domestic and family, routine and order. Where “the city is coded as a masculine and disorderly space… suburbia, as a realm of domesticity and the family, is coded as a feminine and disciplinary space” (Wilson 46). This article argues how the treatment of suburbia in fiction as “feminine” has impacted not only on the representation and development of the character of the “suburban female”, but also on the shape and form of her narrative journeys. Suburbia’s subordination as domestic and everyday, a restrictive realm of housework and child rearing, refers to the anti-suburban critique and establishes the dichotomy of suburbia/feminine/domesticity in contrast to bush or city/masculine/freedom as first observed by Marilyn Lake in her analysis of 1890s Australia. Despite the fact that suburbia necessarily contains the “masculine” as well as the “feminine”, the “feminine” dominates to such an extent that positive masculine traits are threatened there. In social commentary and also literature, the former is viewed negatively as a state from which to escape. As Tim Rowse suggests, “women, domesticity = spiritual starvation. (Men, wide open spaces, achievement = heroism of the Australian spirit)” (208). In twentieth-century Australian fiction, this is especially the case for male characters, the preservation of whose masculinity often depends on a flight from the suburbs to elsewhere—the bush, the city, or overseas. In Patrick White’s The Tree Of Man (1955), for example, During identifies the recurrent male character of the “tear-away” who “flee(s) domesticity and family life” (96). Novelist George Johnston also establishes a satirical depiction of suburbia as both suffocatingly feminine and as a place to escape at any cost. For example, in My Brother Jack (1964), David Meredith “craves escape from the ‘shabby suburban squalor’ into which he was born” (Gerster 566). Suburbia functions as a departure point for the male protagonist who must discard any remnants of femininity, imposed on him by his suburban childhood, before embarking upon narratives of adventure and maturation as far away from the suburbs as possible. Thus, flight becomes essential to the development of male protagonist and proliferates as a narrative trajectory in Australian fiction. Andrew McCann suggests that its prevalence establishes a fictional “struggle with and escape from the suburb as a condition of something like a fully developed personality” (Decomposing 56-57). In this case, any literary attempt to transform the “suburban female”, a character inscribed by her gender and her locale, without recourse to flight appears futile. However, McCann’s assertion rests on a literary tradition of male flight from suburbia, not female. A narrative of female flight is a relatively recent phenomenon, influenced by the second wave feminism of the 1970s and 1980s. For most of the twentieth century, the suburban female typically remained in suburbia, a figure of neglect, satire, and exploitation. A reading of twentieth-century Australian fiction until the 1970s implies that flight from suburbia was not a plausible option for the average “suburban female”. Rather, it is the exceptional heroine, such as Teresa in Christina Stead’s For Love Alone (1945), who is brave, ambitious, or foolish enough to leave, and when she does there were often negative consequences. For most however, suburbia was a setting where she belonged despite its negative attributes. These attributes of conformity and boredom, repetition, and philistinism, as presented by proponents of anti-suburbanism, are mainly depicted as problematic to male characters, not female. Excluded from narratives of flight, for most of the twentieth-century the suburban female typically remained in suburbia, a figure of neglect, satire, and even exploitation, her stories mostly untold. The character of the suburban female emerges out of the suburban/feminine/domestic dichotomy as a recurrent, albeit negative, character in Australian fiction. As Rowse states, the negative image of suburbia is transferred to an equally negative image of women (208). At best, the suburban female is a figure of mild satire; at worst, a menacing threat to masculine values. Male writers George Johnston, Patrick White and, later, David Ireland, portrayed the suburban female as a negative figure, or at least an object of satire, in the life of a male protagonist attempting to escape suburbia and all it stood for. In his satirical novels and plays, for example, Patrick White makes “the unspoken assumption… that suburbia is an essentially female domain” (Gerster 567), exemplifying narrow female stereotypes who “are dumb and age badly, ending up in mindless, usually dissatisfied, maternity and domesticity” (During 95). Feminist Anne Summers condemns White for his portrayal of women which she interprets as a “means of evading having to cope with women as unique and diverse individuals, reducing them instead to a sexist conglomerate”, and for his use of women to “represent suburban stultification” (88). Typically “wife” or “mother”, the suburban female is often used as a convenient device of oppositional resistance to a male lead, while being denied her own voice or story. In Johnston’s My Brother Jack (1964), for example, protagonist David Meredith contrasts “the subdued vigour of fulfillment tempered by a powerful and deeply-lodged serenity” (215) of motherhood displayed by Jack’s wife Shelia with the “smart and mannish” (213) Helen, but nothing deeper is revealed about the inner lives of these female characters. Feminist scholars identify a failure to depict the suburban female as more than a useful stereotype, partially attributing the cause of this failure to a surfeit of patriarchal stories featuring adventuresome male heroes and set in the outback or on foreign battlefields. Summers states how “more written words have been devoted to creating, and then analysing and extolling… [the] Australian male than to any other single facet of Australian life” (82-83). Where she is more active, the suburban female is a malignant force, threatening to undermine masculine goals of self-realisation or achievement, or at her worst, to wholly emasculate the male protagonist such that he is incapable of escape. Even here the motivations behind her actions are not revealed and she appears two-dimensional, viewed only in relation to her destructive effect on the weakened male protagonist. In her criticism of David Ireland’s The Glass Canoe (1976), Joan Kirkby observes how “the suburbs are populated with real women who are represented in the text as angry mothers and wives or simply as the embodiment of voraciously feral sexuality” (5). In those few instances where the suburban female features as more than an accessory to the male narrative, she lacks the courage and inner strength to embark upon her own journey out of suburbia. Instead, she is depicted as a victim, misunderstood and miserable, entrapped by the suburban milieu to which she is meant to belong but, for some unexplored reason, does not. The inference is that this particular suburban female is atypical, potentially flawed in her inability to find contentment within a region strongly designated her own. The unhappy suburban female is therefore tragic, or at least pitiable, languishing in a suburban environment that she loathes, often satirised for her futile resistance to the status quo. Rarely is she permitted the masculine recourse of flight. In those exceptional instances where she does leave, however, she is unlikely to find what she is looking for. A subsequent return to the place of childhood, most often situated in suburbia, is a recurrent narrative in many stories of Australian female protagonist, but less so the male protagonist. Although this mistreatment of the suburban female is most prevalent in fiction by male writers, female writers were also criticised for failing to give a true and authentic voice to her character, regardless of the broader question of whether writers should be truthful in their characterisations. For example, Summers criticises Henry Handel Richardson as “responsible for, if not creating, then at least providing a powerful reinforcement to the idea that women as wives are impediments to male self-realisation” with characters who “reappear, with the monotonous regularity of the weekly wash, as stereotyped and passive suburban housewives” (87-88). All this changed, however, with the arrival of second wave feminism leading to a proliferation of stories of female exodus from the suburbs. A considered portrait of the life of the suburban female in suburbia was neglected in favour of a narrative journey; a trend attributable in part to a feminist polemic that granted her freedom, adventure, and a story so long as she did not dare choose to stay. During the second wave feminism of the 1970s and 1980s, women were urged by leading figures such as Betty Friedan and Germaine Greer to abandon ascribed roles of housewife and mother, led typically in the suburbs, in pursuit of new freedoms and adventures. As Lesley Johnson and Justine Lloyd note, “in exhorting women to ‘leave home’ and find their fulfillment in the world of work, early second wave feminists provided a life story through which women could understand themselves as modern individuals” (154) and it is this “life story” which recurs in women’s fiction of the time. Women writers, many of whom identified as feminist, mirrored these trajectories of flight from suburbia in their novels, transplanting the suburban female from her suburban setting to embark upon “new” narratives of self-discovery. The impact of second wave feminism upon the literary output of Australian women writers during the 1970s and 1980s has been firmly established by feminist scholars Johnson, Lloyd, Lake, and Susan Sheridan, who were also active participants in the movement. Sheridan argues that there has been a strong “relationship of women’s cultural production to feminist ideas and politics” (Faultlines xi) and Johnson identifies a “history of feminism as an awakening” at the heart of these “life stories” (11). Citing Mary Morris, feminist Janet Woolf remarks flight as a means by which a feminine history of stagnation is remedied: “from Penelope to the present, women have waited… If we grow weary of waiting, we can go on a journey” (xxii). The appeal of these narratives may lie in attempts by their female protagonists to find new ways of being outside the traditional limits of a domestic, commonly suburban, existence. Flight, or movement, features as a recurrent narrative mode by which these alternative realities are configured, either by mimicking or subverting traditional narrative forms. Indeed, selection of the appropriate narrative form for these emancipatory journeys differed between writers and became the subject of vigorous, feminist and literary debate. For some feminists, the linear narrative was the only true path to freedom for the female protagonist. Following the work of Carolyn G. Heilbrun and Elaine Showalter, Joy Hooton observes how some feminist critics privileged “the integrated ego and the linear destiny, regarding women’s difference in self-realization as a failure or deprivation” (90). Women writers such as Barbara Hanrahan adopted the traditional linear trajectory, previously reserved for the male protagonist as bushman or soldier, explorer or drifter, to liberate the “suburban female”. These stories feature the female protagonist trading a stultifying life in the suburbs for the city, overseas or, less typically, the outback. During these geographical journeys, she is transformed from her narrow suburban self to a more actualised, worldly self in the mode of a traditional, linear Bildungsroman. For example, Hanrahan’s semi-autobiographical debut The Scent of Eucalyptus (1973) is a story of escape from oppressive suburbia, “concentrating on that favourite Australian theme, the voyage overseas” (Gelder and Salzman, Diversity 63). Similarly, Sea-green (1974) features a “rejection of domestic drabness in favour of experience in London” (Goodwin 252) and Kewpie Doll (1984) is another narrative of flight from the suburbs, this time via pursuit of “an artistic life” (253). In these and other novels, the act of relocation to a specific destination is necessary to transformation, with the inference that the protagonist could not have become what she is at the end of the story without first leaving the suburbs. However, use of this linear narrative, which is also coincidentally anti-suburban, was criticised by Summers (86) for being “masculinist”. To be truly free, she argued, the female protagonist needed to forge her own unique paths to liberation, rather than relying on established masculine lines. Evidence of a “new” non-linear narrative in novels by women writers was interpreted by feminist and literary scholars Gillian Whitlock, Margaret Henderson, Ann Oakley, Sheridan, Johnson, and Summers, as an attempt to capture the female experience more convincingly than the linear form that had been used to recount stories of the journeying male as far back as Homer. Typifying the link between the second wave feminism and fiction, Helen Garner’s Monkey Grip features Nora’s nomadic, non-linear “flights” back and forth across Melbourne’s inner suburbs. Nora’s promiscuity belies her addiction to romantic love that compromises her, even as she struggles to become independent and free. In this way, Nora’s quest for freedom­—fragmented, cyclical, repetitive, impeded by men— mirrors Garner’s “attempt to capture certain areas of female experience” (Gelder and Salzman, Diversity 55), not accessible via a linear narrative. Later, in Honour and Other People’s Children (1980) and The Children’s Bach (1984), the protagonists’ struggles to achieve self-actualisation within a more domesticated, family setting perhaps cast doubt on the efficacy of the feminist call to abandon family, motherhood, and all things domestic in preference for the masculinist tradition of emancipatory flight. Pam Gilbert, for instance, reads The Children’s Bach as “an extremely perceptive analysis of a woman caught within spheres of domesticity, nurturing, loneliness, and sexuality” (18) via the character of “protected suburban mum, Athena” (19). The complexity of this characterisation of a suburban female belies the anti-suburban critique by not resorting to satire or stereotype, but by engaging deeply with a woman’s life inside suburbia. It also allows that flight from suburbia is not always possible, or even desired. Also seeming to contradict the plausibility of linear flight, Jessica Anderson’s Tirra Lirra by the River (1978), features (another) Nora returning to her childhood Brisbane after a lifetime of flight; first from her suburban upbringing and then from a repressive marriage to the relative freedoms of London. The poignancy of the novel, set towards the end of the protagonist’s life, rests in Nora’s inability to find a true sense of belonging, despite her migrations. She “has spent most of her life waiting, confined to houses or places that restrict her, places she feels she does not belong to, including her family home, the city of Brisbane, her husband’s house, Australia itself” (Gleeson-White 184). Thus, although Nora’s life can be read as “the story of a very slow emergence from a doomed attempt to lead a conventional, married life… into an independent existence in London” (Gelder and Salzman, Diversity 65), the novel suggests that the search for belonging—at least for Australian women—is problematic. Moreover, any narrative of female escape from suburbia is potentially problematic due to the gendering of suburban experience as feminine. The suburban female who leaves suburbia necessarily rejects not only her “natural” place of belonging, but domesticity as a way of being and, to some extent, even her sex. In her work on memoir, Hooton identifies a stark difference between the shape of female and male biography to argue that women’s experience of life is innately non-linear. However, the use of non-linear narrative by feminist fiction writers of the second wave was arguably more conscious, even political in seeking a new, untainted form through which to explore the female condition. It was a powerful notion, arguably contributing to a golden age of women’s writing by novelists Helen Garner, Barbara Hanrahan, Jessica Anderson, and others. It also exerted a marked effect on fiction by Kate Grenville, Amanda Lohrey, and Janette Turner Hospital, as well as grunge novelists, well into the 1990s. By contrast, other canonical, albeit older, women writers of the time, Thea Astley and Elizabeth Jolley, neither of whom identified as feminist (Fringe 341; Neuter 196), do not seek to “rescue” the suburban female from her milieu. Like Patrick White, Astley seems, at least superficially, to perpetuate narrow stereotypes of the suburban female as “mindless consumers of fashion” and/or “signifiers of sexual disorder” (Sheridan, Satirist 262). Although flight is permitted those female characters who “need to ‘vanish’ if they are to find some alternative to narrow-mindedness and social oppression” (Gelder and Salzman, Celebration 186), it has little to do with feminism. As Brian Matthews attests of Astley’s work, “nothing could be further from the world-view of the second wave feminist writers of the 1980s” (76) and indeed her female characters are generally less sympathetic than those inhabiting novels by the “feminist” writers. Jolley also leaves the female protagonist to fend for herself, with a more optimistic, forceful vision of “female characters who, in their sheer eccentricity, shed any social expectations” to inhabit “a realm empowered by the imagination” (Gelder and Salzman, Celebration 194). If Jolley’s suburban females desire escape then they must earn it, not by direct or shifting relocations, but via other, more extreme and often creative, modes of transformation. These two writers however, were exceptional in their resistance to the influence of second wave feminism. Thus, three narrative categories emerge in which the suburban female may be transformed: linear flight from suburbia, non-linear flight from suburbia, or non-flight whereby the protagonist remains inside suburbia throughout the entire novel. Evidence of a rejection of the flight narrative by contemporary Australian women writers may signal a re-examination of the suburban female within, not outside, her suburban setting. It may also reveal a weakening of the influence of both second wave feminism and anti-suburban critiques on this much maligned character of Australian fiction, and on suburbia as a fictional setting. References Anderson, Jessica. Tirra Lirra by the River. Melbourne: Macmillan, 1978. Astley, Thea. “Writing as a Neuter: Extracts from Interview by Candida Baker.” Eight Voices of the Eighties: Stories, Journalism and Criticism by Australian Women Writers. Ed. 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