Journal articles on the topic 'Medical protocols Victoria'

AbstractObjective:To examine the policies and practices in hospitals within the state of Victoria, Australia, with respect to vaccination of staff against hepatitis B infection.Design:A written self-administered questionnaire to be completed by the infection control officer (or designated officer for hepatitis B vaccination) within each hospital.Setting:Public (teaching and nonteaching) and private hospitals, including metropolitan and rural institutions in Victoria.Participants:A random sample of 30% of Victorian hospitals were asked to participate in the survey. Of 78 eligible institutions, 69 (88%) completed and returned questionnaires.Results:There was no consistent hepatitis B prevention policy in place across Victoria. Of the 69 responding hospitals, 63 (91%) offered hepatitis B vaccination to staff, and 58 (84%) of these also paid all costs of vaccination. Of the 63 hospitals offering vaccination to staff, 39 offered vaccination to all staff, 23 offered vaccination based on job title, and one offered vaccination based on anticipated exposure. In many institutions, postexposure protocols were recalled more readily than preexposure vaccination guidelines. Numerous respondents indicated a need for clear guidelines on policy and clarification on practical matters of management, such as acceptable immune levels, management of nonresponders to the primary series, and the need for, and timing of, booster doses of vaccine. Eleven (18%) of the 63 hospitals offering hepatitis B vaccination to staff undertook routine prevaccination screening, a practice not generally regarded as cost-effective in Australia. Fifty-five of these hospitals (91%) also undertook postvaccination screening.Conclusions:It is evident from this study that a considerable number of potentially susceptible healthcare personnel in Victorian hospitals remain unprotected against hepatitis B infection. A more reliable and consistent approach to preexposure hepatitis B vaccination is recommended

Aim: To describe the process involved in obtaining ethics approval for a study aiming to recruit women from all maternity hospitals in Victoria, Australia. Design: Observational data of the application process involving 85 hospitals throughout Victoria in 2001. Results: Twenty-three of the 85 hospitals had a Human Research Ethics Committee (HREC) constituted in accordance with the National Health and Medical Council requirements; 27 agreed to accept decisions from other hospitals having HRECs and 27 relied on ethics advisory committees, hospital managers, clinical staff, quality assurance committees or lawyers for ethics decisions. Four of the latter did not approve the study. Eight hospitals no longer provided maternity services in the recruitment period. The process took 16 months, 26 000 sheets of paper, 258 copies of the application and the cost was about $30 000. Approval was eventually obtained for recruitment at 73 hospitals. Discussion: Difficulties exist in obtaining timely ethics approval for multicentre studies due to a complex uncoordinated system. All hospitals should have explicit protocols for dealing with research ethics applications so that they can be processed in a straightforward and timely manner. To facilitate this, those without properly constituted HRECs should be affiliated with one hospital that has an HREC.

Background: Ectopic pregnancy remains the most common cause of early pregnancy mortality, with management options differing according to clinical presentation and investigations. This audit aims to investigate the indications for medical and surgical management of ectopic pregnancy at a tertiary hospital network, in order to assess variances in practice and adherence to local hospital protocols. Methods: A retrospective audit of the management of women with a diagnosis of ectopic pregnancy was performed over 12 months from July 2018 to June 2019, at three hospitals in the largest healthcare network in Victoria, Australia. Information collected included patient demographics, risk factors for ectopic pregnancy, pathology and radiology results, documented indication for surgery, and any complications of treatment. A subgroup analysis of data was done to investigate changes and deficiency in management of ectopic pregnancy compared to local hospital protocol. Results: Over a 12-month period, 138 women were diagnosed with an ectopic pregnancy, of which 99 (72%) received surgical management and 39 (28%) received medical management. Four women within the medical group were excluded from analysis, one due to loss of follow-up and three patients who were diagnosed with nontubal ectopic pregnancies. About 94% (33/35) of women who received methotrexate were within hospital guidelines for medical management and 91% (32/35) were successfully managed without surgery. All women who received surgical management underwent a salpingectomy and 97% (96/99) had clear indications documented for surgery within local protocol. Conclusion: Overall, the majority of women with ectopic pregnancy were treated according to local guidelines. Expectant management and the option of salpingostomy as a surgical alternative could be considered in the local guidelines. The dissemination of this clinical audit data is aimed at continuing clinical governance and improvements in outcomes.

Background Responsibilities of critical care nurses for management of mechanical ventilation may differ among countries. Organizational interventions, including weaning protocols, may have a variable impact in settings that differ in nursing autonomy and interdisciplinary collaboration. Objective To characterize the role of Australian critical care nurses in the management of mechanical ventilation. Methods A 3-month, prospective cohort study was performed. All clinical decisions related to mechanical ventilation in a 24-bed, combined medical-surgical adult intensive care unit at the Royal Melbourne Hospital, a university-affiliated teaching hospital in Melbourne, Victoria, Australia, were determined. Results Of 474 patients admitted during the 81-day study period, 319 (67%) received mechanical ventilation. Death occurred in 12.5% (40/319) of patients. Median durations of mechanical ventilation and intensive care stay were 0.9 and 1.9 days, respectively. A total of 3986 ventilation and weaning decisions (defined as any adjustment to ventilator settings, including mode change; rate or pressure support adjustment; and titration of tidal volume, positive end-expiratory pressure, or fraction of inspired oxygen) were made. Of these, 2538 decisions (64%) were made by nurses alone, 693 (17%) by medical staff, and 755 (19%) by nurses and staff in collaboration. Decisions made exclusively by nurses were less common for patients with predominantly respiratory disease or multiple organ dysfunction than for other patients. Conclusions In this unit, critical care nurses have high levels of responsibility for, and autonomy in, the management of mechanical ventilation and weaning. Revalidation of protocols for ventilation practices in other clinical contexts may be needed.

IntroductionChild maltreatment and other traumatic events can have serious long-term physical, social and emotional effects, including a cluster of distress symptoms recognised as ‘complex trauma’. Aboriginal and Torres Strait Islander (Aboriginal) people are also affected by legacies of historical trauma and loss. Trauma responses may be triggered during the transition to parenting in the perinatal period. Conversely, becoming a parent offers a unique life-course opportunity for healing and prevention of intergenerational transmission of trauma. This paper outlines a conceptual framework and protocol for an Aboriginal-led, community-based participatory action research (action research) project which aims to co-design safe, acceptable and feasible perinatalawareness, recognition, assessmentandsupportstrategies for Aboriginal parents experiencing complex trauma.Methods and analysisThis formative research project is being conducted in three Australian jurisdictions (Northern Territory, South Australia and Victoria) with key stakeholders from all national jurisdictions. Four action research cycles incorporate mixed methods research activities including evidence reviews, parent and service provider discussion groups, development and psychometric evaluation of a recognition and assessment process and drafting proposals for pilot, implementation and evaluation. Reflection and planning stages of four action research cycles will be undertaken in four key stakeholder workshops aligned with the first four Intervention Mapping steps to prepare programme plans.Ethics and disseminationEthics and dissemination protocols are consistent with the National Health and Medical Research Council Indigenous Research Excellence criteria of engagement, benefit, transferability and capacity-building. A conceptual framework has been developed to promote the application of core values of safety, trustworthiness, empowerment, collaboration, culture, holism, compassion and reciprocity. These include related principles and accompanying reflective questions to guide research decisions.

BACKGROUND The sellar and juxtasellar region is a complex area where varied pathologies can occur. Differentiation among various pathologies may not always be easy, since many of these lesions mimic pituitary adenomas on clinical presentation, endocrinologic and radiologic examinations. The study intends to describe the imaging characteristics of the spectrum of pathological conditions affecting these regions using magnetic resonance imaging (MRI). METHODS The main source of data for the study were patients from hospitals attached to Bangalore Medical College and Research Institute, Bengaluru viz. Victoria Hospital, Bowring and Lady Curzon Hospital and Vani Vilas Hospital. Patients with suspected sellar and juxtasellar pathology on clinical examination referred to the Department of Radiodiagnosis from November 2017 to May 2019 underwent MRI study using Siemens 1.5-T Magnetom Avanto MR system. Magnetic resonance imaging was done in all patients according to the pituitary protocol. RESULTS Among the 50 patients, there were 16 males and 34 females. Most of the patients were in the third to fifth decade of life. The various abnormalities on MRI included neoplastic (68 %), malformative (8 %), vascular (6 %), granulomatous, infectious and inflammatory (18 %) lesions. Pituitary adenomas (46 %) were the most common lesions in sellar and juxtasellar regions, followed by tuberculosis (10 %), craniopharyngioma (8 %), Rathke's cleft cyst (6 %), meningioma (6 %), internal carotid artery (ICA) aneurysm (4 %), epidermoid (2 %) and miscellaneous lesions. CONCLUSIONS MR imaging characteristics were sufficiently distinct to allow various sellar and juxtasellar pathologies to be differentiated from each other. The spectrum of MRI findings were related to neoplastic, malformative, infectious, inflammatory, granulomatous and vascular causes. Our study observed that MRI with appropriate imaging protocols is the essential imaging modality in evaluation of sellar and juxtasellar lesions. KEYWORDS Pituitary, Sellar, Juxtasellar, Magnetic Resonance Imaging

Objectives: To determine outcome in displaced tibial shaft fracture in children treated with elastic stable intra-medullary nailing. Study Design: Descriptive, Case Series study. Setting: Department of Orthopedic, Bahawal Victoria Hospital, Bahawalpur, HBS Medical & Dental College, Islamabad and HITEC-IMS Taxila Cantt, Pakistan. Period: 2012 to 2019. Material & Methods: A total of 62 cases of displaced tibial shaft fracture presenting within 7 days of the injury, 6 to 11 years of age of either gender were included. Patients with segmental tibial shaft fractures and open tibial shaft fractures, Gustilo Grade II & III were excluded. The titanium elastic nails system (TENS) was used in all patients according to the departmental protocols. The sampling technique was consecutive with non-probability. All the patients were followed up in OPD at 2 weeks interval up to 24 weeks after surgery and union of fracture was recorded at 24th week. Results: Mean age was8.55 ± 1.77 years. Out of these 62 patients, 45 (72.58%) were male and 17 (27.42%) were females with ratio of 2.65:1. Mean duration of fracture was 3.10 ± 1.95 days. Mean duration of union in displaced tibial shaft fracture in children treated with elastic stable intra-medullary nailing was 19.40 ± 3.35 weeks. Conclusion: This study concluded that use of elastic stable intra-medullary nailing for displaced tibial shaft fracture in children leads to shorter duration of union reliably with minimal complications.

We aimed to determine the extent of use of water-based exercise and to describe swimming training practices in Thoroughbred racehorses in Victoria, Australia. A convenience sample of 118 trainers were interviewed, information relating to swimming protocols, perceived benefits and contra-indications, and use of other water-based exercise recorded and descriptive data analyses performed. Water-based exercise was used by 85.6% (n=101) trainers: 82.2% (n=97) swimming, 25.4% (n=30) using a water walker, 13.6% (n=16) incorporating ridden trotting (‘surging’) exercise in chest deep water, and 1.7% (n=2) using an underwater treadmill. Common reasons (and trainer %) for swimming were training variety and mental ‘freshness’ (62.9%), part of the exercise regime on ‘slow’ days (61.9%) and fitness benefits (60.8%). These horses swam a median of 50-90 m (ranging from a minimum of 40-180 m to a maximum of 40-450 m), continuously or as intervals, after track work, once or twice daily a median 3 days/week (range 0.5-7). Swimming for 50 (range 40-120 m) to 90 m (range 40-200 m) before track work 7 days/week (range 3-7) was used by 43 of the 97 trainers (44.3%) to manage horses prone to exertional rhabdomyolysis. Swimming was used to replace fast work by three trainers who swam horses with limb injuries up to 270-450 m. Common reasons (and % trainers) for not swimming individual horses were demeanour/distress (73.2%), previous swim colic (35.1%) or exercise induced pulmonary haemorrhage (35.1%) although only five trainers had ever seen epistaxis after swimming exercise. Swimming is widely used in training Thoroughbred horses in Australia yet trainer opinions particularly on fitness benefits, contra-indications and protocols vary widely and need to be scientifically validated. Diversifying training activities is a common strategy for managing racehorses in training, yet a better understanding of the best use of swimming and other cross-training options is needed so that evidence-based recommendations can be made.

IntroductionSmoking remains the leading preventable cause of death for Aboriginal and Torres Strait Islander people in Australia. Aboriginal and Torres Strait Islander people who smoke are more likely to make a quit attempt than their non-Aboriginal counterparts but less likely to sustain the quit attempt. There is little available evidence specifically for and by Indigenous peoples to inform best practice smoking cessation care.The provision of a free Koori Quit Pack with optional nicotine replacement therapy sent by mail may be a feasible, acceptable and effective way to access stop smoking support for Aboriginal and Torres Strait Islander peoples.Methods and analysisAn Aboriginal-led, multisite non-randomised single-group, pre–post feasibility study across three states in Australia will be conducted. Participants will be recruited via service-targeted social media advertising and during usual care at their Aboriginal Community Controlled Health Services. Through a process of self-referral, Aboriginal and Torres Strait Islander people who smoke daily will complete a survey and receive mailout smoking cessation support. Data will be collected over the phone by an Aboriginal Research Assistant. This pilot study will inform the development of a larger, powered trial.Ethics and disseminationEthics approval has been obtained from the Aboriginal Health & Medical Research Council Ethics Committee of New South Wales (NSW) (#1894/21) and the University of Newcastle (#H-2022-0174). Findings will be reported through peer-reviewed journals and presentations at relevant local, national and international conferences. The findings will be shared with the NSW and Victoria Quitline, Aboriginal Health and Medical Research Council and Victorian Aboriginal Community Controlled Organisation and the National Heart Foundation.Trial registration numberACTRN12622000654752.

IntroductionInfants born extremely preterm (EP, <28 weeks’ gestation) or with extremely low birth weight (ELBW,<1000 g) in the era when surfactant has been available clinically are at high risk of health and developmental problems in childhood and adolescence. However, how their health and well-being may be affected in adulthood is not well known. This study aims to compare between EP/ELBW and normal birthweight (NBW) controls: (1) physical health, mental health and socioemotional functioning at 25 years of age and (2) trajectories of these outcomes from childhood to adulthood. In addition, this study aims to identify risk factors in pregnancy, infancy, childhood and adolescence for poor physical health and well-being in EP/ELBW young adults.Methods and analysisThe Victorian Infant Collaborative Study (VICS) is a prospective geographical cohort of all EP/ELBW survivors to 18 years of age born in the State of Victoria, Australia, from 1 January 1991 to 31 December 1992 (n=297) and contemporaneous term-born/NBW controls (n=262). Participants were recruited at birth and followed up at 2, 5, 8 and 18 years. This 25-year follow-up includes assessments of physical health (cardiovascular, respiratory and musculoskeletal), mental health and socioemotional functioning. Outcomes will be compared between the birth groups using linear and logistic regression, fitted using generalised estimating equations (GEEs). Trajectories of health outcomes from early childhood will be compared between the birth groups using linear mixed-effects models. Risk factors for adult outcomes will be assessed using linear and logistic regression (fitted using GEEs).Ethics and disseminationThis study was approved by the Human Research Ethics Committees of the Royal Women’s Hospital, Mercy Hospital for Women, Monash Medical Centre and the Royal Children’s Hospital, Melbourne. Study outcomes will be disseminated through conference presentations, peer-reviewed publications, the internet and social media.

40 Background: Chemotherapy scheduling and determining associated nursing resources are complex multiobjective decision problems. Management of DRs are thought to take additional chair and nurse time and should be accounted for in appointment scheduling in order to having an efficiently running clinic. BC Cancer – Victoria is a tertiary care regional site of BC Cancer in Victoria, British Columbia, Canada and currently schedules patients using a regimen-based resource intensity model (Greene et al, 2012). Methods: DRs were tracked in real time over 3 months, where BC Cancer ID, reaction, protocol, agent, cycle number and time of reaction were recorded. Our electronic medical record was interrogated to determine start and end of chair time. We then compared the actual chair time required to manage patients with a DR to scheduled chair time. Results: Thirty reactions occurred, including DRs to paclitaxel (43%), rituximab (13%), docetaxel (10%), nivolumab (7%), oxaliplatin (7%), pertuzumab (7%), bendmustine (3%), and daratumumab (3%). The reactions most commonly occurred with cycles 1 or 2. The averages for total chair time during DR, time from arrival to reaction, and time from reaction to discharge were 281 min (+79.5), 106 min (+ 55), and 171 min (+ 94), respectively. An average of 449 min/month extra were required for DR management above scheduled chair time. Conclusions: The agents precipitating DRs were common and predictable. An average of 7 hours and 29 minutes per month above scheduled chair time was required to manage DRs. This information could be used to more efficiently schedule chair and nursing time. This also highlights the need to minimize the number of DRs as management is resource intensive.[Table: see text]

IntroductionPoor patient assessment results in undetected clinical deterioration. Yet, there is no standardised assessment framework for >29 000 Australian emergency nurses. To reduce clinical variation and increase safety and quality of initial emergency nursing care, the evidence-based emergency nursing framework HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) was developed and piloted. This paper presents the rationale and protocol for a multicentre clinical trial of HIRAID.Methods and analysisUsing an effectiveness-implementation hybrid design, the study incorporates a stepped-wedge cluster randomised controlled trial of HIRAID at 31 emergency departments (EDs) in New South Wales, Victoria and Queensland. The primary outcomes are incidence of inpatient deterioration related to ED care, time to analgesia, patient satisfaction and medical satisfaction with nursing clinical handover (effectiveness). Strategies that optimise HIRAID uptake (implementation) and implementation fidelity will be determined to assess if HIRAID was implemented as intended at all sites.Ethics and disseminationEthics has been approved for NSW sites through Greater Western Human Research Ethics Committee (2020/ETH02164), and for Victoria and Queensland sites through Royal Brisbane & Woman’s Hospital Human Research Ethics Committee (2021/QRBW/80026). The final phase of the study will integrate the findings in a toolkit for national rollout. A dissemination, communications (variety of platforms) and upscaling strategy will be designed and actioned with the organisations that influence state and national level health policy and emergency nurse education, including the Australian Commission for Quality and Safety in Health Care. Scaling up of findings could be achieved by embedding HIRAID into national transition to nursing programmes, ‘business as usual’ ED training schedules and university curricula.Trial registration numberACTRN12621001456842.

Objectives: To know the sensitivity and specificity of ultrasound with plain abdominal film (X-ray KUB) compared to IVU inevaluation of renal colic. To develop a protocol for investigations of renal colic. Design of study: Experimental. Setting: Department of Urologyand Renal Transplantation, Quaid-I-Azam Medical College /Bahawal Victoria Hospital, Bahawalpur. Period: From July 2010 to December2011. Materials & Methods: The number of cases for the study were one hundred and fifty. Patients of either sex of age range from 10 to 50years with suspected urinary tract stone disease, PUJ obstruction and stricture ureterovesical junction were included in this study. Whilepatients of age <10years, renal failure and with history of hypersensitivity to contrast media were excluded from the study. After routineinvestigations, ultrasonography, plain X-ray KUB and IVU were performed in every patient at radiology department, Bahawal Victoria hospital,Bahawalpur. Results: The mean age of patients was 41.14±1.30 years. The ratio of male to female was 2.8:1. Presenting complaints ofpatients were flank pain. Maximum duration of complaint was 5-6 years. USG + X-ray KUB findings were obstructing renal stone, ureteric stoneand PUJO in 97(64.67%), 25(16.67%) and 28(18.67%) patients respectively. While on IVU, obstructing renal stone, PUJO and ureteric stonewas found in 87(58%), 31(20.67%) and 32(21.33%) patients respectively. Conclusions: This study shows that ultrasonography and plain X-rayabdomen (KUB) is sufficient for the diagnosis of renal disease presenting with renal colic.

Objective: Prevalence of Depression in patients presenting with Alcohol and Drug addiction. Place & duration of study: Thestudy was conducted in the Department of Psychiatry & Behavioural Sciences, Bahawal Victoria Hospital & Quaid-e-Azam Medical College,Bahawalpur from March, 2009 to May, 2009. Subjects & methods: The sample consisted of 50 in-patients (Male 46, Female 4) with Alcohol &Drug addiction. They were interviewed and results were analysed from the entries in a Performa and Hamilton Rating Scale for Depression.Results: Majority of the patients were male (92%), age group majority (74%) were between 21-40 years. Depression was found in 23(46%)patients, 14(28%) had severe depression and 9(18%) had mild to moderate depression. Conclusions: Significant numbers of patients ofalcohol and drug addiction have depression as co-morbidity, which can have important implications in the aetiology and prognosis. So everypatient seeking treatment for alcohol and drug addiction should be assessed for depression and we should develop a protocol to treatdepression in these patients.

Termination of Pregnancy (TOP), in our country is carried out only when considerable danger to a fetus due to congenital abnormalities, intrauterine fetal loss or when maternal life is under threat. The principle concerns in providing second trimester termination include safety, efficacy, simplicity, low-cost, and fast acting with minimal side effects. Objectives: To compare the efficacy in term of complete abortion within 48 hours between protocol-I (200 µg misoprostol 4 hourly) versus protocol-II (200 µg misoprostol 6 hourly) for second trimester (14-24 weeks) medical termination of pregnancy. Study Design: Randomized controlled trial. Settings: Gynecology & obstetrics unit-II, Bahawal Victoria Hospital (BVH) Bahawalpur. Period: From 1st July 2017 to 30th June 2018. Material & Method: A total of 182 patients meeting the inclusion criteria were included in study. Ninety one patients were included in group-A and 91 patients were included in group-B. Women allocated to group-A was given misoprostol 200µg every 4 hour. Similar drug and dose were administered to women of group-B intra-vaginally, 6 hourly. Patients in both groups were monitored up to 48. If abortion occurred within 48 hours of induction, it was labeled as effective abortion otherwise it was regarded as failed abortion. Results: The mean age in group-A was 26.71 years 25.49 years in Group-B. In group-A, 89 (97.8%) patients showed efficacy (abortion within 48 hours) and in group-B, 74 (81.32%) patients showed efficacy to misoprostol. Conclusion: The regimen of using 200μg of vaginal misoprostol 4 hourly is more efficacious and quick for 2nd trimester TOP with fewer side effects when compared to 200μg of vaginal misoprostol 6 hourly.

Background Distal radius (wrist) fractures are the second most common fracture admitted to hospital. The anatomical pattern of these types of injuries is diverse, with variation in clinical management, guidelines for management remain inconclusive, and the uptake of findings from clinical trials into routine practice limited. Robust predictive modelling, which considers both the characteristics of the fracture and patient, provides the best opportunity to reduce variation in care and improve patient outcomes. This type of data is housed in unstructured data sources with no particular format or schema. The “Predicting fracture outcomes from clinical Registry data using Artificial Intelligence (AI) Supplemented models for Evidence-informed treatment (PRAISE)” study aims to use AI methods on unstructured data to describe the fracture characteristics and test if using this information improves identification of key fracture characteristics and prediction of patient-reported outcome measures and clinical outcomes following wrist fractures compared to prediction models based on standard registry data. Methods and design Adult (16+ years) patients presenting to the emergency department, treated in a short stay unit, or admitted to hospital for >24h for management of a wrist fracture in four Victorian hospitals will be included in this study. The study will use routine registry data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), and electronic medical record (EMR) information (e.g. X-rays, surgical reports, radiology reports, images). A multimodal deep learning fracture reasoning system (DLFRS) will be developed that reasons on EMR information. Machine learning prediction models will test the performance with/without output from the DLFRS. Discussion The PRAISE study will establish the use of AI techniques to provide enhanced information about fracture characteristics in people with wrist fractures. Prediction models using AI derived characteristics are expected to provide better prediction of clinical and patient-reported outcomes following distal radius fracture.

Background Accurate pre-operative imaging plays a vital role in patient selection for surgery and in allocating stage-appropriate therapies to patients diagnosed with pancreatic cancer (PC). This study aims to: (1) understand the current diagnosis and staging practices for PC; and (2) explore the factors (barriers and enablers) that influence the use of a pancreatic protocol computed tomography (PPCT) or magnetic resonance imaging (MRI) to confirm diagnosis and/or accurately stage PC. Methods Semi-structured interviews were conducted with radiologists, surgeons, gastroenterologists, medical and radiation oncologists from the states of New South Wales (NSW) and Victoria, Australia. Interviews were conducted either in person or via video conferencing. All interviews were recorded, transcribed verbatim, de-identified and data were thematically coded according to the 12 domains explored within the Theoretical Domains Framework (TDF). Common belief statements were generated to compare the variation between participant responses. Findings In total, 21 clinicians (5 radiologists, 10 surgeons, 2 gastroenterologists, 4 medical and radiation oncologists) were interviewed over a four-month-period. Belief statements relevant to the TDF domains were generated. Across the 11 relevant domains, 20 themes and 30 specific beliefs were identified. All TDF domains, with the exception of social influences were identified by participants as relevant to protocol-based imaging using either a PPCT or MRI, with the domains of knowledge, skills and environmental context and resources being offered by most participants as being relevant in influencing their decisions. Conclusions To maximise outcomes and personalise therapy it is imperative that diagnosis and staging investigations using the most appropriate imaging modalities are conducted in a timely, efficient and effective manner. The results provide an understanding of specialists’ opinion and behaviour in relation to a PPCT or MRI and should be used to inform the design of future interventions to improve compliance with this practice.

Background/Aims Networked glucose blood monitoring has been demonstrated as a useful process of care for improving glycaemia and clinical outcomes in hospital inpatients. However, these benefits are partly reliant on the accurate entry of patients' medical record numbers by healthcare staff. This study assessed the accuracy of such data entry, comparing the periods before and after the onset of the COVID-19 pandemic. Methods This retrospective observational study analysed glucose meter medical record number entries at a large hospital in Victoria, Australia. The study period spanned from September 2019, when the networked blood glucose monitoring system was introduced, to July 2020. The proportion of inaccurate entries were presented as a percentage of the total number of entries and comparisons were made between the pre-COVID-19 and post-COVID-19 onset periods. Data were analysed using an interrupted time series methodology and presented using a Quasipoisson distribution. Results A gradual decrease in the percentage of accurate medical record number entries was observed following the introduction of the networked blood glucose monitoring system. This decline in accuracy decreased further following the onset of COVID-19, despite the hospital serving a relatively low number of patients with the virus. Conclusions The ongoing decrease in accuracy of data entry into the networked blood glucose monitoring system is thought to be a result of insufficient training and time constraints, which were exacerbated by the COVID-19 pandemic because of protocol changes and furloughed staff. It is recommended that accurate use of the networked blood glucose monitoring system is allocated more regular training in hospital wards.

Prioritisation of clients requesting physiotherapy in Victorian community health services has occurred in the absence of a uniform evidence-based prioritisation process. The effect of the varying prioritisation procedures on client outcomes is unknown. This two-part study sought to answer two questions: what are the current prioritisation practices? And what is the evidence for prioritisation? Staff of Victorian community health services offering physiotherapy (n = 67) were sent a structured questionnaire regarding their prioritisation practices. The questionnaire data revealed a wide range of poorly defined criteria and methods of assessment for prioritisation. The evidence for prioritisation and the use of specific prioritisation criteria were examined via a literature search. The literature suggested the use of acute severe pain, interference with activities of daily living and falls as indicators of need for priority service. The lack of uniformity found in determining priority of access reflects the complexity of determining need and the lack of research and validated tools to assist decision making. Further research into prioritisation criteria is required to determine their validity and if their use in a prioritisation tool would actually improve outcomes for clients. What is known about the topic? Although there is some research on medical prioritisation of clients awaiting surgery little is known about prioritisation practices in allied health in general and physiotherapy in particular. There is also little known about client outcomes when clients are either not prioritised or have been incorrectly prioritised. The literature provides expert opinion on the potential usefulness of prioritisation criteria in determining client need. What does this paper add? This paper highlights the discrepancy between the various poorly defined and complex physiotherapy prioritisation practices that occurred in Victorian Community Health Services at the time of the study and the literature regarding the assessment of need. The underpinning evidence base for uniform prioritisation criteria is explored. Further research is required into the risks and effect on client outcomes of prioritisation. What are the implications for practitioners? Although practitioners, in the absence of any guidelines, have developed their own prioritisation protocols, the Victorian Department of Health has recently mandated the use of a uniform community health prioritisation procedure for physiotherapy and other allied health services, developed from the findings of this research. This study provides practitioners with an understanding of the evidence base for prioritisation criteria and approaches for assessing criteria in practice.

Background: Smoking following a diagnosis of cancer is a powerful clinical risk indicator, with known poorer health outcomes and associated health care costs. In Australia, smoking rates are higher in rural and regional areas. There are established and effective interventions to promote smoking cessation after a diagnosis of cancer yet these are not in routine practice. Aim: This protocol paper reports on a study that aims to embed evidence-based smoking cessation strategies for people with cancer who are current smokers into routine care, resulting in in system wide improvements, an implemented program and model for further dissemination. Methods: Across three rural/regional sites, and with partners Quit Victoria and Western Alliance, this study employs a variety of methodologies to embed smoking cessation support to improve outcomes for people with cancer who currently smoke. Specifically, the project will embed a system of responsibilities and training in rural and regional health services to routinely engage people with cancer who smoke in support services. The program will: · Promote routine delivery of smoking cessation care by trained oncology staff (oncologists/nurses/ allied health) · Establish referral pathways to Quitline · Correspond with general practitioners, to: i) outline the benefits of quitting in this context, ii) promote access to nicotine replacement therapy and iii) support quitting in the community. · Improve routine recording of smoking status and documentation of provision of brief intervention (personalised advice given, resources provided) and outcomes. Participants: are oncology staff and general practitioners across three health services: Ballarat Health Service, East Grampians Health Service (Ararat), Wimmera Health Care Group (Horsham), all located in Victoria, Australia. Data collection will occur across four sources: 1) Oncology staff: qualitative and quantitative data collection understanding confidence and views on provision on cessation advice; 2) Monitoring Quitline calls, 3) Interview with local general practitioners and 4) Medical record reviews to explore frequency of recording of smoking status. Data will be collected pre/postintervention. Results: The project is underway with the intervention manuals in development. The project is due for completion in 2020. Conclusion: This project takes a health services approach to integration of smoking cessation support in routine care for people with cancer in rural and regional areas. This program of work has capacity to determine best approaches to integrate smoking cessation into routine care, resulting in reduced mortality and morbidity, improved effectiveness of anticancer treatments, and reduced health care costs; by establishing internationally relevant, embedded health care interventions.

IntroductionPatellar tendinopathy is a degenerative disease of the patellar tendon, which affects athletes from a variety of sports, and is especially predominant in sports involving high-impact jumping. The aim of this study is to determine the additional effect of two interventions combined with eccentric exercise and compare which one is the most effective at short-term and long-term follow-up for patients with patellar tendinopathy.Methods and analysisThis study is a randomised controlled trial with blinded participants. Measurements will be carried out by a specially trained blinded assessor. A sample of 57 patients with a medical diagnosis of patellar tendinopathy will participate in this study and will be divided into three treatment groups. Eligible participants will be randomly allocated to receive either: (a) treatment group with percutaneous needle electrolysis, (b) treatment group with dry needling or (c) treatment group with placebo needling. In addition, all groups will perform eccentric exercise. Functionality and muscle strength parameters, pain, ultrasound appearances and patient perceived quality of life shall be evaluated using the Victorian Institute of Sports Assessment for patellar (VISA-P), jump tests, Visual Analogue Scale, ultrasound images and Short Form-36 (SF-36), respectively. Participants will be assessed at baseline, at 10 weeks and at 22 weeks after baseline. The expected findings will allow us to advance in the treatment of this injury, as they will help determine whether a needling intervention has additional effects on an eccentric exercise programme and whether any of the needling modalities is more effective than the other.Ethics and disseminationThis protocol has been approved by the Ethics Committee of Aragon (N° PI15/0017). The trial will be conducted in accordance with the Declaration of Helsinki.Trial registration numberNCT02498795

IntroductionIn Australia, general practitioners usually are the first point of contact for patients with non-urgent medical conditions. Appropriate and efficient utilisation of pathology tests by general practitioners forms a key part of diagnosis and monitoring. However overutilisationand underutilisation of pathology tests have been reported across several tests and conditions, despite evidence-based guidelines outlining best practice in pathology testing. There are a limited number of studies evaluating the impact of these guidelines on pathology testing in general practice. The aim of our quantitative observational study is to define how pathology tests are used in general practice and investigate how test ordering practices align with evidence-based pathology guidelines.Methods and analysisAccess to non-identifiable patient data will be obtained through electronic health records from general practices across three primary health networks in Victoria, Australia. Numbers and characteristics of patients, general practices, encounters, pathology tests and problems managed over time will be described. Overall rates of encounters and tests, alongside more detailed investigation between subcategories (encounter year, patient’s age, gender, and location and general practice size), will also be undertaken. To evaluate how general practitioner test ordering coincides with evidence-based guidelines, five key candidate indicators will be investigated: full blood counts for patients on clozapine medication; international normalised ratio measurements for patients on warfarin medication; glycated haemoglobin testing for monitoring patients with diabetes; vitamin D testing; and thyroid function testing.Ethics and disseminationEthics clearance to collect data from general practice facilities has been obtained by the data provider from the RACGP National Research and Evaluation Ethics Committee (NREEC 17–008). Approval for the research group to use these data has been obtained from Macquarie University (5201700872). This study is funded by the Australian Government Department of Health Quality Use of Pathology Program (Agreement ID: 4-2QFVW4M). Findings will be reported to the Department of Health and disseminated in peer-reviewed academic journals and presentations (national and international conferences, industry forums).

IntroductionWhile tobacco smoking prevalence is falling in many western societies, it remains elevated among high-priority cohorts. Rates up to 95% have been reported in women whose pregnancy is complicated by other substance use. In this group, the potential for poor pregnancy outcomes and adverse physical and neurobiological fetal development are elevated by tobacco smoking. Unfortunately, few targeted and effective tobacco dependence treatments exist to assist cessation in this population. The study will trial an evidence-based, multicomponent tobacco smoking treatment tailored to pregnant women who use other substances. The intervention comprises financial incentives for biochemically verified abstinence, psychotherapy delivered by drug and alcohol counsellors, and nicotine replacement therapy. It will be piloted at three government-based, primary healthcare facilities in New South Wales (NSW) and Victoria, Australia. The study will assess the feasibility and acceptability of the treatment when integrated into routine antenatal care offered by substance use in pregnancy antenatal services.Methods and analysisThe study will use a single-arm design with pre–post comparisons. One hundred clients will be recruited from antenatal clinics with a substance use in pregnancy service. Women must be <33 weeks’ gestation, ≥16 years old and a current tobacco smoker. The primary outcomes are feasibility, assessed by recruitment and retention and the acceptability of addressing smoking among this population. Secondary outcomes include changes in smoking behaviours, the comparison of adverse maternal outcomes and neonatal characteristics to those of a historical control group, and a cost-consequence analysis of the intervention implementation.Ethics and disseminationProtocol approval was granted by Hunter New England Human Research Ethics Committee (Reference 17/04/12/4.05), with additional ethical approval sought from the Aboriginal Health and Medical Research Council of NSW (Reference 1249/17). Findings will be disseminated via academic conferences, peer-reviewed publications and social media.Trial registration numberAustralia New Zealand Clinical Trial Registry (Ref: ACTRN12618000576224).

IntroductionThe incidence of acute coronary syndrome is rising in step with the growth of life expectancy. An increase in the age of patients with coronary artery disease has been related to in-hospital mortality, which has seen an upsurge over a short period of time. However, there is no consensus about the percutaneous coronary angioplasty strategy to follow for older patients with multivessel coronary artery disease (MVCAD). Complete revascularisation (CR) or incomplete revascularisation (ICR) strategy depends on prognosis but this has not yet been accurately described because of geriatric conditions and comorbidities. The aim of this study is to evaluate changes of clinical and biochemical parameters in older patients with MVCAD undergoing revascularisation and to establish a prognostic stratification model for CR and ICR.Methods and analysisThis observational, longitudinal, prospective study will include 150 patients with MVCAD and subsequent revascularisation who attend the Hospital Universitario Virgen de la Victoria (Málaga, Spain). Because of the dropout rates, 180 patients will be recruited at the beginning. Sociodemographic characteristics, clinical and angiographic parameters, and biochemical variables, such as cardiovascular, metabolic, inflammatory, stress oxidative biomarkers, will be collected in the admission for coronary revascularisation and three follow-ups at 6, 12 and 18 months. Statistical analyses will be conducted with these data using CR and ICR as the primary exposure variable. Relevant explanatory variables will be selected from a predictive model for their inclusion in a prognostic stratification model. The primary outcome measures will be major adverse cardiovascular events.Ethics and disseminationProtocols and patient information have been approved by the regional research ethics committee (CEIm Provincial de Málaga-PEIBA (PI0131/2020). The results will be disseminated in international peer-reviewed journals, presented at conferences in Cardiology and Gerontology, and sent to participants, medical and health service managers, clinicians and other researchers.

IntroductionAs cancer treatments may impact on fertility, a high priority for young patients with breast cancer is access to evidence-based, personalised information for them and their healthcare providers to guide treatment and fertility-related decisions prior to cancer treatment. Current tools to predict fertility outcomes after breast cancer treatments are imprecise and do not offer individualised prediction. To address the gap, we are developing a novel personalised infertility risk prediction tool (FoRECAsT) for premenopausal patients with breast cancer that considers current reproductive status, planned chemotherapy and adjuvant endocrine therapy to determine likely post-treatment infertility. The aim of this study is to explore the feasibility of implementing this FoRECAsT tool into clinical practice by exploring the barriers and facilitators of its use among patients and healthcare providers.Methods and analysisA cross-sectional exploratory study is being conducted using semistructured in-depth telephone interviews with 15–20 participants each from the following groups: (1) premenopausal patients with breast cancer younger than 40, diagnosed within last 5 years, (2) breast surgeons, (3) breast medical oncologists, (4) breast care nurses (5) fertility specialists and (6) fertility preservation nurses. Patients with breast cancer are being recruited from the joint Breast Service of three affiliated institutions of Victorian Comprehensive Cancer Centre in Melbourne, Australia—Peter MacCallum Cancer Centre, Royal Melbourne Hospital and Royal Women’s Hospital, and clinicians are being recruited from across Australia. Interviews are being audio recorded, transcribed verbatim and imported into qualitative data analysis software to facilitate data management and analyses.Ethics and disseminationThe study protocol has been approved by Melbourne Health Human Research Ethics Committee, Australia (HREC number: 2017.163). Confidentiality and privacy are maintained at every stage of the study. Findings will be disseminated through peer-reviewed scholarly and scientific journals, national and international conference presentations, social media, broadcast media, print media, internet and various community/stakeholder engagement activities.

Prenatal prognosis is an important part of obstetric care, which aims to reduce fetal and neonatal losses. A differentiated approach to the management of different risk groups allows you to optimize existing approaches.The objective: to identify antenatal factors that correlate with perinatal losses, by conducting a retrospective cohort study of women at high perinatal risk, to build a multifactorial prognostic model of adverse pregnancy outcomes.Materials and methods. A retrospective cohort study was conducted from 2014 to 2016 on the basis of the medical center LLC «Uniclinic», Medical Genetics Center «Genome», Clinic of Reproductive Genetics «Victoria», Kyiv City Maternity Hospital №2. 2154 medical cards of pregnant women from the group of high perinatal risk were selected and analyzed. Of these, 782 pregnant women were included in the final protocol after verification of compliance with the criteria.Results. Cesarean delivery occurred in 115 cases (14.7%). In 50 cases (6.4%) the caesarean section was performed in a planned manner, in 65 (8.3%) – in an emergency. In 39 (5%) cases, the indication for surgical delivery was acute fetal distress. Antenatal fetal death occurred in 11 (1.4%) cases: one case in terms of <34 weeks and <37 weeks of gestation, the remaining 9 cases – in terms of> 37 weeks. Intranatal death of two fetuses (0.3%) was due to acute asphyxia on the background of placental insufficiency. In the early neonatal period, 14 (1.8%) newborns died. Hospitalization of the newborn to the intensive care unit for the first 7 days was registered in 64 (8.2%) cases.The need for mechanical ventilation was stated in 3.96% (31/782) of newborns. The method of construction and analysis of multifactor models of logistic regression was used in the analysis of the relationship between the risk of perinatal losses (antenatal death, intranatal death, early neonatal death) and factor characteristics.Conclusion. Signs associated with the risk of perinatal loss: the presence of chronic hypertension, preeclampsia in previous pregnancies, type of fertilization (natural or artificial), the concentration of PAPP-A (MoM), the concentration of free β-HCG (MoM) in the second trimester, average PI in the uterine arteries in 28–30 weeks of pregnancy, PI in the middle cerebral arteries in 28–30 weeks of pregnancy, episodes of low fetal heart rate variability in the third trimester of pregnancy, episodes of high fetal heart rate variability in the third trimester of pregnancy. The model, built on selected features, allows with a sensitivity of 73.1% (95% CI: 52.2% – 88.4%) and a specificity of 72.7% (95% CI: 69.3% – 75.9%) to predict risk perinatal loss.

Background Asthma is a chronic respiratory disorder that requires long-term pharmacotherapy and patient empowerment to manage the condition and recognize and respond to asthma exacerbations. Mobile health (mHealth) apps represent a potential medium through which patients can improve their ability to self-manage their asthma. Few studies have conducted a systematic evaluation of asthma mobile apps for quality and functionality using a validated tool. None of these reviews have systematically assessed these apps for their content and evaluated them against the available international best practice guidelines. Objective The objective of this study is to conduct a systematic search and evaluation of adult-targeted asthma mHealth apps. As part of this review, the potential of an mHealth app to improve asthma self-management and the overall quality of the app will be evaluated using the Mobile App Rating Scale framework, and the quality of the information within an app will be evaluated using the current Global Initiative for Asthma guidelines as a reference. Methods A stepwise methodological approach was taken in creating this review. First, the most recent Global Initiative for Asthma guidelines were independently reviewed by 2 authors to identify key recommendations that could be feasibly incorporated into an mHealth app. A previously developed asthma assessment framework was identified and was modified to suit our research and ensure that all of these identified recommendations were included. In total, 2 popular app stores were reviewed to identify potential mHealth apps. These apps were screened based on predefined inclusion and exclusion criteria. Suitable apps were then evaluated. Technical information was obtained from publicly available information. The next step was to perform an app quality assessment using the validated Mobile App Rating Scale framework to objectively determine the quality of an app. App functionality was assessed using the Intercontinental Medical Statistics Institute for Health Informatics Functionality Scoring System. Finally, the mHealth apps were assessed using our developed checklist. Results Funding has been received for the project from the Respiratory Department at Northern Health, Victoria. Three reviewers have been recruited to systematically evaluate the apps. The results of this study are expected in 2022. Conclusions To our knowledge, this review represents the first study to examine all mHealth apps available in Australia that are targeted to adults with asthma for their functionality, quality, and consistency with international best practice guidelines. Although this review will only be conducted on mHealth apps available in Australia, many apps are available worldwide; thus, this study should be largely generalizable to other English-speaking regions and users. The results of this review will help to fill gaps in the literature and assist clinicians in providing evidence-based advice to patients wishing to use mHealth apps as part of their asthma self-management. Trial Registration PROSPERO 269894; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=269894 International Registered Report Identifier (IRRID) PRR1-10.2196/33103

BackgroundMobilising patients early after stroke [early mobilisation (EM)] is thought to contribute to the beneficial effects of stroke unit care but it is poorly defined and lacks direct evidence of benefit.ObjectivesWe assessed the effectiveness of frequent higher dose very early mobilisation (VEM) after stroke.DesignWe conducted a parallel-group, single-blind, prospective randomised controlled trial with blinded end-point assessment using a web-based computer-generated stratified randomisation.SettingThe trial took place in 56 acute stroke units in five countries.ParticipantsWe included adult patients with a first or recurrent stroke who met physiological inclusion criteria.InterventionsPatients received either usual stroke unit care (UC) or UC plus VEM commencing within 24 hours of stroke.Main outcome measuresThe primary outcome was good recovery [modified Rankin scale (mRS) score of 0–2] 3 months after stroke. Secondary outcomes at 3 months were the mRS, time to achieve walking 50 m, serious adverse events, quality of life (QoL) and costs at 12 months. Tertiary outcomes included a dose–response analysis.Data sourcesPatients, outcome assessors and investigators involved in the trial were blinded to treatment allocation.ResultsWe recruited 2104 (UK,n = 610; Australasia,n = 1494) patients: 1054 allocated to VEM and 1050 to UC. Intervention protocol targets were achieved. Compared with UC, VEM patients mobilised 4.8 hours [95% confidence interval (CI) 4.1 to 5.7 hours;p < 0.0001] earlier, with an additional three (95% CI 3.0 to 3.5;p < 0.0001) mobilisation sessions per day. Fewer patients in the VEM group (n = 480, 46%) had a favourable outcome than in the UC group (n = 525, 50%) (adjusted odds ratio 0.73, 95% CI 0.59 to 0.90;p = 0.004). Results were consistent between Australasian and UK settings. There were no statistically significant differences in secondary outcomes at 3 months and QoL at 12 months. Dose–response analysis found a consistent pattern of an improved odds of efficacy and safety outcomes in association with increased daily frequency of out-of-bed sessions but a reduced odds with an increased amount of mobilisation (minutes per day).LimitationsUC clinicians started mobilisation earlier each year altering the context of the trial. Other potential confounding factors included staff patient interaction.ConclusionsPatients in the VEM group were mobilised earlier and with a higher dose of therapy than those in the UC group, which was already early. This VEM protocol was associated with reduced odds of favourable outcome at 3 months cautioning against very early high-dose mobilisation. At 12 months, health-related QoL was similar regardless of group. Shorter, more frequent mobilisation early after stroke may be associated with a more favourable outcome.Future workThese results informed a new trial proposal [A Very Early Rehabilitation Trial – DOSE (AVERT–DOSE)] aiming to determine the optimal frequency and dose of EM.Trial registrationThe trial is registered with the Australian New Zealand Clinical Trials Registry number ACTRN12606000185561, Current Controlled Trials ISRCTN98129255 and ISRCTN98129255.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 21, No. 54. See the NIHR Journals Library website for further project information. Funding was also received from the National Health and Medical Research Council Australia, Singapore Health, Chest Heart and Stroke Scotland, Northern Ireland Chest Heart and Stroke, and the Stroke Association. In addition, National Health and Medical Research Council fellowship funding was provided to Julie Bernhardt (1058635), who also received fellowship funding from the Australia Research Council (0991086) and the National Heart Foundation (G04M1571). The Florey Institute of Neuroscience and Mental Health, which hosted the trial, acknowledges the support received from the Victorian Government via the Operational Infrastructure Support Scheme.

A male runner (30 years old; 10-km time: 33 min, 46 s) had been running with suspected insertional Achilles tendinopathy (AT) for ~2 years when the pain reached a threshold that prevented running. Diagnostic ultrasound (US), prior to a high-volume stripping injection, confirmed right-sided medial insertional AT. The athlete failed to respond to injection therapy and ceased running for a period of 5 weeks. At the beginning of this period, the runner completed the Victoria institute of sports assessment–Achilles questionnaire (VISA-A), the foot and ankle disability index (FADI), and FADI sport prior to undergoing an assessment of bi-lateral gastrocnemius medialis (GM) muscle architecture (muscle thickness (MT) and pennation angle (PA); US), muscle contractile properties (maximal muscle displacement (Dm) and contraction time (Tc); Tensiomyography (TMG)) and calf endurance (40 raises/min). VISA-A and FADI scores were 59%/100% and 102/136 respectively. Compared to the left leg, the right GM had a lower MT (1.60 cm vs. 1.74 cm), a similar PA (22.0° vs. 21.0°), a lower Dm (1.2 mm vs. 2.0 mm) and Tc (16.5 ms vs. 17.7 ms). Calf endurance was higher in the right leg compared to the left (48 vs. 43 raises). The athlete began a metronome-guided (15 BPM), 12-week progressive eccentric training protocol using a weighted vest (1.5 kg increments per week), while receiving six sessions of shockwave therapy concurrently (within 5 weeks). On returning to running, the athlete kept daily pain (Numeric Rating Scale; NRS) and running scores (miles*rate of perceived exertion (RPE)). Foot and ankle function improved according to scores recorded on the VISA-A (59% vs. 97%) and FADI (102 vs. 127/136). Improvements in MT (1.60 cm vs. 1.76 cm) and PA (22.0° vs. 24.8°) were recorded via US. Improvements in Dm (1.15 mm vs. 1.69 mm) and Tc (16.5 ms vs. 15.4 ms) were recorded via TMG. Calf endurance was lower in both legs and the asymmetry between legs remained (L: 31, R: 34). Pain intensity (mean weekly NRS scores) decreased between week 1 and week 12 (6.6 vs. 2.9), while running scores increased (20 vs. 38) during the same period. The program was maintained up to week 16 at which point mean weekly NRS was 2.2 and running score was 47.

<p><strong>1. How can we maintain a sustainable private practice in the current political and economic climate?</strong></p><p>Eugene Allers</p><p><strong>2. SASOP Clinical guidelines, protocols and algorithms: Development of treatment guidelines for bipolar mood disorder and major depression</strong></p><p> Eugene Allers, Margaret Nair, Gerhard Grobler</p><p><strong>3. The revolving door phenomenon in psychiatry: Comparing low-frequency and high-frequency users of psychiatric inpatient services in a developing country</strong></p><p>U A Botha, P Oosthuien, L Koen, J A Joska, J Parker, N Horn</p><p><strong>4. Neurophysiology of emotion and senses - The interface between psyche and soma</strong></p><p>Eugene Allers</p><p><strong>5. Suicide prevention: From and beyond the psychiatrist's hands</strong></p><p>O Alonso Betanourt, M Morales Herrera</p><p><strong>6. 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Persocentred diagnosis: Where d ps and mental disorders fit in the International classificaton of diseases (ICD)?</strong></p><p>Werdie van Staden</p><p><strong>60. What every psychiatrist needs to know about scans</strong></p><p>Herman van Vuuren</p><p><strong>61. Psychiatric morbidity in health care workers withle drug-resistant erulosis (MDR-TB) A case series</strong></p><p>Urvashi Vasant, Dinesh Singh</p><p><strong>62. Association between uetrine artery pulsatility index and antenatal maternal psychological stress</strong></p><p>Bavanisha Vythilingum, Lut Geerts, Annerine Roos, Sheila Faure, Dan J Stein</p><p><strong>63. Approaching the dual diagnosis dilemma</strong></p><p>Lize Weich</p><p><strong>64. Women's mental health: Onset of mood disturbance in midlife - Fact or fiction</strong></p><p>Denise White</p><p><strong>65. Failing or faking: Isses in the fiagnosis and treatment of adult ADHD</strong></p><p>Dora Wynchank</p>

Objective Off-protocol prescribing of systemic anti-cancer therapy (SACT) can lead to concerns about effectiveness of patient care. To identify variations in practice, a toolkit was developed for health services to address patient safety and the risk of sub-optimal outcomes for patients. Data sources Following significant incidents with SACT in South Australia and New South Wales, the Department of Health and Human Services, Victoria (the department) conducted an assessment of Victorian public health services to understand current practice regarding SACT protocol governance. A literature review examining SACT auditing was also undertaken to guide improvements. A department supported Chemotherapy Audit Toolkit (CAT) was created for implementation at public hospitals in Victoria. A post-implementation survey was done on uptake and issue identification. Data summary An initial assessment showed that 27% of Victorian public health services were undertaking retrospective review of SACT dosing, which was targeted for improvement. The literature review identified little guidance, however an audit of current sector practices found several audit methodologies. A process that involved audits by health services assessing their own practice was adopted. The toolkit was developed and piloted with health services. A post-implementation survey showed that 20% of services were using the toolkit, 35% were implementing the toolkit and 45% did not use the toolkit. Conclusions The VicTAG CAT has been adopted by more than half of Victorian public health services and is being used to influence prescribing. Implementation of the toolkit has been affected by resource reallocation due to the COVID-19 pandemic. The CAT is available online.

BackgroundEvidence-based clinical practice guidelines recommend discussion by a multidisciplinary team (MDT) to review and plan the management of patients for a variety of cancers. However, not all patients diagnosed with cancer are presented at an MDT.Objectives(1) To identify the factors (barriers and enablers) influencing presentation of all patients to, and the perceived value of, MDT meetings in the management of patients with pancreatic cancer and; (2) to identify potential interventions that could overcome modifiable barriers and enhance enablers using the theoretical domains framework (TDF).MethodsSemistructured interviews were conducted with radiologists, surgeons, medical and radiation oncologists, gastroenterologists, palliative care specialists and nurse specialists based in New South Wales and Victoria, Australia. Interviews were conducted either in person or via videoconferencing. All interviews were recorded, transcribed verbatim, deidentified and data were thematically coded according to the 12 domains explored within the TDF. Common belief statements were generated to compare the variation between participant responses.ResultsIn total, 29 specialists were interviewed over a 4-month period. Twenty-two themes and 40 belief statements relevant to all the TDF domains were generated. Key enablers influencing MDT practices included a strong organisational focus (social/professional role and identity), beliefs about the benefits of an MDT discussion (beliefs about consequences), the use of technology, for example, videoconferencing (environmental context and resources), the motivation to provide good quality care (motivation and goals) and collegiality (social influences). Barriers included: absence of palliative care representation (skills), the number of MDT meetings (environmental context and resources), the cumulative cost of staff time (beliefs about consequences), the lack of capacity to discuss all patients within the allotted time (beliefs about capabilities) and reduced confidence to participate in discussions (social influences).ConclusionsThe internal and external organisational structures surrounding MDT meetings ideally need to be strengthened with the development of agreed evidence-based protocols and referral pathways, a focus on resource allocation and capabilities, and a culture that fosters widespread collaboration for all stages of pancreatic cancer.

ABSTRACT In this work, we describe a SYBR-Green one-step reverse transcription-PCR protocol coupled with a melting temperature analysis (RT-PCR-Tm), which allows the discrimination of influenza B lineages Yamagata and Victoria. The assay is performed using a regular real-time thermocycler and is based on differences in melting temperature (Tm) of a 131-bp amplicon, obtained from a conserved region of hemagglutinin gene. A total of 410 samples collected during the 2004, 2008, and 2010–2017 influenza seasons in Brazil were tested, and the lineages were correctly characterized using their melting profiles. The temperature range is significantly different between both lineages throughout the time (Mann-Whitney test; P < 0.0001, confidence interval = 95%), and the Tm is not affected by viral load (Spearman correlation test; r = 0.287, P = 2.245 × 10−9). The simplicity and cost-effectiveness of this protocol make it an option for influenza B lineage surveillance worldwide.

Introduction: Telemedicine can address limited access to medical specialists in rural hospitals. Stroke provides an important case study because: it is a major cause of disease burden; effective treatments to reduce disability (e.g., thrombolysis) can be provided within the initial hours of stroke onset; careful selection of patients is needed by skilled doctors to minimize adverse events from thrombolysis; and there are major treatment gaps (only about half of regional hospitals in Australia provide thrombolysis for stroke). Few economic analyses have been undertaken on telestroke and the majority have been simulation models. The aim of this protocol and statistical analysis plan is to outline the methods for the cost-effectiveness evaluation of a large, multicentre acute stroke telemedicine program being conducted in Victoria, Australia.Methods: Using a historical- and prospective-controlled design, we will compare patient-level data obtained in the 12 months prior to the Victorian Stroke Telemedicine (VST) program implementation and during the first 12 months of VST to determine the incremental difference in costs and patient outcomes at 3 and 12 months. Secondary aims include assessing the cost per additional patient receiving intravenous thrombolysis and the cost per additional patient receiving intravenous thrombolysis within 60 min. Tertiary aims include assessing the potential longer-term cost-effectiveness in the second year of the program at the hospitals to determine whether any program benefits are sustained once site coordinators are no longer employed; and modeling the potential net life-time costs and benefits from a societal perspective. Multivariable uncertainty and one-way sensitivity analyses will be performed to assess the robustness of results.Results: Sixteen hospitals participated. Patient-level data collection including 12-month outcomes for the cohorts obtained in the first and second year of the program for each hospital was completed in January 2020.Conclusion: The results from this real-world study with patient-level data will provide high quality evidence of the costs, health benefits and policy implications of telestroke programs, including the potential for application in other locations within Australia or other countries with similar health system delivery and financing.

Abstract Background Nearly 50% of men living with HIV in many countries are unaware of their HIV status; men also have lower uptake of HIV treatment and pre-exposure prophylaxis (PrEP). In SSA, highly mobile men such as those working in fishing communities alongside Lake Victoria have low uptake of HIV testing and low rates of linkage to HIV treatment and PrEP, despite increasing availability of these services. HIV self-testing (HIVST) kits hold promise for overcoming barriers to HIV testing and linkage to services for HIV-positive and HIV-negative men. We describe here a protocol for an HIV status-neutral, social network-based approach to promote HIV testing, linkage to care and prevention, and better health outcomes, including adherence, in fishermen around Lake Victoria. Methods Utilizing beach management unit (BMU) registries of fishermen operating in three Lake Victoria fishing communities in Siaya County, Kenya, we completed a census and social network mapping to identify close social networks of men. Network clusters identified by a socially-central lead (“promotor”) and selected to ensure maximal separation between treatment and control will be randomized. Promotors in both arms will receive basic HIV training; intervention promotors are further trained in HIVST to distribute kits to their cluster, while control promotors will distribute to their cluster vouchers for free HIVST at nearby clinics. We will test whether these promoters can enhance linkage to ART and PrEP after self-testing, thereby addressing a key limitation of HIVST. We will also measure 6- and 12-month viral load in those living with HIV and PrEP adherence among those without HIV via urine tenofovir levels as objective markers of adherence. Discussion This study has the potential to improve HIV health and promote HIV prevention among a hard to reach, at-risk, and highly mobile population of men in Western Kenya—a critical population in Kenya’s HIV prevention and treatment program. Further, if successful, this innovative social networks-based model could be scaled at the regional level to address HIV prevention and care among similarly at-risk populations of men in eastern Africa and inland fisheries settings across the continent. Trial registration Self-Test Strategies and Linkage Incentives to Improve ART and PrEP Uptake in Men, registered on February 26, 2021, registration #NCT04772469.

Introduction: Some emergency medical services (EMS) have shown increases in survival from out-of-hospital cardiac arrest (OHCA) following the implementation of a high-performance cardiopulmonary resuscitation (CPR) protocol. Despite this, little is known about the effect of high-performance CPR on OHCA witnessed by EMS personnel. Methods: We performed a retrospective cohort study of adult, EMS-witnessed OHCA patients of medical etiology from a population-based registry in Victoria, Australia. Patients treated after the introduction of a high-performance CPR protocol and training program between February 2019 and January 2020 were compared to historical controls between January 2015 and January 2019. The effect of the intervention on survival to hospital discharge was examined using logistic regression models adjusted for temporal and arrest factors. Results: A total of 1,561 and 420 EMS-witnessed OHCA patients were treated in the control and intervention periods, respectively. Baseline characteristics were similar across control and intervention periods, including the median age of cases (69 vs. 69 years, p=0.97), male sex (65.2% vs. 60.5%, p=0.08) and initial shockable arrests (33.7% vs. 29.3%, p=0.09). Resuscitation interventions were similar across groups, except for the use of mechanical CPR which declined during the intervention period (17.0% vs. 10.7%, p<0.001). Unadjusted survival to hospital discharge was similar across control and intervention periods for the overall population (29.4% vs. 32.1%, p=0.27), but significantly higher during the intervention period for initial shockable arrests (66.6% vs. 76.9%, p=0.03). After adjustment for confounders, cases in the intervention period were associated with a 43% increase (adjusted odds ratio [AOR] 1.43; 95% CI: 1.05, 1.94; p=0.02) in the risk-adjusted odds of survival to hospital discharge or a 79% increase (AOR 1.79, 95% CI: 1.09, 2.95; p=0.02) for initial shockable arrests. Conclusions: The implementation of a high-performance CPR quality improvement intervention was associated with significant improvement in survival from EMS witnessed OHCA. Efforts to monitor and improve CPR performance could yield further improvements in patient outcomes.

Statement about the Abnormal Medical Condition Although disc herniation is the most common etiology of compressive radiculopathy [1,2]. Lumbar radiculopathy is indication to operative surgery [3-5]. Purpose of this study is to show the results of regenerative treatment of compressive radiculo-neuropathy in yung girl without neurosurgical treatment. Case report: patient V., 24 years had been treating in Private Scientific Institute ITHEC “Victoria” for 1 year with diagnosis: vertebral osteochondrosis, hernia disk L5-S1 with rightside lateralization, chronic radicular syndrome, compressive radiculo-neuropathy, disk protrusion L4-5. At the moment of coming patient had complaints on pain and hypestesy in lumbar part of back and in the dorsal surface of thigh rightside and in lateral surface of shin and foot, paresis of right foot and gait disorder. From anamnesis-patient was volleyball player for 10 years. In neurological status was determinate segmental loss of sensitivity and paresis of right foot. MRI showed hernia disk L5-S1 rightside localization, size 16mm and compression of radix S1. Patient refused surgery and got start regenerative treatment by “Protocol of medical care for patient with radiculopathy” №V-14.3.3.4.2.13-M54.1. After 4 hours pain reduced and to finish of 2d month paresis was reduced. For 1 year patient hasn’t pain and performed gymnastic yet. MRI-control of lumbar part of spine showed hernia disk reduce (calcification) to 10 mm. was performed style life modification and patient hasn’t pain and paresis for 3 years. The patient is monitored yet. Findings: Regenerative treatment has anti-inflammatory effect and promotes faster regeneration of the radix and peripheral nerve.

Abstract STUDY QUESTIONS What are the long-term health and reproductive outcomes for young men conceived using ICSI whose fathers had spermatogenic failure (STF)? Are there epigenetic consequences of ICSI conception? WHAT IS KNOWN ALREADY Currently, little is known about the health of ICSI-conceived adults, and in particular the health and reproductive potential of ICSI-conceived men whose fathers had STF. Only one group to date has assessed semen parameters and reproductive hormones in ICSI-conceived men and suggested higher rates of impaired semen quality compared to spontaneously conceived (SC) peers. Metabolic parameters in this same cohort of men were mostly comparable. No study has yet evaluated other aspects of adult health. STUDY DESIGN, SIZE, DURATION This cohort study aims to evaluate the general health and development (aim 1), fertility and metabolic parameters (aim 2) and epigenetic signatures (aim 3) of ICSI-conceived sons whose fathers had STF (ICSI study group). There are three age-matched control groups: ICSI-conceived sons whose fathers had obstructive azoospermia (OAZ) and who will be recruited in this study, as well as IVF sons and SC sons, recruited from other studies. Of 1112 ICSI parents including fathers with STF and OAZ, 78% (n = 867) of mothers and 74% (n = 823) of fathers were traced and contacted. Recruitment of ICSI sons started in March 2017 and will finish in July 2020. Based on preliminary participation rates, we estimate the following sample size will be achieved for the ICSI study group: mothers n = 275, fathers n = 225, sons n = 115. Per aim, the sample sizes of OAZ-ICSI (estimated), IVF and SC controls are: Aim 1—OAZ-ICSI: 28 (maternal surveys)/12 (son surveys), IVF: 352 (maternal surveys)/244 (son surveys), SC: 428 (maternal surveys)/255 (son surveys); Aim 2—OAZ-ICSI: 12, IVF: 72 (metabolic data), SC: 391 (metabolic data)/365 (reproductive data); Aim 3—OAZ-ICSI: 12, IVF: 71, SC: 292. PARTICIPANTS/MATERIALS, SETTING, METHODS Eligible parents are those who underwent ICSI at one of two major infertility treatment centres in Victoria, Australia and gave birth to one or more males between January 1994 and January 2000. Eligible sons are those aged 18 years or older, whose fathers had STF or OAZ, and whose parents allow researchers to approach sons. IVF and SC controls are age-matched men derived from previous studies, some from the same source population. Participating ICSI parents and sons complete a questionnaire, the latter also undergoing a clinical assessment. Outcome measures include validated survey questions, physical examination (testicular volumes, BMI and resting blood pressure), reproductive hormones (testosterone, sex hormone-binding globulin, FSH, LH), serum metabolic parameters (fasting glucose, insulin, lipid profile, highly sensitive C-reactive protein) and semen analysis. For epigenetic and future genetic analyses, ICSI sons provide specimens of blood, saliva, sperm and seminal fluid while their parents provide a saliva sample. The primary outcomes of interest are the number of mother-reported hospitalisations of the son; son-reported quality of life; prevalence of moderate-severe oligozoospermia (sperm concentration &lt;5 million/ml) and DNA methylation profile. For each outcome, differences between the ICSI study group and each control group will be investigated using multivariable linear and logistic regression for continuous and binary outcomes, respectively. Results will be presented as adjusted odds ratios and 95% CIs. STUDY FUNDING/COMPETING INTERESTS This study is funded by an Australian National Health and Medical Research Council Partnership Grant (NHMRC APP1140706) and was partially funded by the Monash IVF Research and Education Foundation. L.R. is a minority shareholder and the Group Medical Director for Monash IVF Group, and reports personal fees from Monash IVF group and Ferring Australia, honoraria from Ferring Australia, and travel fees from Merck Serono, MSD and Guerbet; R.J.H. is the Medical Director of Fertility Specialists of Western Australia and has equity in Western IVF; R.I.M. is a consultant for and a shareholder of Monash IVF Group and S.R.C. reports personal fees from Besins Healthcare and non-financial support from Merck outside of the submitted work. The remaining authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER Not applicable. TRIAL REGISTRATION DATE Not applicable. DATE OF FIRST PATIENT’S ENROLMENT Not applicable.

Abstract Background Males in Australia and many other countries account for three-quarters of all deaths by suicide. School-based programs to support young men’s wellbeing have become increasingly common in recent years and show much promise to tackle the issue of male suicide by fostering protective factors and mitigating harmful factors. However, only a few of these programs have been evaluated. This trial seeks to address the lack of knowledge about the potential for school-based gender-transformative programs to have a positive impact on boys. Breaking the Man Code workshops, delivered by Tomorrow Man in Australia, challenge and transform harmful masculinities with young men with a view to ultimately reducing their suicide risk. The trial aims to examine whether adolescent boys who participate in the Breaking the Man Code workshop demonstrate an increase in their likelihood of seeking help for personal or emotional problems compared to boys waiting to take part in the workshop. Methods A stratified cluster randomized controlled superiority trial with two parallel groups will be conducted. Schools will be randomly allocated 1:1, stratified by location of the schools (rural or urban), state (Victoria, NSW, or WA), and mode of workshop delivery (face-to-face or online), to the intervention group and waitlist control group. Discussion The Breaking the Man Code workshops show great promise as a school-based prevention intervention. The trial will fill a gap in knowledge that is critically needed to inform future interventions with boys and men. Some methodological challenges have been identified related to the COVID-19 pandemic in Australia, such as delays in ethics approvals and the need for Tomorrow Man to introduce an online delivery option for the workshop. The trial protocol has been designed to mitigate these challenges. The findings from the trial will be used to improve the workshops and will assist others who are designing and implementing suicide prevention interventions for boys and men. Trial registration Australian New Zealand Clinical Trials Registry (ACTRN12620001134910). Registered on 30 October 2020

Abstract Background Australian guidelines recommend that all people aged 50–70 years old actively consider taking daily low-dose aspirin (100–300 mg per day) for 2.5 to 5 years to reduce their risk of colorectal cancer (CRC). Despite the change of national CRC prevention guidelines, there has been no active implementation of the guidelines into clinical practice. We aim to test the efficacy of a health consultation and decision aid, using a novel expected frequency tree (EFT) to present the benefits and harms of low dose aspirin prior to a general practice consultation with patients aged 50–70 years, on informed decision-making and uptake of aspirin. Methods Approximately five to seven general practices in Victoria, Australia, will be recruited to participate. Patients 50–70 years old, attending an appointment with their general practitioner (GP) for any reason, will be invited to participate in the trial. Two hundred fifty-eight eligible participants will be randomly allocated 1:1 to intervention or active control arms using a computer-generated allocation sequence stratified by general practice, sex, and mode of trial delivery (face-to-face or teletrial). There are two co-primary outcomes: informed decision-making at 1-month post randomisation, measured by the Multi-dimensional Measure of Informed Choice (MMIC), and self-reported daily use of aspirin at 6 months. Secondary outcomes include decisional conflict at 1-month and other behavioural changes to reduce CRC risk at both time points. Discussion This trial will test the efficacy of novel methods for implementing national guidelines to support informed decision-making about taking aspirin in 50–70-year-olds to reduce the risk of CRC and other chronic diseases. Trial registration The Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620001003965. Registered on 10 October 2020.

Abstract Background No conclusive evidence recommends a prior treatment for insertional Achilles tendinopathy (IAT). It is theorized that both percutaneous radiofrequency coblation and extracorporeal shockwave therapy (ESWT) relieve pain within the insertion. However, no clinical evidence shows that either treatment promotes the regeneration of the tendon or if the combination of these 2 interventions offers better function and less pain than one therapy. Methods The study is a randomized, controlled trial with patients allocated in a 1:1 ratio to one of two parallel groups. Patients with insertional Achilles tendinopathy who are not satisfied with the effect of conservative treatment will be screened. A minimum of 38 patients will be enrolled after deciding to participate in the trial on an informed basis. Then the intervention group and the control group perform radial ESWT and sham-ESWT respectively at 6 months after percutaneous radiofrequency coblation. The primary outcome will be the Victorian Institute of Sports Assessment Achilles (VISA-A) Score. Secondary outcome measures will be Foot and Ankle Outcome Score (FAOS) scale, visual analog scale (VAS), Tegner Score, and MRI ultra-short echo time (UTE) T2* value. The assessments will occur in 6 months, 1 year, and 2 years, post-operatively. The differences between the 2 groups will be conducted as intention-to-treat basis. Discussion We aim to investigate if radiofrequency coblation associated with ESWT can provide more encouraging imaging findings as well as functional and clinical outcomes regarding the treatment of the IAT comparing to the single radiofrequency coblation treatment. Trial registration ChiCTR1800017898; pre-results. Registered on 20 August 2018.

Abstract Objectives Primary objective: To determine the efficacy of a candidate antiviral on time to virological cure compared to standard of care within 14 days of randomisation Secondary objectives: • To determine the safety of the antiviral • To determine the clinical benefit of the antiviral over placebo according to the WHO 7-point ordinal scale • To determine the clinical benefit of the antiviral over placebo on time to resolution of clinical symptoms • To determine the effect of the antiviral over placebo on biomarkers of inflammation and immune activation Trial design This is a multi-centre, triple-blind, randomised placebo controlled phase II, 2-arm trial with parallel-group design with allocation ratio 1:1. Participants Inclusion Criteria: • Provision of informed consent by the participant • Age ≥18 years • Confirmed SARS-CoV-2 by nucleic acid testing in the past 5 days • COVID-19 related symptom initiation within 5 days • Female patients of childbearing potential must have a negative pregnancy test at Screening. Female patients of childbearing potential and fertile male patients who are sexually active with a female of childbearing potential must use highly effective methods of contraception throughout the study and for 1 week following the last dose of study treatment. Exclusion criteria: • Known allergy to the study medication • Is on another clinical trial investigating an antiviral treatment for COVID-19 • Pregnancy • Patients with severe hepatic dysfunction equivalent to Grade C in the Child-Pugh classification • Patients with renal impairment requiring dialysis • Is deemed by the Investigator to be ineligible for any reason Participants will be recruited from, and the study visits will take place at Alfred Hospital, Monash Health, Austin Health in Victoria, Australia for hospitalised participants as well as recruitment in the community in participants homes for eligible people not requiring hospitalisation. Intervention and comparator The first candidate antiviral is favipiravir Arm 1: Favipiravir 1800 mg favipiravir BD on Day 1 followed by 800 mg BD favipiravir for the next 13 days. Arm 2: Placebo Main outcomes Primary outcome: Time to virological cure as defined by 2 successive throat (or combined nose/throat) swabs negative for SARS-CoV-2 by nucleic acid testing during the 14 days after enrolment. Randomisation Randomisation performed at the Alfred Hospital Clinical Trials Pharmacy using computer generated block-randomisation lists with 6 participants per block. Within each block half of the participants will be randomised to the candidate antiviral and the other half to placebo. Randomisation is stratified by study site, with participants enrolled in the community considered as a study site. Blinding (masking) Study participants, study investigators and the study statistician will be blinded to treatment allocation. Numbers to be randomised (sample size) The study aims to recruit 190 people (95/arm) with the first candidate antiviral favipiravir Trial Status Protocol version 2.0 Dated 31-Jul-2020. Recruitment will take place between July 2020 and December 2020. Trial registration clinicaltrials.gov NCT04445467 First posted 24-Jun-2020 Full protocol The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

Abstract Background Assuming that the mechanisms inducing adaptation in healthy tendons yield similar responses in tendinopathic tendons, we hypothesized that a high-loading exercise protocol that increases tendon stiffness and cross-sectional area in male healthy Achilles tendons may also induce comparable beneficial adaptations in male tendinopathic Achilles tendons in addition to improving pain and function. Objectives We investigated the effectiveness of high-loading exercise in Achilles tendinopathy in terms of inducing mechanical (tendon stiffness, maximum strain), material (Young’s modulus), morphological (tendon cross-sectional area (CSA)), maximum voluntary isometric plantar flexor strength (MVC) as well as clinical adaptations (Victorian Institute of Sports Assessment—Achilles (VISA-A) score and pain (numerical rating scale (NRS))) as the primary outcomes. As secondary outcomes, drop (DJ) and counter-movement jump (CMJ) height and intratendinous vascularity were assessed. Methods We conducted a controlled clinical trial with a 3-month intervention phase. Eligibility criteria were assessed by researchers and medical doctors. Inclusion criteria were male sex, aged between 20 and 55 years, chronic Achilles tendinopathy confirmed by a medical doctor via ultrasound-assisted assessment, and a severity level of less than 80 points on the VISA-A score. Thirty-nine patients were assigned by sequential allocation to one of three parallel arms: a high-loading intervention (training at ~ 90% of the MVC) (n = 15), eccentric exercise (according to the Alfredson protocol) as the standard therapy (n = 15) and passive therapy (n = 14). Parameters were assessed pre- and-post-intervention. Data analysis was blinded. Results Primary outcomes: Plantar flexor MVC, tendon stiffness, mean CSA and maximum tendon strain improved only in the high-loading intervention group by 7.2 ± 9.9% (p = 0.045), 20.1 ± 20.5% (p = 0.049), 8.98 ± 5.8% (p < 0.001) and −12.4 ± 10.3% (p = 0.001), respectively. Stiffness decreased in the passive therapy group (−7.7 ± 21.2%; p = 0.042). There was no change in Young’s modulus in either group (p > 0.05). The VISA-A score increased in all groups on average by 19.8 ± 15.3 points (p < 0.001), while pain (NRS) dropped by −0.55 ± 0.9 points (p < 0.001). Secondary outcomes: CMJ height decreased for all groups (−0.63 ± 4.07 cm; p = 0.005). There was no change in DJ height and vascularity (p > 0.05) in either group. Conclusion Despite an overall clinical improvement, it was exclusively the high-loading intervention that induced significant mechanical and morphological adaptations of the plantar flexor muscle–tendon unit. This might contribute to protecting the tendon from strain-induced injury. Thus, we recommend the high-loading intervention as an effective (alternative) therapeutic protocol in Achilles tendinopathy rehabilitation management in males. Clinical Trials Registration Number: NCT02732782.

Abstract Objectives The aim of the RAAS-COVID-19 randomized control trial is to evaluate whether an upfront strategy of temporary discontinuation of renin angiotensin aldosterone system (RAAS) inhibition versus continuation of RAAS inhibition among patients admitted with established COVID-19 infection has an impact on short term clinical and biomarker outcomes. We hypothesize that continuation of RAAS inhibition will be superior to temporary discontinuation with regards to the primary endpoint of a global rank sum score. The global rank sum score has been successfully used in previous cardiovascular clinical trials. Trial design This is an open label parallel two arm (1,1 ratio) randomized control superiority trial of approximately 40 COVID-19 patients who are on chronic RAAS inhibitor therapy. Participants Adults who are admitted to hospital within the McGill University Health Centre systems (MUHC) including Royal Victoria Hospital (RVH), Montreal General Hospital (MGH) and Jewish General Hospital (JGH) and who are within 96 hours of COVID-19 diagnosis (confirmed via PCR on any biological sample) will be considered for the trial. Of note, the initial protocol to screen and enrol within 48 hours of COVID-19 diagnosis was extended through an amendment, to 96 hours to increase feasibility. Participants have to be 18 years or older and would have to be on RAAS inhibitors for at least a month to be considered eligible for the study. Additionally, RAAS inhibitors should not have been held for more than 48 hours before randomization. A list of inclusion and exclusion criteria can be found in the full protocol document. In order to prevent heart failure exacerbation, patients with reduced ejection fraction were excluded from the trial. Once a patient is admitted on the ward with a diagnosis of COVID-19, we will confirm with the treating physician if the participant is suitable for the RAAS-COVID trial and meets all the inclusion and exclusion criteria. If the patient is eligible and informed consent has been obtained we will collect data on sex, age, ethnicity, past medical history and list of medications (e.g. other anti-hypertensives or anticoagulants), for further analysis. Intervention and comparator All the study participants will be randomized to a strategy of temporarily holding the RAAS inhibitor [intervention] versus continuing the RAAS inhibitor [continued standard of care]. Among participants who are randomized to the intervention arm, alternative guide-line directed anti-hypertensive medication will be provided to the treating physician team (detail in study protocol). In the intervention arm RAAS inhibitor will be withheld for a total of 7 days with the possibility of the withdrawn medication being initiated at any point after day 7 or on the day of discharge. The recommendation for re-initiating the withdrawn medication will be made to the treating physician. The re-initiation of these therapies are according to standard convention and follow-up as per Canadian guidelines. Additionally, the date of restarting the withdrawn medication or whether the medication was re-prescribed on discharge or not, will be collected. This will be used to conduct a sensitivity analysis. Furthermore, biomarkers such as troponin, c-reactive protein (CRP) and lymphocyte count will be assessed during the same time period. Samples will be collected on randomization, day 4 and day 7. Main outcomes Primary endpoint In this study the primary end point is a global rank score calculated for all participants, regardless of treatment assignment ( score from 0 to 7). Please refer to table 4 in the full protocol. In the context of the current trial, it is estimated that death is the most meaningful endpoint, and therefore has the highest score ( score of 7). This is followed by admission to ICU, the need for mechanical ventilation etc. The lowest scores ( score of 1) are assigned to biomarker changes (e.g. change in troponin, change in CRP). This strategy has been used successfully in cardiovascular disease trials and therefore is applicable to the current trial. The primary endpoint for the present trial is assessed from baseline to day 7 (or discharge). Participants are ranked across the clinical and biomarker domains. Lower values indicate better health (or stability). Participants who died during the 7th day of the study will be ranked based on all events occurring before their death and also including the fatal event in the score. Next, participants who did not die but were transferred to ICU for invasive ventilation will be ranked based on all the events occurring before the ICU entry and also including the ICU admission in the score. Those participants who did not die were not transferred to ICU for invasive ventilation, will be ranked based on the subsequent outcomes. The mean rank score will then be compared between groups. In this scheme, a lower mean rank score indicates greater overall stability for participants. Secondary endpoints : The key secondary endpoints are the individual components of the primary components and include the following: death, transfer to ICU primarily for invasive ventilation, transfer to ICU for other indication, non-fatal MACE ( any of following, MI, stroke, acute HF, new onset Afib), length of stay > 4 days, development of acute kidney injury ( > 40% decline in eGFR or doubling of serum creatinine), urgent intravenous treatment for high blood pressure, 30% increase in baseline high sensitivity troponin, 30% increase in baseline BNP, increase in CRP to > 30% in 48 hours and lymphocyte count drop> 30%. We will also look at the World Health Organization (WHO) ordinal scale for clinical improvement (in COVID-19) in our data. In this scale death will be assigned the highest score of 8. Patients with no limitation of activity will be assigned a score of 1 which indicates overall more stability (3). Additionally, we will evaluate the potential effects of discontinuing RAAS inhibition on alternative schedules (longer/shorter than 7 days, intermittent discontinuation) using a mechanistic mathematical model of COVID-19 immunopathology calibrated to data collected from our patient cohort. In particular, we will assess the impact of alternative schedules on primary and secondary endpoints including increases to baseline CRP and lymphocyte counts. Randomization Participants will be randomized in a 1:1 ratio. Randomization will be performed within an electronic database system at the time of enrolment using a random number generator, an approach that has been successfully used in other clinical trials. Neither participant, study team, or treating team will be blinded to the intervention arm. Blinding This is an open label study with no blinding. Numbers to be randomised (sample size) The approximate number of participants required for this trial is 40 patients (randomized 1:1 to continuation versus discontinuation of RAAS inhibitors). This number was calculated based on previous rates of outcomes for COVID-19 in the literature (e.g. death, ICU transfer) and statistical power calculations. Trial Status Protocol number: MP-37-2021-6641, Version 4: 01-10-2020. Trial start date September 1st 2020 and currently enrolling participants. Estimated end date for recruitment of participants : July 2021. Estimated end date for study completion: September 1st 2021. Trial registration Trial registration: ClincalTrials.gov: NCT04508985, date of registration: August 11th , 2020 Full protocol The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

Surgery Design: A case series study Purpose: 1) To study the protocol for repair of incisional hernia. 2) To compare different other methods of repair given in literature with prosthetic mesh repair in terms of advantages / disadvantages of the prosthetic repair. Suit & period: The study was conducted in Surgical Unit, Bahawal Victoria Hospital, Bahawalpur from August 19, 1997 to January 31, 2000. Material & method: This was a prospective type of case series study. Selection criteria of the patients in this study was that all adult patients of either sex being diagnosed as the case of incisional hernia and have undergone repair by the prosthetic mesh during this study period were included in the study. A record of patient`s data, previous surgery, the size of the defect, which gives idea about indication for surgery, was noted. A record of their postoperative course and a follow-up for four months was made. Results: In this study we have included 23 patients. Out of these 15 were female and 8 were male. The age was ranging from 28 - 65 years, with an average of 43 years. Patients presented with pain/ discomfort, Gradual increase in size of defect and unacceptable appearance in all patients, sub acute obstruction in 3 patients, Intestinal obstruction in 2 patients & Skin ulceration in 2 patients. Ten patients had got uneventful satisfactory post-operative course. Six patients developed wound infection; one patient developed seroma & was cured by needle aspiration & antibiotic. Five patients developed sinus. 2 of them cured without any surgical intervention with antiseptic dressings and antibiotics after culture and sensitivity. 3 needed exploration, 2 of them cured satisfactorily but in 1 patient because of continuing infection mesh was removed after one year and recurrence took place. No mortality, enterocutaneous fistula or haematoma was noted. One patient developed MY D.V.T. and was managed by Medical advice. Conclusion: Although wide variety of procedures has been adopted for recurrent ventral hernia repair. The prosthetic repair with prolene mesh is most cost effective and efficient method of dealing with incisional hernia.

In February 2021, during the third COVID-19 lockdown in the state of Victoria, Australia, artist Shaun Wilson used the teleconferencing platforms Teams and Skype to create a slow cinema feature length artwork titled Fading Light to demonstrate how innovative creative practice can overcome barriers of distance experienced by creative practitioners from the limitations sustained during the COVID-19 pandemic. While these production techniques offer free access to develop new methodologies through practice, the wider scope of pandemic lockdowns mediated artists with teleconferencing as a tool to interrogate the nature of life during our various global lockdowns. It thus afforded a pioneering ability for artists to manufacture artwork about lockdowns whilst in lockdown, made from the tools commonly used for virtual communication. The significance of such opportunities, as this article will argue, demonstrates a novel approach to making artwork about COVID-19 in ways that were limited prior to the start of 2020 in terms of commonality, that now are “turning us all into broadcasters, streamers and filmmakers” (Sullivan). However, as we are only just becoming familiar with the cultural innovation pioneered from the limitations brought about by the pandemic, new aesthetics are emerging that challenge normative traditions of manufacturing and thinking about creative artefacts. Teleconferencing platforms were used differently prior to 2020 when compared to the current pandemic era. Throughout the 2000s and 2010s, there were no global gigascale movement restrictions or medical dangers to warrant a global shutdown that would ultimately determine how a person interacts with public places. In a pre-pandemic context, the daily use of teleconferencing was a luxury. Its subsequent use in the COVID-19 era became a necessity in many parts of day-to-day life. As artists have historically been able to comment through their work on global health crises, how has contemporary art responded since 2020 in using teleconferencing within critical studio practice? To explore such an idea, this article will probe examples of practice from artists making artworks with teleconferencing about pandemics during the COVID-19 pandemic. Discussion will purposely not consider a wider historical scope of teleconferencing in art and scholarship as the context in this article explicitly addresses art made in and commenting on the COVID-19 pandemic using the tools of lockdown readily available through teleconferencing platforms. It will instead concentrate on three artists addressing the pandemic during 2020 and 2021. The first example will be There Is No Such Thing as Internet from Polish artists Maria Magdalena Kozlowska and Maria Tobola, “performers who identify as one artist, Maria Małpecki” (“Pogo”). The second example is New York artist Michael Mandiberg’s Uncle Bob 85th Birthday via Zoom 3:00-4:00PM, August 16, 2020 (#24), from the series Zoom Paintings. The third example is Australian artist Shaun Wilson’s Fading Light. These works will be discussed as a means of considering teleconferencing as a contemporary art medium used in response to COVID-19 and art made as pandemic commentary through the technology that has defined its global social integration. Figure 1: Maria Małpecki, There Is No Such Thing as Internet, used with permission. There Is No Such Thing as Internet was presented as a live stream on 7 May 2020 and as an online video between 7-31 May 2020 in the “Online Cocktail Party with Maria Małpecki” at Pogo Bar, KW Institute for Contemporary Art, Berlin by Maria Małpecki and curator Tomek Pawlowski Jarmolajew (“Pogo”). The work represents a twenty-minute livestream essay created in part by a teleconferencing video call performance and appropriated video streams. This includes video chat examples from Chomsky and Žižek, compiled together through intertextual video collages which The Calvert Journal described as a work “that explore[s] identity and different modes of communication in times of isolation” (De La Torre). One of the key strengths of this work in terms of teleconferencing is how it embraces the medium as an integral part of the performative methodology. To such an extent, one might argue that if it was removed and replaced by traditional video camera shots, which do feature in the video but are not the main aesthetic driver, the Metamodernist troupe of Małpecki’s videos would not perform the same critique of the pandemic. So, for Małpecki to comment on isolation through the Internet requires video calls to be central in the artwork in order for it to hold the cultural value it embeds through the subject. The conceptual framework relies on short segments to create episodic moments reliant on philosophical laments relating to each part of the work. For example, the first act unfolds with a montage of short video clip collages reminiscent of the quick-clip YouTube browsing habit culture from the pandemic to expedite an argument that indeed, there really is no singular internet. Rather, from this, what we are experiencing is arguably something else entirely. From here we move to the second act titled “We wake up in a different room every morning. We wander in a labyrinth where most doors are already open” (Małpecki); but as Małpecki comments, “sometimes our job is to shut them”. The sequence evolves into a disorientating dual screen sequence of the artists panicking to what they are viewing on screen. What this is exactly remains unclear. It may be us as the audience or something else as Malpecki holds their webcam devices upside down to provide an unnerving menage amidst the screams and exacerbations that invites spatial disorientation as a point of engagement for the viewer. As we recognise that video call protocols during the pandemic are visually static and that normative ‘rules’ of video calls require stabilised video and clean sound, Małpecki subverts these protocols to that of an uncomfortable, anarchic performance. It's at odds with the gentility of video call aesthetics which, in the case of this artwork, is more like watching a continuous point of view shot from a participant on a roller coaster or an extreme fairground ride. As the audience moves through each of the eclectic acts, this randomness laments a continuity that, sometimes satirical and at other times sublime, infuses the silliness and obliqueness of habitual lockdown video viewing. Even the most mundane of videos we watch to pass the time have become anthems of the COVID-19 era as a mixture of boredom, stupidity, and collective grief. Małpecki’s work in this regard becomes a complex observation for a society in crisis. It eloquently uses video calls as a way to comment on what this article argues to be an important cultural artefact in contemporary art’s response to COVID-19. Just as Goya subverted the Venetian pandemic in the grim Plague Hospital, Małpecki reflects our era in the same disruptive way by using frailty as a mirror to reveal an uneasy reflection masked in satirical obscurity, layered with fragments of the Internet and its subjective “other”. Figure 2: Michael Mandiberg, Uncle Bob 85th Birthday via Zoom 3:00-4:00PM, August 16, 2020 (#24), used with permission. Conversely, the work of New York artist Michael Mandiberg uses teleconferencing in a different way by painting the background of video calls onto stretched canvases mostly over the duration of the actual call time. Yet in doing so, the removal of people from inside the frame highlights aspects of isolation and absence in lockdown. At the Denny Dinin Gallery exhibition in New York, The Zoom Paintings “presented in the digital sphere where they were born” (Defoe). Zoom provided both the frame and the exhibition space for these works, with “one painting … on view each day [on Zoom], for a total of ten paintings” (“Zoom”). Describing the works, Mandiberg states that they are “about the interchangeability of people and places. It’s not memorializing a particular event; it’s memorializing how unmemorable it is” (Mandiberg; Defoe). This defines an innovative approach to teleconferencing that engages with place in times when the same kinds of absence experienced in the images of peopleless Zoom video calls mirror the external absence of people in public places during lockdown. Uncle Bob 85th Birthday via Zoom 3:00-4:00PM, August 16, 2020 (#24) is time stamped with the diaristic nature of the Zoom Paintings series. These works are not just a set of painting subjects interlinked through a common theme of paintings ‘about Zoom backgrounds’. They, rather, operate as a complex depiction of absence located in the pandemic, evidently capturing a powerful social commentary about what the artist experienced during these times. In doing so, it immediately prompts the viewer into tensions that conceptually frame COVID-19, whether that be the isolation of waiting out the pandemic in lockdown, the removal of characters through illness from the virus, or even a sudden death from the virus itself. The camera’s point of view illustrates an empty space where we know something is missing. At the very least the artist suggests that someone nearby once inhabited these empty spaces but they are, at present, removed from the scene or have vanished altogether. On 16 August 2020, the day that the painting was made, the New York Times estimated that 514 people in the United States died from COVID-19 (“Coronavirus”). When measured against a further death rate peaking at 5,463 people in the United States who died on 11 February 2021, the catastrophic mortality data in the United States alone statistically supports Mandiberg’s lament as to the severity of the pandemic, which serves as the context of his work. Based on this data alone, the absence in Mandiberg’s paintings intensifies a sense of isolation and loss insofar as the subjectivity embedded within the video call frame speaks to a powerful way that contemporary art is providing commentary during the pandemic (“Coronavirus”). Art in this context becomes a silent observer using teleconferencing to address both what is taken away from us and what visually remains behind. This article acknowledges the absence in Mandiberg’s paintings as a timely reminder of the socio-devastation experienced in the pandemic’s wake. Therein lies a three-folded image within an image within an image, not unlike what we see in Blade Runner when Deckard’s Esper Machine investigates the reflection in a mirror of someone else, and no more vivid than in Van Eyck’s Arnolfini Portrait. From a structural point of view, we witness Mandiberg’s images during its exhibition on Zoom in much the same conceptual way. In this case though, it is a mirrored online image of an image painted from a video call interpreted online from a recorded image transmitted online through teleconferencing. Through similar transactions, Shaun Wilson’s utilisation of video calls is represented in Fading Light as a way to comment on COVID-19 through the lens of Teams and Skype. The similarities of Fading Light to There Is No Such Thing as Internet stem obviously from the study of figuration used as the driver of the works but at the same time, it also draws comparison with Mandiberg’s stillness as represented in the frozen poses of each figure. At a more complex level, there is, though, a polar opposite in the mechanics that, for Mandiberg, uses video to translate into painted subjects. Fading Light does the opposite, with paintings recontextualised into video subjects. Such an analysis of both works brings about a sense of trepidation. For Mandiberg, it is the unsettling stillness through absence. In Fading Light it is the oppressive state of the motionlessness in frame that offers the same sense of awkwardness found in Mandiberg’s distorted painted laptop angles, and that makes the same kind of uncomfortableness bearable. It is only as much as an audience affords the time to allow before the loneliness of the subject renders the Zoom paintings a memorial to what is lost. Of note in Fading Light are the characteristically uncomfortable traits of what we detect should be in the frame of the subject but isn’t, which lends a tension to the viewer who has involuntarily been deprived of what is to be expected. For a modern Internet audience, a video without movement invites a combination of tension, boredom, and annoyance, drawing parallels to Hitchcock’s premise that something has just happened but we’re not entirely sure exactly what it was or is. Likewise, Małpecki’s same juxtaposition of tension with glimpses of Chomsky and Žižek videos talking over each other is joined by the artists’ breaking the fourth wall of cinema theory. Observing the artists lose concentration while watching the other videos in the video call scenario enact the mundane activities we encounter in the same kinds of situations of watching someone else on Zoom. However, in this context, we are watching them watching someone else whom we are also watching, while watching ourselves at the same time. Figure 3: Shaun Wilson, Fading Light, used with permission. The poses in Fading Light are reconfigured from characters in German medieval paintings and low relief religious iconography created during the Black Death era. Such works hang in the Gothic St. Michael’s Church in Schwäbisch Hall in Germany originally used by Martin Luther as his Southern Germany outpost during the Reformation. Wilson documented these paintings in October 2006, which then became the ongoing source images used in the 51 Paintings Suite films. The church itself has a strong connection to pandemics where a large glass floor plate behind the altar reveals an open ossuary of people who died of plague during the Black Death. This association brings an empirical linkage to the agency in Fading Light that mediates the second handed nature of the image, initially painted during a medieval pandemic, and now juxtaposed into the video frame captured in a current pandemic. From a conceptual standpoint, the critical analysis reflected in such a framework allows the artwork to reveal itself at a multi-level perspective, operating within a Metamodernist methodology. Two separate elements oscillate in tandem with one another, yet completely independent, or in this case, impervious to each other’s affect. Fading Light’s key affordance from this oscillation consolidate Wilson’s methodology in the artwork in as much detail as what Małpecki and Mandiberg construct in their respective works, yet obviously for very different motivations. If the basis of making video art in the pandemic using teleconferencing changes the way we might think about using these platforms, which otherwise may not have previously been taken serious by the academy as a valid medium in art, then the quiet meaningfulness throughout the film transcends a structured method to ascertain a pictorial presence of the image in its facsimile state. This pays respect to the source images but also embraces and overlays the narrative of the current pandemic intertwined within the subject. Given that Fading Light allows a ubiquitous dialogue to grow from the framed image, a subjective commonality in these mentioned works provide insight into how artists have engaged innovation strategies with teleconferencing to develop artwork made and commenting about the current pandemic. Whether it be Małpecki’s subversive pandemic variety show, the loneliness of Mandiberg’s Zoom call paintings or Wilson’s refilming of Black Death era paintings, all three artists use video call platforms as a contemporary art medium capable of social commentary during histo-trauma. These works also raise the possibility of interdisciplinary Metamodernist approaches to consider the implications of non-traditional mediums in offering socio-commentary during profoundly impactful times. It remains to be seen if contemporary video call platforms will become a frequented tool in contemporary art long after the COVID-19 pandemic is over. However, by these works and indeed, from the others to follow and not yet revealed, the current ossuary provides an opportunity for artists to respond to their own immediate surroundings to redefine existing boundaries in art and look to innovation in the methods they use. We are in a new era of art making, only now beginning to reveal itself. It may take years or even decades to better understand the magnitude of the significance that artists have contributed towards their own practices since the beginnings of the pandemic. This time of profound change only strengthens the need for contemporary art to preserve and enlighten humanity through the journey from crisis to hope. References Blade Runner. Dir. by Ridley Scott, Warner Brothers, 1982. “Coronavirus US Cases.” New York Times, 27 Mar. 2021. 28 Mar. 2021 <http://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html>. Defoe, Taylor. “‘It's Memorializing How Unmemorable It Is’: Artist Michael Mandiberg on Painting Melancholy Portraits on Zoom.” Artnet News 10 Nov. 2020. 19 Mar. 2021 <http://news.artnet.com/exhibitions/mandiberg-zoom-paintings-1922159>. De La Torre, Lucia. “Art in the Age of Zoom: Explore the Video Art Collage Unraveling the Complexities of the Digital Age.” The Culvert Journal, 5 May 2020. 19 Mar. 2021 <https://www.calvertjournal.com/articles/show/11788/online-performance-art-polish-artist-maria-malpecki-digital-age>. Goya, Francisco. Plaga Hospital. Private Collection. 1800. Małpecki, Maria. There Is No Such Thing as Internet. Vimeo, 2020. <http://vimeo.com/415998383>. Mandiberg, Michael. Uncle Bob 85th Birthday via Zoom 3:00-4:00PM, August 16, 2020 (#24). New York: Denny Dinin Gallery, 2020. “Pogo Bar: Maria Małpecki & Tomek Pawłowski Jarmołajew.” KW Institute for Contemporary Art, 7 May 2020. 19 Mar. 2021 <http://www.kw-berlin.de/en/maria-malpecki-tomek-pawlowski-jarmolajew/>. Sullivan, Eve. “Video Art during and after the Pandemic: 2020 Limestone Coast Video Art Festival.” Artlink, 2020. 19 Mar. 2021 <http://www.artlink.com.au/articles/4885/video-art-during-and-after-the-pandemic-2020-limes/>. Van Eyck, Jan. Arnolfini Portrait. Canberra: National Gallery, 1434. Wilson, Shaun. Fading Light. Bakers Road Entertainment, 2021. “The Zoom Paintings.” Denny Dimin Gallery, 12 Nov. 2020. <http://dennydimingallery.com/news/virtual_exhibition/zoom-paintings/>.

Introduction It is now commonplace for babies to begin their lives inhabiting media environments characterised by the presence, distribution, and mobility of digital devices and screens. Such arrangements can be traced, in part, to the birth of a new regime of mobile and touchscreen media beginning with the release of the iPhone in 2007 and the iPad in 2010, which stimulated a surge in household media consumption, underpinned by broadband and wireless Internet infrastructures. Research into these conditions of ambient mediation at the beginnings of life, however, is currently dominated by medical and educational literature, largely removed from media studies approaches that seek to understand the everyday contexts of babies using media. Putting aside discourses of promise or peril familiar to researchers of children’s media (Buckingham; Postman), this paper draws on ongoing research in both domestic and social media settings exploring infants’ everyday encounters and entanglements with mobile media and communication technologies. The paper identifies the ways infants’ mobile communication is assembled and distributed through touchscreen interfaces, proxy parent users, and commercial software sorting. It argues that within these interfacial, intermediary, and interactive contexts, we can conceptualise infants’ communicative agency through an emerging repertoire of techniques: accidental, assisted and automated. This assemblage of infant communication recognises that children no longer live with but in media (Deuze), which underscores the impossibility of a path of media resistance found in medical discourses of ‘exposure’ and restriction, and instead points to the need for critical and ethical responses to these immanent conditions of infant media life. Background and Approach Infants, understandably, have largely been excluded from analyses of mobile mediality given their historically limited engagement with or capacity to use mobile media. Yet, this situation is undergoing change as mobile devices become increasingly prominent in children’s homes (OfCom; Rideout), and as touchscreen interfaces lower thresholds of usability (Buckleitner; Hourcade et al.). The dominant frameworks within research addressing infants and media continue to resonate with long running and widely circulated debates in the study of children and mass media (Wartella and Robb), responding in contradictory ways to what is seen as an ever-increasing ‘technologization of childhood’ (McPake, Plowman and Stephen). Education research centres on digital literacy, emphasising the potential of mobile computing for these future digital learners, labourers, and citizens (McPake, Plowman and Stephen). Alternatively, health research largely positions mobile media within the rubric of ‘screen time’ inherited from older broadcast models, with paediatric groups continuing to caution parents about the dangers of infants’ ‘exposure’ to electronic screens (Strasburger and Hogan), without differentiating between screen types or activities. In turn, a range of digital media channels seek to propel or profit from infant media culture, with a number of review sites, YouTube channels and tech blogs promoting or surveying the latest gadgets and apps for babies. Within media studies, research is beginning to analyse the practices, conceptions and implications of digital interfaces and content for younger children. Studies are, for example, quantifying the devices, activities, and time spent by young children with mobile devices (Ofcom; Rideout), reviewing the design and marketing of children’s mobile application software products (e.g. Shuler), analysing digital content shared about babies on social media platforms (Kumar & Schoenebeck; Morris), and exploring emerging interactive spaces and technologies shaping young children’s ‘postdigital’ play (Giddings; Jayemanne, Nansen and Apperley). This paper extends this growing area of research by focusing specifically on infants’ early encounters, contexts, and configurations of mobile mediality, offering some preliminary analysis of an emerging repertoire of mobile communication techniques: accidental, assisted, and automated. That is, through infants playing with devices and accidentally activating them; through others such as parents assisting use; and through software features in applications that help to automate interaction. This analysis draws from an ongoing research project exploring young children’s mobile and interactive media use in domestic settings, which is employing ethnographic techniques including household technology tours and interviews, as well as participant observation and demonstrations of infant media interaction. To date 19 families, with 31 children aged between 0 and 5, located in Melbourne, Australia have participated. These participating families are largely homogeneous and privileged; though are a sample of relatively early and heavy adopters that reveal emerging qualities about young children’s changing media environments and encounters. This approach builds on established traditions of media and ethnographic research on technology consumption and use within domestic spaces (e.g. Mackay and Ivey; Silverstone and Hirsch), but turns to the digital media encountered by infants, the geographies and routines of these encounters, and how families mediate these encounters within the contexts of home life. This paper offers some preliminary findings from this research, drawing mostly from discussions with parents about their babies’ use of digital, mobile, and touchscreen media. In this larger project, the domestic and family research is accompanied by the collection of online data focused on the cultural context of, and content shared about, infants’ mobile media use. In this paper I report on social media analysis of publicly shared images tagged with #babyselfie queried from Instagram’s API. I viewed all publicly shared images on Instagram tagged with #babyselfie, and collected the associated captions, comments, hashtags, and metadata, over a period of 48 hours in October 2014, resulting in a dataset of 324 posts. Clearly, using this data for research purposes raises ethical issues about privacy and consent given the posts are being used in an unintended context from which they were originally shared; something that is further complicated by the research focus on young children. These issues, in which the ease of extracting online data using digital methods research (Rogers), needs to be both minimised and balanced against the value of the research aims and outcomes (Highfield and Leaver). To minimise risks, captions and comments cited in this paper have been de-identified; whist the value of this data lies in complementing and contextualising the more ethnographically informed research, despite perceptions of incompatibility, through analysis of the wider cultural and mediated networks in which babies’ digital lives are now shared and represented. This field of cultural production also includes analysis of examples of children’s software products from mobile app stores that support baby image capture and sharing, and in particular in this paper discussion of the My Baby Selfie app from the iTunes App Store and the Baby Selfie app from the Google Play store. The rationale for drawing on these multiple sources of data within the larger project is to locate young children’s digital entanglements within the diverse places, platforms and politics in which they unfold. This research scope is limited by the constraints of this short paper, however different sources of data are drawn upon here in order to identify, compare, and contextualise the emerging themes of accidental, assisted, and automated. Accidental Media Use The domestication and aggregation of mobile media in the home, principally laptops, mobile phones and tablet computers has established polymediated environments in which infants are increasingly surrounded by mobile media; in which they often observe their parents using mobile devices; and in which the flashing of screens unsurprisingly draws their attention. Living within these ambient media environments, then, infants often observe, find and reach for mobile devices: on the iPad or whatever, then what's actually happening in front of them, then naturally they'll gravitate towards it. These media encounters are animated by touchscreens interfaces that are responsive to the gestural actions of infants. Conversely, touchscreen interfaces drive attempts to swipe legacy media screens. Underscoring the nomenclature of ‘natural user interfaces’ within the design and manufacturer communities, screens lighting up through touch prompts interest, interaction, and even habituation through gestural interaction, especially swiping: It's funny because when she was younger she would go up the T.V. and she would try swiping to turn the channel.They can grab it and start playing with it. It just shows that it's so much part of their world … to swipe something. Despite demonstrable capacities of infants to interact with mobile screens, discussions with parents revealed that accidental forms of media engagement were a more regular consequence of these ambient contexts, interfacial affordances and early encounters with mobile media. It was not uncommon for infants to accidentally swipe and activate applications, to temporarily lock the screen, or even to dial contacts: He didn't know the password, and he just kept locking it … find it disabled for 15 minutes.If I've got that on YouTube, they can quite quickly get on to some you know [video] … by pressing … and they don't do it on purpose, they're just pushing random buttons.He does Skype calls! I think he recognizes their image, the icon. Then just taps it and … Similarly, in the analysis of publicly shared images on Instagram tagged with #babyselfie, there were instances in which it appeared infants had accidentally taken photos with the cameraphone based on the image content, photo framing or descriptions in the caption. Many of these photos showed a baby with an arm in view reaching towards the phone in a classic trope of a selfie image; others were poorly framed shots showing parts of baby faces too close to the camera lens suggesting they accidentally took the photograph; whilst most definitive was many instances in which the caption of the image posted by parents directly attributed the photographic production to an infant: Isabella's first #babyselfie She actually pushed the button herself! My little man loves taking selfies lol Whilst, then, the research identified many instances in which infants accidentally engaged in mobile media use, sometimes managing to communicate with an unsuspecting interlocutor, it is important to acknowledge such encounters could not have emerged without the enabling infrastructure of ambient media contexts and touchscreen interfaces, nor observed without studying this infrastructure utilising materially-oriented ethnographic perspectives (Star). Significantly, too, was the intermediary role played by parents. With parents acting as intermediaries in household environments or as proxy users in posting content on their behalf, multiple forms of assisted infant communication were identified. Assisted Media Use Assisted communication emerged from discussions with parents about the ways, routines, and rationale for making mobile media available to their children. These sometimes revolved around keeping their child engaged whilst they were travelling as a family – part of what has been described as the pass-back effect – but were more frequently discussed in terms of sharing and showing digital content, especially family photographs, and in facilitating infant mediated communication with relatives abroad: they love scrolling through my photos on my iPhone …We quite often just have them [on Skype] … have the computers in there while we're having dinner … the laptop will be there, opened up at one end of the table with the family here and there will be my sister having breakfast with her family in Ireland … These forms of parental mediated communication did not, however, simply situate or construct infants as passive recipients of their parents’ desires to make media content available or their efforts to establish communication with extended family members. Instead, the research revealed that infants were often active participants in these processes, pushing for access to devices, digital content, and mediated communication. These distributed relations of agency were expressed through infants verbal requests and gestural urging; through the ways parents initiated use by, for example, unlocking a device, preparing software, or loading an application, but then handed them over to infants to play, explore or communicate; and through wider networks of relations in which others including siblings, acted as proxies or had a say in the kinds of media infants used: she can do it, once I've unlocked … even, even with iView, once I'm on iView she can pick her own show and then go to the channel she wants to go to.We had my son’s birthday and there were some photos, some footage of us singing happy birthday and the little one just wants to watch it over and over again. She thinks it's fantastic watching herself.He [sibling] becomes like a proxy user … with the second one … they don't even need the agency because of their sibling. Similarly, the assisted communication emerging from the analysis of #babyselfie images on Instagram revealed that parents were not simply determining infant media use, but often acting as proxies on their behalf. #Selfie obsessed baby. Seriously though. He won't stop. Insists on pressing the button and everything. He sees my phone and points and says "Pic? Pic?" I've created a monster lol. In sharing this digital content on social networks, parents were acting as intermediaries in the communication of their children’s digital images. Clearly they were determining the platforms and networks where these images were published online, yet the production of these images was more uncertain, with accidental self-portraits taken by infants suggesting they played a key role in the circuits of digital photography distribution (van Dijck). Automated Media Use The production, archiving, circulation and reception of these images speaks to larger assemblages of media in which software protocols and algorithms are increasingly embedded in and help to configure everyday life (e.g. Chun; Gillespie), including young children’s media lives (Ito). Here, software automates process of sorting and shaping information, and in doing so both empowers and governs forms of infant media conduct. The final theme emerging from the research, then, is the identification of automated forms of infant mobile media use enabled through software applications and algorithmic operations. Automated techniques of interaction emerged as part of the repertoire of infant mobile mediality and communication through observations and discussions during the family research, and through surveying commercial software applications. Within family discussions, parents spoke about the ways digital databases and applications facilitated infant exploration and navigation. These included photo galleries stored on mobile devices, as well as children’s Internet television services such as the Australian Broadcasting Corporation’s catch-up online TV service, iView, which are visually organised and easily scrollable. In addition, algorithmic functions for sorting, recommending and autoplay on the video-sharing platform YouTube meant that infants were often automatically delivered an ongoing stream of content: They just keep watching it [YouTube]. So it leads on form the other thing. Which is pretty amazing, that's pretty interactive.Yeah, but the kids like, like if they've watched a YouTube clip now, they'll know to look down the next column to see what they want to play next … you get suggestions there so. Forms of automated communication specifically addressing infants was also located in examples of children’s software products from mobile app stores: the My Baby Selfie app from the iTunes App Store and the Baby Selfie app from the Google Play store. These applications are designed to support baby image capture and sharing, promising to “allow your baby to take a photo of him himself [sic]” (Giudicelli), based on automated software features that use sounds and images to capture a babies attention and touch sensors to activate image capture and storage. In one sense, these applications may appear to empower infants to participate in the production of digital content, namely selfies, yet they also clearly distribute this agency with and through mobile media and digital software. Moreover, they imply forms of conduct, expectations and imperatives around the possibilities of infant presence in a participatory digital culture. Immanent Ethic and Critique Digital participation typically assumes a degree of individual agency in deciding what to share, post, or communicate that is not typically available to infants. The emerging communicative practices of infants detailed above suggests that infants are increasingly connecting, however this communicative agency is distributed amongst a network of ambient devices, user-friendly interfaces, proxy users, and software sorting. Such distributions reflect conditions Deuze has noted, that we do not live with but in media. He argues this ubiquity, habituation, and embodiment of media and communication technologies pervade and constitute our lives becoming effectively invisible, negating the possibility of an outside from which resistance can be mounted. Whilst, resistance remains a solution promoted in medical discourses and paediatric advice proposing no ‘screen time’ for children aged below two (Strasburger and Hogan), Deuze’s thesis suggests this is ontologically futile and instead we should strive for a more immanent relation that seeks to modulate choices and actions from within our media life: finding “creative ways to wield the awesome communication power of media both ethically and aesthetically” ("Unseen" 367). An immanent ethics and a critical aesthetics of infant mediated life can be located in examples of cultural production and everyday parental practice addressing the arrangements of infant mobile media and communication discussed above. For example, an article in the Guardian, ‘Toddlers pose a serious risk to smartphones and tablets’ parodies moral panics around children’s exposure to media by noting that media devices are at greater risk of physical damage from children handling them, whilst a design project from the Eindhoven Academy – called New Born Fame – built from soft toys shaped like social media logos, motion and touch sensors that activate image capture (much like babyselfie apps), but with automated social media sharing, critically interrogates the ways infants are increasingly bound-up with the networked and algorithmic regimes of our computational culture. Finally, parents in this research revealed that they carefully considered the ethics of media in their children’s lives by organising everyday media practices that balanced dwelling with new, old, and non media forms, and by curating their digitally mediated interactions and archives with an awareness they were custodians of their children’s digital memories (Garde-Hansen et al.). I suggest these examples work from an immanent ethical and critical position in order to make visible and operate from within the conditions of infant media life. Rather than seeking to deny or avoid the diversity of encounters infants have with and through mobile media in their everyday lives, this analysis has explored the ways infants are increasingly configured as users of mobile media and communication technologies, identifying an emerging repertoire of infant mobile communication techniques. The emerging practices of infant mobile communication outlined here are intertwined with contemporary household media environments, and assembled through accidental, assisted, and automated relations of living with mobile media. Moreover, such entanglements of use are both represented and discursively reconfigured through multiple channels, contexts, and networks of public mediation. Together, these diverse contexts and forms of conduct have implications for both studying and understanding the ways babies are emerging as active participants and interpellated subjects within a continually expanding digital culture. Acknowledgments This research was supported with funding from the Australian Research Council (ARC) Discovery Early Career Researcher Award (DE130100735). I would like to express my appreciation to the children and families involved in this study for their generous contribution of time and experiences. References Buckingham, David. 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Introduction: Bubbles and Sport The ephemeral materiality of bubbles – beautiful, spectacular, and distracting but ultimately fragile – when applied to protect or conserve in the interests of sport-media profit, creates conditions that exacerbate existing inequalities in sport and society. Bubbles are usually something to watch, admire, and chase after in their brief yet shiny lives. There is supposed to be, technically, nothing inside them other than one or more gasses, and yet we constantly refer to people and objects being inside bubbles. The metaphor of the bubble has been used to describe the life of celebrities, politicians in purpose-built capital cities like Canberra, and even leftist, environmentally activist urban dwellers. The metaphorical and material qualities of bubbles are aligned—they cannot be easily captured and are liable to change at any time. In this article we address the metaphorical sporting bubble, which is often evoked in describing life in professional sport. This is a vernacular term used to capture and condemn the conditions of life of elite sportspeople (usually men), most commonly after there has been a sport-related scandal, especially of a sexual nature (Rowe). It is frequently paired with connotatively loaded adjectives like pampered and indulged. The sporting bubble is rarely interrogated in academic literature, the concept largely being left to the media and moral entrepreneurs. It is represented as involving a highly privileged but also pressurised life for those who live inside it. A sporting bubble is a world constructed for its most prized inhabitants that enables them to be protected from insurgents and to set the terms of their encounters with others, especially sport fans and disciplinary agents of the state. The Covid-19 pandemic both reinforced and reconfigured the operational concept of the bubble, re-arranging tensions between safety (protecting athletes) and fragility (short careers, risks of injury, etc.) for those within, while safeguarding those without from bubble contagion. Privilege and Precarity Bubble-induced social isolation, critics argue, encourages a loss of perspective among those under its protection, an entitled disconnection from the usual rules and responsibilities of everyday life. For this reason, the denizens of the sporting bubble are seen as being at risk to themselves and, more troublingly, to those allowed temporarily to penetrate it, especially young women who are first exploited by and then ejected from it (Benedict). There are many well-documented cases of professional male athletes “behaving badly” and trying to rely on institutional status and various versions of the sporting bubble for shelter (Flood and Dyson; Reel and Crouch; Wade). In the age of mobile and social media, it is increasingly difficult to keep misbehaviour in-house, resulting in a slew of media stories about, for example, drunkenness and sexual misconduct, such as when then-Sydney Roosters co-captain Mitchell Pearce was suspended and fined in 2016 after being filmed trying to force an unwanted kiss on a woman and then simulating a lewd act with her dog while drunk. There is contestation between those who condemn such behaviour as aberrant and those who regard it as the conventional expression of youthful masculinity as part of the familiar “boys will be boys” dictum. The latter naturalise an inequitable gender order, frequently treating sportsmen as victims of predatory women, and ignoring asymmetries of power between men and women, especially in homosocial environments (Toffoletti). For those in the sporting bubble (predominantly elite sportsmen and highly paid executives, also mostly men, with an array of service staff of both sexes moving in and out of it), life is reflected for those being protected via an array of screens (small screens in homes and indoor places of entertainment, and even smaller screens on theirs and others’ phones, as well as huge screens at sport events). These male sport stars are paid handsomely to use their skill and strength to perform for the sporting codes, their every facial expression and bodily action watched by the media and relayed to audiences. This is often a precarious existence, the usually brief career of an athlete worker being dependent on health, luck, age, successful competition with rivals, networks, and club and coach preferences. There is a large, aspirational reserve army of athletes vying to play at the elite level, despite risks of injury and invasive, life-changing medical interventions. Responsibility for avoiding performance and image enhancing drugs (PIEDs) also weighs heavily on their shoulders (Connor). Professional sportspeople, in their more reflective moments, know that their time in the limelight will soon be up, meaning that getting a ticket to the sporting bubble, even for a short time, can make all the difference to their post-sport lives and those of their families. The most vulnerable of the small minority of participants in sport who make a good, short-term living from it are those for whom, in the absence of quality education and prior social status, it is their sole likely means of upward social mobility (Spaaij). Elite sport performers are surrounded by minders, doctors, fitness instructors, therapists, coaches, advisors and other service personnel, all supporting athletes to stay focussed on and maximise performance quality to satisfy co-present crowds, broadcasters, sponsors, sports bodies and mass media audiences. The shield offered by the sporting bubble supports the teleological win-at-all-costs mentality of professional sport. The stakes are high, with athlete and executive salaries, sponsorships and broadcasting deals entangled in a complex web of investments in keeping the “talent” pivotal to the “attention economy” (Davenport and Beck)—the players that provide the content for sale—in top form. Yet, the bubble cannot be entirely secured and poor behaviour or performance can have devastating effects, including permanent injury or disability, mental illness and loss of reputation (Rowe, “Scandals and Sport”). Given this fragile materiality of the sporting bubble, it is striking that, in response to the sudden shutdown following the economic and health crisis caused by the 2020 global pandemic, the leaders of professional sport decided to create more of them and seek to seal the metaphorical and material space with unprecedented efficiency. The outcome was a multi-sided tale of mobility, confinement, capital, labour, and the gendering of sport and society. The Covid-19 Gilded Cage Sociologists such as Zygmunt Bauman and John Urry have analysed the socio-politics of mobilities, whereby some people in the world, such as tourists, can traverse the globe at their leisure, while others remain fixed in geographical space because they lack the means to be mobile or, in contrast, are involuntarily displaced by war, so-called “ethnic cleansing”, famine, poverty or environmental degradation. The Covid-19 global pandemic re-framed these matters of mobilities (Rowe, “Subjecting Pandemic Sport”), with conventional moving around—between houses, businesses, cities, regions and countries—suddenly subjected to the imperative to be static and, in perniciously unreflective technocratic discourse, “socially distanced” (when what was actually meant was to be “physically distanced”). The late-twentieth century analysis of the “risk society” by Ulrich Beck, in which the mysterious consequences of humans’ predation on their environment are visited upon them with terrifying force, was dramatically realised with the coming of Covid-19. In another iteration of the metaphor, it burst the bubble of twenty-first century global sport. What we today call sport was formed through the process of sportisation (Maguire), whereby hyper-local, folk physical play was reconfigured as multi-spatial industrialised sport in modernity, becoming increasingly reliant on individual athletes and teams travelling across the landscape and well over the horizon. Co-present crowds were, in turn, overshadowed in the sport economy when sport events were taken to much larger, dispersed audiences via the media, especially in broadcast mode (Nicholson, Kerr, and Sherwood). This lucrative mediation of professional sport, though, came with an unforgiving obligation to generate an uninterrupted supply of spectacular live sport content. The pandemic closed down most sports events and those that did take place lacked the crucial participation of the co-present crowd to provide the requisite event atmosphere demanded by those viewers accustomed to a sense of occasion. Instead, they received a strange spectacle of sport performers operating in empty “cathedrals”, often with a “faked” crowd presence. The mediated sport spectacle under the pandemic involved cardboard cut-out and sex doll spectators, Zoom images of fans on large screens, and sampled sounds of the crowd recycled from sport video games. Confected co-presence produced simulacra of the “real” as Baudrillardian visions came to life. The sporting bubble had become even more remote. For elite sportspeople routinely isolated from the “common people”, the live sport encounter offered some sensory experience of the social – the sounds, sights and even smells of the crowd. Now the sporting bubble closed in on an already insulated and insular existence. It exposed the irony of the bubble as a sign of both privileged mobility and incarcerated athlete work, both refuge and prison. Its logic of contagion also turned a structure intended to protect those inside from those outside into, as already observed, a mechanism to manage the threat of insiders to outsiders. In Australia, as in many other countries, the populace was enjoined by governments and health authorities to help prevent the spread of Covid-19 through isolation and immobility. There were various exceptions, principally those classified as essential workers, a heterogeneous cohort ranging from supermarket shelf stackers to pharmacists. People in the cultural, leisure and sports industries, including musicians, actors, and athletes, were not counted among this crucial labour force. Indeed, the performing arts (including dance, theatre and music) were put on ice with quite devastating effects on the livelihoods and wellbeing of those involved. So, with all major sports shut down (the exception being horse racing, which received the benefit both of government subsidies and expanding online gambling revenue), sport organisations began to represent themselves as essential services that could help sustain collective mental and even spiritual wellbeing. This case was made most aggressively by Australian Rugby League Commission Chairman, Peter V’landys, in contending that “an Australia without rugby league is not Australia”. In similar vein, prominent sport and media figure Phil Gould insisted, when describing rugby league fans in Western Sydney’s Penrith, “they’re lost, because the football’s not on … . It holds their families together. People don’t understand that … . Their life begins in the second week of March, and it ends in October”. Despite misgivings about public safety and equality before the pandemic regime, sporting bubbles were allowed to form, re-form and circulate. The indefinite shutdown of the National Rugby League (NRL) on 23 March 2020 was followed after negotiation between multiple entities by its reopening on 28 May 2020. The competition included a team from another nation-state (the Warriors from Aotearoa/New Zealand) in creating an international sporting bubble on the Central Coast of New South Wales, separating them from their families and friends across the Tasman Sea. Appeals to the mental health of fans and the importance of the NRL to myths of “Australianness” notwithstanding, the league had not prudently maintained a financial reserve and so could not afford to shut down for long. Significant gambling revenue for leagues like the NRL and Australian Football League (AFL) also influenced the push to return to sport business as usual. Sport contests were needed in order to exploit the gambling opportunities – especially online and mobile – stimulated by home “confinement”. During the coronavirus lockdowns, Australians’ weekly spending on gambling went up by 142 per cent, and the NRL earned significantly more than usual from gambling revenue—potentially $10 million above forecasts for 2020. Despite the clear financial imperative at play, including heavy reliance on gambling, sporting bubble-making involved special licence. The state of Queensland, which had pursued a hard-line approach by closing its borders for most of those wishing to cross them for biographical landmark events like family funerals and even for medical treatment in border communities, became “the nation's sporting hub”. Queensland became the home of most teams of the men’s AFL (notably the women’s AFLW season having been cancelled) following a large Covid-19 second wave in Melbourne. The women’s National Netball League was based exclusively in Queensland. This state, which for the first time hosted the AFL Grand Final, deployed sport as a tool in both national sports tourism marketing and internal pre-election politics, sponsoring a documentary, The Sporting Bubble 2020, via its Tourism and Events arm. While Queensland became the larger bubble incorporating many other sporting bubbles, both the AFL and the NRL had versions of the “fly in, fly out” labour rhythms conventionally associated with the mining industry in remote and regional areas. In this instance, though, the bubble experience did not involve long stays in miners’ camps or even the one-night hotel stopovers familiar to the popular music and sport industries. Here, the bubble moved, usually by plane, to fulfil the requirements of a live sport “gig”, whereupon it was immediately returned to its more solid bubble hub or to domestic self-isolation. In the space created between disciplined expectation and deplored non-compliance, the sporting bubble inevitably became the scrutinised object and subject of scandal. Sporting Bubble Scandals While people with a very low risk of spreading Covid-19 (coming from areas with no active cases) were denied entry to Queensland for even the most serious of reasons (for example, the death of a child), images of AFL players and their families socialising and enjoying swimming at the Royal Pines Resort sporting bubble crossed our screens. Yet, despite their (players’, officials’ and families’) relative privilege and freedom of movement under the AFL Covid-Safe Plan, some players and others inside the bubble were involved in “scandals”. Most notable was the case of a drunken brawl outside a Gold Coast strip club which led to two Richmond players being “banished”, suspended for 10 matches, and the club fined $100,000. But it was not only players who breached Covid-19 bubble protocols: Collingwood coaches Nathan Buckley and Brenton Sanderson paid the $50,000 fine imposed on the club for playing tennis in Perth outside their bubble, while Richmond was fined $45,000 after Brooke Cotchin, wife of team captain Trent, posted an image to Instagram of a Gold Coast day spa that she had visited outside the “hub” (the institutionally preferred term for bubble). She was subsequently distressed after being trolled. Also of concern was the lack of physical distancing, and the range of people allowed into the sporting bubble, including babysitters, grandparents, and swimming coaches (for children). There were other cases of players being caught leaving the bubble to attend parties and sharing videos of their “antics” on social media. Biosecurity breaches of bubbles by players occurred relatively frequently, with stern words from both the AFL and NRL leaders (and their clubs) and fines accumulating in the thousands of dollars. Some people were also caught sneaking into bubbles, with Lekahni Pearce, the girlfriend of Swans player Elijah Taylor, stating that it was easy in Perth, “no security, I didn’t see a security guard” (in Barron, Stevens, and Zaczek) (a month later, outside the bubble, they had broken up and he pled guilty to unlawfully assaulting her; Ramsey). Flouting the rules, despite stern threats from government, did not lead to any bubble being popped. The sport-media machine powering sporting bubbles continued to run, the attendant emotional or health risks accepted in the name of national cultural therapy, while sponsorship, advertising and gambling revenue continued to accumulate mostly for the benefit of men. Gendering Sporting Bubbles Designed as biosecurity structures to maintain the supply of media-sport content, keep players and other vital cogs of the machine running smoothly, and to exclude Covid-19, sporting bubbles were, in their most advanced form, exclusive luxury camps that illuminated the elevated socio-cultural status of sportsmen. The ongoing inequalities between men’s and women’s sport in Australia and around the world were clearly in evidence, as well as the politics of gender whereby women are obliged to “care” and men are enabled to be “careless” – or at least to manage carefully their “duty of care”. In Australia, the only sport for women that continued during the height of the Covid-19 lockdown was netball, which operated in a bubble that was one of sacrifice rather than privilege. With minimum salaries of only $30,000 – significantly less than the lowest-paid “rookies” in the AFL – and some being mothers of small children and/or with professional jobs juggled alongside their netball careers, these elite sportswomen wanted to continue to play despite the personal inconvenience or cost (Pavlidis). Not one breach of the netballers out of the bubble was reported, indicating that they took their responsibilities with appropriate seriousness and, perhaps, were subjected to less scrutiny than the sportsmen accustomed to attracting front-page headlines. National Netball League (also known after its Queensland-based naming rights sponsor as Suncorp Super Netball) players could be regarded as fortunate to have the opportunity to be in a bubble and to participate in their competition. The NRL Women’s (NRLW) Premiership season was also completed, but only involved four teams subject to fly in, fly out and bubble arrangements, and being played in so-called curtain-raiser games for the NRL. As noted earlier, the AFLW season was truncated, despite all the prior training and sacrifice required of its players. Similarly, because of their resource advantages, the UK men’s and boy’s top six tiers of association football were allowed to continue during lockdown, compared to only two for women and girls. In the United States, inequalities between men’s and women’s sports were clearly demonstrated by the conditions afforded to those elite sportswomen inside the Women’s National Basketball Association (WNBA) sport bubble in the IMG Academy in Florida. Players shared photos of rodent traps in their rooms, insect traps under their mattresses, inedible food and blocked plumbing in their bubble accommodation. These conditions were a far cry from the luxury usually afforded elite sportsmen, including in Florida’s Walt Disney World for the men’s NBA, and is just one of the many instances of how gendered inequality was both reproduced and exacerbated by Covid-19. Bursting the Bubble As we have seen, governments and corporate leaders in sport were able to create material and metaphorical bubbles during the Covid-19 lockdown in order to transmit stadium sport contests into home spaces. The rationale was the importance of sport to national identity, belonging and the routines and rhythms of life. But for whom? Many women, who still carry the major responsibilities of “care”, found that Covid-19 intensified the affective relations and gendered inequities of “home” as a leisure site (Fullagar and Pavlidis). Rates of domestic violence surged, and many women experienced significant anxiety and depression related to the stress of home confinement and home schooling. During the pandemic, women were also more likely to experience the stress and trauma of being first responders, witnessing virus-related sickness and death as the majority of nurses and care workers. They also bore the brunt of much of the economic and employment loss during this time. Also, as noted above, livelihoods in the arts and cultural sector did not receive the benefits of the “bubble”, despite having a comparable claim to sport in contributing significantly to societal wellbeing. This sector’s workforce is substantially female, although men dominate its senior roles. Despite these inequalities, after the late March to May hiatus, many elite male sportsmen – and some sportswomen - operated in a bubble. Moving in and out of them was not easy. Life inside could be mentally stressful (especially in long stays of up to 150 days in sports like cricket), and tabloid and social media troll punishment awaited those who were caught going “over the fence”. But, life in the sporting bubble was generally preferable to the daily realities of those afflicted by the trauma arising from forced home confinement, and for whom watching moving sports images was scant compensation for compulsory immobility. The ethical foundation of the sparkly, ephemeral fantasy of the sporting bubble is questionable when it is placed in the service of a voracious “media sports cultural complex” (Rowe, Global Media Sport) that consumes sport labour power and rolls back progress in gender relations as a default response to a global pandemic. Covid-19 dramatically highlighted social inequalities in many areas of life, including medical care, work, and sport. For the small minority of people involved in sport who are elite professionals, the only thing worse than being in a sporting bubble during the pandemic was not being in one, as being outside precluded their participation. Being inside the bubble was a privilege, albeit a dubious one. But, as in wider society, not all sporting bubbles are created equal. Some are more opulent than others, and the experiences of the supporting and the supported can be very different. The surface of the sporting bubble may be impermanent, but when its interior is opened up to scrutiny, it reveals some very durable structures of inequality. Bubbles are made to burst. They are, by nature, temporary, translucent structures created as spectacles. As a form of luminosity, bubbles “allow a thing or object to exist only as a flash, sparkle or shimmer” (Deleuze, 52). In echoing Deleuze, Angela McRobbie (54) argues that luminosity “softens and disguises the regulative dynamics of neoliberal society”. The sporting bubble was designed to discharge that function for those millions rendered immobile by home confinement legislation in Australia and around the world, who were having to deal with the associated trauma, risk and disadvantage. 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In Australia the “intimacy” of citizenship (Berlant 2), is often used to reinforce subscription to heteronormative romantic and familial structures. Because this framing promotes discourses of moral failure, recent political attention to sexuality and same-sex couples can be filtered through insights into coalitional affiliations. This paper uses contemporary shifts in Australian politics and culture to think through the concept of coalition, and in particular to analyse connections between sexuality and governmentality (or more specifically normative bias and same-sex relationships) in what I’m calling post-coalitional Australia. Against the unpredictability of changing parties and governments, allegiances and alliances, this paper suggests the continuing adherence to a heteronormatively arranged public sphere. After the current Australian Prime Minister Julia Gillard deposed the previous leader, Kevin Rudd, she clung to power with the help of independents and the Greens, and clichés of a “rainbow coalition” and a “new paradigm” were invoked to describe the confused electorate and governmental configuration. Yet in 2007, a less confused Australia decisively threw out the Howard–led Liberal and National Party coalition government after eleven years, in favour of Rudd’s own rainbow coalition: a seemingly invigorated party focussed on gender equity, Indigenous Australians, multi-cultural visibility, workplace relations, Austral-Asian relations, humane refugee processing, the environment, and the rights and obligations of same-sex couples. A post-coalitional Australia invokes something akin to “aftermath culture” (Lambert and Simpson), referring not just to Rudd’s fall or Howard’s election loss, but to the broader shifting contexts within which most Australian citizens live, and within which they make sense of the terms “Australia” and “Australian”. Contemporary Australia is marked everywhere by cracks in coalitions and shifts in allegiances and belief systems – the Coalition of the Willing falling apart, the coalition government crushed by defeat, deposed leaders, and unlikely political shifts and (re)alignments in the face of a hung parliament and renewed pushes toward moral and cultural change. These breakdowns in allegiances are followed by swift symbolically charged manoeuvres. Gillard moved quickly to repair relations with mining companies damaged by Rudd’s plans for a mining tax and to water down frustration with the lack of a sustainable Emissions Trading Scheme. And one of the first things Kevin Rudd did as Prime Minister was to change the fittings and furnishings in the Prime Ministerial office, of which Wright observed that “Mr Howard is gone and Prime Minister Kevin Rudd has moved in, the Parliament House bureaucracy has ensured all signs of the old-style gentlemen's club… have been banished” (The Age, 5 Dec. 2007). Some of these signs were soon replaced by Ms. Gillard herself, who filled the office in turn with memorabilia from her beloved Footscray, an Australian Rules football team. In post-coalitional Australia the exile of the old Menzies’ desk and a pair of Chesterfield sofas works alongside the withdrawal of troops from Iraq and renewed pledges for military presence in Afghanistan, apologising to stolen generations of Indigenous Australians, the first female Governor General, deputy Prime Minister and then Prime Minister (the last two both Gillard), the repealing of disadvantageous workplace reform, a focus on climate change and global warming (with limited success as stated), a public, mandatory paid maternity leave scheme, changes to the processing and visas of refugees, and the amendments to more than one hundred laws that discriminate against same sex couples by the pre-Gillard, Rudd-led Labor government. The context for these changes was encapsulated in an announcement from Rudd, made in March 2008: Our core organising principle as a Government is equality of opportunity. And advancing people and their opportunities in life, we are a Government which prides itself on being blind to gender, blind to economic background, blind to social background, blind to race, blind to sexuality. (Rudd, “International”) Noting the political possibilities and the political convenience of blindness, this paper navigates the confusing context of post-coalitional Australia, whilst proffering an understanding of some of the cultural forces at work in this age of shifting and unstable alliances. I begin by interrogating the coalitional impulse post 9/11. I do this by connecting public coalitional shifts to the steady withdrawal of support for John Howard’s coalition, and movement away from George Bush’s Coalition of the Willing and the War on Terror. I then draw out a relationship between the rise and fall of such affiliations and recent shifts within government policy affecting same-sex couples, from former Prime Minister Howard’s amendments to The Marriage Act 1961 to the Rudd-Gillard administration’s attention to the discrimination in many Australian laws. Sexual Citizenship and Coalitions Rights and entitlements have always been constructed and managed in ways that live out understandings of biopower and social death (Foucault History; Discipline). The disciplining of bodies, identities and pleasures is so deeply entrenched in government and law that any non-normative claim to rights requires the negotiation of existing structures. Sexual citizenship destabilises the post-coalitional paradigm of Australian politics (one of “equal opportunity” and consensus) by foregrounding the normative biases that similarly transcend partisan politics. Sexual citizenship has been well excavated in critical work from Evans, Berlant, Weeks, Richardson, and Bell and Binnie’s The Sexual Citizen which argues that “many of the current modes of the political articulation of sexual citizenship are marked by compromise; this is inherent in the very notion itself… the twinning of rights with responsibilities in the logic of citizenship is another way of expressing compromise… Every entitlement is freighted with a duty” (2-3). This logic extends to political and economic contexts, where “natural” coalition refers primarily to parties, and in particular those “who have powerful shared interests… make highly valuable trades, or who, as a unit, can extract significant value from others without much risk of being split” (Lax and Sebinius 158). Though the term is always in some way politicised, it need not refer only to partisan, multiparty or multilateral configurations. The subscription to the norms (or normativity) of a certain familial, social, religious, ethnic, or leisure groups is clearly coalitional (as in a home or a front, a club or a team, a committee or a congregation). Although coalition is interrogated in political and social sciences, it is examined frequently in mathematical game theory and behavioural psychology. In the former, as in Axelrod’s The Evolution of Cooperation, it refers to people (or players) who collaborate to successfully pursue their own self-interests, often in the absence of central authority. In behavioural psychology the focus is on group formations and their attendant strategies, biases and discriminations. Experimental psychologists have found “categorizing individuals into two social groups predisposes humans to discriminate… against the outgroup in both allocation of resources and evaluation of conduct” (Kurzban, Tooby and Cosmides 15387). The actions of social organisation (and not unseen individual, supposedly innate impulses) reflect the cultural norms in coalitional attachments – evidenced by the relationship between resources and conduct that unquestioningly grants and protects the rights and entitlements of the larger, heteronormatively aligned “ingroup”. Terror Management Particular attention has been paid to coalitional formations and discriminatory practices in America and the West since September 11, 2001. Terror Management Theory or TMT (Greenberg, Pyszczynski and Solomon) has been the main framework used to explain the post-9/11 reassertion of large group identities along ideological, religious, ethnic and violently nationalistic lines. Psychologists have used “death-related stimuli” to explain coalitional mentalities within the recent contexts of globalised terror. The fear of death that results in discriminatory excesses is referred to as “mortality salience”, with respect to the highly visible aspects of terror that expose people to the possibility of their own death or suffering. Naverette and Fessler find “participants… asked to contemplate their own deaths exhibit increases in positive evaluations of people whose attitudes and values are similar to their own, and derogation of those holding dissimilar views” (299). It was within the climate of post 9/11 “mortality salience” that then Prime Minister John Howard set out to change The Marriage Act 1961 and the Family Law Act 1975. In 2004, the Government modified the Marriage Act to eliminate flexibility with respect to the definition of marriage. Agitation for gay marriage was not as noticeable in Australia as it was in the U.S where Bush publicly rejected it, and the UK where the Civil Union Act 2004 had just been passed. Following Bush, Howard’s “queer moral panic” seemed the perfect decoy for the increased scrutiny of Australia’s involvement in the Iraq war. Howard’s changes included outlawing adoption for same-sex couples, and no recognition for legal same-sex marriages performed in other countries. The centrepiece was the wording of The Marriage Amendment Act 2004, with marriage now defined as a union “between a man and a woman to the exclusion of all others”. The legislation was referred to by the Australian Greens Senator Bob Brown as “hateful”, “the marriage discrimination act” and the “straight Australia policy” (Commonwealth 26556). The Labor Party, in opposition, allowed the changes to pass (in spite of vocal protests from one member) by concluding the legal status of same-sex relations was in no way affected, seemingly missing (in addition to the obvious symbolic and physical discrimination) the equation of same-sex recognition with terror, terrorism and death. Non-normative sexual citizenship was deployed as yet another form of “mortality salience”, made explicit in Howard’s description of the changes as necessary in protecting the sanctity of the “bedrock institution” of marriage and, wait for it, “providing for the survival of the species” (Knight, 5 Aug. 2003). So two things seem to be happening here: the first is that when confronted with the possibility of their own death (either through terrorism or gay marriage) people value those who are most like them, joining to devalue those who aren’t; the second is that the worldview (the larger religious, political, social perspectives to which people subscribe) becomes protection from the potential death that terror/queerness represents. Coalition of the (Un)willing Yet, if contemporary coalitions are formed through fear of death or species survival, how, for example, might these explain the various forms of risk-taking behaviours exhibited within Western democracies targeted by such terrors? Navarette and Fessler (309) argue that “affiliation defences are triggered by a wider variety of threats” than “existential anxiety” and that worldviews are “in turn are reliant on ‘normative conformity’” (308) or “normative bias” for social benefits and social inclusions, because “a normative orientation” demonstrates allegiance to the ingroup (308-9). Coalitions are founded in conformity to particular sets of norms, values, codes or belief systems. They are responses to adaptive challenges, particularly since September 11, not simply to death but more broadly to change. In troubled times, coalitions restore a shared sense of predictability. In Howard’s case, he seemed to say, “the War in Iraq is tricky but we have a bigger (same-sex) threat to deal with right now. So trust me on both fronts”. Coalitional change as reflective of adaptive responses thus serves the critical location of subsequent shifts in public support. Before and since September 11 Australians were beginning to distinguish between moderation and extremism, between Christian fundamentalism and productive forms of nationalism. Howard’s unwavering commitment to the American-led war in Iraq saw Australia become a member of another coalition: the Coalition of the Willing, a post 1990s term used to describe militaristic or humanitarian interventions in certain parts of the world by groups of countries. Howard (in Pauly and Lansford 70) committed Australia to America’s fight but also to “civilization's fight… of all who believe in progress and pluralism, tolerance and freedom”. Although Bush claimed an international balance of power and influence within the coalition (94), some countries refused to participate, many quickly withdrew, and many who signed did not even have troops. In Australia, the war was never particularly popular. In 2003, forty-two legal experts found the war contravened International Law as well as United Nations and Geneva conventions (Sydney Morning Herald 26 Feb. 2003). After the immeasurable loss of Iraqi life, and as the bodies of young American soldiers (and the occasional non-American) began to pile up, the official term “coalition of the willing” was quietly abandoned by the White House in January of 2005, replaced by a “smaller roster of 28 countries with troops in Iraq” (ABC News Online 22 Jan. 2005). The coalition and its larger war on terror placed John Howard within the context of coalitional confusion, that when combined with the domestic effects of economic and social policy, proved politically fatal. The problem was the unclear constitution of available coalitional configurations. Howard’s continued support of Bush and the war in Iraq compounded with rising interest rates, industrial relations reform and a seriously uncool approach to the environment and social inclusion, to shift perceptions of him from father of the nation to dangerous, dithery and disconnected old man. Post-Coalitional Change In contrast, before being elected Kevin Rudd sought to reframe Australian coalitional relationships. In 2006, he positions the Australian-United States alliance outside of the notion of military action and Western territorial integrity. In Rudd-speak the Howard-Bush-Blair “coalition of the willing” becomes F. Scott Fitzgerald’s “willingness of the heart”. The term coalition was replaced by terms such as dialogue and affiliation (Rudd, “Friends”). Since the 2007 election, Rudd moved quickly to distance himself from the agenda of the coalition government that preceded him, proposing changes in the spirit of “blindness” toward marginality and sexuality. “Fix-it-all” Rudd as he was christened (Sydney Morning Herald 29 Sep. 2008) and his Labor government began to confront the legacies of colonial history, industrial relations, refugee detention and climate change – by apologising to Aboriginal people, timetabling the withdrawal from Iraq, abolishing the employee bargaining system Workchoices, giving instant visas and lessening detention time for refugees, and signing the Kyoto Protocol agreeing (at least in principle) to reduce green house gas emissions. As stated earlier, post-coalitional Australia is not simply talking about sudden change but an extension and a confusion of what has gone on before (so that the term resembles postcolonial, poststructural and postmodern because it carries the practices and effects of the original term within it). The post-coalitional is still coalitional to the extent that we must ask: what remains the same in the midst of such visible changes? An American focus in international affairs, a Christian platform for social policy, an absence of financial compensation for the Aboriginal Australians who received such an eloquent apology, the lack of coherent and productive outcomes in the areas of asylum and climate change, and an impenetrable resistance to the idea of same-sex marriage are just some of the ways in which these new governments continue on from the previous one. The Rudd-Gillard government’s dealings with gay law reform and gay marriage exemplify the post-coalitional condition. Emulating Christ’s relationship to “the marginalised and the oppressed”, and with Gillard at his side, Rudd understandings of the Christian Gospel as a “social gospel” (Rudd, “Faith”; see also Randell-Moon) to table changes to laws discriminating against gay couples – guaranteeing hospital visits, social security benefits and access to superannuation, resembling de-facto hetero relationships but modelled on the administering and registration of relationships, or on tax laws that speak primarily to relations of financial dependence – with particular reference to children. The changes are based on the report, Same Sex, Same Entitlements (HREOC) that argues for the social competence of queer folk, with respect to money, property and reproduction. They speak the language of an equitable economics; one that still leaves healthy and childless couples with limited recognition and advantage but increased financial obligation. Unable to marry in Australia, same-sex couples are no longer single for taxation purposes, but are now simultaneously subject to forms of tax/income auditing and governmental revenue collection should either same-sex partner require assistance from social security as if they were married. Heteronormative Coalition Queer citizens can quietly stake their economic claims and in most states discreetly sign their names on a register before becoming invisible again. Mardi Gras happens but once a year after all. On the topic of gay marriage Rudd and Gillard have deferred to past policy and to the immoveable nature of the law (and to Howard’s particular changes to marriage law). That same respect is not extended to laws passed by Howard on industrial relations or border control. In spite of finding no gospel references to Jesus the Nazarene “expressly preaching against homosexuality” (Rudd, “Faith”), and pre-election promises that territories could govern themselves with respect to same sex partnerships, the Rudd-Gillard government in 2008 pressured the ACT to reduce its proposed partnership legislation to that of a relationship register like the ones in Tasmania and Victoria, and explicitly demanded that there be absolutely no ceremony – no mimicking of the real deal, of the larger, heterosexual citizens’ “ingroup”. Likewise, with respect to the reintroduction of same-sex marriage legislation by Greens senator Sarah Hanson Young in September 2010, Gillard has so far refused a conscience vote on the issue and restated the “marriage is between a man and a woman” rhetoric of her predecessors (Topsfield, 30 Sep. 2010). At the same time, she has agreed to conscience votes on euthanasia and openly declared bi-partisan (with the federal opposition) support for the war in Afghanistan. We see now, from Howard to Rudd and now Gillard, that there are some coalitions that override political differences. As psychologists have noted, “if the social benefits of norm adherence are the ultimate cause of the individual’s subscription to worldviews, then the focus and salience of a given individual’s ideology can be expected to vary as a function of their need to ally themselves with relevant others” (Navarette and Fessler 307). Where Howard invoked the “Judaeo-Christian tradition”, Rudd chose to cite a “Christian ethical framework” (Rudd, “Faith”), that saw him and Gillard end up in exactly the same place: same sex relationships should be reduced to that of medical care or financial dependence; that a public ceremony marking relationship recognition somehow equates to “mimicking” the already performative and symbolic heterosexual institution of marriage and the associated romantic and familial arrangements. Conclusion Post-coalitional Australia refers to the state of confusion borne of a new politics of equality and change. The shift in Australia from conservative to mildly socialist government(s) is not as sudden as Howard’s 2007 federal loss or as short-lived as Gillard’s hung parliament might respectively suggest. Whilst allegiance shifts, political parties find support is reliant on persistence as much as it is on change – they decide how to buffer and bolster the same coalitions (ones that continue to privilege white settlement, Christian belief systems, heteronormative familial and symbolic practices), but also how to practice policy and social responsibility in a different way. Rudd’s and Gillard’s arguments against the mimicry of heterosexual symbolism and the ceremonial validation of same-sex partnerships imply there is one originary form of conduct and an associated sacred set of symbols reserved for that larger ingroup. Like Howard before them, these post-coalitional leaders fail to recognise, as Butler eloquently argues, “gay is to straight not as copy is to original, but as copy is to copy” (31). To make claims to status and entitlements that invoke the messiness of non-normative sex acts and romantic attachments necessarily requires the negotiation of heteronormative coalitional bias (and in some ways a reinforcement of this social power). As Bell and Binnie have rightly observed, “that’s what the hard choices facing the sexual citizen are: the push towards rights claims that make dissident sexualities fit into heterosexual culture, by demanding equality and recognition, versus the demand to reject settling for heteronormativity” (141). The new Australian political “blindness” toward discrimination produces positive outcomes whilst it explicitly reanimates the histories of oppression it seeks to redress. The New South Wales parliament recently voted to allow same-sex adoption with the proviso that concerned parties could choose not to adopt to gay couples. The Tasmanian government voted to recognise same-sex marriages and unions from outside Australia, in the absence of same-sex marriage beyond the current registration arrangements in its own state. In post-coalitional Australia the issue of same-sex partnership recognition pits parties and allegiances against each other and against themselves from within (inside Gillard’s “rainbow coalition” the Rainbow ALP group now unites gay people within the government’s own party). Gillard has hinted any new proposed legislation regarding same-sex marriage may not even come before parliament for debate, as it deals with real business. Perhaps the answer lies over the rainbow (coalition). As the saying goes, “there are none so blind as those that will not see”. References ABC News Online. “Whitehouse Scraps Coalition of the Willing List.” 22 Jan. 2005. 1 July 2007 ‹http://www.abc.net.au/news/newsitems/200501/s1286872.htm›. Axelrod, Robert. The Evolution of Cooperation. New York: Basic Books, 1984. 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