Journal articles on the topic 'Royal Park Hospital'

This paper documents the initial phase of a new research direction which began in 1984 at Royal Park Hospital. Attention is focussed on the place of the university and the research institute in the psychiatric hospital and on the perceived need for concerted research on the major psychoses in Australia. The focal point of the Royal Park research programme, the Aubrey Lewis Clinical Research Unit, has been open since October 1984. The development of the unit's research activities during the initial few years of its existence required an awareness of specific scientific, administrative and political issues. These are discussed in detail in order to convey something of the process, as well as the content of such development, and in an attempt to provide some assistance to others undertaking similar developments.

In June 1962 at the age of 87 years, Sir Winston Churchill (1874–1965) fell over in his hotel room at the Hotel de Paris in Monte Carlo and sustained a fracture to the neck of his left femur. He was flown back to London and the fracture operated on at The Middlesex Hospital by two eminent orthopaedic surgeons, Mr Phillip Newman (1911–1994), Consultant to the The Middlesex Hospital and The Royal National Orthopaedic Hospital, Stanmore, and The Institute of Orthopaedics, London, and Professor Herbert Seddon (1903–1977), Consultant to the The Royal National Orthopaedic Hospital, Stanmore, and Director of The Institute of Orthopaedics under whom Churchill was admitted as a private patient. Churchill’s recovery was complicated by the development of deep vein thrombosis. During his convalescence, Churchill befriended Seddon who recorded his time with him in his private papers. On 21 August, Churchill was discharged to his home at 28 Hyde Park Gate which had been modified during his admission and made a return to public life in November 1962 at a dinner at the dining club he had originally founded, The Other Club.

Brian was born in 1922 into a religious family who lived near Liverpool where his father was a jobber at the Liverpool Stock Exchange. He was the youngest of three brothers of whom the eldest, Frank, like Brian, studied medicine with a view to becoming a missionary in India. Brian began his studies in Edinburgh in 1940 and qualified with the ‘Scottish Triple’ in 1945. After house jobs at the Edinburgh Royal Infirmary and a period as Senior R.M.O. at the Royal Liverpool Children's Hospital. He was rejected for military service on medical grounds, so he decided to go to sea; he served with the Cunard White Star Line for the greater part of the 1950s. However, it was his contact with the crew and his involvement in negotiations to settle conflicts between them which most interested him and led to him to develop an interest in psychiatry. In the late 1950s he joined the junior staff at Warlingham Park Hospital in Surrey where he found himself among a stimulating group of trainees, many of whom later became distinguished in the psychiatric world. He obtained the DPM in 1961.

With fierce competition for the best consultant posts in surgery, a fellowship is almost becoming an essential requirement. There are numerous fellowships available but finding the right one and organising family life around it is extremely difficult. After a lot of scepticism from some trainees about the post-Certificate of Completion of Training (CCT) national surgical fellowships scheme, it was advertised in July 2008 through The Royal College of Surgeons of England in partnership with the surgical specialist associations. I was extremely fortunate to be successful in the interview in November 2008 as the first Fellow in Bariatric and Upper Gastrointestinal (GI) Surgery under the scheme and opted for the fellowship at Musgrove Park Hospital, Taunton, for one year.

Handover is widely identified by the National Confidential Enquiry into Patient Outcome and Death, the Royal College of Physicians (RCP) and Health Foundation as an area that can lead to shortcomings in patient care. We recognised that the current weekend handover process in the Trauma and Orthopaedics department at Frimley Park Hospital was dated, time-consuming and did not promote handover of sufficient patient details.The Royal College of Surgeons, British Medical Association and RCP have guidelines on handover. Our aim was to use these to establish the quality of handovers and introduce methods to better the accuracy and effectiveness of weekend handover in the department, thus improving patient care and safety.Initially, we measured the quality of the existing handover documentation for how comprehensively it was completed. We then implemented a two-step change, reauditing each step, resulting in a handover tool on the trust intranet. Finally, we repeated our audit to monitor sustainability.The 10 categories measured were: ‘Patient name’, ‘Date of birth’, ‘Hospital number’, ‘Date of admission’, ‘Location’, ‘Consultant’, ‘Admission reason’, ‘Date of operation’, ‘Frequency of review’ and discharge paperwork (‘TTO’).The original handover documentation had good compliance with ‘Patient name’ (99%), ‘Hospital number’ (94%) and ‘Admission reason’ (91%) but was poor in all other categories, ranging from 12% to 84%. The only category that met its standard was ‘Admission reason’.Almost every category improved with the new intranet tool. Five areas met their standard (‘Patient name’, ‘Location’, ‘Consultant’, ‘Admission reason’ and ‘Frequency of review’). Specific prompts resulted in 100% compliance for ‘Frequency of review’. The poorest compliance was again seen for ‘TTO’ (18%).In a short four months, we created an intranet handover tool that resulted in significant and sustainable improvements in the quality, detail and accuracy of handovers, making identification of sick patients safer and more efficient.

Objective: There has been an accumulation of so-called ‘new long-stay’ (NLS) patients in psychiatric hospitals. To date, no Australian studies have characterised this patient group. We aimed to study the demography, and clinical and social functioning of the NLS population at Royal Park Hospital (RPH) together with patients' attitudes to treatment and views on future placement. Method: All 30 NLS patients at RPH were identified. Twenty-seven consenting patients were assessed using the following standardised instruments: Manchester Scale for psychopathology, Life Skills Profile (LSP), Physical Health Index and Patient Attitude Questionnaire. Information on past psychiatric history, past treatment and current treatment was collected. Insight and compliance were assessed. Results: The majority of patients were single men with a diagnosis of schizophrenia. Forty-one percent were detained in hospital involuntarily and 56% were considered dangerous to themselves or others. The patients were characterised by high levels of positive and negative symptoms. They were most impaired with respect to ‘social contact’ relative to the other subscales of the LSP. While 10 (48%) patients expressed a desire to leave hospital, only one patient considered that anyone would cohabit with them. Over two-thirds considered they had been unwell and that medication had helped. Staff rated one-third as having major problems with compliance. About two-thirds of patients had disability secondary to comorbid physical illnesses. Conclusion: Like other NLS patients studied in the United Kingdom and Ireland, this group had significant handicaps secondary to psychiatric illness, concomitant physical illness and disability and behaviour unacceptable in community settings. They were also characterised by significant social isolation. These factors may be important determinants of rehabilitation failure and need to be addressed in the process of de-institutionalisation as well as in longitudinal studies examining these and other factors predicting NLS status.

AbstractDr Rodney Franklin is the focus of our third in a planned series of interviews in Cardiology in the Young entitled, “Global Leadership in Paediatric and Congenital Cardiac Care.” Dr Franklin was born in London, England, spending the early part of his childhood in the United States of America before coming back to England. He then attended University College London Medical School and University College Hospital in London, England, graduating in 1979. Dr Franklin would then go on to complete his general and neonatal paediatrics training in 1983 at Northwick Park Hospital and University College Hospital in London, England, followed by completing his paediatric cardiology training in 1989 at Great Ormond Street Hospital for Children in London, England. During this training, he additionally would hold the position of British Heart Foundation Junior Research Fellow from 1987 to 1989. Dr Franklin would then complete his training in 1990 as a Senior Registrar and subsequent Consultant in Paediatric and Fetal Cardiology at Wilhelmina Sick Children’s Hospital in Utrecht, the Netherlands. He subsequently obtained his research doctorate at University of London in 1997, consisting of a retrospective audit of 428 infants with functionally univentricular hearts.Dr Franklin has spent his entire career as a Consultant Paediatric Cardiologist at the Royal Brompton & Harefield Hospital NHS Foundation Trust, being appointed in 1991. He additionally holds honorary Consultant Paediatric Cardiology positions at Hillingdon Hospital, Northwick Park Hospital, and Lister Hospital in the United Kingdom, and Honorary Senior Lecturer at Imperial College, London. He has been the Clinical Lead of the National Congenital Heart Disease Audit (2013–2020), which promotes data collection within specialist paediatric centres. Dr Franklin has been a leading figure in the efforts towards creating international, pan European, and national coding systems within the multidisciplinary field of congenital cardiac care. These initiatives include but are not limited to the development and maintenance of The International Paediatric & Congenital Cardiac Code and the related International Classification of Diseases 11th Revision for CHD and related acquired terms and definitions. This article presents our interview with Dr Franklin, an interview that covers his experience in developing these important coding systems and consensus nomenclature to both improve communication and the outcomes of patients. We additionally discuss his experience in the development and implementation of strategies to assess the quality of paediatric and congenital cardiac care and publicly report outcomes.

AimsTo measure the standard of care provided to patients who had a natural and expected death whilst in secure care at Roseberry Park Hospital, Middlesbrough.Mallard ward is a low secure psychiatric ward for older aged men suffering from cognitive difficulties and significant physical comorbidity in addition to a severe and enduring mental illness. The patient population is such that it will remain the most appropriate placement for some patients until their death. It is vital that staff members on Mallard ward and indeed all parts of the Trust are aware of the priorities for care of the dying person and ensure that care is provided in accordance with these priorities.The Leadership Alliance for the Care of Dying People (LACDP), a coalition of 21 national organisations, published One Chance to get it Right – Improving people's experience of care in the last few days and hours of life in June 2014. This document laid out five priorities for care of the dying person focussing on sensitive communication, involvement of the person and relevant others in decisions and compassionately delivering an individualised care plan.MethodThe data collection tool was adapted from End of Life Care Audit: Dying in Hospital, a national clinical audit commissioned by Healthcare Quality Improvement Partnership (HQIP) and run by the Royal College of Physicians. Data were collected from both electronic and paper records. There were three natural and expected deaths in the last two years.ResultFor all three patients, there was documented evidence that they were likely to die in the coming hours or days.End of life care discussion was held with the nominated persons and not with the patients due to their lack of mental capacity.The needs of the patients and their nominated persons were explored in all three cases.All patients had an individualised care plan which was followed.The palliative care team supported the staff with the care of these patients.The care provided was largely consistent with the priorities listed.ConclusionThe national audit compares performance of only acute NHS Trusts with no data to reflect the performance of mental health hospitals. It is imperative that mental health services work in collaboration with physical health and palliative care services so they are able to continue providing a high level of care to this patient group. Clinicians and staff involved in the care of dying patients also need to be adequately trained.

AbstractIntroductionComprehensive studies on the relationship between patient demographics and subsequent treatment and disposition at a single mass-gathering event are lacking. The Sydney Royal Easter Show (SRES; Sydney Olympic Park, New South Wales, Australia) is an annual, 14-day, agricultural mass-gathering event occurring around the Easter weekend, attracting more than 800,000 patrons per year. In this study, patient records from the SRES were analyzed to examine relationships between weather, crowd size, day of week, and demographics on treatment and disposition. This information would help to predict factors affecting patient treatment and disposition to guide ongoing training of first responders and to evaluate the appropriateness of staffing skills mix at future events.HypothesisPatient demographics, environmental factors, and attendance would influence the nature and severity of presentations at the SRES, which would influence staffing requirements.MethodsA retrospective analysis of 4,141 patient record forms was performed for patients who presented to St John Ambulance (Australian Capital Territory, Australia) at the SRES between 2012 and 2014 inclusive. Presentation type was classified using a previously published minimum data set. Data on weather and crowd size were obtained from the Australian Bureau of Meteorology (Melbourne, Victoria, Australia) and the SRES, respectively. Statistical analyses were performed using SPSS v22 (IBM; Armonk, New York USA).ResultsBetween 2012 to 2014, over 2.5 million people attended the SRES with 4,141 patients treated onsite. As expected, the majority of presentations were injuries (49%) and illnesses (46%). Although patient demographics and presentation types did not change over time, the duration of treatment increased. A higher proportion of patients were discharged to hospital or home compared to the proportion of patients discharged back to the event. Patients from rural/regional locations (accounting for 15% of all patients) were more likely to require advanced treatment, health professional review, and were more likely to be discharged to hospital or home rather than discharged back to the event. Extremes of temperature were associated with a lower crowd size and higher patient presentation rate (PPR), but had no impact on transfer or referral rates to hospital.ConclusionThis study demonstrated that analyses of patient presentations at an agricultural show provide unique insights on weather, attendance, and demographic features that correlated with treatment and disposition. These data can help guide organizers with information on how to better staff and train health care providers at future mass-gathering events of this type.CrabtreeN,MoS,OngL,JegatheesT,WeiD,FaheyD,LiuJ.Retrospective analysis of patient presentations at the Sydney (Australia) Royal Easter Show from 2012 to 2014.Prehosp Disaster Med.2017;32(2)187–194.

I am connected to a family nursery business that has been running for four generations. My links go back to the early 1890s when my great grandfather had a nursery at Upper Mt Gravatt. He then shifted to South Brisbane where he moved into floristry. The business, however, was destroyed in the flood of 1893. His daughter, my grandmother, married Tom Perrott who had started in a nursery business with a well known nurseryman in Brisbane called T. H. Woods. They established the shop in George Street. They were also in the florist business and, in 1919, they decided to buy a nursery at Herston, near Ballymore Park and the Royal Brisbane Hospital, which ran until 1963. In the meantime, they had bought another nursery at Enoggera in 1936 (which I now own), and ran the two nurseries simultaneously. At that time, the main part of the business was still floristry and they did quite well in the depression years. The nursery at Enoggera was a 20 acre dairy farm that had been purchased mainly for the purpose of growing flowers for the floral trade. We used to grow rows and rows of different annuals and creepers and anything we could plant to flower, including many camellias which are still there today. A team of women would arrive at 6 o'clock every morning to pick these flowers and prepare them for packaging and transporting to the floral room at Herston.

Purpose There is growing awareness in New Zealand (NZ) of the impact that Autistic Spectrum Disorder (ASD) has on individuals and their families and the ability to engage in health services. Although it is a relatively rare condition, approximately 1 per cent of the population will have ASD, directly affecting approximately 40,000 individuals in NZ. The purpose of this paper is to provide some reflections and questions on what we can learn from a NZ perspective. This is based on an overview of the limited literature around ASD and offending and the author’s experience in the UK working in a medium secure unit. Design/methodology/approach Through a past site visit as part of the annual international conference on the Care and Treatment of Offenders with an Intellectual and/or Developmental Disability in the United Kingdom (UK), the author became aware of the medium secure forensic unit for male patients with ASD at the Roseberry Park Hospital (UK’s Tees, Esk and Wear Valleys NHS Foundation Trust). During the author’s advanced training in forensic psychiatry with the Royal Australian and New Zealand College of Psychiatrists the author was privileged to be able to apply and be accepted for a four-month sabbatical training position at this hospital. Findings Outlined is background information about ASD and review findings from the limited literature on ASD and offending. Also outlined is the author’s learning as a trainee working in medium secure unit for people with ASD who have offended, and finally how this experience may help in the development of services in NZ, given that at this stage such services are under-developed. Originality/value To be able to share the valuable experience and learning opportunity the author was able to have, as well as raise the awareness of ASD generally, and specifically the need for specialist services for the small number of people with ASD who come into contact with Justice Services.

Resumo:O objetivo deste artigo é demonstrar como a literatura devocional, em língua portuguesa, colaborou para a difusão de uma série de ideias associadas à caridade, assistência e misericórdia que orientaram as práticas régias e sociais de apoio aos enfermos. Dar-se-á destaque a duas instituições portuguesas criadas em fins da Idade Média: o Hospital de Todos os Santos, em Lisboa e o Hospital de Nossa Senhora do Pópulo, nas Caldas da Rainha como exemplo da reforma da assistência aos enfermos.Palavras-Chave:Assistência, enfermos, hospitais, Idade Média, Portugal, literatura devocional. Abstract: The purpose of this article is to demonstrate how the devotional literature in Portuguese, contributed to the spread of a number of ideas associated with love, care with the sicks and mercy that guided the royal and social practices of support to the sick. We will highlight the two Portuguese institutions created in the late Middle Ages: theHospital ofAll Saints inLisbon and the Hospital of Our Lady of Populo, in Caldas da Rainha as example of reform of the care of the sick.Keywords: Care, sick, hospitals, Middle Ages,Portugal, devotional literature.

The implementation of audit in most hospital departments in the UK has been instigated by the guidelines set out by the Royal Colleges. This paper aims to demonstrate the results of regular subregional audit meetings in the ENT departments involving three District Hospitals in East Anglia. We report the effects of audit meetings in improving the management of epistaxis, whereby a protocol for treatment and discharge was established, the duration of the nasal pack left in situ was reduced, and the material of the pack was changed.

The Royal College of Surgeons of England rugby club is flourishing but needs your support. It has a very young history when compared with the United Hospitals Cup (the oldest competition, dating back to 1874 and still being played despite many amalgamations of the London teaching hospitals). Our College club was founded in 2003 to play against the Royal College of Surgeons of Edinburgh for the Park–Parker Cup. The first game was played at the Rosslyn Park ground on the morning of the Calcutta Cup and, sadly, after suturing various parts of players' anatomy from both sides, I presented the Cup to the Edinburgh side who had been triumphant, reversing a large half-time lead by the English College. The next two years belonged to England winning in Edinburgh and in London.

Eu havia retornado da Inglaterra onde havia realizado meu treinamento na famosa The Radcliffe Infirmary, da Universidade de Oxford. O meu mentor foi Mr. Christopher Adams, neurocirurgião dotado de rara maestria e com um profundo conhecimento de neurologia clínica, visto que houvera feito dois anos detreinamento no Serviço de Neurologia do renomado National Hospital for Nervous Diseases, popularmente conhecido como The Queens’ Square. Adams teve como mestres Murray Falconer and Joe Pennybacher. Segundo a tradição, todo cirurgião é chamado de Mister apenas substituído quando alcança o título de Professor, enquanto Doctor é reservado para os clínicos.

Abstract Introduction The cost to healthcare of wasted medicines has been estimated at around £300million per annum (1). In response to this figure and efforts to increase medicines management performance across pharmacy and patient outcomes, the practice of ‘medicines optimisation’ has developed into a key aspect of patient care. In particular, concerns exist around whether patients are deriving the optimum benefit from their medications and the extent to which adherence ‘drops off’ at varying intervals after prescription and collection. In order to tackle medicines adherence and waste, a multi-disciplinary approach must be applied to ensure patients who are prescribed a new medicine take it as intended, experience no problems and receive as much information as they feel they need from healthcare professionals (HCP’s). Adapting Cognitive Behavioural Therapy (CBT)-based techniques to medicines-related consultations has proven effective in supporting medicines adherence in previous studies (2). Collectively, findings demonstrate scope for improving the way HCP’s communicate with patients around starting a new medication and monitoring ongoing use. Aim The study aim was to adapt an existing, Royal College of General Practitioners accredited ’10-minute CBT’ training package to be suitable for wider use by a range of healthcare professionals (HCP’s) (i.e. Practice Nurses, Community Pharmacists, Hospital Pharmacists and General Practitioners). Methods The research design adopted a repeated-measures, pre/ post questionnaire study that gathered data on HCP knowledge around the use of CBT-based techniques in consultations at the start and end of the training intervention. Two training days were attended by HCP’s that took place three weeks apart. The degree of satisfaction with the training intervention was assessed, along with a formulation exercise that was completed on a hypothetical patient case study pre- and post-training. Results Training of healthcare professionals took place at the Oxford Science Park and 105 NHS staff members participated. Feedback questionnaires were received by 96 HCP’s and 46 HCP’s provided additional follow-up questionnaires at 6-months, demonstrating favourable results regarding intervention content and delivery that were consistent with a prior feasibility study. Paired samples t-tests were performed on each formulation exercise rating scale domain and for total scores. There was a highly statistically significant increase in scores for all domains including total pre- and post-training scores as measured by the Formulation Rating Scale. Intra-class Correlation Coefficient for mean FRS ratings was 0.99 (p=.000) and there was no statistically significant change in any score when attendees repeated the skills assessment at 6 months, indicating once learning had been incorporated into practice, there was no recognisable training degradation over the 6-month period. See Table 1. Conclusion The training intervention was rated favourably by attendees and was reported by participants as providing a safe environment from which to increase knowledge of CBT-based techniques, practice implementation of formulation skills and access additional peer support to help integrate learning into medicines-related consultations. The study also demonstrates this group of HCP’s were able to integrate CBT-based techniques into hypothetical medicines-related scenarios and that learning was retained over a six-month period following training intervention. References 1. York Health Economics Consortium and the School of Pharmacy, University of London. Evaluation of the Scale, Causes and Costs of Waste Medicines. 2010. http://php.york.ac.uk/inst/yhec/web/news/documents/Evaluation_of_NHS_Medicines_Waste_Nov_2010.pdf 2. Easthall C, Song F, Bhattacharya D. A meta-analysis of cognitive-based behaviour change techniques as interventions to improve medication Adherence. BMJ Open 2013;3:e002749.

Paramedics are the primary providers of prehospital care to children in an emergency. However, they deal with children's emergencies infrequently, and consistently report a lack of confidence in this area. The Royal College of Paediatrics and Child Health standards state that clinicians with Advanced Paediatric Life Support (APLS) training or equivalent must be available at all times to deal with emergencies involving children. While APLS is widely recognised as the gold standard in paediatric training, it focuses on in-hospital providers of paediatric life support, so may not adequately meet the needs of prehospital providers. The Paramedic Advanced Resuscitation of Children (PARC) course attempts to condense the most important aspects of APLS for paramedics into a simulation-based programme that is practical and cost effective. Evaluation of the views of the eight paramedics who took part in the pilot revealed that they felt more confident in managing children's emergencies after attending the course. The PARC course may be a simple, cost-effective method to improve paramedics’ confidence in dealing with emergencies involving children.

Abstract Introduction Dispensing is a complex multi-step process where mistakes can arise at any stage leading to a potential to cause patient harm. Published literature identifies near miss dispensing error rates up to 2.7% in UK hospitals.1 Near misses are ‘a dispensing error detected by the checker before it reaches the patient’. Near miss audits are routinely undertaken across two main dispensaries at this teaching hospital where one dispensary (site 1) is automated and the other (site 2) is not. Aim To determine the frequency of near miss dispensing errors, by site, and review the potential clinical significance of near misses observed. Methods Locally adapted data collection tool based on Royal Pharmaceutical Society near miss error codes2 was developed and piloted. Details on prescription type, drug, dose, strength, route, formulation and near misses were included. Details of all medication orders dispensed were also recorded. Prospective observational audit of near misses identified at the checking bench was undertaken, on three separate days, across three consecutive months. Dean and Barber method3 was used for assessing potential clinical significance of near misses. Four independent assessors: two pharmacists; one nurse and one doctor; reviewed near misses for the likelihood to cause harm. The mean severity score attained across assessors was calculated. Approval was obtained by the Trust Pharmacy Research and Audit Committee. The need for ethical submission was waived. Results Overall 3027 items were dispensed; 1539 and 1488 at sites 1 and 2 respectively. There were 177 (5.8%) erroneous dispensed items involving 193 near misses in total (15 items had two near misses and one item had three near misses). Ninety one (5.9%) erroneous dispensed items were captured at site 1 and 86 (5.8%) at site 2 (χ 2, p=0.94). Overall 161 near miss descriptions were assessed for clinical significance: 97 (60.2%) minor, 63 (39.1%) moderate and one (0.6%) severe. Statistically significant difference in severity rating of near misses between prescription type (χ 2(2) = 32.268, p <0.001); mean ranks 80, 57, 125 for discharge, inpatient and outpatient prescriptions respectively. No statistical difference in severity rating of near misses between error type (χ 2(2) = 2.402, p =0.3). Discussion/Conclusion Local prevalence of near misses is higher than in published literature.1 However, the majority of errors were considered to have minor clinical impact on patients. Difficult to make direct comparisons between studies due to differences in research methods, definitions, operating systems and hospital settings. There was no statistical difference noted in prevalence between sites despite presence of automation at one and manual dispensing at the other. Two factors may explain this: Firstly, part-pack robotic dispensing, where generation of medication barcodes is a manual process and one subject to human input error itself; although not explored explicitly as part of this study. Secondly, lack of knowledge and complex prescriptions are known to be key contributory factors associated with dispensing errors, but the categories of drugs dispensed at a specialist tertiary dispensary (site 1) were broader and more complex. Further study is needed on the impact of part-pack robotic dispensing on dispensing errors. References 1. James KL et al. Incidence, type and causes of dispensing errors. A review of literature. Int J Pharm Pract 2009; 17:9-30. 2. Royal Pharmaceutical Society [Internet]. Near Miss Error Log. London: Royal Pharmaceutical Society; 2015. Available from: RPS-NearMissError-LOG.pdf (rpharms.com) 3. Dean BS, Barber ND. A validated, reliable method for scoring the severity of medication errors. Am J Health Syst Pharm. 1999;56:57-62.

Este estudo prospectivo avaliou a dose mínima de sangue, precisão e exatidão da glicemia capilar obtidos em glicosímetro digital. Foram avaliados 108 portadores de diabetes mellitus tipo 1 (DM1), adolescentes e adultos, de ambos os sexos, recrutados junto à Clínica de Diabetes do Royal Victoria Hospital, McGill University, Canadá, durante 6 meses. No monitoramento capilar, foi utilizado glicosímetro AccuChek Compact (Roche). Para o volume, testaram-se 6 amostras de sangue, em três glicosímetros, utilizando o desenho cross-over (432 leituras). Para exatidão, comparou-se 100 amostras de sangue arterial e venoso, testadas no glicosímetro e no laboratório. Para precisão, testou-se repetidamente duas amostras de sangue venoso e soluções-controle. Os resultados demonstraram que o volume de 3,0 µL de sangue é suficiente para leitura reprodutível. Os resultados da glicemia venosa e capilar obtidos pelo glicosímetro e testadas no laboratório não apresentaram diferença estatisticamente significativa (p > 0,05). Comparação dos valores de glicemia capilar medida pelo glicosímetro com glicemia venosa e capilar medida no laboratório resultou em coeficientes de correlação de 0,9819 e 0,9842, respectivamente. Estes dados confirmam a alta exatidão e precisão do glicosímetro testado. O estabelecimento de punção digital de 3,0 µL pode ter impacto positivo na aderência ao automonitoramento.

Introducción. La valoración nutricional en pacientes con cirrosis es compleja, y se recomienda para ello la aplicación del Royal Free Hospital Global Assessment (RFH-GA). Por otro lado, la sarcopenia representa un factor de riesgo de mortalidad independiente, siendo difícil su medición en la práctica clínica. Actualmente, se recomienda evaluar la fuerza muscular como predictor de sarcopenia probable. Objetivos. Describir el estado nutricional mediante el RFH-GA así como la fuerza muscular; y la asociación entre dichas variables con la escala Child-Pugh y las complicaciones de la enfermedad en pacientes hospitalizados con cirrosis hepática en el Hospital Dr. C. B. Udaondo. Materiales y métodos. Se recopilaron datos sobre valoración nutricional, dinamometría, Child-Pugh y complicaciones en pacientes con cirrosis, entre enero de 2019 y marzo de 2020. Los análisis estadísticos se llevaron a cabo utilizando el software STATA (Stata versión 14.0 Corp, College Station, TX, Estados Unidos). Resultados. Se obtuvo una muestra de 129 pacientes (75,2% sexo masculino), mediana de edad: 53 años. Las principales causas de cirrosis fueron el consumo de alcohol (56,6%) y NASH (12,4%). Según escala Child-Pugh, el 50,4% fue B y el 38%, C. El 42% de la muestra tuvo malnutrición y un 37,2%, baja dinamometría. La mediana de dinamometría fue 26,3 kg, siendo menor en el sexo femenino (p < 0,0001). Se halló una asociación significativa entre estado nutricional/fuerza de agarre y Child- Pugh (p = 0,048 y p = 0,042, respectivamente); también se observó una asociación entre estado nutricional y fuerza de agarre (p < 0,001). Con respecto a las complicaciones, una baja fuerza de agarre (aOR: 4,53, IC 95%: 1,66-12,41; p = 0,003) se asoció con encefalopatía hepática; el sexo masculino (aOR: 3,71, IC 95%: 1,28-10,79; p = 0,005), la malnutrición (aOR: 3,77, IC 95%: 1,15-12,32; p = 0,028) y child B/C (aOR: 54,2, IC 95%: 6,43-456,81; p < 0,001) se asociaron con ascitis; y el sexo masculino (aOR: 3,66, IC 95%: 1,22-11,02; p = 0,021) y la malnutrición (aOR: 3,43, IC 95%: 1,39-8,48; p = 0,008) se asociaron con peritonitis bacteriana espontánea. Conclusión. Sería conveniente combinar ambas herramientas, RFH- GA y dinamometría, para identificar a pacientes con malnutrición y sarcopenia probable, y así iniciar un tratamiento nutricional precoz e individualizado.

AimsNICE guidelines and Maudsley prescribing guidelines both stipulate that patients over the age of 65 prescribed lithium or antipsychotic medication should have their bloods and physical parameters monitored regularly. There is currently no provision from the community mental health teams in Edinburgh to provide this monitoring, which falls to the patients GP. Following an initial data collection, it was found that there was no monitoring advice being provided on immediate discharge letters (IDLs) for patients discharged from two functional old age psychiatry inpatient wards at the Royal Edinburgh Hospital. This patient group often have comorbid medical conditions and therefore monitoring of their psychotropic medication is especially important. The aim of the QI project was for 100% of patients discharged from thesewards on lithium or antipsychotic medication to have appropriate advice documented on their immediate discharge letter (IDL) with regards to medication monitoring.MethodData were collected monthly by reviewing the notes of all discharged patients to determine the frequency at which medication monitoring advice was documented on IDLs from the two wards. A proposed new template for discharge letters which included advice on medication monitoring was discussed and agreed with the old age psychiatry team in Edinburgh. This was disseminated to the appropriate medical staff members and was included in induction packs for junior doctors. Following this a new “canned text” template was implemented to automatically populate the discharge letter with advice depending on whether they were antipsychotics/lithium/neither.ResultIDLs for 91 patients discharged between May 2020 and February 2021 were reviewed. Baseline data showed that 0% of patients (n = 15) had appropriate monitoring advice documented on their IDL. Following initial introduction of monitoring advice to the induction pack for junior doctors, the mean frequency of completed advice on IDLs was 50.9% across 6 months. Following implementation of the canned text, the frequency of completed advice on discharge letters for February 2021 was 100% (n = 7).ConclusionThis QI project has been successful in improving the rate of appropriate advice for antipsychotic and lithium monitoring being provided on immediate discharge letters. It is hoped that this will help reduce adverse effects associated with antipsychotics and lithium in older psychiatric patients. Further work could be done on determining the frequency that the advised monitoring is being carried out.

I departed hospitable Athens on the first of February, the city of Pallas Athena glowing in the evening sun. My Greek Palace-servant Spiro had taken me to Piraeus in a Vienna-cart, where my numerous belongings were stored. It was the last minute to still be able to reach the ship, and steam could already be seen as we came closer to Piraeus. I am not the most punctual person, but when it is really necessary I can be on time. This time, however, it was a close call. Instead of being able to pack my own things, like other people of my standing, with my own hands or with my servants’, two of the most loveable and highly regarded people appeared on my threshold. The lady wore Turkish spectacles in front of her lovely eyes, the gentleman smiled warmly. And who were the lady and the gentleman? No less than His Royal Highness King George of Greece and his majesty's lovely Queen! “Mrs. Jerichau, you will not be ready, can we help? Here is a hairbrush and there is a silk ribbon you are forgetting, and your sketch book.” All this was put into the luggage, along with many pleasurable things “for the children.” These small things were later unpacked in Copenhagen with much enjoyment and laughter. At the same time, the carpenter was waiting who still had to box up my recently finished paintings. Truly, he had to wait, and Mrs. Jerichau tip-toed from the innermost rooms to the entrance hall, away from the swelling suitcases, which seemed to be filled up more and more as if by fairies, while the owner ran away from them towards the carpenter outside, and again away from the carpenter – a Greek who only poorly understood her, and who had even poorer understanding of how to pack pictures. Because he had not brought with him enough of the boards made in the King's palace, he had to make do with thin wooden bars such as one uses when sending chickens to the market. Out between the bars, the beautiful “Girl from Hymettus” and her companion, the “Shepherd on the Acropolis,” peeked. Finally, everything was ready, Mrs. Jerichau made as deep a curtsey as she was capable of, and thanked [her guests and helpers] from the bottom of her heart, but secretly did not believe that she would manage to reach the boat in time.

<p>The Royal Commission on the Law Relating to Mental Illness and Mental Deficiency (the Percy Commission) in its 1957 report put the case for providing “forms of control, within stated limits, over people suffering from mental disorder which do not apply to other people”. Paragraph 314 (i) of the report offers the following justification for compulsory treatment in the interests of the patient’s health: “When an illness or disability itself affects the patient’s judgment and appreciation of his own condition, there is a specially strong argument for saying that his own interests demand that the decision whether or not to accept medical examination, care or treatment should not be left entirely to his own distorted or defective judgment. Admission to hospital against the patient’s wishes at the time may be the only way of providing him with the treatment or training which may restore his health or enable him to take his place as a self-supporting member of the community or to develop his limited capabilities to the greatest possible extent. The better the prospects are of treatment or training being successful, the more important this consideration becomes.” The report goes on to say: “No form of mental disorder should be considered to be, by itself, a sufficient ground for depriving a person of his liberty. It is necessary to balance the possible benefits of treatment or training, the protection of the patient and the protection of other persons, on the one hand, against the patient’s loss of liberty on the other.”</p><p>This rationale, which is reflected in the provisions of the 1983 Act, is rejected in the Report of the Expert Committee on the Review of the Mental Health Act 1983 because it discriminates against the mentally disordered by depriving them of the right to patient autonomy, that is the right of people to make effective treatment choices. Crucially, the right depends upon the patient having capacity to make such choices: “Patient autonomy brings with it an inevitable emphasis on capacity.” (para.2.4) The purpose of this paper is to argue that the Expert Committee’s approach is flawed. First, because it would merely, to use the terminology of discrimination law, replace direct discrimination with indirect discrimination. Second, because in conceptualising the detainable mentally ill patient as lacking capacity to make choices about treatment it erodes the validity of other choices which such a person may make. Third, that it tends to weaken the criteria for compulsion to what is, in effect, a best interests test. Fourth, that the justiciability of questions of capacity is problematic where the incapacity both results from mental illness and is considered in the context of treatment for mental illness.</p>

Dr Joseph Dudley ‘Benjy’ Benjafield qualified from University College Hospital Medical School, London in 1912. He joined the Royal Army Medical Corps during World War I and was in charge of the 37th Mobile Bacteriological Laboratory serving with the British Egyptian Expeditionary Force when the Spanish flu struck in late 1918. He observed the features and clinical course of the pandemic and published his findings in the British Medical Journal in 1919. On return to civilian life, he was appointed as Consultant physician to St George’s Hospital, Hyde Park Corner, London where he remained in practice for the rest of his career. He was a respected amateur gentleman racing driver frequently racing at the Brooklands circuit from 1924 after buying a Bentley 3-litre and entering the Le Mans 24 h race seven times between 1925 and 1935, winning in 1927. He was one of an elite club of young men known as The Bentley Boys and went on to become a founding member of the British Racing Drivers Club (BRDC) in 1927. He rejoined the Royal Army Medical Corps during World War II, serving briefly again in Egypt. He died in 1957.

Abstract Aim The primary aim was to review current venous thromboembolism (VTE) prophylaxis prescribing against national and European guidelines at two hospitals in northwest England. A secondary aim was to standardise VTE prescribing practices. Method 3 standards were identified (NICE, BAUS and EUA) for VTE prophylaxis in nephrectomy. All simple and radical nephrectomies and nephroureterectomies were included. Open and laparoscopic cases were included. Data was collected from Royal Liverpool University Hospital (RLUH) and Arrowe Park Hospital (APH). Cases from surgical diaries between January 2019 to January 2020 were identified and compared to the 3 standards. 49 cases were identified at RLUH and 83 at APH Results At APH, 77/83 (92.7%) cases received inpatient LMWH. The remaining 6 were already on a DOAC. 98.7% received inpatient mechanical VTE prophylaxis. 85.5% of patients received extended VTE prophylaxis with no documented indication, and only 20% of open nephrectomies received 28 days LMWH. At RLUH 44/49 cases (89.7%) received inpatient LMWH. All 5 patients who did not had a documented reason why. 100% of inpatients at received inpatient mechanical VTE prophylaxis. 4 patients underwent open nephrectomy, however none of these received 28-day extended LMWH prophylaxis. Conclusions Comparing guidelines with local data reveals that prescribing practice for both in- and outpatient LMWH is variable and often is based on personal preferences. The above results have been presented locally at each institution and practice standardised with re-audit ongoing.

ObjectivesThe Dietetic Assessment and Intervention in Lung Cancer (DAIL) study was an observational cohort study. It triaged the need for dietetic input in patients with lung cancer, using questionnaires with 137 responses. This substudy tested if machine learning could predict need to see a dietitian (NTSD) using 5 or 10 measures.Methods76 cases from DAIL were included (Royal Surrey NHS Foundation Trust; RSH: 56, Frimley Park Hospital; FPH 20). Univariate analysis was used to find the strongest correlates with NTSD and ‘critical need to see a dietitian’ CNTSD. Those with a Spearman correlation above ±0.4 were selected to train a support vector machine (SVM) to predict NTSD and CNTSD. The 10 and 5 best correlates were evaluated.Results18 and 13 measures had a correlation above ±0.4 for NTSD and CNTSD, respectively, producing SVMs with 3% and 7% misclassification error. 10 measures yielded errors of 7% (NTSD) and 9% (CNTSD). 5 measures yielded between 7% and 11% errors. SVM trained on the RSH data and tested on the FPH data resulted in errors of 20%.ConclusionsMachine learning can predict NTSD producing misclassification errors <10%. With further work, this methodology allows integrated early referral to a dietitian independently of a healthcare professional.

Abstract Introduction Several NHS trusts rely on handwritten notes, including ward round (WR) reviews. These are essential in-patient care and must be completed/documented thoroughly. The General Medical Council and Royal College of Surgeons have both published guidance on WR documentation. Method This was a prospective study aiming to review WR documentation within general surgery at Frimley Park Hospital. 17 WR entries were reviewed using an 18-point checklist. A proforma was created based on published guidance and gaps in reviewed documentation. This was introduced for two months before a repeat review was conducted. A third review was conducted after an additional month to monitor for sustained improvement. Results Strengths in the baseline included documentation of WR leads (100%) and plans (100%), legible handwriting (95%), and NEWS score (88%). Common weaknesses were documentation of full observations, anticoagulation (both 6%), and relevant bloods and imaging (both 12%). The two months post-proforma review found improvement in all 18 areas of documentation, with five elements scoring 100%. Documentation of anticoagulation improved from 6% to 94%, relevant bloods from 12% to 82%, and full observations from 6% to 76%. Higher scoring WRs were linked to pre-prepared proformas, with lower scores linked to post-take WRs. The review was repeated after an additional month, showing consistently improved results in all areas. Conclusions This project has shown significant and sustainable improvement in WR documentation with the proforma. This project would therefore recommend the continued use of the proforma, and an additional review after the junior doctor change over to show continued sustainability.

El patrocinio y soporte económico hacia las casas de religiosos fue uno de los métodos mediante el cual las reinas podían demostrar su poder o reforzar su linaje. La creación o reforma de conventos, monasterios u hospitales no cumplió una función meramente piadosa por parte de su promotor, sino que además jugó un papel fundamental con respecto al control político de sus reinos. Para María de Castilla (1401-1458), reina de Aragón, el respaldo hacia ciertos cenobios fue acompañado de la difusión de la Reforma Observante. En ese sentido, el artículo estudia a la reina como benefactora del convento de Santa María de Jesús y el Hospital de Gracia, en Zaragoza, y la iglesia de Magallón, además de destacar su aptitud y manejo en la resolución de los problemas de convivencia de ciertos monasterios aragoneses, a través de las noticias aparecidas básicamente en los registros de la Real Cancillería de la reina custodiados en el ARV y ACA. Palabras clave: María de Castilla, Reino de Aragón, Reforma franciscana observante, Convento de Santa María de Jesús de Zaragoza, Hospital de Gracia de Zaragoza, Iglesia de Magallón. Abstract: Patronage and financial support for religious houses was one of the methods by which queens could demonstrate their power or reinforce their lineage. The creation or reform of convents, monasteries or hospitals did not merely fulfil a pious function on the part of their promoter, but also played a fundamental role with regard to the political control of their kingdoms. For María of Castile (1401-1458), Queen of Aragon, support for certain monasteries was accompanied by the spread of the Observant Reformation. This article studies this monarch as benefactress of the convent of Santa María de Jesús and the hospital of Gracia in Zaragoza, and the church of Magallón as well as highlighting her aptitude and management in resolving the problems of coexistence of certain Aragonese monasteries, through the news that basically appeared in the records of the Queen’s Royal Chancery kept in the Archives of the Kingdom of Valencia and the Crown of Aragon. Keywords: María of Castile, Kingdom of Aragon, Observant Franciscan Reform, Convent of Santa María de Jesús de Zaragoza, Hospital de Gracia of Zaragoza, Church of Magallón.

IntroductionIn July 1997, the Mackay campus of Central Queensland University hosted a conference with the theme Regional Australia: Visions of Mackay. It was the first academic conference to be held at the young campus, and its aim was to provide an opportunity for academics, business people, government officials, and other interested parties to discuss their visions for the development of Mackay, a regional community of 75,000 people situated on the Central Queensland coast (Danaher). I delivered a presentation at that conference and authored a chapter in the book that emerged from its proceedings. The chapter entitled “Mackay Online” explored the potential impact that the Internet could have on the Mackay region, particularly in the areas of regional business, education, health, and entertainment (Pace). Two decades later, how does the reality compare with that vision?Broadband BluesAt the time of the Visions of Mackay conference, public commercial use of the Internet was in its infancy. Many Internet services and technologies that users take for granted today were uncommon or non-existent then. Examples include online video, video-conferencing, Voice over Internet Protocol (VoIP), blogs, social media, peer-to-peer file sharing, payment gateways, content management systems, wireless data communications, smartphones, mobile applications, and tablet computers. In 1997, most users connected to the Internet using slow dial-up modems with speeds ranging from 28.8 Kbps to 33.6 Kbps. 56 Kbps modems had just become available. Lamenting these slow data transmission speeds, I looked forward to a time when widespread availability of high-bandwidth networks would allow the Internet’s services to “expand to include electronic commerce, home entertainment and desktop video-conferencing” (Pace 103). Although that future eventually arrived, I incorrectly anticipated how it would arrive.In 1997, Optus and Telstra were engaged in the rollout of hybrid fibre coaxial (HFC) networks in Sydney, Melbourne, and Brisbane for the Optus Vision and Foxtel pay TV services (Meredith). These HFC networks had a large amount of unused bandwidth, which both Telstra and Optus planned to use to provide broadband Internet services. Telstra's Big Pond Cable broadband service was already available to approximately one million households in Sydney and Melbourne (Taylor), and Optus was considering extending its cable network into regional Australia through partnerships with smaller regional telecommunications companies (Lewis). These promising developments seemed to point the way forward to a future high-bandwidth network, but that was not the case. A short time after the Visions of Mackay conference, Telstra and Optus ceased the rollout of their HFC networks in response to the invention of Asynchronous Digital Subscriber Line (ADSL), a technology that increases the bandwidth of copper wire and enables Internet connections of up to 6 Mbps over the existing phone network. ADSL was significantly faster than a dial-up service, it was broadly available to homes and businesses across the country, and it did not require enormous investment in infrastructure. However, ADSL could not offer speeds anywhere near the 27 Mbps of the HFC networks. When it came to broadband provision, Australia seemed destined to continue playing catch-up with the rest of the world. According to data from the Organisation for Economic Cooperation and Development (OECD), in 2009 Australia ranked 18th in the world for broadband penetration, with 24.1 percent of Australians having a fixed-line broadband subscription. Statistics like these eventually prompted the federal government to commit to the deployment of a National Broadband Network (NBN). In 2009, the Kevin Rudd Government announced that the NBN would combine fibre-to-the-premises (FTTP), fixed wireless, and satellite technologies to deliver Internet speeds of up to 100 Mbps to 90 percent of Australian homes, schools, and workplaces (Rudd).The rollout of the NBN in Mackay commenced in 2013 and continued, suburb by suburb, until its completion in 2017 (Frost, “Mackay”; Garvey). The rollout was anything but smooth. After a change of government in 2013, the NBN was redesigned to reduce costs. A mixed copper/optical technology known as fibre-to-the-node (FTTN) replaced FTTP as the preferred approach for providing most NBN connections. The resulting connection speeds were significantly slower than the 100 Mbps that was originally proposed. Many Mackay premises could only achieve a maximum speed of 40 Mbps, which led to some overcharging by Internet service providers, and subsequent compensation for failing to deliver services they had promised (“Optus”). Some Mackay residents even complained that their new NBN connections were slower than their former ADSL connections. NBN Co representatives claimed that the problems were due to “service providers not buying enough space in the network to provide the service they had promised to customers” (“Telcos”). Unsurprisingly, the number of complaints about the NBN that were lodged with the Telecommunications Industry Ombudsman skyrocketed during the last six months of 2017. Queensland complaints increased by approximately 40 percent when compared with the same period during the previous year (“Qld”).Despite the challenges presented by infrastructure limitations, the rollout of the NBN was a boost for the Mackay region. For some rural residents, it meant having reliable Internet access for the first time. Frost, for example, reports on the experiences of a Mackay couple who could not get an ADSL service at their rural home because it was too far away from the nearest telephone exchange. Unreliable 3G mobile broadband was the only option for operating their air-conditioning business. All of that changed with the arrival of the NBN. “It’s so fast we can run a number of things at the same time”, the couple reported (“NBN”).Networking the NationOne factor that contributed to the uptake of Internet services in the Mackay region after the Visions of Mackay conference was the Australian Government’s Networking the Nation (NTN) program. When the national telecommunications carrier Telstra was partially privatised in 1997, and further sold in 1999, proceeds from the sale were used to fund an ambitious communications infrastructure program named Networking the Nation (Department of Communications, Information Technology and the Arts). The program funded projects that improved the availability, accessibility, affordability, and use of communications facilities and services throughout regional Australia. Eligibility for funding was limited to not-for-profit organisations, including local councils, regional development organisations, community groups, local government associations, and state and territory governments.In 1998, the Mackay region received $930,000 in Networking the Nation funding for Mackay Regionlink, a project that aimed to provide equitable community access to online services, skills development for local residents, an affordable online presence for local business and community organisations, and increased external awareness of the Mackay region (Jewell et al.). One element of the project was a training program that provided basic Internet skills to 2,168 people across the region over a period of two years. A second element of the project involved the establishment of 20 public Internet access centres in locations throughout the region, such as libraries, community centres, and tourist information centres. The centres provided free Internet access to users and encouraged local participation and skill development. More than 9,200 users were recorded in these centres during the first year of the project, and the facilities remained active until 2006. A third element of the project was a regional web portal that provided a free easily-updated online presence for community organisations. The project aimed to have every business and community group in the Mackay region represented on the website, with hosting fees for the business web pages funding its ongoing operation and development. More than 6,000 organisations were listed on the site, and the project remained financially viable until 2005.The availability, affordability and use of communications facilities and services in Mackay increased significantly during the period of the Regionlink project. Changes in technology, services, markets, competition, and many other factors contributed to this increase, so it is difficult to ascertain the extent to which Mackay Regionlink fostered those outcomes. However, the large number of people who participated in the Regionlink training program and made use of the public Internet access centres, suggests that the project had a positive influence on digital literacy in the Mackay region.The Impact on BusinessThe Internet has transformed regional business for both consumers and business owners alike since the Visions of Mackay conference. When Mackay residents made a purchase in 1997, their choice of suppliers was limited to a few local businesses. Today they can shop online in a global market. Security concerns were initially a major obstacle to the growth of electronic commerce. Consumers were slow to adopt the Internet as a place for doing business, fearing that their credit card details would be vulnerable to hackers once they were placed online. After observing the efforts that finance and software companies were making to eliminate those obstacles, I anticipated that it would only be a matter of time before online transactions became commonplace:Consumers seeking a particular product will be able to quickly find the names of suitable suppliers around the world, compare their prices, and place an order with the one that can deliver the product at the cheapest price. (Pace 106)This expectation was soon fulfilled by the arrival of online payment systems such as PayPal in 1998, and online shopping services such as eBay in 1997. eBay is a global online auction and shopping website where individuals and businesses buy and sell goods and services worldwide. The eBay service is free to use for buyers, but sellers are charged modest fees when they make a sale. It exemplifies the notion of “friction-free capitalism” articulated by Gates (157).In 1997, regional Australian business owners were largely sceptical about the potential benefits the Internet could bring to their businesses. Only 11 percent of Australian businesses had some form of web presence, and less than 35 percent of those early adopters felt that their website was significant to their business (Department of Industry, Science and Tourism). Anticipating the significant opportunities that the Internet offered Mackay businesses to compete in new markets, I recommended that they work “towards the goal of providing products and services that meet the needs of international consumers as well as local ones” (107). In the two decades that have passed since that time, many Mackay businesses have been doing just that. One prime example is Big on Shoes (bigonshoes.com.au), a retailer of ladies’ shoes from sizes five to fifteen (Plane). Big on Shoes has physical shopfronts in Mackay and Moranbah, an online store that has been operating since 2009, and more than 12,000 followers on Facebook. This speciality store caters for women who have traditionally been unable to find shoes in their size. As the store’s customer base has grown within Australia and internationally, an unexpected transgender market has also emerged. In 2018 Big on Shoes was one of 30 regional businesses featured in the first Facebook and Instagram Annual Gift Guide, and it continues to build on its strengths (Cureton).The Impact on HealthThe growth of the Internet has improved the availability of specialist health services for people in the Mackay region. Traditionally, access to surgical services in Mackay has been much more limited than in metropolitan areas because of the shortage of specialists willing to practise in regional areas (Green). In 2003, a senior informant from the Royal Australasian College of Surgeons bluntly described the Central Queensland region from Mackay to Gladstone as “a black hole in terms of surgery” (Birrell et al. 15). In 1997 I anticipated that, although the Internet would never completely replace a visit to a local doctor or hospital, it would provide tools that improve the availability of specialist medical services for people living in regional areas. Using these tools, doctors would be able to “analyse medical images captured from patients living in remote locations” and “diagnose patients at a distance” (Pace 108).These expectations have been realised in the form of Queensland Health’s Telehealth initiative, which permits medical specialists in Brisbane and Townsville to conduct consultations with patients at the Mackay Base Hospital using video-conference technology. Telehealth reduces the need for patients to travel for specialist advice, and it provides health professionals with access to peer support. Averill (7), for example, reports on the experience of a breast cancer patient at the Mackay Base Hospital who was able to participate in a drug trial with a Townsville oncologist through the Telehealth network. Mackay health professionals organised the patient’s scans, administered blood tests, and checked her lymph nodes, blood pressure and weight. Townsville health professionals then used this information to advise the Mackay team about her ongoing treatment. The patient expressed appreciation that the service allowed her to avoid the lengthy round-trip to Townsville. Prior to being offered the Telehealth option, she had refused to participate in the trial because “the trip was just too much of a stumbling block” (Averill 7).The Impact on Media and EntertainmentThe field of media and entertainment is another aspect of regional life that has been reshaped by the Internet since the Visions of Mackay conference. Most of these changes have been equally apparent in both regional and metropolitan areas. Over the past decade, the way individuals consume media has been transformed by new online services offering user-generated video, video-on-demand, and catch-up TV. These developments were among the changes I anticipated in 1997:The convergence of television and the Internet will stimulate the creation of new services such as video-on-demand. Today television is a synchronous media—programs are usually viewed while they are being broadcast. When high-quality video can be transmitted over the information superhighway, users will be able to watch what they want, when and where they like. […] Newly released movies will continue to be rented, but probably not from stores. Instead, consumers will shop on the information superhighway for movies that can be delivered on demand.In the mid-2000s, free online video-sharing services such as YouTube and Vimeo began to emerge. These websites allow users to freely upload, view, share, comment on, and curate online videos. Subscription-based streaming services such as Netflix and Amazon Prime have also become increasingly popular since that time. These services offer online streaming of a library of films and television programs for a fee of less than 20 dollars per month. Computers, smart TVs, Blu-ray players, game consoles, mobile phones, tablets, and other devices provide a multitude of ways of accessing streaming services. Some of these devices cost less than 100 dollars, while higher-end electronic devices include the capability as a bundled feature. Netflix became available in Mackay at the time of its Australian launch in 2015. The growth of streaming services greatly reduced the demand for video rental shops in the region, and all closed down as a result. The last remaining video rental store in Mackay closed its doors in 2018 after trading for 26 years (“Last”).Some of the most dramatic transformations that have occurred the field of media and entertainment were not anticipated in 1997. The rise of mobile technology, including wireless data communications, smartphones, mobile applications, and tablet computers, was largely unforeseen at that time. Some Internet luminaries such as Vinton Cerf expected that mobile access to the Internet via laptop computers would become commonplace (Lange), but this view did not encompass the evolution of smartphones, and it was not widely held. Similarly, the rise of social media services and the impact they have had on the way people share content and communicate was generally unexpected. In some respects, these phenomena resemble the Black Swan events described by Nassim Nicholas Taleb (xvii)—surprising events with a major effect that are often inappropriately rationalised after the fact. They remind us of how difficult it is to predict the future media landscape by extrapolating from things we know, while failing to take into consideration what we do not know.The Challenge for MackayIn 1997, when exploring the potential impact that the Internet could have on the Mackay region, I identified a special challenge that the community faced if it wanted to be competitive in this new environment:The region has traditionally prospered from industries that control physical resources such as coal, sugar and tourism, but over the last two decades there has been a global ‘shift away from physical assets and towards information as the principal driver of wealth creation’ (Petre and Harrington 1996). The risk for Mackay is that its residents may be inclined to believe that wealth can only be created by means of industries that control physical assets. The community must realise that its value-added information is at least as precious as its abundant natural resources. (110)The Mackay region has not responded well to this challenge, as evidenced by measures such as the Knowledge City Index (KCI), a collection of six indicators that assess how well a city is positioned to grow and advance in today’s technology-driven, knowledge-based economy. A 2017 study used the KCI to conduct a comparative analysis of 25 Australian cities (Pratchett, Hu, Walsh, and Tuli). Mackay rated reasonably well in the areas of Income and Digital Access. But the city’s ratings were “very limited across all the other measures of the KCI”: Knowledge Capacity, Knowledge Mobility, Knowledge Industries and Smart Work (44).The need to be competitive in a technology-driven, knowledge-based economy is likely to become even more pressing in the years ahead. The 2017 World Energy Outlook Report estimated that China’s coal use is likely to have peaked in 2013 amid a rapid shift toward renewable energy, which means that demand for Mackay’s coal will continue to decline (International Energy Agency). The sugar industry is in crisis, finding itself unable to diversify its revenue base or increase production enough to offset falling global sugar prices (Rynne). The region’s biggest tourism drawcard, the Great Barrier Reef, continues to be degraded by mass coral bleaching events and ongoing threats posed by climate change and poor water quality (Great Barrier Reef Marine Park Authority). All of these developments have disturbing implications for Mackay’s regional economy and its reliance on coal, sugar, and tourism. Diversifying the local economy through the introduction of new knowledge industries would be one way of preparing the Mackay region for the impact of new technologies and the economic challenges that lie ahead.ReferencesAverill, Zizi. “Webcam Consultations.” Daily Mercury 22 Nov. 2018: 7.Birrell, Bob, Lesleyanne Hawthorne, and Virginia Rapson. The Outlook for Surgical Services in Australasia. Melbourne: Monash University Centre for Population and Urban Research, 2003.Cureton, Aidan. “Big Shoes, Big Ideas.” Daily Mercury 8 Dec. 2018: 12.Danaher, Geoff. Ed. Visions of Mackay: Conference Papers. Rockhampton: Central Queensland UP, 1998.Department of Communications, Information Technology and the Arts. Networking the Nation: Evaluation of Outcomes and Impacts. Canberra: Australian Government, 2005.Department of Industry, Science and Tourism. Electronic Commerce in Australia. Canberra: Australian Government, 1998.Frost, Pamela. “Mackay Is Up with Switch to Speed to NBN.” Daily Mercury 15 Aug. 2013: 8.———. “NBN Boost to Business.” Daily Mercury 29 Oct. 2013: 3.Gates, Bill. The Road Ahead. New York: Viking Penguin, 1995.Garvey, Cas. “NBN Rollout Hit, Miss in Mackay.” Daily Mercury 11 Jul. 2017: 6.Great Barrier Reef Marine Park Authority. Reef Blueprint: Great Barrier Reef Blueprint for Resilience. Townsville: Great Barrier Reef Marine Park Authority, 2017.Green, Anthony. “Surgical Services and Referrals in Rural and Remote Australia.” Medical Journal of Australia 177.2 (2002): 110–11.International Energy Agency. World Energy Outlook 2017. France: IEA Publications, 2017.Jewell, Roderick, Mary O’Flynn, Fiorella De Cindio, and Margaret Cameron. “RCM and MRL—A Reflection on Two Approaches to Constructing Communication Memory.” Constructing and Sharing Memory: Community Informatics, Identity and Empowerment. Eds. Larry Stillman and Graeme Johanson. Newcastle: Cambridge Scholars Publishing, 2007. 73–86.Lange, Larry. “The Internet: Where’s It All Going?” Information Week 17 Jul. 1995: 30.“Last Man Standing Shuts Doors after 26 Years of Trade.” Daily Mercury 28 Aug. 2018: 7.Lewis, Steve. “Optus Plans to Share Cost Burden.” Australian Financial Review 22 May 1997: 26.Meredith, Helen. “Time Short for Cable Modem.” Australian Financial Review 10 Apr. 1997: 42Nassim Nicholas Taleb. The Black Swan: The Impact of the Highly Improbable. New York: Random House, 2007.“Optus Offers Comp for Slow NBN.” Daily Mercury 10 Nov. 2017: 15.Organisation for Economic Cooperation and Development. “Fixed Broadband Subscriptions.” OECD Data, n.d. <https://data.oecd.org/broadband/fixed-broadband-subscriptions.htm>.Pace, Steven. “Mackay Online.” Visions of Mackay: Conference Papers. Ed. Geoff Danaher. Rockhampton: Central Queensland University Press, 1998. 111–19.Petre, Daniel and David Harrington. The Clever Country? Australia’s Digital Future. Sydney: Lansdown Publishing, 1996.Plane, Melanie. “A Shoe-In for Big Success.” Daily Mercury 9 Sep. 2017: 6.Pratchett, Lawrence, Richard Hu, Michael Walsh, and Sajeda Tuli. The Knowledge City Index: A Tale of 25 Cities in Australia. Canberra: University of Canberra neXus Research Centre, 2017.“Qld Customers NB-uN Happy Complaints about NBN Service Double in 12 Months.” Daily Mercury 17 Apr. 2018: 1.Rudd, Kevin. “Media Release: New National Broadband Network.” Parliament of Australia Press Release, 7 Apr. 2009 <https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id:"media/pressrel/PS8T6">.Rynne, David. “Revitalising the Sugar Industry.” Sugar Policy Insights Feb. 2019: 2–3.Taylor, Emma. “A Dip in the Pond.” Sydney Morning Herald 16 Aug. 1997: 12.“Telcos and NBN Co in a Crisis.” Daily Mercury 27 Jul. 2017: 6.

Abstract Introduction Autoinflammatory diseases are an emerging group, characterised by recurrent inflammatory episodes due to dysregulated innate immunity. Common features include fevers, rash, arthralgia, lymphadenopathy and systemic symptoms. Castleman’s disease is a rare lymphoproliferative disease, associated with the overproduction of interleukin-6 (IL-6). Its two main variants: unicentric and multicentric differ in aetiology and clinical outcomes. The cytokine storm driven by IL-6 can mimic autoinflammatory disease. We present the case of an acquired autoinflammatory syndrome in a 33-year-old male with the clinical phenotype of Castleman’s but no culprit lymph node detected radiologically. Symptoms dramatically improved with yocilizumab, an IL-6 blocker. Case description A 33-year-old Caucasian man was referred to rheumatology at his local District General Hospital with flitting joint pains, fevers, night sweats and weight loss for eighteen months. He had associated fatigue, myalgia, sore throat and an intermittent maculopapular rash. There were no specific symptoms of infection, malignancy or underlying connective tissue disease. No risk factors for blood-borne viruses were identified. Past medical history included hearing difficulties in childhood, and maternal family history of Crohn’s disease. Currently he was unemployed, having previously worked in a concrete factory. There was a 30 pack-year smoking history with moderate alcohol intake. Physical examination revealed a faint maculopapular rash over his right forearm but was otherwise normal. Full blood count showed an improved microcytic anaemia with recent haemoglobin 132 g/L, raised white cell count up to 33 x 109/L (predominant neutrophilia) and mild thrombocytosis up to 480 x 109/L. Inflammatory were persistently elevated with CRP 124 mg/L and ESR 67 mm/hr. Renal, liver and thyroid functions were all normal as well as creatine kinase. Iron studies suggested iron-deficiency with negative anti-endomysial antibodies. Serum ferritin peaked at 1028 during µg/L during flares, with normal triglycerides. A full autoimmune screen was negative. Immunoglobulins showed a polyclonal rise only. HIV and Hepatitis screens were negative. CT chest, abdomen and pelvis and subsequent PET-CT scan were unremarkable. A bone marrow biopsy showed reactive changes only. A trial of low-dose prednisolone provided dramatic symptomatic improvement but symptoms flared on weaning to 10mg daily. Both steroid-sparing agents azathioprine and methotrexate were not tolerated. After further investigations by the National Amyloidosis Centre, he was commenced on weekly tocilizumab 162mg subcutaneous injections after a successful individual funding request. This provided an excellent clinical response which has been sustained for over two years. Discussion This case was difficult given the wide differential diagnoses. It was important to rule out infection, malignancy and autoimmune disease which were commoner causes of recurrent fevers and systemic symptoms. The long duration of symptoms, negative blood cultures and unremarkable CT imaging were against deep-seated infection. He was low risk for tuberculosis, zoonosis and tropical infections. No solid tumours or lymph nodes were seen on imaging but the PET-CT noted non-specific bone marrow changes. Bone marrow biopsy showed increased granulopoiesis without features of malignancy, and JAK-2 mutation was negative. Lactate dehydrogenase was normal with negative haemolysis screen. Upper and lower gastrointestinal endoscopies to investigate his iron-deficiency anaemia were normal. A full autoimmune screen was normal including anti-nuclear antibody, extractible nuclear antigen, rheumatoid factor, anti-cyclic citrullinated peptide antibody, complement C3 and C4 and anti-double-stranded DNA antibody. As no malignancy was found, prednisolone 40mg daily was trialled with fortnightly tapering. This produced a marked improvement in symptoms and inflammatory markers. However there were frequent flares on tapering the dose. He was therefore referred to the National Amyloidosis Centre at the Royal Free Hospital in London for an expert opinion. A genetic screen was negative for NLPR3 (CAPS gene), LRP12, TRAPS gene and the mevalonate kinase gene. Serum amyloid A (SAA) was very high 591 m/l (<10) with CRP 120 mg/L. The clinical picture suggested an acquired autoinflammatory disease, most consistent with Castleman’s disease of the solitary plasma cell type. Adult-onset Still’s disease was considered but ferritin levels were not typical. A culprit lymph node is usually seen on imaging but occasionally can be too small to identify. Castleman’s responds very well to IL-6 blockade and SAA and CRP normalised with four doses of tocilizumab. Duration of treatment is unclear. Interval imaging was planned in case a resectable lymph node developed. Key learning points Autoinflammatory diseases are rare but treatable causes of fever syndromes. Extensive investigations are needed to exclude mimics such as infection, malignancy (especially haematological) and autoimmune conditions. Genetic testing can reveal the diagnosis for monogenic types such as familial Mediterranean fever (FMF), cryopyrin-associated periodic syndrome (CAPS) and tumour necrosis factor receptor-associated periodic syndrome (TRAPS). Castleman’s disease can be caused by a single lymph node (unicentric) or diffuse lymph nodes (multicentric). The unicentric type is less associated with systemic symptoms compared to multicentric, except for its rarer plasmacytosis variant. Consider HIV and human herpes virus-8 infection in the multicentric type. IL-6 blockade is extremely effective in Castleman’s but optimum duration of therapy remains unclear. Surgical resection of the solitary lymph node in unicentric Castleman’s has a good prognosis. Serum amyloid A can be a useful marker of disease activity in autoinflammatory disease compared with CRP. Conflict of interest The authors declare no conflicts of interest.

Ao serem administrados, os Anestésicos Locais e Vasoconstritores (VC) iniciam os processos de absorção e eliminação, passando pela circulação sanguínea podendo atingir níveis tóxicos ou induzir alterações cardiovasculares. Objetivou-se avaliar o comportamento da atividade cardiovascular nas cirurgias para a remoção de terceiros molares utilizando a mepivacaína 2% com adrenalina na concentração de 1:100.000 em um período de até 120 min após a injeção anestésica. Trata-se de um estudo longitudinal, interventivo com caráter quantitativo e descritivo, com dados mensuráveis para análise e interpretação, realizado com pacientes da disciplina de clínica cirúrgica do curso de odontologia da UniCatólica. Os resultados obtidos foram analisados através do teste de normalidade de Kolmogorov-Smirnov e comparados ao longo do trans-operatório pelos testes ANOVA para medidas repetidas seguidas do pós-teste de Bonferroni ou Friedman seguido do pós-teste de Dunn adotando um nível de 5% de significância (p < 0,05). O procedimento com o anestésico utilizado não provocou alterações na Pressão Arterial Sistólica (PAS) (p=0,712), Pressão Arterial Diastólica (PAD) (p=0,098) bem como da diferença de PAS e PAD (p=0,546). Na Frequência Cardíaca (FC) houve diferença significante nos tempos de 10 min (p=0,013) e 120 min (p=0,013). Já na Saturação Periférica O2 (SPO2) houve diferença estatística significante nos tempos da 1ª visita (p=0,001), 0 (p=0,001), 5 (p=0,001) e 20 (p=0,001). Conclui-se assim, que o anestésico local pode ser utilizado em pacientes normotensivos durante a realização de procedimentos cirúrgicos odontológicos, e este leve aumento na FC e SPO2pode estar relacionado à ansiedade e/ou ao estresse emocional dos pacientes.Descritores: Anestésicos Locais; Mepivacaína; Sistema Cardiovascular; Pressão Arterial. ReferênciasAndrade ED. Terapêutica Medicamentosa em Odontologia. 3. ed. São Paulo: Artes Médicas; 2014.Teixeira RN. Anestesia Local sem Vasoconstritor versus com Vasoconstritor. Porto: Faculdade de Ciências da Saúde; 2014.Malamed SF. Manual de Anestesia Local. 5ª. ed. São Paulo: Elsevier; 2004.Silvestre FJ, Verdu MJ, Sanchis JM, Grau D, Penarrocha M. Effects of vasoconstrictors in dentistry upon systolic and diastolic arterial pressure. Medicina Oral. 2001;6(1):57-63.Ponzoni D, Sanches MG, Okamoto T. Influência de solução anestésica local contendo mepivacaína no processo de reparo em feridas de extração dental: análise histológica em ratos. Rev ABO. 2003;11(5):287-92.Dicionário de Especialidades Farmacêuticas, 2004/05. 33. ed. Rio de Janeiro: Editora de Publicações Científicas; 2004.Frabett IL, Checchi L, Finelli K. Cardiovascular effects of local anesthesia with epinephrine in periodontal treatment. Quintessence Int. 1992;23(1):19-24.Lambrecth JT, Filippi A. Arrigoni J, Cardiovascular monitoring and its consequences in oral surgery. Ann Maxillofac Surg. 2011;1(2):102-6.Fukayama H, Yagiela J. A. Monitoring of vital signs during dental care. Int Dent J. 2006;56(2):102-8.Dantas MVM, Gabrielli MAC, Hochuli-Vieira E. Efeito da mepivacaína 2% com adrenalina 1:100.000 sobre a pressão sanguínea. Rev Odontol Unesp. 2008;37(3):223-27.Nichols C. Dentistry and hipertension. J Am Dent Assoc. 1997;128(11):1557-62.Zottis D, Bernardes R, Wannmacher L. Efeito de vasoconstritor usado em anestesia local sobre a PA sistêmica e FC durante o atendimento odontológico. Rev ABO. 1999; 7:289-93.Neves RS, Neves IL, Giorgi DM, Grupi CJ, César LA, Hueb W et al. Effects of epinephrine in local dental anesthesia in patients with coronary artery disease. Arq Bras Cardiol. 2007; 88(5):545-51.Laragnoit AB, Neves RS, Neves IL, Vieira JE. Locoregional anesthesia for dental treatment in cardiac patients: a comparative study of 2% plain lidocaine and 2% lidocaine with epinephrine (1:100,000). Clinics. 2009;64(3):177-82.Silvestre FJ, Salvador-Martínez I, Bautista D, Silvestre-Rangil J. Clinical study of hemodynamic changes during extraction in controlled hyperten- controlled hypertensive patients. Med Oral Patol Oral Cir Bucal. 2011;16(3):e354-58.Dutra RM. Saturação periférica de oxigênio, frequência cardíaca e pressão arterial sistêmica em crianças portadoras de cardiopatia congênita cianogênica com hipofluxo pulmonar durante procedimento odontológico [tese]. São Paulo: Faculdade de Medicina da Universidade de São Paulo/Programa de Pneumologia; 2012.Braga AFA, D’Ottaviano LH, Braga FSS, Morais SS. Extração de terceiros molares retidos sob anestesia local. Avaliação de ansiedade, dor, alterações hemodinâmicas e respiratórias. Rev Fac Odontol Porto Alegre. 2010;51(2):9-14.Prado RMS. Efeitos cardiovasculares da mepivacaína com epinefrina seguida hialuronidase: ensaio duplo-cego controlado em cirurgias bilaterais de terceiros molares inferiores [dissertação]. São Paulo: Faculdade de Odontologia da USP; 2007.Alemany-Martinez A, Valmaseda-Castellón E, Berini-Aytés L, Gay-Escoda C. Hemodynamic changes during the surgical removal of lower third molars. J. Oral Maxillofac. Surg. 2008;66(3):453-61.Paramaesvaran M, Kingon AM. Alterations in blood pressure and pulse rate in exodontia patients. Aust Dent J. 1994;39(5):282-86.Sociedade Brasileira de Anestesiologia. Tutorial de Anestesia da Semana - Oximetria de Pulso – parte 1. WILSON, Iain. Royal Devon & Exeter Hospital, UK, 2013. Disponível em: <http://grofsc.net/wp/wp-content/uploads/ 2013/ 03/Oximetria-de-pulso-parte-11.pdf>. Acesso em: 22 de novembro, 2016.Tolas AG, Pflug AE, Halter JB. Arterial plasma epinephrine concentrations and hemodynamic responses after dental injection of local anesthetic with epinephrine. J Am Dent Assoc.1982;104(1):41-3.Brand HS, Abraham-Inpijn L. Cardiovascular responses induced by dental treatment. Eur J Oral Sci.1996;104(3):245-52.Takahashi Y, Nakano M, Kanri KST. The effects of epinephrine in local anesthetics on plasma catecholamine and hemodynamic responses. Odontology.2005;93(1):72-9.Muzyka BC, Glick M. The hypertensive dental patient. J Am Dent Assoc.1997;128(8):1109-20.Báguena JC, Chiva F. Efectos de los anestésicos de uso odontológico sobre la presión arterial y la frecuencia cardíaca. Rev Eur Odontoestomatol. 1999;1(5):291-95.Eyigor C, Cagiran E, Balcioglu T, Uyar M. Comparação dos efeitos de remifentanil e remifentanil + lidocaína em intubação de pacientes intelectualmente deficientes. Rev Bras Anestesiol. 2014;64(4):263-68.Pavan MV, Saura GE, Korkes HÁ, Nascimento KM, Neto NMN, Dávila R, Rodrigues CIS, Almeida FA. Similaridade entre os valores da pressão arterial aferida pelo método auscultatório com aparelho de coluna de mercúrio e o método oscilométrico automático com aparelho digital. J Bras Nefrol. 2012;34(1):43-9.

Teichman notes in her study of illegitimacy that “the point of the legitimate/illegitimate distinction is not to cause suffering; rather, it has to do with certain widespread human aims connected with the regulation of sexual activities and of population” (4). She also writes that, until relatively recently, “the shame of being an unmarried mother was the worst possible shame a woman could suffer” (119). Hence the secrecy, silences, and lies that used to be so common around the issue of an illegitimate birth and adoption.I was adopted at birth in the mid-1960s in New Zealand because my mother was a long way from family in England and had no support. She and my father had fallen in love, and planned to marry, but it all fell apart, and my mother was left with decisions to make. It was indeed a difficult time for unwed mothers, and that issue of shame and respectability was in force. The couple who adopted me were in their late forties and had been married for twenty-five years. My adoptive father had served in World War Two in the Royal Air Force before being invalided out for health problems associated with physical and psychological injuries. He was working in the same organisation as my mother and approached her when he learned of her situation. My adoptive mother loved England as her Home all of her life, despite living in Australia permanently from 1974 until her death in 2001. I did not know of my adoption until 1988, when I was twenty-three years old. The reasons for this were at least partly to do with my adoptive parents’ fear that I would leave them to search for my birth parents. My feelings about this long-held secret are complex and mixed. My adoptive mother never once mentioned my adoption, not on the day I was told by my adoptive father, nor at any point afterwards. My adoptive father only mentioned it again in the last two years of his life, after a long estrangement from me, and it made him weep. Even in the nursing home he did not want me to tell anyone that I had been adopted. It was impossible for me to obey this request, for my sense of self and my own identity, and for the recognition of the years of pain that I had endured as his daughter. He wanted to keep so much a secret; I could not, and would not, hold anything back anymore.And so I found myself telling anyone who would listen that I was adopted, and had only found out as an adult. This did not transmogrify into actively seeking out my birth parents, at least not immediately. It took some years before I obtained my original birth certificate, and then a long while again before I searched for, and found, my birth mother. It was not until my adoptive mother died that I launched into the search, probably because I did not want to cause her pain, though I did not consciously think of it that way. I did not tell my adoptive father of the search or the discovery. This was not an easy decision, as my birth mother would have liked to see him again and thank him, but I knew that his feelings were quite different and I did not want to risk further hurt to either my birth mother or my adoptive father. My own pain endures.I also found myself writing about my family. Other late discovery adoptees, as we are known, have written of their experiences, but not many. Maureen Watson records her shock at being told by her estranged husband when she was 40 years old; Judith Lucy, the comedian, was told in her mid-twenties by her sister-in-law after a tumultuous Christmas day; the Canadian author Wayson Choy was in his late fifties when he received a mysterious phone call from a woman about seeing his “other” mother on the street.I started with fiction, making up fairy tales or science fiction scenarios, or one act plays, or poetry, or short stories. I filled notebooks with these words of confusion and anger and wonder. Eventually, I realised I needed to write about my adoptive life in fuller form, and in life story mode. The secrecy and silences that had dominated my family life needed to be written out on the page and given voice and legitimacy by me. For years I had thought my father’s mental disturbance and destructive behaviour was my fault, as he often told me it was, and I was an only child isolated from other family and other people generally. My adoptive mother seemed to take the role of the shadow in the background, only occasionally stepping forward to curb my father’s disturbing and paranoid reactions to life.The distinction between legitimacy and illegitimacy may not have been created and enforced to cause suffering, but that, of course, is what it did for many caught in its circle of grief and exclusion. For me, I did not feel the direct effect of being illegitimate at birth, because I did not “know”. (What gathered in my unconscious over the years was another thing altogether.) This was different for my birth mother, who suffered greatly during the time she was pregnant, hoping something would happen that would enable her to keep me, but finally having to give me up. She does not speak of shame, only heartache. My adoptive father, however, felt the shame of having to adopt a child; I know this because he told me in his own words at the end of his life. Although I did not know of my adoption until I was an adult, I picked up his fear of my inadequacy for many years beforehand. I realise now that he feared that I was “soiled” or “tainted”, that the behaviour of my mother would be revisited in me, and that I needed to be monitored. He read my letters, opened my diaries, controlled my phone calls, and told me he had spies watching me when I was out of his range. I read in Teichman’s work that the word “bastard”, the colloquial term for an illegitimate child or person, comes from the Old French ba(s)t meaning baggage or luggage or pack-saddle, something that could be slept on by the traveller (1). Being illegitimate could feel like carrying heavy baggage, but someone else’s, not yours. And being adopted was supposed to render you legitimate by giving you the name of a father. For me, it added even more heavy baggage. Writing is one way of casting it off, refusing it, chipping it away, reducing its power. The secrecy of my adoption can be broken open. I can shout out the silence of all those years.The first chapter of the memoir, “A Shark in the Garden”, has the title “Revelation”, and concerns the day I learned of my adoptive status. RevelationI sat on my bed, formed fists in my lap, got up again. In the mirror there was my reflection, but all I saw was fear. I sat down, thought of what I was going to say, stood again. If I didn’t force myself out through my bedroom door, all would be lost. I had rung the student quarters at the hospital, there was a room ready. I had spoken to Dr P. It was time for me to go. The words were formed in my mouth, I had only to speak them. Three days before, I had come home to find my father in a state of heightened anxiety, asking me where the hell I had been. He’d rung my friend C because I had told him, falsely, that I would be going over to her place for a fitting of the bridesmaid dresses. I lied to him because the other bridesmaid was someone he disliked intensely, and did not approve of me seeing her. I had to tell him the true identity of the other bridesmaid, which of course meant that I’d lied twice, that I’d lied for a prolonged period of time. My father accused me of abusing my mother’s good nature because she was helping me make my bridesmaid’s dress. I was not a good seamstress, whereas my mother made most of her clothes, and ours, so in reality she was the one making the dress. When you’ve lied to your parents it is difficult to maintain the high ground, or any ground at all. But I did try to tell him that if he didn’t dislike so many of my friends, I wouldn’t have to lie to him in order to shield them and have a life outside home. If I knew that he wasn’t going to blaspheme the other bridesmaid every time I said her name, then I could have been upfront. What resulted was a dark silence. I was completing a supplementary exam in obstetrics and gynaecology. Once passed, I would graduate with a Bachelor of Medicine, Bachelor of Surgery degree, and be able to work as an intern in a hospital. I hated obstetrics and gynaecology. It was about bodies like my own and their special functions, and seemed like an invasion of privacy. Women were set apart as specimens, as flawed creatures, as beings whose wombs were always going wrong, a difficult separate species. Men were the predominant teachers of wisdom about these bodies, and I found this repugnant. One obstetrician in a regional hospital asked my friend and me once if we had regular Pap smears, and if our menstrual blood contained clots. We answered him, but it was none of his business, and I wished I hadn’t. I can see him now, the small eyes, the bitchiness about other doctors, the smarminess. But somehow I had to get through it. I had to get up each morning and go into the hospital and do the ward rounds and see patients. I had to study the books. I had to pass that exam. It had become something other than just an exam to me. It was an enemy against which I must fight.My friend C was getting married on the 19th of December, and somehow I had to negotiate my father as well. He sometimes threatened to confiscate the keys to the car, so that I couldn’t use it. But he couldn’t do that now, because I had to get to the hospital, and it was too far away by public transport. Every morning I woke up and wondered what mood my father would be in, and whether it would have something to do with me. Was I the good daughter today, or the bad one? This happened every day. It was worse because of the fight over the wedding. It was a relief to close my bedroom door at night and be alone, away from him. But my mother too. I felt as if I was betraying her, by not being cooperative with my father. It would have been easier to have done everything he said, and keep the household peaceful. But the cost of doing that would have been much higher: I would have given my life over to him, and disappeared as a person.I could wake up and forget for a few seconds where I was and what had happened the day before. But then I remembered and the fear exploded in my stomach. I lived in dread of what my father would say, and in dread of his silence.That morning I woke up and instantly thought of what I had to do. After the last fight, I realised I did not want to live with such pain and fear anymore. I did not want to cause it, or to live with it, or to kill myself, or to subsume my spirit in the pathology of my father’s thinking. I wanted to live.Now I knew I had to walk into the living room and speak those words to my parents.My mother was sitting in her spot, at one end of the speckled and striped grey and brown sofa, doing a crossword. My father was in his armchair, head on his hand. I walked around the end of the sofa and stood by ‘my’ armchair next to my mother.“Mum and Dad, I need to talk with you about something.”I sat down as I said this, and looked at each of them in turn. Their faces were mildly expectant, my father’s with a dark edge.“I know we haven’t been getting on very well lately, and I think it might be best if I leave home and go to live in the students’ quarters at the hospital. I’m twenty-three now. I think it might be good for us to spend some time apart.” This sounded too brusque, but I’d said it. It was out in the atmosphere, and I could only wait. And whatever they said, I was going. I was leaving. My father kept looking at me for a moment, then straightened in his chair, and cleared his throat.“You sound as if you’ve worked this all out. Well, I have something to say. I suppose you know you were adopted.”There was an enormous movement in my head. Adopted. I suppose you know you were adopted. Age of my parents at my birth: 47 and 48. How long have you and Dad been married, Mum? Oooh, that’s a tricky one. School principal’s wife, eyes flicking from me to Mum and back again, You don’t look much like each other, do you? People referring to me as my Mum’s friend, not her daughter. I must have got that trait from you Oh no I know where you got that from. My father not wanting me to marry or have children. Not wanting me to go back to England. Moving from place to place. No contact with relatives. This all came to me in a flash of memory, a psychological click and shift that I was certain was audible outside my mind. I did not move, and I did not speak. My father continued. He was talking about my biological mother. The woman who, until a few seconds before, I had not known existed.“We were walking on the beach one day with you, and she came towards us. She didn’t look one way or another, just kept her eyes straight ahead. Didn’t acknowledge us, or you. She said not to tell you about your adoption unless you fell in with a bad lot.”I cannot remember what else my father said. At one point my mother said to me, “You aren’t going to leave before Christmas are you?”All of her hopes and desires were in that question. I was not a good daughter, and yet I knew that I was breaking her heart by leaving. And before Christmas too. Even a bad daughter is better than no daughter at all. And there nearly was no daughter at all. I suppose you know you were adopted.But did my mother understand nothing of the turmoil that lived within me? Did it really not matter to her that I was leaving, as long as I didn’t do it before Christmas? Did she understand why I was leaving, did she even want to know? Did she understand more than I knew? I did not ask any of these questions. Instead, at some point I got out of the chair and walked into my bedroom and pulled out the suitcase I had already packed the night before. I threw other things into other bags. I called for a taxi, in a voice supernaturally calm. When the taxi came, I humped the suitcase down the stairs and out of the garage and into the boot, then went back upstairs and got the other bags and humped them down as well. And while I did this, I was shouting at my father and he was shouting at me. I seem to remember seeing him out of the corner of my eye, following me down the stairs, then back up again. Following me to my bedroom door, then down the stairs to the taxi. But I don’t think he went out that far. I don’t remember what my mother was doing.The only words I remember my father saying at the end are, “You’ll end up in the gutter.”The only words I remember saying are, “At least I’ll get out of this poisonous household.”And then the taxi was at the hospital, and I was in a room, high up in a nondescript, grey and brown building. I unpacked some of my stuff, put my clothes in the narrow wardrobe, my shoes in a line on the floor, my books on the desk. I imagine I took out my toothbrush and lotions and hairbrush and put them on the bedside table. I have no idea what the weather was like, except that it wasn’t raining. The faces of the taxi driver, of the woman in reception at the students’ quarters, of anyone else I saw that day, are a blur. The room is not difficult to remember as it was a rectangular shape with a window at one end. I stood at that window and looked out onto other hospital buildings, and the figures of people walking below. That night I lay in the bed and let the waves of relief ripple over me. My parents were not there, sitting in the next room, speaking in low voices about how bad I was. I was not going to wake up and brace myself for my father’s opprobrium, or feel guilty for letting my mother down. Not right then, and not the next morning. The guilt and the self-loathing were, at that moment, banished, frozen, held-in-time. The knowledge of my adoption was also held-in-time: I couldn’t deal with it in any real way, and would not for a long time. I pushed it to the back of my mind, put it away in a compartment. I was suddenly free, and floating in the novelty of it.ReferencesChoy, Wayson. Paper Shadows: A Chinatown Childhood. Ringwood: Penguin, 2000.Lucy, Judith. The Lucy Family Alphabet. Camberwell: Penguin, 2008.Teichman, Jenny. Illegitimacy: An Examination of Bastardy. New York: Cornell University Press, 1982. Watson, Maureen. Surviving Secrets. Short-Stop Press, 2010.