A 36-year-old man presented with symptoms of acute pulmonary oedema at the conclusion of the Australian ironman triathlon. He was alert, orientated, with an oxygen saturation of 75% on room air. Chest examination revealed bilateral basal crepitations. Serum sodium was 120 mmol/L and chest x ray revealed bilateral basal opacities. He was treated for acute pulmonary oedema with prompt improvement and given 200 ml of intravenous hypertonic saline followed by normal saline. Serum sodium decreased to 117 mmol/L and 30 hours after presentation he had a seizure. He fully recovered and was discharged 5 days after admission. This case highlights that exercise-associated hyponatraemia and pulmonary oedema are still not widely understood and there is still a reluctance to treat hyponatraemia aggressively with ongoing hypertonic saline.

Fluid is typically administered via intravenous (IV) infusion to athletes who develop clinical symptoms of heat illness, based on the perception that dehydration is a primary factor contributing to the condition. However, other athletes also voluntarily rehydrate with IV fluid as opposed to, or in conjunction with, oral rehydration. The voluntary use of IV fluids to accelerate rehydration in dehydrated, though otherwise healthy athletes, has recently been banned by the World Anti-Doping Agency. However, the technique remains appealing to many athletes. Given that it now violates the Anti-Doping Code, it is important to determine whether potential benefits of using this technique outweigh the risks involved. Several studies have shown that rehydration is more rapid with IV fluid. However, the benefits are generally transient and only small differences to markers of hydration status are seen when comparing IV and oral rehydration. Furthermore, several studies have shown improvements in cardiovascular function and thermoregulation with IV fluid, while others have indicated that oral fluid is superior. Subsequent exercise performance has not been improved to a greater extent with one technique over the other. The paucity of definitive findings is probably related to the small number of studies investigating these variables and the vast differences in the designs of studies that have been conducted. The major limitation of IV rehydration is that it bypasses oropharyngeal stimulation, which has an influence on factors such as thirst sensation, antidiuretic hormone (arginine vasopressin) release, cutaneous vasodilation and mean arterial pressure. Further research is necessary to determine the relative benefits of oral and IV rehydration for athletes.

Supervision must be both structured and dynamic. Besides providing a regular forum for discussion and reflection, supervision must accommodate the variable needs of individual junior doctors and navigate between being hands-on and hands-off. Such dynamic approach is necessary to reassure junior doctors they are in a 'zone of safe learning' where they can act with adequate and flexible support and negotiate changes in supervisory attention.

An exercise program designed to improve fitness is essential for most adults. Exercise decreases the risk of cardiovascular disease, type 2 diabetes, some cancers, depression, and anxiety. Most fail to achieve recommended exercise levels. Only 1.3% of Australian general practice (GP) consultations provide exercise counseling and advice. Australia provides Medicare reimbursement for consultations with Accredited Exercise Physiologists through allied health care plans initiated through primary care. Exercise Is Medicine is an initiative to equip primary care providers with resources, education, and strategies to increase physical activity and reduce sedentary behavior. The objective of Exercise Is Medicine is to improve the health and well-being of our nation. We describe Exercise Is Medicine and encourage primary care providers to discuss physical activity and exercise with their patients and provide them with resources to encourage this activity and referral pathways to train exercise professionals. This will assist primary care providers in treating their patients.

Most ARISE participants did not meet the Sepsis-3 definition for septic shock at baseline. However, the majority fulfilled the new sepsis definition and mortality was higher than for participants not fulfilling the criteria. A quarter of participants meeting the new sepsis definition did not fulfill the qSOFA screening criteria, potentially limiting its utility as a screening tool for sepsis trials with patients with suspected infection in the ED. The implications of the new definitions for patients not eligible for recruitment into the ARISE trial are unknown.

OBJECTIVE AND DESIGN:This study examined the effects of the anti-obesity agents, phentermine and dexfenfluramine given alone or in combination, on in vitro and in vivo 5HT release from rat brain tissue. RESULTS: In vitro, phentermine was without effect on basal [ 3 H]5HT efflux from hypothalamic slices whereas dexfenfluramine (10 mM) evoked a 131% increase in [ 3 H]5HT release. In combination, the two drugs did not alter [ 3 H]5HT release beyond that caused by dexfenfluramine alone. At pharmacologically equivalent doses, phentermine (5.7 mg=kg, i.p.) caused a rapid, modest elevation, and dexfenfluramine (3 mg=kg, i.p.) a larger but equally rapid elevation of extracellular 5HT in the microdialysates from the rat anterior hypothalamus. In combination, the increase in extracellular 5HT evoked by these drugs was not significantly greater than the sum of their individual effects. CONCLUSIONS: This study provides evidence that phentermine's actions are not restricted to catecholamine systems and indicates that combining phentermine with dexfenfluramine results in an additive increase in neuronal 5HT release.

Patient contact with medical students and clinicians may be on the decline. Increasing medical graduate numbers, workforce and training demands, and the institution of safe working hours are putting pressure on opportunities for direct clinical interaction. Medical education curricula and clinical postgraduate education supervisors must ensure that students and junior doctors recognise the importance of hands‐on clinical contact with patients. Although many new developments aid health care efficiencies and can assist with the complexities of care required in a modern hospital, clinicians need to maintain their focus on the patient.

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