Klinefelter syndrome (KS) is a common genetic condition that is currently under-diagnosed. The phenotype is broad, with physical, medical and psychosocial features ranging from mild to severe. When a child is diagnosed with KS, the parents may spend months to years searching for a diagnosis. This study used a qualitative methods approach to explore parents' experiences of having a child with KS and receiving a diagnosis. Fifteen semistructured one-to-one in-depth interviews were conducted to explore their experiences and views. The interviews were then transcribed, coded and thematically analysed. The interviews revealed that parents had diverse experiences related to: the timing of the diagnosis of their child and reasons why their child was investigated for KS; the information that was provided at the time of diagnosis; the supports that were available and the concerns that parents held for the future of their child. The conclusions from this study were that parents' experiences of having a child with KS and receiving a diagnosis were complex and multifaceted. This experience was shaped by the timing of when the diagnosis was received, who provided the diagnosis, what information was provided from health-care professionals and that which parents may have encountered on the internet. The long-term experiences for parents were also impacted by the level of support they received. These findings have implications for the process by which KS is recognised by the health-care community and supports available for families.

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ow back pain is the most common musculoskeletal symptom among people visiting emergency departments, and it is one of the top five most frequent complaints in emergency medicine. 1 A systematic review of 21 studies undertaken during 2000-2016 in 12 countries found that low back pain was consistently among the most frequent complaints in emergency medicine. 2 Despite numerous studies and recommendations, a recent systematic review found that the utility of standard pharmacological treatments for acute back pain is limited. 3 Accepted class II evidence indicates that patient education, superficial heat, paracetamol, non-steroidal antiinflammatory drugs, and the limited use of skeletal muscle relaxants and opioids can be beneficial. 1 It is reported that emergency physicians often choose opioid therapy, including 61% in a large American national sample 4 and 70% in an Australian study. 5 However, medical therapy for low back pain is of modest benefit. Cannabidiol (CBD) is the major non-psychotropic phytocannabinoid in Cannabis sativa (up to 40% of extracted alkaloids). 6 Unlike most cannabinoids, including tetrahydrocannabinol (THC), CBD does not have psychomotor or cognitive effects, and its safety profile is good. 6 CBD has attracted increasing medical interest because of its anxiolytic, anti-inflammatory, anti-emetic, anti-epileptic, and anti-psychotic effects. [6][7][8][9] It has been approved in several countries for the treatment of neuropathic pain. 10 The most frequently reported side effects of acute ingestion of CBD are dizziness or drowsiness, itching or rash, headache, abdominal discomfort, nausea, and vomiting or diarrhoea. 9,11 Although CBD and its analogues may be beneficial for reducing pain caused by inflammation, its utility for treating acute low back pain has not been assessed. 11 The objective of our study was to compare the analgesic effect and safety of single oral administration of CBD as an adjunct to standard care for patients who presented to an emergency department with acute, non-traumatic low back pain, with those of a placebo. MethodsThe CANBACK trial was a single centre, randomised, double blinded, placebo-controlled clinical trial. Adults with acute, nontraumatic low back pain who presented to the Austin Hospital emergency department (Melbourne) during 21 May 2018 -13 June 2019 were recruited. The Austin Hospital tertiary emergency department treats 90 000 patients each year, and offers a wide range of clinical services. The trial was registered with the Australian New Zealand Clinical Trials Registry on 4 April 2018 (ACTRN12618000487213). ParticipantsPatients with acute low back pain were identified by the study investigators and clinical staff (medical and nursing) working in the triage and fast track areas of the emergency department, and were managed in the short stay unit. Participants were provided

Aim To characterise the key features and management of young people presenting to the emergency department (ED) with a mental health (MH) complaint and a known diagnosis of autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD). Methods Retrospective review of all ED MH presentations in children aged 7–17 years, presenting over a 12‐month period from the 1st of January 2018 to the 31st of December 2018, to the Royal Children's Hospital in Melbourne, Australia. Univariate analyses were carried out to examine the relationship between an underlying diagnosis of ASD and/or ADHD and a number of key presentation variables. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated for ED management outcomes. Results There were 374 presentations in this cohort, representing 28% of the total MH presentations in 2018. The most common reason for presentation was acute severe behavioural disturbance. Young people with ASD and ADHD were at increased risk of having an acute crisis team response activated (ASD RR 2.3, CI 1.6–3.3, ADHD RR 2.2, CI 1.2–4.1). Compared to those without either diagnosis, young people with ASD were more likely to be physically restrained (RR 2.8, CI 1.7–4.6), managed in seclusion (RR 3.3, CI 1.7–6.4) and to receive medication to assist with behavioural de‐escalation (RR 2.8, CI 1.6–4.9). Conclusions Children with ASD and/or ADHD represent one‐quarter of all children presenting to the ED with MH complaints. They experience high rates of acute severe behavioural disturbance. Future research is needed to co‐design, implement and evaluate better approaches for their management.

Background This study aimed to determine the impact of pulmonary complications on death after surgery both before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Methods This was a patient-level, comparative analysis of two, international prospective cohort studies: one before the pandemic (January–October 2019) and the second during the SARS-CoV-2 pandemic (local emergence of COVID-19 up to 19 April 2020). Both included patients undergoing elective resection of an intra-abdominal cancer with curative intent across five surgical oncology disciplines. Patient selection and rates of 30-day postoperative pulmonary complications were compared. The primary outcome was 30-day postoperative mortality. Mediation analysis using a natural-effects model was used to estimate the proportion of deaths during the pandemic attributable to SARS-CoV-2 infection. Results This study included 7402 patients from 50 countries; 3031 (40.9 per cent) underwent surgery before and 4371 (59.1 per cent) during the pandemic. Overall, 4.3 per cent (187 of 4371) developed postoperative SARS-CoV-2 in the pandemic cohort. The pulmonary complication rate was similar (7.1 per cent (216 of 3031) versus 6.3 per cent (274 of 4371); P = 0.158) but the mortality rate was significantly higher (0.7 per cent (20 of 3031) versus 2.0 per cent (87 of 4371); P < 0.001) among patients who had surgery during the pandemic. The adjusted odds of death were higher during than before the pandemic (odds ratio (OR) 2.72, 95 per cent c.i. 1.58 to 4.67; P < 0.001). In mediation analysis, 54.8 per cent of excess postoperative deaths during the pandemic were estimated to be attributable to SARS-CoV-2 (OR 1.73, 1.40 to 2.13; P < 0.001). Conclusion Although providers may have selected patients with a lower risk profile for surgery during the pandemic, this did not mitigate the likelihood of death through SARS-CoV-2 infection. Care providers must act urgently to protect surgical patients from SARS-CoV-2 infection.

Objective: To compare the efficacy of intravenous chlorpromazine versus intravenous prochlorperazine for the treatment of acute migraine in adults presenting to the emergency department (ED).Background: Migraine is a common, incapacitating neurological condition. Although chlorpromazine and prochlorperazine are known to be safe, efficacious treatments for migraine, they have never been directly compared. Design:We performed a prospective, randomized, double-blind clinical trial at a tertiary hospital in Melbourne, Australia. Adults aged 18-65 years, who presented with migraine, were eligible for recruitment. Sixty-six patients were randomized to either chlorpromazine 12.5 mg or prochlorperazine 12.5 mg, both infused in 500 ml of sodium chloride 0.9% over 30 min. Headache severity score, nausea severity score, and the presence of photophobia and phonophobia were assessed at 0, 30, 60, and 120 min. Adverse effects and the need for rescue therapy were recorded. The primary outcome was a reduction in headache severity score from baseline at 60 min post-commencement of the study medicine infusion.Results: Sixty-five patients were included in the analysis. There was a median reduction in headache severity score at 60 min of 3.0 (interquartile range 1.0-4.0) in the chlorpromazine arm versus 2.0 (1.0-4.0) in the prochlorperazine arm (median difference −0.5 (95% confidence interval, −1.9 to 0.9)). We saw no evidence of a difference in secondary outcomes at 30, 60, or 120 min. Side effects were reported in 16/32 (50%) patients in the chlorpromazine group versus 7/33 (21%) in the prochlorperazine group (p = 0.020). Rescue therapy was required in 7/32 (22%) patients in the chlorpromazine group versus 12/33 (36%) in the prochlorperazine group (p = 0.277).

Objectives With an increasingly dynamic global illicit drug market, including the emergence of novel psychoactive substances, many jurisdictions have moved to establish toxicosurveillance systems to enable timely detection of harmful substances in the community. This paper describes the methodology for the Emerging Drugs Network of Australia – Victoria (EDNAV) project, a clinical registry focused on the collection of high‐quality clinical and analytical data from ED presentations involving illicit drug intoxications. Drug intelligence collected from the project is utilised by local health authorities with the aim to identify patterns of drug use and emerging drugs of concern. Methods The project involves 10 public hospital EDs in Victoria, Australia. Patients 16 years and over, presenting to a network ED with a suspected illicit drug‐related toxicity and a requirement for venepuncture are eligible for inclusion in the study under a waiver of consent. Clinical and demographic parameters are documented by site‐based clinicians and comprehensive toxicological analysis is conducted on patient blood samples via specialised forensic services. All data are then deidentified and compiled in a project specific database. Results Cases are discussed in weekly multidisciplinary team meetings, with a view to identify potentially harmful substances circulating in the community. High‐risk signals are escalated to key stakeholders to produce timely and proportionate public health alerts with a focus on harm minimisation. Conclusions The EDNAV project represents the first centralised system providing near real‐time monitoring of community drug use in Victoria and is fundamental in facilitating evidence‐based public health intervention.

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