Establishing an esketamine clinic in Australia: Practical recommendations and clinical guidance from an expert panel.

BACKGROUND: Major depressive disorder (MDD) can have severe impacts on function and quality of life. Up to one third of patients will have an inadequate response to their first line of treatment, with subsequent lines of therapy associated with lower remission rates and higher relapse rates. Recently esketamine has become available for Australian patients, and this agent provides an additional treatment option for those with MDD who have had an inadequate response to two or more antidepressant therapies during the current moderate to severe depressive episode. This paper provides an expert panel's practical recommendations and clinical guidance for establishing esketamine clinics in Australia. METHODS: An expert panel (n = 11) comprising psychiatrists, mental health care nurses, pharmacists, and individuals with experience establishing esketamine clinics was convened in Sydney. The panel developed practical recommendations and clinical guidance, which were then further refined. RESULTS: Five key areas were identified: practical considerations for esketamine clinic set-up, including multidisciplinary care considerations; patient selection; administering esketamine; adverse event management and long-term follow-up. CONCLUSIONS: Guidance presented in this paper should assist Australian clinicians to set up an esketamine clinic, and provide practical advice on the infrastructure and clinical requirements for treatment of patients with this agent.

The theory of planned behavior as a behavior change model for tobacco control strategies among adolescents in Botswana.

BACKGROUND: Behavioral intentions (motivational factors), attitudes, subjective norm (social pressures), and perceived behavioral control promote or discourage smoking behavior among adolescents. OBJECTIVE: To assess students' behavioral intentions, attitudes, subjective norms and perceived behavioral control on smoking using the Theory of Planned Behavior. The prevalence of smoking among the adolescents is also calculated. METHODS: In this cross-sectional study, structured self-administered questionnaires were used to collect data from adolescents in primary and secondary schools. Data on demographics, behavioral intentions, attitudes, subjective norms, and perceived behavioral control towards smoking were collected. Pearson product moment correlations and logistic regression models were used to determine factors associated with current smoking. RESULTS: A total sample of 2554 (mean age = 15; Range = 12-18 years) students participated in the study. Twenty-nine percent (n = 728) of the students had tried smoking at least once. Smoking was predicted by attitudes, subjective norms, perceived behavioral control and intention.There was a strong association between having a parent or guardian, caregiver or close friend who smoked (p < 0.001) and being a smoker. The majority of students (57%) conveyed that adults talked to them about the harmful effects of cigarette smoking and 50% had discussed smoking concerns with their friends. Students who had positive attitudes towards smoking like "smoking makes you confident" were more likely to be current smokers (OR: 1.63, 95% CI: 1.03-2.59). The feeling or conviction that they could refuse a cigarette if offered was an impediment from smoking (OR: 0.18, 95% CI: 0.13-0.26). CONCLUSIONS: Attitudes, subjective norms, and perceived behavioral control contributed significantly to the students' smoking. Right attitudes must be cultivated and behavioral control must be strengthened for early effective interventions to curtail smoking among adolescents.

Centralisation of oesophagectomy in Australia: is only caseload critical?

Objective High caseload is considered one of the most important factors for good outcomes after high-risk surgeries such as oesophagectomy. However, many Australian centres perform low volumes of oesophagectomies due to demographics. The aim of the present study was to audit outcome after oesophagectomy in an Australian low-volume centre over a period of 13 years and to discuss potential contributors to outcome other than just case volume. Methods Perioperative and long-term outcomes of all oesophagectomies over a 13-year period in a low-volume Australian tertiary care centre were analysed retrospectively. Data were compared in subgroups of patients in two separate time periods: 2000-05 (n=23) and 2006-12 (n=24). Results There were two perioperative deaths over the entire 13-year period with no postoperative mortality in the last decade. The complication and long-term survival rates for each of the two separate time periods were similar to those from high-volume centres, more so in the second half of the study period. Conclusions The data suggest that under specific conditions, oesophagectomies can be safely performed even in smaller- or low-volume centres in Australia. The policy of centralisation for these procedures in Australia needs to be carefully tailored to the needs of the population, clinical outcomes, cost-effectiveness and optimal utilisation of existing facilities rather than on caseload alone. What is known about the topic? High caseload is considered one of the most important factors for good outcomes after oesophagectomy and a driving force behind centralisation of this procedure. However, other factors may also affect outcome - such as availability of experienced surgeons, specialist nurses, interventional radiology, gastroenterology, etc. What does this paper add? With the availability of appropriate levels of expertise, infrastructure and specialist nursing staff as is the case in most Australian tertiary centres, good perioperative outcomes can be obtained despite low volumes. Case load only should not be used as a surrogate marker of quality. What are the implications for practitioners? The policy of centralisation for oesophagectomy in Australia needs to be carefully thought out on the basis of population demographics, outcomes and cost-effectiveness, with the appropriate use of existing facilities, rather than on a caseload basis alone.

Predictors of smoking among primary and secondary school students in Botswana.

This study seeks to determine the prevalence and risk factors for smoking among students aged 12-18 years in two cities in Botswana. Using a sample of 2554 students we adapted the Global Youth Tobacco Survey (GYTS) methodology to assess students' smoking practices, knowledge, beliefs and attitudes. Logistic regression models were used to evaluate factors associated with smoking. The results revealed that 10% of students were current tobacco smokers with 29% reporting having tried smoking. Self-image and acceptance by peers were the strongest predictors of smoking overall (adjusted Odds Ratio [aOR]: 3.13, 95%, Confidence Interval [CI]: 2.67-3.66). Intention to smoke or to continue to smoke and perceived norms in conformity with smoking were also independently associated with smoking (aOR: 1.81, 95% CI: 167-2.11 and aOR: 1.31, 95% CI: 1.10-1.57, respectively). Perceived prevalence and exposure to smoking by peers and family and access to tobacco products was stronger among females (aOR: 1.69, 95% CI: 1.52-1.91) compared to males (aOR: 0.93, 95% CI: 0.70-1.24). Our results indicate that anti-tobacco interventions in Botswana should prioritize intra-personal factors associated with smoking. Our findings also suggest that different interventions targeting male and female students should be explored.

The impact of capacity growth in national telecommunications networks.

This paper discusses both UK-based and global Internet data bandwidth growth, beginning with historical data for the BT network. We examine the time variations in consumer behaviour and how this is statistically aggregated into larger traffic loads on national core fibre communications networks. The random nature of consumer Internet behaviour, where very few consumers require maximum bandwidth simultaneously, provides the opportunity for a significant statistical gain. The paper looks at predictions for how this growth might continue over the next 10-20 years, giving estimates for the amount of bandwidth that networks should support in the future. The paper then explains how national networks are designed to accommodate these traffic levels, and the various network roles, including access, metro and core, are described. The physical layer network is put into the context of how the packet and service layers are designed and the applications and location of content are also included in an overall network overview. The specific role of content servers in alleviating core network traffic loads is highlighted. The status of the relevant transmission technologies in the access, metro and core is given, showing that these technologies, with adequate research, should be sufficient to provide bandwidth for consumers in the next 10-20 years.

Field trial of a quantum secured 10 Gb/s DWDM transmission system over a single installed fiber.

We present results from the first field-trial of a quantum-secured DWDM transmission system, in which quantum key distribution (QKD) is combined with 4 × 10 Gb/s encrypted data and transmitted simultaneously over 26 km of field installed fiber. QKD is used to frequently refresh the key for AES-256 encryption of the 10 Gb/s data traffic. Scalability to over 40 DWDM channels is analyzed.

First field demonstration of cloud datacenter workflow automation employing dynamic optical transport network resources under OpenStack and OpenFlow orchestration.

For the first time, we demonstrate the orchestration of elastic datacenter and inter-datacenter transport network resources using a combination of OpenStack and OpenFlow. Programmatic control allows a datacenter operator to dynamically request optical lightpaths from a transport network operator to accommodate rapid changes of inter-datacenter workflows.

Proximal anastomosis using the OrVil circular stapler in major upper gastrointestinal surgery.

Anastomoses in major upper gastrointestinal surgery can be technically demanding, especially handsewn anastomoses traversing the diaphragmatic hiatus. The OrVil stapler is a unique circular stapler that allows rapid creation of various upper gastrointestinal anastomoses in technically challenging circumstances, particularly if additional proximal clearance is desirable. Little is reported in the literature regarding its outcomes and complication rates. In this 'How I do It' article, we describe our technique and experience with the OrVil in major upper gastrointestinal surgery.

Effect of link margin and frequency granularity on the performance of a flexgrid optical network.

We show how dynamically adjustable modulation formats can be used to reduce link margins in flexgrid networks, reverting to lower order QAM due to reduced OSNR, if ageing occurs. Spectral savings amount to as much as 63% gain in capacity across a network using 64QAM with a fine frequency granularity of 6.25 GHz, with variable baud rate transponder. Further, a fixed baud rate, demand multiplexed transponder with adaptive modulation has been suggested. These transponders provide twice as much network capacity as compared to widely used fixed baud rate transponders operating at fixed grid of 50 GHz.

Designing national IP/MPLS networks with flexgrid optical technology.

We propose a two-step procedure to design flexgrid-based national networks. Locations are first partitioned into a set of metro areas interconnected through a flexgrid optical network. The problem is modeled as a Mixed Integer Linear Programming (ILP). Next, each network is designed separately. Optimal results show a future large (>200 nodes) flexgrid core network inter-connecting small (~10 nodes) metro regions.