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Precision medicine should aspire to reduce error and improve accuracy in medical and health recommendations by comparison with contemporary practice, while maintaining safety and cost-effectiveness. The etiology, clinical manifestation and prognosis of diseases such as obesity, diabetes, cardiovascular disease, kidney disease and fatty liver disease are heterogeneous. Without standardized reporting, this heterogeneity, combined with the diversity of research tools used in precision medicine studies, makes comparisons across studies and implementation of the findings challenging. Specific recommendations for reporting precision medicine research do not currently exist. The BePRECISE (Better Precision-data Reporting of Evidence from Clinical Intervention Studies & Epidemiology) consortium, comprising 23 experts in precision medicine, cardiometabolic diseases, statistics, editorial and lived experience, conducted a scoping review and participated in a modified Delphi and nominal group technique process to develop guidelines for reporting precision medicine research. The BePRECISE checklist comprises 23 items organized into 5 sections that align with typical sections of a scientific publication. A specific section about health equity serves to encourage precision medicine research to be inclusive of individuals and communities that are traditionally under-represented in clinical research and/or underserved by health systems. Adoption of BePRECISE by investigators, reviewers and editors will facilitate and accelerate equitable clinical implementation of precision medicine.

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Post-mortem microbiology (PMM) is an important tool in identifying possible causes of sudden unexpected death, as an infectious cause is highly suspected. However, contamination is a major problem in microbiology, and this has increased the difficulty determining the true pathogen that contributes to death in post-mortem cases. Skin commensals are common contaminants in blood cultures. This study was conducted to investigate the skin flora on early deceased bodies and observe the bacteria detected at different post-mortem intervals (PMIs). As blood is usually drawn from the neck and femoral sites for PMM examination, the two body sites were chosen as the sampling sites. Skin swab samples from the neck and femoral (n=80) of each early deceased body were collected by sterile cotton swabs. DNA was extracted from the swabs and then subjected to high-throughput 16S rRNA sequencing by using the Illumina MiSeq platform. Staphylococcus was found to be the most dominant genus in both neck and femoral sites. LEfSe results showed that Cutibacterium is significantly different at the neck site while Corynebacterium is more abundant at femoral site. There are significant differences at genus level between PMI<5H and PMI>5H at both neck and femoral sites. The findings of the present study may act as a reference for microbiologists and forensic pathologists when mixed growth or contamination occurs in post-mortem blood cultures.

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Individual and health system barriers can impede clinicians from supporting weight-related behaviour change for pregnant women, particularly in publicly funded antenatal care accessed by women from diverse socioeconomic backgrounds. The aim was to understand clinicians' experiences of supporting healthy gestational weight gain for pregnant women in a publicly funded antenatal setting. The work was undertaken to guide the implementation of systems changes, resource development, and workforce capacity building related to nutrition, physical activity, and gestational weight gain in the service. The qualitative descriptive study used purposive sampling and semi-structured interviews conducted between October 2019 and February 2020. Nine midwives and five obstetricians from a publicly funded hospital antenatal service in Tasmania, Australia participated. Interview transcripts were analysed using inductive thematic analysis. The three dominant themes were prioritising immediate needs, continuity of care support weight-related conversations, and limited service capacity for weight- and nutrition-related support. The subthemes were different practices for women according to weight and the need for appropriately tailored resources. Improving access to continuity of care and clinician training, and providing resources that appropriately consider women's socioeconomic circumstances and health literacy would enhance the ability and opportunities for clinicians to better support all women.

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@#Post-mortem microbiology (PMM) is an important tool in identifying possible causes of sudden unexpected death, as an infectious cause is highly suspected. However, contamination is a major problem in microbiology, and this has increased the difficulty determining the true pathogen that contributes to death in post-mortem cases. Skin commensals are common contaminants in blood cultures. This study was conducted to investigate the skin flora on early deceased bodies and observe the bacteria detected at different post-mortem intervals (PMIs). As blood is usually drawn from the neck and femoral sites for PMM examination, the two body sites were chosen as the sampling sites. Skin swab samples from the neck and femoral (n=80) of each early deceased body were collected by sterile cotton swabs. DNA was extracted from the swabs and then subjected to high-throughput 16S rRNA sequencing by using the Illumina MiSeq platform. Staphylococcus was found to be the most dominant genus in both neck and femoral sites. LEfSe results showed that Cutibacterium is significantly different at the neck site while Corynebacterium is more abundant at femoral site. There are significant differences at genus level between PMI<5H and PMI>5H at both neck and femoral sites. The findings of the present study may act as a reference for microbiologists and forensic pathologists when mixed growth or contamination occurs in post-mortem blood cultures.

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Tuberculosis (TB) caused by Mycobacterium tuberculosis remains a serious public health threat with the World Health Organisation (WHO) reporting 5.8 million cases and 1.3 million deaths in the year 2020 due to TB. TB can be diagnosed by imaging, histopathological and bacteriological methods with culture remaining the gold standard. This study was performed to look at the sensitivity and specificity of post-mortem computed tomography (PMCT) imaging when compared to culture in diagnosing pulmonary tuberculosis. This was a retrospective comparative study looking at post mortem cases where lung tissue samples sent for TB culture at Hospital Kuala Lumpur were compared against PMCT imaging. Exclusion criteria included contaminated samples, decomposed cases, immunocompromised subjects and those below 18 years of age. Subjects included 80 medico-legal autopsy cases at the National Institute of Forensic Medicine, Hospital Kuala Lumpur, Malaysia who had whole body PMCT done in accordance with the Institute's protocol and tissue samples sent for bacteriology culture for tuberculosis. PMCT findings were positively associated with acid-fast organisms in 23.5 out of 33 cases (71.2%). Our study also showed that PMCT had a sensitivity of 71.3% and specificity of 54.3% (95% CI: 39.5-68.4) in diagnosing TB based on the protocol set in this study. This study showed that there was relatively good agreement between radiological PMCT findings and bacterial culture, suggesting that radiological examination is a relatively reliable tool for preliminary screening and possible diagnosis of TB prior to a postmortem examination which would be beneficial in reducing the risk of transmission of TB to health workers during autopsy.

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INTRODUCTION: PMCT is superior to autopsy for identification of intravascular or extravascular gas pockets and their distribution. However, differentiation between air embolism and putrefactive gas can prove challenging due to overlapping imaging findings. CASE REPORT: We report a case of a healthy young man who was involved in a fight, sustained a slash wound to the right side of his head by a kitchen knife and died at the scene. Pre-autopsy PMCT demonstrated complex fractures of the right mastoid bone extending to the right petrous apex and jugular bulb, exposing the right sigmoid sinus. There was also asymmetric intravascular air distribution suspicious of air embolism with ancillary findings of traumatic carotid-jugular pseudoaneurysm and arteriovenous fistulous formation. Post-mortem examination revealed a slash wound measuring 12x2 cm at the right side of the head, cutting through the scalp, right temporal bone, right temporal meninges, right sigmoid venous sinus and part of the right occipital lobe. No intracranial haemorrhage was found on both PMCT and autopsy. DISCUSSION: PMCT findings of air embolism versus putrefactive air on PMCT are discussed in this case. Detailed history on mechanism, circumstances, time of death and careful analysis of intravascular and extravascular air distribution patterns on PMCT are essential in guiding differentiation of true fatal air embolism and "normal" post-mortem putrefactive air. Needless to say, it is recommended that PMCT be performed as early as possible after death to reduce the chances and presence of artifactual decomposition changes.

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@#Tuberculosis (TB) caused by Mycobacterium tuberculosis remains a serious public health threat with the World Health Organisation (WHO) reporting 5.8 million cases and 1.3 million deaths in the year 2020 due to TB. TB can be diagnosed by imaging, histopathological and bacteriological methods with culture remaining the gold standard. This study was performed to look at the sensitivity and specificity of post-mortem computed tomography (PMCT) imaging when compared to culture in diagnosing pulmonary tuberculosis. This was a retrospective comparative study looking at post mortem cases where lung tissue samples sent for TB culture at Hospital Kuala Lumpur were compared against PMCT imaging. Exclusion criteria included contaminated samples, decomposed cases, immunocompromised subjects and those below 18 years of age. Subjects included 80 medico-legal autopsy cases at the National Institute of Forensic Medicine, Hospital Kuala Lumpur, Malaysia who had whole body PMCT done in accordance with the Institute’s protocol and tissue samples sent for bacteriology culture for tuberculosis. PMCT findings were positively associated with acid-fast organisms in 23.5 out of 33 cases (71.2%). Our study also showed that PMCT had a sensitivity of 71.3% and specificity of 54.3% (95% CI: 39.5–68.4) in diagnosing TB based on the protocol set in this study. This study showed that there was relatively good agreement between radiological PMCT findings and bacterial culture, suggesting that radiological examination is a relatively reliable tool for preliminary screening and possible diagnosis of TB prior to a postmortem examination which would be beneficial in reducing the risk of transmission of TB to health workers during autopsy.

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This study aimed at comparing two main existing diagnostic methods for the detection of lung infection in post-mortem cases of sudden adult death. Post-mortem computed tomography (PMCT) imaging of lungs and histopathology examination (HPE) of lung tissue were selected to compare their sensitivity and specificity. This retrospective case control study was conducted in a tertiary referral centre on 220 deceased individuals who underwent PMCT imaging prior to autopsy and had histology sampling during autopsy in the years 2016 - 2019. The bodies were examined with PMCT prior to conventional autopsy. Histology sampling were taken in those selected cases as part of medicolegal investigations. The reports and images of PMCT, and HPE reports with slides were retrieved and re-evaluated. Findings of PMCT and HPE were divided into pneumonia and non-pneumonia groups. Only PMCT images of chest and histology slides of lungs were accessed and evaluated. The result showed that the sensitivity and specificity of PMCT in the diagnosis of lung infection was 98.2% and 36.4%, whereas HPE showed a sensitivity and specificity of 97.3% and 100%. The accuracy of PMCT and HPE were 67.2 % and 98.6 % respectively. In conclusion, HPE had better accuracy compared to PMCT with almost similar sensitivity but higher specificity. PMCT may act as a good screening tool for pneumonia but is insufficient to substitute conventional autopsy in the diagnosis of pneumonia. Routine histology sampling during autopsy should be practised whenever dealing with sudden death.

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BACKGROUND: Rheumatic heart disease (RHD) remains an important cause of morbidity and mortality in New Zealand. Factors associated with the choice of surgical treatment for advanced RHD in young adults are poorly understood. We sought to review our local experience with the surgical management of young adults with rheumatic mitral valvular disease. METHODS: From 2003 to 2016, all patients aged 15-24 years undergoing mitral valve surgery for rheumatic disease at Auckland City Hospital, New Zealand were retrospectively reviewed. RESULTS: During the 13-year study period, 73 young adults underwent mitral surgery; 85% were Maori or Pacific Islanders. Mitral repair was performed in 32 patients and replacement in 41 patients. Isolated mitral valve surgery was performed in 36%, double valve procedures in 47%, and triple valve procedures in 17% of patients. The 30-day mortality rate and stroke rate were 1.4% and 2.7% respectively. The medium-term mortality rate was 11.9% across a mean follow-up of 6 years (6.9% in the repair group, 15.8% in the replacement group, p = 0.25). There were increased bleeding complications (p = 0.04) in patients with mechanical mitral valve replacement. For patients on warfarin, across medium-term follow-up, the INR was in the therapeutic range only 23% of the time. CONCLUSION: Most young adults in New Zealand with severe RHD requiring surgery are of indigenous Maori or Pacific Island ethnicity. There is a trend towards improved survival with mitral repair. There is a significant tendency towards increased bleeding complications in patients on warfarin for mechanical mitral replacement. Warfarin compliance is poor.

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Cardiovascular disease, especially coronary heart disease and cerebrovascular disease, is a leading cause of mortality and morbidity in women globally. The development of cardiometabolic conditions in pregnancy, such as gestational diabetes mellitus and hypertensive disorders of pregnancy, portend an increased risk of future cardiovascular disease in women. Pregnancy therefore represents a unique opportunity to detect and manage risk factors, prior to the development of cardiovascular sequelae. Risk prediction models for gestational diabetes mellitus and hypertensive disorders of pregnancy can help identify at-risk women in early pregnancy, allowing timely intervention to mitigate both short- and long-term adverse outcomes. In this narrative review, we outline the shared pathophysiological pathways for gestational diabetes mellitus and hypertensive disorders of pregnancy, summarise contemporary risk prediction models and candidate predictors for these conditions, and discuss the utility of these models in clinical application.

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OBJECTIVE: To study the barriers and facilitators to lifestyle management in PCOS from the perspectives of endocrinologists and obstetricians and gynecologists (Ob/Gyns) to inform the translation and implementation of the international evidence-based guideline on lifestyle management in PCOS. METHODS: 11 endocrinologists and ten Ob/Gyns participated in semi-structured interviews and transcripts were thematically analyzed on NVIVO software. RESULTS: Both endocrinologists and Ob/Gyns supported lifestyle as key to PCOS management but faced systemic barriers of lack of access to allied health services and had limited capacity for in-depth lifestyle discussions. They suggested team-based approach to address these barriers. Endocrinologists reported lifestyle could be a less effective treatment option and most of their patients had challenges with past failed lifestyle attempts while Ob/Gyns perceived the desire to conceive among patients a facilitator. The importance of credible, individualised and PCOS-specific lifestyle advice was highlighted. CONCLUSION: Endocrinologists and Ob/Gyns perceived lifestyle management as integral to PCOS management but experience barriers to lifestyle management related to specialist care. PRACTICE IMPLICATIONS: Resources that provide credible, individualized and PCOS-specific lifestyle advice, team care approach and professional development on motivating patients for lifestyle modification may address these barriers.

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OBJECTIVE: To determine the relationships of self-management strategies and physical activity (PA) and diet quality in women with PCOS. METHODS: An online cross-sectional study involving women (n = 501), 18-45 years in the general Australian community with a self-reported PCOS diagnosis. The self-management and lifestyle behaviour questionnaires were completed between August 2017 and March 2018. RESULTS: Implementation of PA related self-management strategies increased the odds of meeting PA recommendations [Odds ratio (OR): 2.929 (95%CI: 2.172, 3.951), p < 0.001] but had no association with body mass index (BMI) [OR: 0.-0.984 (95%CI: -1.010, 0.959), p = 0.217] nor perception of self weight [OR: 1.382 (95% CI: 0.700, 2.725), p = 0.352]. Nutrition related self-management strategies were inversely associated with BMI [OR: - 0.115 (95%CI: -7.159, -0.980), p = 0.010] but had no association with diet quality [OR: 0.183 (95%CI: -2.328, 2.800), p = 0.855], energy intake [OR: - 0.092 (95%CI: -1204.443, 527.496) p = 0.438] or weight [OR: - 0.034 (95%CI: -4.020, 1.930), p = 0.491]. CONCLUSIONS: PA self-management strategies were associated with meeting PA recommendations. Nutrition strategies were associated with lower BMI but not diet quality, energy intake or weight in women with PCOS. PRACTICE IMPLICATIONS: Other behaviour change determinants (e.g. education, skills and self-efficacy) should be considered when designing a PCOS lifestyle programme in conjunction with self-management strategies.

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BACKGROUND: Polycystic ovary syndrome (PCOS) is a common condition affecting up to 13% of reproductive-aged women. Weight and lifestyle management are key initial treatment strategies for individuals with PCOS, as recommended in international evidence-based guidelines. Allied health professionals, including dietitians, exercise physiologists, and psychologists, are crucial in delivering support for lifestyle and weight management. OBJECTIVE: Our aim was to explore the barriers and enablers to lifestyle and weight management for individuals with PCOS from the perspectives of allied health professionals. DESIGN: This was a qualitative study using a phenomenology approach to understand the allied health professionals lived experiences managing the lifestyles of individuals with PCOS. Semi-structured interviews were conducted with allied health professionals (ie, dietitians, exercise physiologists, and psychologist). Interviews were audio-recorded and professionally transcribed. Transcripts were coded inductively and analyzed thematically. PARTICIPANTS/SETTING: Participants were 15 allied health professionals (ie, 9 dietitians, 5 exercise physiologists, and 1 psychologist) involved in the management of PCOS in Australia (n = 10 in Victoria, n = 5 in other states) and interviewed between June and September 2019. MAIN OUTCOME MEASURES: Barriers and enablers of allied health professionals relating to the provision of lifestyle and weight management in individuals with PCOS were analyzed. RESULTS: Barriers relating to individuals with PCOS included insufficient knowledge on lifestyle management; lack of time; socioeconomic disadvantage preventing access to lifestyle support; and psychological issues, such as eating disorders or depression. Barriers relating to health professionals included insufficient knowledge about PCOS and insufficient time during consultation. Barriers relating to the health system included lifestyle recommendations in the PCOS guidelines that are too general and weight-focused, funding system that does not facilitate long-term care, and low integration of care among health professionals. CONCLUSIONS: Barriers for the individual, health professional, and health system all need to be addressed to improve the implementation of lifestyle management in PCOS care to optimize consistency with the PCOS international evidence-based guidelines.

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Polycystic ovary syndrome (PCOS) is a heterogeneous disorder and many women are dissatisfied with their healthcare under the current fragmented health services. Here, we review existing literature on PCOS healthcare services and qualitatively evaluate an integrated PCOS service based on experiences of women with PCOS. Limited prior PCOS-dedicated services have been studied and their quantitative and efficacy-focused evaluations are summarized. Here, we also provide a broader PCOS service evaluation via semistructured interviews and surveys, with thematic analysis based on a predetermined evaluation framework. Fifteen women completed interviews and surveys. Overall the integrated, evidence-based PCOS service was well-received and women were generally satisfied with appropriateness, effectiveness, and reported positive health impact resulting from the service. Integrated care, tailored treatments, education, lifestyle support, and laser therapy were highly valued. Patients reported improvements on symptoms, understanding and confidence in managing PCOS, and emotional well-being. Elements of efficiency in the initial stages, awareness and communication, and the need for service expansion and tensions between evidence-based treatments and patient preferences were also captured to guide improvement. Further research into models of care is recommended to meet the needs of women with PCOS.

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AIM: The 2018 evidence-based polycystic ovary syndrome (PCOS) guidelines recommend lifestyle management as first-line treatment. This study aims to understand the preferred intervention characteristics of a PCOS lifestyle program from the perspectives of women with PCOS to inform the translation of the guidelines into practice. METHODS: Women with self-reported PCOS residing in Australia took part in semi-structured interviews (n = 20) and an online survey (n = 286). The survey and interview schedule were developed using the template for intervention description and replication checklist. RESULTS: Women want to take part in a lifestyle program (94.6%) and use government-subsidised sessions to attend (83%). Sessions of 45 to 60 minutes (75%) costing less than AUD$50 are preferred (60%). Topics of most interest related to sustainable daily physical activity (58%), overcoming non-hungry eating (54%), PCOS-specific diets (51%) and how to overcome barriers to behaviour change (45%). A delivery mode that combines online and in-person support is preferred (53%). Women are in need of long-term professional lifestyle support (6-12 months) that provides evidence-based, PCOS-specific, personalised prescription. Multidisciplinary support from a range of PCOS-trained professions is also preferred to address women's physical, psychological and emotional needs. CONCLUSION: Women with PCOS are willing to take part in lifestyle programs that are low cost, long term, evidence based, PCOS-specific and provide practical strategies for nutrition and physical activity changes. Future online and in-person PCOS programs are strongly recommended to incorporate these findings to improve program engagement and patient satisfaction.

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BACKGROUND: The 2018 Evidence-Based Polycystic Ovary Syndrome (PCOS) Clinical Guidelines recommend lifestyle management as first-line treatment for PCOS, yet implementation of PCOS lifestyle programs into practice is not well understood. OBJECTIVE: To complete systematic intervention mapping by identifying the facilitators and barriers to lifestyle management in women with PCOS using the theoretical domains framework (TDF) and the Capacity, Opportunity, Motivation and Behaviour model (COM-B). PATIENT INVOLVEMENT: Women (N = 20) in Australian with PCOS were interviewed. METHODS: Telephone semi-structured interviews. RESULTS: Nine themes mapped onto seven TDF domains and the COM-B. Capability: psychological co-morbidities, knowledge and awareness of lifestyle change and ability to identify and resolve barriers. Opportunity: presence of other medical conditions, access to practical resources and availability of social support. MOTIVATION: outcomes expectancies of lifestyle behaviour, personal values, enjoyment and readiness to change and the impact of stress on lifestyle choices. DISCUSSION: This is the first study to explore barriers and facilitators to lifestyle change from the perspectives of women with PCOS using the TDF and COM-B. Addressing these themes will facilitate patient-centred care and long-term behaviour change. PRACTICAL IMPLICATIONS: May increase the efficacy and effectiveness of PCOS lifestyle programs and reduce the risk of PCOS-associated disease in this population.

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INTRODUCTION: Methanol is a widely available chemical with a range of uses including as solvent, as a fuel, in chemical synthesis and anti-freeze preparations. Most of the cases are accidental exposures to drinking beverages contaminated with methanol. MATERIALS AND METHODS: In mid-September 2018, there was a single outbreak of methanol poisoning in Malaysia especially involving the state of Federal Territory Kuala Lumpur and Selangor. There were 33 reported deaths suspected due to methanol poisoning in this current outbreak where 11 of them were brought in to the Institute of Forensic Medicine (NIFM), Kuala Lumpur. The last outbreak was in the year 2013 with 29 deaths reported out of 44 cases. RESULTS: There were 3 cases (27.2%) died in hospital and the remaining 8 cases (72.8%) were found dead at home and were later brought in dead to the hospital. A full autopsy was carried out for each case. Autopsy findings, as well as lab results pertaining to cases that survived and directly brought in dead, were of a different spectrum. CONCLUSION: Methanol related deaths are almost always as a result of greed. The running truism is 'methanol poisoning is a result of deliberate addition/adulteration with industrial methanol'. Prevention of the illegal production of methanol and methylated spirits should be established to curb this matter in the future.

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This review describes the relationship between obesity and the most common reproductive (infertility) and metabolic (gestational diabetes mellitus [GDM] and type 2 diabetes mellitus [T2DM]) consequences in polycystic ovary syndrome (PCOS). It also describes the vital role of lifestyle management for PCOS. PCOS is a heterogeneous endocrine disorder common in reproductive-age women. Consensus on the exact etiological mechanisms of PCOS is unreached. Overweight or obesity is present in at least 60% of the PCOS population, but the condition occurs irrespective of BMI, with excess BMI increasing both the prevalence and severity of clinical features. Use of lifestyle therapies (nutrition, physical activity, and/or behavioral) for the prevention and management of excess weight gain, infertility, GDM, and T2DM is a vital component of best-practice PCOS care. Lifestyle management is recommended for all women with PCOS as the first-line treatment with or without medications. Due to a lack of high-quality trials demonstrating the efficacy of specific lifestyle approaches, PCOS lifestyle recommendations are as those for the general population. This review summarizes current knowledge relating to obesity and its impact on fertility, GDM, and T2DM. It also summarizes the lifestyle recommendations to best manage these conditions in women with PCOS and obesity.

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