Lymphoedema of the arm is a potentially serious consequence of any axillary procedure performed during the management of breast cancer. In an attempt to reduce its incidence and severity, patients are instructed to avoid venepunctures and blood pressure measurements on the treated arm. These precautions are not possible in some patients and attempts to adhere to them can cause discomfort, anxiety and stress for both patients and their health-care workers. The strength with which these recommendations are made is in contrast to the level of evidence underpinning them. This paper reviews this evidence regarding the safety, or lack thereof, of blood pressure monitoring and intravenous puncture in women who have had axillary surgery. With this evidence generally being anecdotal in nature, there appears to be no rigorous evidence-based support for the risk-reduction behaviours of avoiding blood pressure monitoring and venepuncture in the affected arm in the prevention of lymphoedema after axillary procedure. A clinical trial was proposed to investigate whether such avoidance measures were valuable, but failed during its inception. There remains a need for research from prospective trials on this controversial topic to determine the most appropriate patient recommendations that should be provided after axillary procedure regarding the risks for development of lymphoedema.

Introduction: Migraines are one of the commonest presenting complaints to emergency departments (ED), and may result in prolonged length of stay with symptoms being severe and refractory to typical remedies, such as paracetamol, non-steroidal anti-inflammatory drugs and triptans. The objective of this study was to describe and compare patient demographics, presentation, management and outcomes to hospital discharge between first presenters and patients with a history of migraines in two metropolitan emergency departments in Melbourne, Australia. Given that the assessment and management of patients who have had a prior history of migraines is likely to be substantially different, patients were subgrouped by this exposure variable. Methods: A total of 365 patients were identified retrospectively during the study period of March 2013 – September 2014 that met the inclusion criteria of a headache with no organic cause and/or symptoms consistent with visual or abdominal migraines. Presenting pain scores, assessment, management and disposition were extracted using explicit chart review. Results: The mean age of patients included was 37.8 years and 23.3% were males. Significantly more first presenters were investigated with a CT scan of the brain (34.4% as compared to 22.9% of patients with a prior history of migraine). Initial management included administration of paracetamol in 178 (48.8%) cases, NSAIDs (mostly ibuprofen and aspirin) in 187 (51.2%) and parenteral dopamine antagonists (e.g. metoclopramide, prochlorperazine and chlorpromazine) in 191 (52.3%) cases. Migraine-specific agents such as triptans were prescribed in 46 (12.6%) and ergots in two (0.5%) cases. Opioids such as morphine or oxycodone were administered in 94 (25.8%) cases. There was no statistical difference in the management of patients with a history of migraines as compared to first presenters, with the exception of the use of intravenous fluids and parenteral dopamine antagonists. The median length of stay in the ED was 4 (inter-quartile range 2–7) hours, with 163 (44.7%) patients admitted to the short-stay unit. A pain score of ≥ 5 was recorded at discharge in 31 (8.5%) patients. Disposition was similar across both groups of patients. Conclusions: Although first presenters seem to be more thoroughly investigated, the acute management of migraine did not differ largely between patients who had a history of migraine compared with first presenters. The management of acute migraine in the ED setting has varied efficacy, suggesting that further research into newer therapeutic options is needed.

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A survey done in 2012 by the Pew Internet & American Life Project (1) interviewed 3014 adults and found that 59% of American adults go online in search of health information, with 77% beginning their search at a search engine. Undeniably, the Internet provides unrestricted access to a sea of information, and information is indeed power. Thirty-five percent of adults have used the Internet to figure out what medical

BackgroundPolicies, protocols and processes within organisations can facilitate or hinder guideline adoption. There is limited knowledge on the strategies used by organisations to disseminate and implement evidence‐based deprescribing guidelines or their impact.MethodsWe aimed to develop an online survey targeting key organisations involved in deprescribing guideline endorsement, dissemination, modification or translation internationally. Survey questions were drafted, mirroring the six components of the reach, effectiveness, adoption, implementation and maintenance (RE‐AIM) framework. Content validation was undertaken and established by a panel of clinicians, researchers and implementation experts.ResultsA 52‐item survey underwent two rounds of content validation. The minimum threshold (I‐CVI > 0.78) for relevance and importance was met for 39 items (75%) in the first round and 44 of 48 items (92%) in the second round. The expert panel concluded that the adoption, implementation and effectiveness survey sections were largely relevant and important to this topic, whereas the reach and maintenance sections were harder to understand and may be less pertinent to the research question.ConclusionsA 44‐item survey investigating dissemination and implementation strategies for deprescribing guidelines has been developed and its content validated. Widespread survey distribution may identify effective strategies and inform dissemination and implementation planning for newly developed guidelines.