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Intern Med J [journal]
- A systematic review of prevalence, disease characteristics, and management of systemic lupus erythematosus in Australia: Identifying areas of unmet need. [JOURNAL ARTICLE]
- Intern Med J 2014 Aug 28.
Few epidemiological studies of systemic lupus erythematosus (SLE) have been conducted in Australia, and current management practice and levels of unmet need in this country are not well characterised.To perform a systematic literature review to identify Australia-specific information on SLE, particularly areas of unmet need.MEDLINE, EMBASE, and the Cochrane Library were searched (1 January 1990 to 29 November 2013). All articles on prevalence, disease characteristics, management, and outcomes of SLE in Australia were included.There is limited published information on SLE in Australia. Of 24 articles included, 18 described results from observational studies, 3 were narrative reviews, 1 was a clinical update, and 2 were medical education articles. In remote regions, SLE was reported to be more prevalent in Aboriginal Australians than non-Aboriginal Australians; information in urban populations is lacking. Asian Australians may be more affected by SLE than non-Asian Australians. Pregnancy outcomes may also be adversely affected. Many Australians with SLE may experience high levels of unmet need, including delayed diagnosis, ongoing symptoms, flares, depression/anxiety, sleeping difficulty, and decreased quality of life. Published guidance on the SLE management in Australia is limited and dated.Published information on SLE in Australia is limited, but suggests that ethnicity may affect the prevalence and disease characteristics and that many Australians with SLE have unmet needs. Improvements in diagnosis, treatment, and management are needed to alleviate these needs. Up-to-date guidance on the management of SLE would benefit healthcare professionals and patients.
- Paediatric Heart Transplantation in Australia Comes of Age - Twenty-One Years of Experience in a National Centre. [JOURNAL ARTICLE]
- Intern Med J 2014 Aug 28.
Heart transplantation (HT) is established therapy for end-stage heart failure in children with cardiomyopathy or congenital heart disease.This review summarizes experience at a national referral center since the first local transplant.Medical records of children referred for HT between 1 April 1988 and 1 January 2010 were retrospectively reviewed. All patients listed for HT were included. Survival analysis was used to summarize waitlist time to death/transplant, and separately, time to death in HT recipients.139 children were accepted onto the HT waiting list during the study (median age 7.7 (Interquartile range (IQR) 2.5, 13.6) years), of whom 93 underwent HT (median age 10.9 (IQR 4.4, 14.6) years). Wait-list mortality was 32% (45 of 139 patients), lowest among children aged >10 years at listing (p<0.001). Median time to HT was 69 days (range 29-146). Survival post-transplantation was 90% (95% confidence interval 82-95) at 1 year, 82% (72-89%) at 5 years and 68% (50-80%) at 10 years. Increasing case complexity over the study period included pre- and post-transplant circulatory support, management of pulmonary hypertension, and introduction of ABO-incompatible HT for infants. Post-transplant survival did not vary according to age, pre-transplant diagnosis or use of pre-transplant circulatory support (all p>0.05).Results of paediatric HT in Australia are comparable with international results, despite limitations of geographic isolation, small population and low organ-donation rate. Increasing case complexity has not impacted on post-transplant survival.
- Management of Systemic Light Chain (AL) Amyloidosis: Recommendations of the Myeloma Foundation of Australia Medical and Scientific Advisory Group. [JOURNAL ARTICLE]
- Intern Med J 2014 Aug 28.
Systemic light chain (AL) amyloidosis is a plasma cell dyscrasia with a characteristic clinical phenotype caused by multiorgan deposition of an amyloidogenic monoclonal protein. This condition poses a unique management challenge due to the complexity of the clinical presentation and the narrow therapeutic window of available therapies. Improved appreciation of the need for risk stratification, standardised use of sensitive laboratory testing for monitoring disease response, vigilant supportive care and the availability of newer agents with more favourable toxicity profiles have contributed to the improvement in treatment-related mortality and overall survival seen over the past decade. Nonetheless, with respect to the optimal management approach, there is a paucity of high-level clinical evidence due to the rarity of the disease and enrolment in clinical trials is still the preferred approach where available. This review will summarise the Clinical Practice Guidelines on the Management of Systemic Light Chain (AL) Amyloidosis recently prepared by the Medical Scientific Advisory Group (MSAG) of the Myeloma Foundation of Australia. It is hoped that these Guidelines will assist clinicians in better understanding and optimizing the management of this difficult disease.
- Retrospective Imaging Audit and Cost Analysis of Medical Oncology Inpatients Admitted to Westmead Hospital. [JOURNAL ARTICLE]
- Intern Med J 2014 Aug 28.
Cancer patients often require complex and expensive admissions necessitating multiple investigations. We conducted an audit of cost of imaging performed on medical oncology inpatients in a teaching hospital in NSW.Our overall aim was to assess cost and appropriateness of imaging studies in inpatients.Data were collected on 219 consecutive evaluable inpatients admitted to Westmead Hospital (August - October 2012). A panel of oncology doctors assessed cost and appropriateness of imaging.The total expenditure for the cohort was $106488.15 over 624 investigations (range 0-26, median 2 per admission). Of this sum, $8881.91 (8%) was deemed inappropriate. The most frequently ordered test was CXR (251). Imaging cost per admission was 0 - $2478 (range), $324.95 (median), $486.99 (mean). Cost trended to increase with age of patient ($186.40 (18-40), $477.22 (41-65), $489.50 (66-75), $575.33 >75). Mean cost was higher for patients treated with palliative ($493.98) vs curative ($307.59) intent. Mean cost was higher for patients consulted by palliative care and other subspecialties. There was variation of average cost by discharge destination- other hospital ($262.23), palliative care unit ($334.08), home ($480.84), death ($769.93).Though imaging ordered was deemed overwhelmingly clinically appropriate, approximately $35000/yr is spent on inappropriate tests, mostly due to duplication or scans that could have been performed as an outpatient.Our audit supports that the current spending patterns on imaging within our department is predominantly appropriate and necessary. Duplication and expenditure may be reduced by improving electronic access from the ward to outpatient scan results.
- Physical activity and sedentary behaviour: applying lessons to chronic obstructive pulmonary disease. [JOURNAL ARTICLE]
- Intern Med J 2014 Aug 27.
In health and disease, the benefits of regular participation in moderate to vigorous intensity physical activity are well documented. However, individuals with chronic conditions, such as those with chronic obstructive pulmonary disease (COPD), typically do very little activity at a moderate or vigorous intensity. Much of their day is instead spent in sedentary behaviour, such as sitting or reclining, which requires very little energy expenditure. This high level of time spent in sedentary behaviour can have serious health consequences, including increased risk of diabetes, cardiovascular disease and premature mortality. There is emerging evidence to suggest that participation in light intensity physical activities (e.g. standing or slow walking) may have benefits for cardio-metabolic health. Given the low aerobic capacity of individuals with moderate to severe COPD, increasing light intensity activity (through reducing sedentary time) may be a feasible additional strategy to improve health in this population, alongside traditional recommendations to increase the time spent in moderate to vigorous intensity physical activity. This review provides an overview of physical activity and sedentary behaviour, with a particular emphasis on these behaviours for people with COPD. It provides suggestions for the measurement of these behaviours within the clinical setting, as well as for interventions that may be effective at increasing physical activity and reducing sedentary behaviour in this population.
- Outcomes of Haematology/Oncology patients admitted to Intensive Care Unit (ICU) at The Canberra Hospital (TCH). [JOURNAL ARTICLE]
- Intern Med J 2014 Aug 5.
Outcomes for haematology/oncology patients have improved, however determining their suitability for ICU admission remains challenging and controversial.Examine outcomes of patients admitted to an Australian tertiary hospital Intensive Care Unit (ICU) and explore potential prognostic factors.A retrospective review of patients with haematological and solid tumour malignancies non-electively admitted to The Canberra Hospital (TCH) ICU, between January 2008 and December 2012. Patient demographics, cancer details, reasons for ICU admission and APACHE II scores were collected and survival rates calculated and correlated with potential prognostic factors.Of 205 patients, 113 (55%) had haematological malignancies, and 92 (45%) solid tumours; 58% male, and mean age 60.3 years (SD 13.4). 82% of solid tumour patients had metastatic disease and 55% received palliative chemotherapy. Primary reasons for ICU admission included sepsis (59%), respiratory distress (37%) and hypotension/shock (18%). Mean APACHE II score was 20.1(SD 0.55); mean length of stay in ICU, 4 days (SD 5.2); ICU survival was 76% with 62% and 41% alive at 30-days and 6 months respectively. Overall 1 year survival was 36%. High APACHE II scores and ≥2 organs failing were significant risk factors for 30-day mortality.Short-term outcomes were similar to contemporary studies from a general tertiary hospital setting and better than historical data. 62% of patients were alive 30 days post-ICU admission, with a significant minority alive at 12 months, confirming some patients achieved worthwhile outcomes. Further research is needed to ensure appropriate patient selection and to explore quality of life post ICU.
- Advances in classification, basic mechanisms and clinical science in ankylosing spondylitis and axial spondyloarthritis. [JOURNAL ARTICLE]
- Intern Med J 2014 Aug 5.
The field of spondyloarthritis has seen huge advances over the past 5 years. The classification of axial disease has been redefined by the axial spondyloarthritis criteria that incorporate disease captured before radiographic damage is evident as well as established erosive sacroiliac joint disease. Our knowledge of genetics and basic immunological pathways has progressed significantly. In addition, revolutionary progress has been achieved with the availability of tumour necrosis factor inhibitors for treating patients with moderate to severe disease. In parallel a number of novel biomarkers have been identified that show significant promise for the future. Advances in magnetic resonance imaging have helped define positive disease. We have identified that T1 and short tau inversion recovery sequences are best for the diagnosis of axial spondyloarthritis and gadolinium contrast is not additive for diagnosis. Progress has been made in identifying potential agents and strategies that reduce radiographic progression. A number of referral strategies aimed at appropriate identification of patients have been trialed and found to be effective. There is still substantial work ahead but the advances of the last 5 years have made a huge and tangible difference at the clinical coalface and we suggest this trend will continue.
- A Single-Centre Cross-Sectional Analysis of Advance Care Planning among Elderly Inpatients. [JOURNAL ARTICLE]
- Intern Med J 2014 Aug 11.
Advance Care Planning (ACP) has been shown to provide beneficial outcomes for elderly patients, however it may not be commonly implemented.To assess prevalence of Advance Care Directives (ACDs) and documented medical orders about end-of-life care for elderly inpatients; to explore the feasibility of an ACP Screening Interview.A single-centre cross-sectional analysis of 100 consecutive patients aged ≥80 admitted for ≥48 hours to a tertiary referral hospital, conducted between 16th-18th January 2013. Medical-records were reviewed for presence of 1) an ACD, 2) Resuscitation/ End-of-Life Care Intervention Orders (REOLs), and 3) documented substitute decision maker (SDM). If able, patients completed an ACP Screening Interview exploring: 1) their views on ACP, and 2) if an ACD was previously documented.In 100 medical-records there were: zero ACDs, 17 REOLs, and 8 with clear documentation of patients' preferred SDM. 33/100 patients completed the interview: 32(97%) were able to identify their preferred SDM, in 9(27%) the nominated SDM was different from their 'next of kin'. 7/33(21%) reported having an Enduring Guardian, 4/33(12%) an ACD. 23/29(79%) interviewees without an ACD were interested in discussing ACP further. 8/30(27%) interviewees without REOLs, said they would not wish to have aggressive life-prolonging measures. No patients reported discomfort with the screening interview.ACDs and correct documentation of SDM were uncommon in the medical records in this sample of elderly inpatients. The ACP Screening Interview appears feasible and acceptable, and may be a useful tool for identifying patients' preferred SDM and willingness to further discuss ACP.
- Prevalence and predictors of advance directives in Australia. [JOURNAL ARTICLE]
- Intern Med J 2014 Aug 11.
Advance care planning is regarded as integral to better patient outcomes yet little is known about the prevalence of advance directives in Australia.To determine the prevalence of advance directives (ADs) in the Australian population.A national telephone survey about estate and advance planning. Sample was stratified by age (18-45 and >45 years) and quota sampling occurred based on population size in each State and Territory.Fourteen percent of the Australian population has an AD. There is State variation with people from South Australia and Queensland more likely to have an AD than people from other states. Will making and particularly completion of a financial enduring power of attorney are associated with higher rates of AD completion. Standard demographic variables were of limited use in predicting whether a person would have an AD.Despite efforts to improve uptake of advance care planning (including ADs), barriers remain. One likely trigger for completing an AD and advance care planning is undertaking a wider future planning process (e.g. making a will or financial enduring power of attorney). This presents opportunities to increase advance care planning but steps are needed to ensure that planning which occurs outside the health system is sufficiently informed and supported by health information so that it is useful in the clinical setting. Variations by State could also suggest that redesign of regulatory frameworks (such as a user-friendly and well publicised form backed by statute) may help improve uptake of ADs.
- Analysis of knowledge and attitude surveys to identify barriers and enablers of appropriate antimicrobial prescribing in three Australian tertiary hospitals. [Journal Article, Research Support, Non-U.S. Gov't]
- Intern Med J 2014 Jun; 44(6):568-74.
Antimicrobial stewardship programmes aim to optimise use of antibiotics and are now mandatory in all Australian hospitals.We aimed to identify barriers to and enablers of appropriate antimicrobial prescribing among hospital doctors.Two paper-based and one web-based surveys were administered at three Australian university teaching hospitals from March 2010 to May 2011. The 18-item questionnaire recorded doctors’ level of experience, their knowledge regarding the use of common antimicrobials and their attitudes regarding antimicrobial prescribing. Local survey modifications allowed inclusion of specific questions on: infections in intensive care unit patients, clinical microbiology and use of local guidelines.The respondents (n = 272) were comprised of 96 (35%) registrars, 67 (25%)residents, 57 (21%) interns and 47 (17%) consultant hospital doctors. Forty-one per cent were working in a medical specialty. Identified barriers included: gaps in antimicrobial prescribing knowledge (especially among interns), a lack of awareness about which antimicrobials were restricted and a reliance on senior colleagues to make antimicrobial prescribing decisions. Enablers of optimal prescribing included: an acknowledgement of the need for assistance in prescribing and reported readiness to consult national prescribing guidelines. These results were used to help guide and prioritise interventions to improve prescribing practices.A transferable knowledge and attitudes survey tool can be used to highlight barriers and facilitators to optimal hospital antimicrobial prescribing in order to inform tailored antimicrobial stewardship interventions.