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Intern Med J [journal]
- Management and outcomes of axial isolated distal deep venous thrombosis (IDDVT) at North Shore Hospital, New Zealand: A Retrospective Audit. [JOURNAL ARTICLE]
- Intern Med J 2014 Dec 17.
It is standard of care to treat proximal vein deep vein thrombosis (DVT) for a minimum of 3 months. Conversely, management of isolated distal deep vein thrombosis (IDDVT) is controversial, with options including observation and repeat ultrasound scan within one week to detect and anticoagulate those with proximal propagation, or anticoagulation for periods of up to 3 months.The aim was to assess the rates of proximal propagation and venous thromboembolism (VTE) recurrence within 3 months of diagnosis of IDDVT, and to examine how the duration of treatment might influence this.Study patients were identified by retrospective audit of data from the North Shore Hospital VTE database. All patients presenting with established axial vein distal DVT from July 2007-June 2012 were included. A 6 week treatment duration cut-off was used to separate the treatment arms (<6 weeks versus 6 weeks versus >6 weeks), and Fisher's exact or Pearson's chi-squared tests were used to assess between-group comparisons.507 patients were included in the study, mean age 59.7 years; 53% female. There were three cases of proximal propagation, all occurring in those receiving <6 weeks treatment. There were six VTE recurrences, three in the <6 week and three in the ≥6 week treatment groups respectively. Malignancy was the only significant predictor of VTE recurrence (P=0.001). In conclusion, a six-week duration of anticoagulation appears to be an effective and safe treatment for isolated axial distal DVT, with low rates of VTE recurrence and proximal propagation.
- The Reversible Cerebral Vasoconstriction Syndrome. [JOURNAL ARTICLE]
- Intern Med J 2014 Dec 16.
Reversible cerebral vasoconstriction syndrome (RCVS) is a clinical-radiological syndrome characterized by severe thunderclap headaches with or without other neurological symptoms and multifocal constriction of cerebral arteries which usually resolves spontaneously within 3 months. Most patients recover completely but up to 10% have a permanent neurological disability and some even die. Previously RCVS has been described in many clinical contexts and under different names with the term RCVS first being suggested in 2007 to unify the group. The condition may be spontaneous but in up to 60% of cases it is secondary to another cause, including vasoactive substances (medications and illicit drugs), blood products and the post-partum state. It is believed to have a similar pathophysiological mechanism to the posterior reversible encephalopathy syndrome (PRES) and both can occur in similar clinical contexts and are frequently associated. Treatment options include calcium channel antagonists. RCVS occurs in a broad range of clinical situations making it an increasingly recognized condition about which doctors in various specialties need to be aware.
- Increased Interventricular Septum Wall Thickness Predicts All-Cause Death in Patients with Coronary Artery Disease. [JOURNAL ARTICLE]
- Intern Med J 2014 Dec 16.
There is debate regarding the predictive value of interventricular septum (IVS) wall thickness for adverse events.The study investigated the association between the severity of thickened IVS and all-cause death in Chinese patients with coronary artery disease (CAD).A total of 2297 CAD patients verified by angiography were consecutively included. Patients were grouped according to the severity of thickened IVS. Cox regression analysis was conducted to determine the independent prognostic value of thickened IVS for all-cause death.During a median follow-up of 25 months, 149 patients died. A gradient increase in the risk of death was observed across thickened IVS groups. Compared to patients with normal IVS thickness, the adjusted hazard ratio (HR) was 1.49 (95% confidential interval [CI] 1.00-2.23, P=0.05) and 2.13 (95% CI 1.29-3.54, P=0.003) for all-cause death in those with mildly and moderately/severely thickened IVS, respectively. For one unit increase in IVS thickness, the risk of all-cause death elevated by 14% (adjusted HR 1.14, 95%CI 1.05-1.24, P=0.003). In patients with normal indexed left ventricular mass, thickened IVS was also demonstrated as an independent risk factor for all-cause death.Thickened IVS can be served as a reliable marker for predicting all-caused death in Chinese patients with CAD, even in those with normal left ventricular mass.
- Comprehensive dietary education in treated gout patients does not further improve serum urate. [JOURNAL ARTICLE]
- Intern Med J 2014 Dec 12.
To investigate the influence of dietary education in patients with gout on a stable dose of urate lowering therapy (ULT) METHOD: Males and females aged >18 years with a history of gout, receiving an appropriate and stable dose of ULT, were recruited from two tertiary hospitals and randomised into two groups. The control group received basic advice regarding the importance of compliance with therapy and the benefit of weight loss. The intervention group received comprehensive dietary advice based on the British Society of Rheumatology Guidelines. Both groups received education at baseline and 3 months. Serum urate was measured at baseline, 3 months and 6 months and a questionnaire was completed at baseline and at 6 months. The primary outcome of the study was to compare the change in serum urate between groups.Thirty patients were recruited into the study. There was no difference in serum urate between the control and intervention group at 6 months (0.29mmol/L vs 0.29mmol/L at baseline and 0.27mmol/L vs 0.30mmol/L at 6 months). The intervention group showed a statistically significant improvement in knowledge (8/13 in control group at baseline to 9/13 at 6 months vs 8/13 in intervention group at baseline to 12/13 at 6 months, p<0.05) and self-reported dietary modification (1 in control vs 7 in intervention p<0.05) at 6 months.This randomised controlled trial shows that in patients on ULT, providing education on diet does not lead to any clinically significant difference in serum urate at 6 months.
- Consensus guidelines for implementation of quality processes to prevent invasive fungal disease and enhanced surveillance measures during hospital building works, 2014. [Journal Article]
- Intern Med J 2014 Dec; 44(12b):1389-97.
Healthcare-associated fungal outbreaks impose a substantial economic burden on the health system and typically result in high patient morbidity and mortality, particularly in the immunocompromised host. As the population at risk of invasive fungal infection continues to grow due to the increased burden of cancer and related factors, the need for hospitals to employ preventative measures has become increasingly important. These guidelines outline the standard quality processes hospitals need to accommodate into everyday practice and at times of healthcare-associated outbreak, including the role of antifungal stewardship programmes and best practice environmental sampling. Specific recommendations are also provided to help guide the planning and implementation of quality processes and enhanced surveillance before, during and after high-risk activities, such as hospital building works. Areas in which information is still lacking and further research is required are also highlighted.
- Consensus guidelines for optimising antifungal drug delivery and monitoring to avoid toxicity and improve outcomes in patients with haematological malignancy, 2014. [Journal Article]
- Intern Med J 2014 Dec; 44(12b):1364-88.
Antifungal agents may be associated with significant toxicity or drug interactions leading to sub-therapeutic antifungal drug concentrations and poorer clinical outcomes for patients with haematological malignancy. These risks may be minimised by clinical assessment, laboratory monitoring, avoidance of particular drug combinations and dose modification. Specific measures, such as the optimal timing of oral drug administration in relation to meals, use of pre-hydration and electrolyte supplementation may also be required. Therapeutic drug monitoring (TDM) of antifungal agents is warranted, especially where non-compliance, non-linear pharmacokinetics, inadequate absorption, a narrow therapeutic window, suspected drug interaction or unexpected toxicity are encountered. Recommended indications for voriconazole and posaconazole TDM in the clinical management of haematology patients are provided. With emerging knowledge regarding the impact of pharmacogenomics upon metabolism of azole agents (particularly voriconazole), potential applications of pharmacogenomic evaluation to clinical practice are proposed.
- Consensus guidelines for diagnosis, prophylaxis and management of Pneumocystis jirovecii pneumonia in patients with haematological and solid malignancies, 2014. [Journal Article]
- Intern Med J 2014 Dec; 44(12b):1350-63.
Pneumocystis jirovecii infection (PJP) is a common cause of pneumonia in patients with cancer-related immunosuppression. There are well-defined patients who are at risk of PJP due to the status of their underlying malignancy, treatment-related immunosuppression and/or concomitant use of corticosteroids. Prophylaxis is highly effective and should be given to all patients at moderate to high risk of PJP. Trimethoprim-sulfamethoxazole is the drug of choice for prophylaxis and treatment, although several alternative agents are available.
- Consensus guidelines for the treatment of invasive mould infections in haematological malignancy and haemopoietic stem cell transplantation, 2014. [Journal Article]
- Intern Med J 2014 Dec; 44(12b):1333-49.
Mould species represent the pathogens most commonly associated with invasive fungal disease in patients with haematological malignancies and patients of haemopoietic stem cell transplants. Invasive mould infections in these patient populations, particularly in the setting of neutropenia, are associated with high morbidity and mortality, and significantly increase the complexity of management. While Aspergillus species remain the most prevalent cause of invasive mould infections, Scedosporium and Fusarium species and the Mucormycetes continue to place a significant burden on the immunocompromised host. Evidence also suggests that infections caused by rare and emerging pathogens are increasing within the setting of broad-spectrum antifungal prophylaxis and improved survival times placing immunosuppressed patients at risk for longer. These guidelines present evidence-based recommendations for the antifungal management of common, rare and emerging mould infections in both adult and paediatric populations. Where relevant, the role of surgery, adjunctive therapy and immunotherapy is also discussed.
- Consensus guidelines for the treatment of yeast infections in the haematology, oncology and intensive care setting, 2014. [Journal Article]
- Intern Med J 2014 Dec; 44(12b):1315-32.
Pathogenic yeast forms are commonly associated with invasive fungal disease in the immunocompromised host, including patients with haematological malignancies and patients of haemopoietic stem cell transplants. Yeasts include the Candida spp., Cryptococcus spp., Pneumocystis jirovecii and some lesser-known pathogens. Candida species remain the most common cause of invasive yeast infections (and the most common human pathogenic fungi). These guidelines present evidence-based recommendations for the antifungal management of established, invasive yeast infections in adult and paediatric patients in the haematology/oncology setting. Consideration is also given to the critically ill patient in intensive care units, including the neonatal intensive care unit. Evidence for 'pre-emptive' or 'diagnostic-driven antifungal therapy' is also discussed. For the purposes of this paper, invasive yeast diseases are categorised under the headings of invasive candidiasis, cryptococcosis and uncommon yeast infections. Specific recommendations for the management of Pneumocystis jirovecii are presented in an accompanying article (see consensus guidelines by Cooley et al. appearing elsewhere in this supplement).
- Consensus guidelines for the use of empiric and diagnostic-driven antifungal treatment strategies in haematological malignancy, 2014. [Journal Article]
- Intern Med J 2014 Dec; 44(12b):1298-314.
Invasive fungal disease (IFD) causes significant morbidity and mortality in patients undergoing allogeneic haemopoietic stem cell transplantation or chemotherapy for haematological malignancy. Much of these adverse outcomes are due to the limited ability of traditional diagnostic tests (i.e. culture and histology) to make an early and accurate diagnosis. As persistent or recurrent fevers of unknown origin (PFUO) in neutropenic patients despite broad-spectrum antibiotics have been associated with the development of IFD, most centres have traditionally administered empiric antifungal therapy (EAFT) to patients with PFUO. However, use of an EAFT strategy has not been shown to have an overall survival benefit and is associated with excessive antifungal therapy use. As a result, the focus has shifted to developing more sensitive and specific diagnostic tests for early and more targeted antifungal treatment. These tests, including the galactomannan enzyme-linked immunosorbent assay and Aspergillus polymerase chain reaction (PCR), have enabled the development of diagnostic-driven antifungal treatment (DDAT) strategies, which have been shown to be safe and feasible, reducing antifungal usage. In addition, the development of effective antifungal prophylactic strategies has changed the landscape in terms of the incidence and types of IFD that clinicians have encountered. In this review, we examine the current role of EAFT and provide up-to-date data on the newer diagnostic tests and algorithms available for use in EAFT and DDAT strategies, within the context of patient risk and type of antifungal prophylaxis used.