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Intern Med J [journal]
- Perspectives of Paediatric and Adult Gastroenterologists on Transfer and Transition Care of Adolescents with Inflammatory Bowel Disease. [JOURNAL ARTICLE]
- Intern Med J 2014 Mar 3.
Programs specific to inflammatory bowel disease (IBD) that facilitate transition from paediatric to adult care are currently lacking. We aimed to explore the perceived needs of adolescents with IBD among paediatric and adult gastroenterologists and to identify barriers to effective transition.A web-based surveyof paediatric and adult gastroenterologists in Australia and New Zealand, employed both ranked items (Likert scale; from 1 not important to 5 very important) and forced choice items regarding the importance of various factors in facilitating effective transition of adolescents from paediatric to adult care.Response rate among 178 clinicians was 41%. Only 23% of respondents felt that adolescents with IBD were adequately prepared for transition to adult care. Psychological maturity (Mean = 4.3, SD = .70) and readiness as assessed by adult caregiver (Mean = 4, SD = .72) were prioritized as the most important factors in determining timing of transfer. Self-efficacy and readiness as assessed by adult caregiver were considered the two most important factors to determine timing of transition by both groups of gastroenterologists. Poor medical and surgical handover (Mean = 4.10, SD = .8)and patients lack of responsibility for their own care (Mean= 4.10, SD = .82) were perceived as major barriers to successful transition by both paediatric and adult gastroenterologists.Deficiencies exist in current transition care of adolescents with IBD in Australia and New Zealand. Standardizing transition care practices with strategies aimed at optimizing communication, patient education, self-efficacy and adherence may improve outcomes.
- Opioid Conversion Ratios used in Palliative Care; Is there an Australian Consensus? [JOURNAL ARTICLE]
- Intern Med J 2014 Mar 3.
Opioid switching or rotation is reported to be a common practice in Palliative Care. Published tables of opioid conversion ratios have been found to vary in their recommendations, potentially leading to significant differences in clinical practice.To identify common practices in the calculation of opioid equianalgesia by specialist Palliative Medicine practitioners and trainees.An anonymous, cross-sectional, on-line survey completed by eighty five Australian Palliative Care specialists or advanced trainees. Questions focused on conversion ratios used in switching between oral and parenteral opioid doses; conversion ratios used when switching from other opioids to oral morphine; practice of commencing methadone.The majority of respondents calculated equianalgesic doses for morphine, oxycodone and hydromorphone using the same conversion ratios. Methadone was used almost equally as either the sole opioid or as a "co-opioid". The majority surveyed converted slow-release hydromorphone differently to the manufacturer's recommendations.Further discussion amongst Australian Palliative Care specialist organisations is recommended in order to produce uniform conversion guidelines to improve consistency and safety in the prescribing of opioids.
- Adult T-cell leukaemia/lymphoma can mimic other lymphomas in a non-endemic area: dilemmas in diagnosis and treatment. [JOURNAL ARTICLE]
- Intern Med J 2014 Feb 17.
The diagnosis of Adult T-cell leukaemia/lymphoma (ATL) in non-endemic regions is challenging. This study analyzes the clinicopathologic features and diagnostic processes of ATL patients in Taiwan.ATL patients diagnosed and treated at Taipei Veterans General Hospital from 1998 through 2010 were retrospectively identified. The diagnosis of ATL was confirmed by in situ detection of human T-cell leukaemia virus type 1 (HTLV-1) when necessary. Patients' data was reviewed and analyzed.14 ATL patients were identified, among whom 6 (42.9%) had an antecedent diagnosis of other malignant lymphomas before the ATL diagnosis, including 2 diagnosed with Hodgkin's disease (HD), 1 with peripheral T cell lymphoma, 2 with chronic lymphocytic leukemia and 1 with angioimmunoblastic T-cell lymphoma. Of the 14 patients, 8 (57%) were subclassified as the acute type, 3 (21.4%) as the lymphoma type, and 3 (21.4%) as the chronic type ATL. Five of 6 (83.3%) patients with initial non-ATL misdiagnosis were diagnosed with non-acute type ATL. In particular, a patient with an antecedent diagnosis of HD presented with typical Reed Sternberg (RS)-like cells harboring Epstein Barr virus genomes in affected lymph nodes. The patient progressed to acute type ATL three years after the initial diagnosis, and HTLV-1 genomes were identified in the previous RS-like cells.In non-endemic areas, such as Taiwan, ATL, particularly the non-acute type, may mimic other lymphomas and easily be misdiagnosed. HTLV-1 serology should be routinely screened in all malignant lymphoma patients. In situ detection of HTLV-1 is helpful in cases with diagnostic dilemmas.
- Care of the dying cancer patient in the emergency department: findings from a National survey of Australian emergency department clinicians. [JOURNAL ARTICLE]
- Intern Med J 2014 Feb 16.
Patients with cancer are presenting to emergency departments (EDs) for end of life care (EOLC) with increasing frequency. Little is known about this experience for patients and ED clinicians in Australia.to assess the barriers and enablers regarding EOLC for cancer patients as perceived by Australian ED clinicians.4501 Australian ED clinicians were invited through their professional colleges to complete an online survey, using multiple-choice and free-text responses.681 ED clinicians responded, most (84.2%) felt comfortable providing care to the dying and found it to be rewarding (70.9%). Although 83.8% found caring for the dying a reasonable demand on their role as clinician, 83.8% also agreed that the ED is not the right place to die. Respondents demonstrated a wide range of views regarding caring for this patient group in ED through free text responses. In addition, 64.5% reported that futile treatment is frequently provided in the ED, the main reasons reported were that limitations of care were not clearly documented, or discussed with the patient or their family. Almost all (94.6%) agreed that advance care plans assist in caring for dying patients in the ED.Our findings provide important new insights into a growing area of care for EDs. Barriers and enablers to optimal care of the dying patient in ED were identified, and especially the reported high occurrence of futile care, likely a result of these barriers, is detrimental to both optimal patient care and allocation of valuable healthcare resources.
- Evidence-based prescribing of drugs for secondary prevention of acute coronary syndrome in Aboriginal and non-Aboriginal patients admitted to Western Australian hospitals. [JOURNAL ARTICLE]
- Intern Med J 2014 Feb 14.
To assess the level of evidence-based drugs prescribing for acute coronary syndrome (ACS) at discharge from Western Australian (WA) hospitals and determine predictors of such prescribing in Aboriginal and non-Aboriginal patients.All Aboriginal (2002-04) and a random sample of non-Aboriginal (2003) hospital admissions with a principal diagnosis of ACS were extracted from the WA Hospital Morbidity Data Collection (HMDC) of WA Data Linkage System. Clinical information, history of co-morbidities and drugs were collected from medical notes by trained data collectors. Evidence-based prescribing (EBP) was defined as prescribing of aspirin, statin, and beta-blocker or angiotensin converting enzyme (ACE) inhibitor/Angiotensin II antagonist (ARB).Records for 1717 ACS patients discharged alive from hospitals were reviewed. The majority of patients (71%) had EBP and there was no significant difference between Aboriginal and non-Aboriginal patients (70% vs 71%, p=0.36). Conversely, a significantly higher proportion of Aboriginal patients had none of the drugs prescribed compared to non-Aboriginal patients (11% vs 7%, p<0.01). EBP for ACS was independently associated with male sex (OR 1.63, 95% CI 1.26 -2.11), previous admission for ACS (OR 1.83, 95% CI 1.39-2.42) and diabetes (OR 1.36, 95% CI 1.04-1.79). However, ACS patients living in regional and remote areas, attending district or private hospitals, or with a history of COPD were significantly less likely to have ACS drugs prescribed at discharge.Opportunity exists to improve prescribing of recommended drugs for ACS patients at discharge from WA hospitals in both Aboriginal and non-Aboriginal patients. Attention regarding pharmaceutical management post-ACS is particularly required for patients from rural and remote areas, and those attending district and private hospitals.
- Procalcitonin, a valuable biomarker assisting clinical decision making in the management of community-acquired pneumonia. [JOURNAL ARTICLE]
- Intern Med J 2014 Feb 14.
Procalcitonin, a valuable biomarker assisting clinical decision making in the management of community-acquired pneumonia Background and objective: Community-acquired pneumonia (CAP) is a leading cause of mortality, morbidity and hospital admission which places strain on our healthcare system. Procalcitonin (PCT) is a biomarker of bacterial infection which may help gauge the severity and prognosis of patients with CAP. In addition to clinical predictors, PCT may assist in decisions pertaining to timing of discharge from hospital and the discontinuation of antibiotics. Aim: To determine the predictive role of PCT measurement in reducing hospital admissions, length of stay (LOS), and antibiotic (AB) usage in patients with CAP. Methods: Prospective, single-blinded, externally controlled study of consenting adult patients admitted with CAP. PCT levels were obtained on day 1 and day 3 (when indicated). Investigator evaluated clinical parameters together with results of PCT levels determined the timing of oral AB switch and discharge from hospital. This process was compared against standard practice, but was not actually implemented for the purpose of this study. Results: Sixty patients were included in the study. The mean age was 66.5±21.2 years (56.3% male). The average Pneumonia Severity Index (PSI) was 93±39 (Class IV) and the median CURB-65 was 2. The mean LOS for the standard practice cohort was 5.3±4.6 days versus calculated LOS using the PCT guidance pathway of 3.7±2.8 days. (p=0.00006) Conclusions: Our study supports the hypothesis that by incorporation of PCT levels, hospital admission and LOS in patients with CAP can be reduced. A randomised prospective clinical trial is planned in an attempt to help confirm these findings.
- Author reply. [Letter]
- Intern Med J 2014 Feb; 44(2):210-1.
- Successful management of life-threatening disseminated intravascular coagulopathy due to metastatic melanoma. [Letter]
- Intern Med J 2014 Feb; 44(2):207-8.
- Disease progress in patients with Morbus Fabry after switching from agalsidase beta to agalsidase alpha. [Letter]
- Intern Med J 2014 Feb; 44(2):205-7.