A pre-post study of pharmacist-led medication reviews within a hospital-based residential aged care support service

BACKGROUND

Hospital-based residential aged-care support service teams typically consist of doctors and nurses who provide hospital substitutive care to aged-care residents. There is limited literature evaluating the pharmacist's role in such aged-care support teams.

OBJECTIVE

To analyse the effect of residential aged-care support service pharmacist-led medication reviews on polypharmacy, drug burden index, potentially inappropriate medications, and potential prescribing omissions for aged-care residents.

METHODS

Residents referred to a residential aged-care support service pharmacist for medication review over a 12-month period were included. The pharmacist communicated medication-related problems and recommendations to the resident's general practitioner and residential aged-care support service medical practitioner. Residents' medication histories were obtained at baseline and one-month postintervention. The number of medications and their associated drug burden indices were compared using paired t-tests; potentially inappropriate medications and potential prescribing omissions were compared using Wilcoxon's signed rank test.

KEY FINDINGS

Of 175 residents (mean age 84 years) referred for pharmacist-led medication review, 146 had postintervention evaluation after one-month (median 29 days). Mean number of medications reduced from 12.47 at baseline to 11.84 postintervention (mean difference (95% CI): 0.63(0.33-0.93), P < .001). Mean drug burden index score reduced from 1.54 at baseline to 1.37 postintervention (mean difference (95% CI): 0.17(0.10-0.24), P < .001). More residents experienced a decrease in inappropriate medications (median (IQR) pre: 2(1-3), post: 1(0-2), P < .001) and prescribing omissions (median (IQR) pre: 0(0-1), post: 0(0-0), P = .003) compared with those that had an increase.

CONCLUSIONS

Medication reviews performed by pharmacists embedded in hospital-based residential aged-care support services may improve medication prescribing. Further research into such preventative health service models is required.

Spot urinary sodium guided titration of intravenous diuretic therapy in acute heart failure: A pilot randomised controlled trial

BACKGROUND

Spot urinary sodium concentration (UNa) is advocated in guidelines to assess diuretic response and titrate dosage in acute heart failure (AHF). However, no randomised controlled trial data exists to support this approach. We performed a prospective pilot trial to investigate the feasibility of this approach.

METHODS

60 patients with AHF (n = 30 in each arm) were randomly assigned to titration of loop diuretics for the first 48 hours of admission according to UNa levels (intervention arm) or based on clinical signs and symptoms of congestion (standard care arm). Diuretic insufficiency was defined as UNa < 50 mmol/L. Endpoints relating to diuretic efficacy, safety and AHF outcomes were evaluated.

RESULTS

UNa-guided therapy patients experienced less acute kidney injury (20% vs 50%, p = 0.01) and a tendency towards less hypokalaemia (serum K+<3.5 mmol, 7% vs 27%, p = 0.04), with greater weight loss (3.3 kg vs 2.1 kg, p = 0.01). They reported a greater reduction in the clinical congestion score (-4.7 vs -2.6, p < 0.01) and were more likely to report marked symptom improvement (40% vs 13.3%, p = 0.04) at 48 hours. There was no difference in the length of hospital stay (median LOS: 8 days in both groups, p = 0.98), 30-day mortality or readmission rate.

CONCLUSION

UNa-guided titration of diuretic therapy in AHF is feasible and safer than titration based on clinical signs and symptoms of congestion, with more effective decongestion at 48 hours. Further large-scale trials are needed to determine if the superiority of this approach translates into improved patient outcomes.

Preoperative Renin-Angiotensin System Antagonists Intake and Blood Pressure Responses During Ambulatory Surgical Procedures: A Prospective Cohort Study

BACKGROUND

There is limited evidence to inform the association between the intake of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs) and intraoperative blood pressure (BP) changes in an ambulatory surgery population.

METHODS

Adult patients who underwent ambulatory surgery and were discharged on the same day or within 24 hours of their procedure were enrolled in this prospective cohort study. The primary outcome of the study was early intraoperative hypotension (first 15 minutes of induction). Secondary outcomes included any hypotension, BP variability, and recovery. Hypotension was defined as a decrease in systolic BP of >30% from baseline for ≥5 minutes or a mean BP of <55 mm Hg. Four exposure groups were compared (no antihypertensives, ACEI/ARB intake <10 hours before surgery, ACEI/ARB intake ≥10 hours before surgery, and other antihypertensives).

RESULTS

Of the 537 participants, early hypotension was observed in 25% (n = 134), and any hypotension in 41.5% (n = 223). Early hypotension occurred in 30% (29 of 98) and 41% (17 of 41) with the intake of ACEI/ARBs <10 and ≥10 hours before surgery, respectively, compared to 30% (9 of 30) with other antihypertensives and 21% (79 of 368) with no antihypertensives ( P = .02). Those on antihypertensives also experienced any hypotension more frequently than those who were not on antihypertensives ( P < .001). After adjusting for age and baseline BP in a regression analysis, antihypertensive exposure groups were observed to be associated only with any intraoperative hypotension ( P = .012). In the ACEI/ARB subset, there was no evidence of an association between time since the last ACEI/ARB dose, and hypotension or minimum mean or systolic BP. Compared to normal baseline BP, BP ≥ 140/90 mm Hg increased the odds of early and any hypotension (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.1-7.1 and OR, 7.7; 95% CI, 3.7-14.9, respectively; P < .001). Intraoperative variability in systolic and diastolic BP demonstrated significant differences with age, baseline BP, and antihypertensive exposure group ( P < .001).

CONCLUSIONS

Early and any hypotension occurred more frequently in those on antihypertensives than those not on antihypertensives. Unadjusted associations between antihypertensive exposure and intraoperative hypotension were largely explained by baseline hypertension rather than the timing of ACEI/ARBs or type of antihypertensive exposure. Patients with hypertension and on treatment experience more intraoperative BP variability and should be monitored appropriately.

Excess Bed Days and Hospitalization Costs Associated With 30-Day Complications Following Catheter Ablation of Atrial Fibrillation

BACKGROUND

The incidence and type of complications following catheter ablation of atrial fibrillation have been extensively examined, but the impact associated with these complications on the length of stay and hospitalization costs is unknown.

METHODS AND RESULTS

This cohort study included 20 117 adult patients (mean age 62.6±11.4 years, 30.3% women, median length of stay 1 day [interquartile range 1-2 days]) undergoing atrial fibrillation ablation in financial years 2011 to 2017 in Australia with available cost data from the National Hospital Cost Data Collection, which determines government reimbursement of health services provided. The primary outcome was the costs associated with complications occurring up to 30 days postdischarge adjusted for inflation to 2021 Australian dollars. We used generalized linear models to estimate the increase in length of stay and cost associated with complications, adjusting for patient characteristics. Within 30 days of hospital discharge, 1151 (5.72%) patients experienced a complication with bleeding (3.35%) and pericardial effusion (0.75%) being the most common. On average, the occurrence of a complication was associated with an adjusted 3.3 (95% CI, 3.1-3.6) excess bed days of hospital care (totaling 3851 days), and a $7812 (95% CI, $6754-$8870) increase in hospitalization cost (totaling $9.0 million). Most of the total excess cost was attributable to bleeding ($3.8 million, 41.9% of total excess cost) and pericardial effusion ($1.6 million, 18.2%).

CONCLUSIONS

Complications following atrial fibrillation ablation were associated with significant increase in length of stay and hospitalization costs, most of which were attributable to bleeding and pericardial effusion. Strategies to improve procedural safety and reduce health care costs should focus on these complications.

A protocol of an international validation study to assess the clinical accuracy of the eDIS-ICU delirium screening tool

BACKGROUND

Delirium is a common, yet underdiagnosed neuropsychiatric complication of intensive care unit (ICU) admission, associated with significant mortality and morbidity. Delirium can be difficult to diagnose, with gold standard assessments by a trained specialist being impractical and rarely performed. To address this, various tools have been developed, enabling bedside clinicians to assess for delirium efficiently and accurately. However, the performance of these tools varies depending on factors including the assessor's training. To address the shortcomings of current tools, electronic tools have been developed.

AIMS AND OBJECTIVES

The aims of this validation study are to assess the feasibility, acceptability, and generalisability of a recently developed and pilot-tested electronic delirium screening tool (eDIS-ICU) and compare diagnostic concordance, sensitivity, and specificity between eDIS-ICU, Confusion Assessment Method for the ICU (CAM-ICU), and the Diagnostic and Statistical Manual of Mental Disorders - 5th edition (DSM-V) gold standard in diverse ICU settings.

METHODS

Seven hundred participants will be recruited across five sites in three countries. Participants will complete three assessments (eDIS-ICU, CAM-ICU, and DSM-V) twice within one 24-h period. At each time point, assessments will be completed within one hour. Assessments will be administered by three different people at any given time point, with the assessment order and assessor for eDIS-ICU and CAM-ICU randomly allocated. Assessors will be blinded to previous and concurrent assessment results.

RESULTS

The primary outcome is comparing diagnostic sensitivity of eDIS-ICU and CAM-ICU against the DSM-V.

RELEVANCE TO CLINICAL PRACTICE

This protocol describes a definitive validation study of an electronic diagnostic tool to assess for delirium in the ICU. Delirium remains a common and difficult challenge in the ICU and is linked with multiple neurocognitive sequelae. Various challenges to routine assessment mean many cases are still unrecognised or misdiagnosed. An improved ability for bedside clinicians to screen for delirium accurately and efficiently will support earlier diagnosis, identification of underlying cause(s) and timely treatments, and ultimately improved patient outcomes.

CLINICAL TRIAL REGISTRATION NUMBER

This study was prospectively registered on the Australian New Zealand Clinical Trials Registry (ANZCTR) on 8th February 2022 (ACTRN12622000220763).

Prehospital Activation of the Cardiac Catheterization Laboratory in ST-Segment-Elevation Myocardial Infarction for Primary Percutaneous Coronary Intervention

Background Prehospital activation of the cardiac catheter laboratory is associated with significant improvements in ST-segment-elevation myocardial infarction (STEMI) performance measures. However, there are equivocal data, particularly within Australia, regarding its influence on mortality. We assessed the association of prehospital activation on performance measures and mortality in patients with STEMI treated with primary percutaneous coronary intervention from the Queensland Cardiac Outcomes Registry (QCOR). Methods and Results Consecutive ambulance-transported patients with STEMI treated with primary percutaneous coronary intervention were analyzed from January 1, 2017 to December 31, 2020 from the QCOR. The total and direct effects of prehospital activation on the primary outcomes (30-day and 1-year cardiovascular mortality) were estimated using logistic regression analyses. Secondary outcomes were STEMI performance measures. Among 2498 patients (mean age: 62.2±12.4 years; 79.2% male), 73% underwent prehospital activation. Median door-to-balloon time (34 minutes [26-46] versus 86 minutes [68-113]; P<0.001), first-electrocardiograph-to-balloon time (83.5 minutes [72-98] versus 109 minutes [81-139]; P<0.001), and proportion of patients meeting STEMI targets (door-to-balloon <60 minutes 90% versus 16%; P<0.001), electrocardiograph-to-balloon time <90 minutes (62% versus 33%; P<0.001) were significantly improved with prehospital activation. Prehospital activation was associated with significantly lower 30-day (1.6% versus 6.6%; P<0.001) and 1-year cardiovascular mortality (2.9% versus 9.5%; P<0.001). After adjustment, no prehospital activation was strongly associated with increased 30-day (odds ratio [OR], 3.6 [95% CI, 2.2-6.0], P<0.001) and 1-year cardiovascular mortality (OR, 3.0 [95% CI, 2.0-4.6]; P<0.001). Conclusions Prehospital activation of cardiac catheterization laboratory for primary percutaneous coronary intervention was associated with significantly shorter time to reperfusion, achievement of STEMI performance measures, and lower 30-day and 1-year cardiovascular mortality.

State-wide prevalence of pressure injury in intensive care versus acute general patients: A five-year analysis

AIM

The aim of this study was to analyse prevalence of pressure injury in intensive care versus non-intensive care patients.

BACKGROUND

Hospital-acquired pressure injury is an enduring problem. Intensive care patients are more susceptible due to multiple risk factors. Several studies have indicated that intensive care patients are more likely than general patients to develop pressure injuries.

DESIGN

Secondary data analysis.

METHODS

Eighteen general hospitals with intensive care units were included. The sample included all consenting patients. Logistic regression modelling was used to derive prevalence and effect estimates. STROBE reporting guidelines were followed.

RESULTS

The sample comprised 15,678 patients; 611 were in intensive care. The crude prevalence estimate of hospital-acquired pressure injury was 9.6% in intensive care and 2.1% in non-intensive care patients. The ≥Stage II hospital-acquired prevalence estimate in was 8.6% intensive care and 1.2% in non-intensive care patients. Intensive care patients were at markedly increased risk of hospital-acquired pressure injury compared with non-intensive care patients, with risk persisting after adjusting for pressure injury risk score. Risk of ≥ Stage II hospital-acquired pressure injury was further elevated. Intensive care patients had a higher pressure injury risk level and developed a greater proportion of severe hospital-acquired pressure injuries than non-intensive care patients. In intensive care, most hospital-acquired pressure injuries were found on the sacrum/coccyx and heels.

CONCLUSIONS

There were significant differences between the hospital-acquired pressure injury prevalence of intensive care versus non-intensive care patients, which is consistent with previous studies. Overall, the prevalence of hospital-acquired pressure injury in intensive care is relatively high, indicating that their prevention should remain a high priority within the intensive care setting.

RELEVANCE TO CLINICAL PRACTICE

These results may be used for benchmarking and provide a focus for future education and practice improvement efforts.

PATIENT OR PUBLIC CONTRIBUTION

Neither patients nor the public were directly involved in the project.

Association Between Thromboelastometry Identified Hypercoagulability and Thromboembolic Complications After Arthroplasty: A Prospective Observational Study in Patients With Obesity

The prothrombotic state of obesity can increase the risk of thromboembolism. We aimed to investigate if there was an association between baseline hypercoagulable rotational thromboelastometry (ROTEM) profile and thromboembolic complications in arthroplasty patients with obesity. Patients with a body mass index ≥ 25 kg/m2 and/or waist circumference ≥94 cm (M) and 80 cm (F) undergoing hip and knee arthroplasty had pre- and postoperative ROTEM. ROTEM values were compared by outcome status using an independent sample equal-variance t-test. Of the 303 total participants, hypercoagulability defined as extrinsically activated thromboelastometry maximum clot firmness G score ≥ 11 K dyne/cm2, was observed in 90 (30%) of the 300 participants with preoperative ROTEM assays. Clinically significant thromboembolic complications occurred in 5 (1.7%) study participants before discharge and in 10 (3.3%) by 90 days. These included 6 with pulmonary emboli, 3 with deep venous thrombus, and 1 with myocardial infarction. We found no evidence for an association between baseline hypercoagulability and incident thromboembolic events, analysis limited by the number of events. Postoperative decrease in platelets and an increase in fibrinogen were observed. ROTEM parameter changes differed across obesity categories.

The association between urinary sodium concentration (UNa) and outcomes of acute heart failure: a systematic review and meta-analysis

AIMS

Urinary sodium concentration (UNa) is a simple test advocated to assess diuretics efficacy and predict outcomes in acute heart failure (AHF). We performed a systematic review and meta-analysis to examine the association of UNa with outcomes of AHF.

METHODS AND RESULTS

We searched Embase and Medline for eligible studies that reported the association between UNa and outcomes of urinary output, weight loss, worsening renal function, length of hospital stay, re-hospitalization, worsening heart failure, and all-cause mortality in AHF. Nineteen observational studies out of 1592 screened records were included. For meta-analyses of outcomes, we grouped patients into high vs. low UNa, with most studies defining high UNa as &gt;48-65 mmol/L. In the high UNa group, pooled data showed a higher urinary output (mean difference 502 mL, 95% CI 323-681, P &lt; 0.01), greater weight loss (mean difference 1.6 kg, 95% CI 0.3-2.9, P = 0.01), and a shorter length of stay (mean difference -1.4 days, 95% CI -2.8 to -0.1, P = 0.03). There was no significant difference in worsening kidney function (OR 0.54, 95% CI 0.25-1.16, P = 0.1). Due to the small number of studies, we did not report pooled estimates for re-hospitalization and worsening heart failure. High UNa was associated with lower odds of 30-day (OR 0.27; 95% CI 0.14-0.49, P &lt; 0.01), 90-day (OR 0.39,95% CI 0.25-0.59, P &lt; 0.01) and 12-month (OR 0.35; 95% CI 0.20-0.61, P &lt; 0.01) mortality.

CONCLUSION

High UNa after diuretic administration is associated with higher urinary output, greater weight loss, shorter length of stay, and lower odds of death. UNa is a promising marker of diuretic efficacy in AHF which should be confirmed in randomized trials.

Sex differences in time to primary percutaneous coronary intervention and outcomes in patients presenting with ST-segment elevation myocardial infarction

OBJECTIVES

We assessed sex differences in treatment and outcomes in ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PCI).

BACKGROUND

Historically, delays to timely reperfusion and poorer outcomes have been described in women who suffer STEMI. However, whether these sex discrepancies still exist with contemporary STEMI treatment remains to be evaluated.

METHODS

Consecutive STEMI patients treated with primary PCI patients over a 10-year period (January 1, 2010 to December 31, 2019) from a tertiary referral center were assessed. Comparisons were performed between patient's sex. Primary outcomes were 30-day and 1-year mortality. Secondary outcomes were STEMI performance measures.

RESULTS

Most patients (n = 950; 76%) were male. Females were on average older (66.8 vs. 61.4 years males; p < 0.001). Prehospital treatment delays did not differ between sexes (54 min [IQR: 44-65] females vs. 52 min [IQR: 43-62] males; p = 0.061). STEMI performance measures (door-to-balloon, first medical contact-to-balloon [FMCTB]) differed significantly with longer median durations in females and fewer females achieving FMCTB < 90 min (28% females vs. 39% males; p < 0.001). Women also experienced greater rates of initial radial arterial access failure (11.3% vs. 3.1%; p < 0.001). However, there were no significant sex differences in crude or adjusted mortality between sexes at 30-days (3.6% male vs. 5.1% female; p = 0.241, adjusted OR: 1.1, 95% CI: 0.5-2.2, p = 0.82) or at 1-year (4.8% male vs. 6.8% female; p = 0.190, adjusted OR: 1.0, (95% CI: 0.5-1.8; p = 0.96).

CONCLUSION

Small discrepancies between sexes in measures of timely reperfusion for STEMI still exist. No significant sex differences were observed in either 30-day or 1-year mortality.

Communication Success and Speaking Valve Use in Intensive Care Patients Receiving Mechanical Ventilation

BACKGROUND

Communication with patients receiving mechanical ventilation in an intensive care unit can be challenging. Once a patient is tracheostomized, a speaking valve may enable restoration of verbal communication. To date, no data are available on the effect of speaking valves on communication success in intensive care units.

OBJECTIVE

The aim of this prospective cohort study was to measure communication success before and during speaking valve use for intensive care patients being weaned from mechanical ventilation, from both the nurses' and the patients' perspectives.

METHODS

In a prospective cohort study, consecutive eligible patients and their nurses were asked to complete newly developed questionnaires on communication success before and while patients used a speaking valve (6 questions for patients, 5 questions for nurses, answers on a 10-point scale with 10 the best score). The Wilcoxon signed rank test was used to analyze score differences.

RESULTS

For all questionnaire items, both patients (n = 25) and nursing staff (n = 52) reported significantly higher communication success during speaking valve use. Nurses understood moderately well that their patients were in pain (median [IQR], 5.8 [4.7-7.4]) even before speaking valve use. Most patients found it challenging to say something quickly even while using a speaking valve (6.9 [5.7-10.0]). Overall, speaking valve use markedly increased communication success.

CONCLUSION

A speaking valve should be considered for patients with a tracheostomy as soon as possible to improve their communication success.

Mental health and child refugees

This paper presents an overview of the importance of mental health services for unaccompanied asylum-seeking children in the United Kingdom. It reviews what mental health support appears to be available in the United Kingdom following an on-line search which took place in Spring 2021 and using information gathered through 22 interviews and focus groups with stakeholders. The latter group are defined as people working with asylum-seeking children. The primary stakeholders were local authority staff, although interviews were also conducted with local government associations (London Councils, the Local Government Association), NHS bodies and the voluntary sector. Often, further relevant stakeholders were identified during interviews. The report details the aims, methodology and context, before the findings are presented which is followed by recommendations for improving mental and social care provision for unaccompanied asylum-seeking children in the United Kingdom.

Clinical Outcomes in Pre-Hospital Activation and Direct Cardiac Catheterisation Laboratory Transfer of STEMI for Primary PCI

INTRODUCTION

Pre-hospital activation and direct cardiac catheterisation laboratory (CCL) transfer of ST segment elevation myocardial infarction (STEMI) has previously been shown to improve door-to-balloon (DTB) times yet there is limited outcome data in the Australian context. We aimed to assess the impact of pre-hospital activation on STEMI performance measures and mortality.

METHODS

Prospective cohort study of consecutive ambulance transported STEMI patients treated with primary percutaneous coronary intervention (PCI) patients over a 10-year period (1 January 2008-31 December 2017) at The Prince Charles Hospital, a large quaternary referral centre in Brisbane, Queensland Australia. Comparisons were performed between patients who underwent pre-hospital CCL activation and patients who did not. STEMI performance measures, 30-day and 1-year mortality were examined.

RESULTS

Amongst 1,009 patients included (mean age: 62.8 yrs±12.6), pre-hospital activation increased over time (26.6% in 2008 to 75.0% in 2017, p<0.001). Median DTB time (35 mins vs 76 mins p<0.001) and percentage meeting targets (DTB<60 mins 92% vs 27%, p<0.001) improved significantly with pre-hospital activation. Pre-hospital activation was associated with significantly lower 30-day (1.0% vs 3.5%, p=0.007) and 1-year (1.2% vs 7.7%, p<0.001) mortality. After adjusting for confounders and mediators, we observed a strong total effect of pre-hospital activation on 1-year mortality (OR 5.3, 95%CI 2.2-12.4, p<0.001) compared to patients who did not have pre-hospital activation. False positive rates were 3.7% with pre-hospital activation.

CONCLUSION

In patients who underwent primary PCI for STEMI, pre-hospital activation and direct CCL transfer is associated with low false positive rates, significantly reduced time to reperfusion and lower 30-day and 1-year mortality.

Long-Term Survival, Stroke Recurrence, and Life Expectancy After an Acute Stroke in Australia and New Zealand From 2008-2017: A Population-Wide Cohort Study

BACKGROUND

Data on long-term outcomes following an acute stroke are sparse. We assessed survival, risk of recurrent stroke and loss in life expectancy following an acute stroke using population-wide data from Australia and New Zealand.

METHODS

We included all adults with the first stroke hospitalization during 2008 and 2017 at all public and most private hospitals. Patients were followed up to 10 years after the stroke by linkage to each region's Registry of Deaths and subsequent hospitalizations. Flexible parametric survival modeling was used to estimate all-cause mortality, stroke recurrence, and loss in life expectancy. Competing risk model was used when estimating the risk of stroke recurrence.

RESULTS

Three hundred thirteen thousand one hundred sixty-two patients were included (mean age 73.0±14.6 y, 52.0% males) with ischemic stroke (175 547, 56.1%) being the most common, followed by hemorrhagic stroke (77 940, 24.9%) and unspecified stroke (59 675, 19.1%). The overall survival probability was 79.4% at 3 months, 73.0% at 1 year, 52.8% at 5 years, and 36.4% at 10 years. Cumulative incidence of stroke recurrence was 7.8% at 3 months, 11.0% at 1 year, 19.8% at 5 years, and 26.8% at 10 years. Hemorrhagic stroke was associated with greater mortality (hazard ratio, 2.02 [95% CI, 1.99-2.04]) and recurrent stroke (hazard ratio, 1.63 [95% CI, 1.59-1.67]) compared with ischemic stroke. Female sex (hazard ratio, 1.10 [95% CI, 1.09-1.11]) and increasing age (≥85 years versus 18-54 years: hazard ratio, 7.36 [95% CI, 7.15-7.57]) were also associated with increased mortality. Several risk factors including atherosclerotic coronary and noncoronary vascular disease, cardiac arrhythmia, and diabetes were associated with increased risk of mortality and recurrent stroke. Compared with the general population, an acute stroke was associated with a loss of 5.5 years of life expectancy, or 32.7% of the predicted life expectancy, and was pronounced in patients with a hemorrhagic stroke (7.4 years and 38.5% of predicted life expectancy lost).

CONCLUSIONS

In this population-wide study, death and recurrence of stroke were common after an acute stroke and an acute stroke was associated with considerable loss in life expectancy. Further improvements in treatment and secondary prevention of stroke are needed to reduce these risks.

Impact of Patient BMI on Patient and Operator Radiation Dose During Percutaneous Coronary Intervention

AIMS

This study sought to investigate patient and operator radiation dose in patients undergoing percutaneous coronary intervention (PCI) and the impact of body mass index (BMI) on patient and operator dose.

METHODS

In patients undergoing PCI, radiation dose parameters, baseline characteristics and procedural data were collected in a tertiary centre for 3.5 years. Operators wore real time dosimeters. Patients were grouped by BMI. Dose area product (DAP) and operator radiation dose were compared across patient BMI categories. Multivariable analysis was performed to investigate the impact of patient BMI and other procedural variables on patient and operator dose.

RESULTS

2,043 patients underwent 2,197 PCI procedures. Each five-unit increase in BMI increased patient dose (expressed as DAP) by an average 31% (95% CI: 29-33%) and operator dose by 27% (95% CI: 20-33%). Patient dose was 2.3 times higher and operator dose was 2.4 times higher in patients with a BMI>40 than for normal BMI patients. Multivariable analysis indicated that there were many procedural factors that were predictors for increasing operator dose and patient dose but that patient BMI was a major contributor for both operator dose and patient dose.

CONCLUSION

Increasing BMI increases the DAP and operator dose for PCI procedures and BMI is demonstrated to be a major factor that contributes to both patient and operator radiation dose.

Mindfulness based cognitive therapy for youth with inflammatory bowel disease and depression - Findings from a pilot randomised controlled trial

BACKGROUND

Mindfulness-based cognitive therapy (MBCT) is a promising adjunctive treatment for adolescents and young adults (AYAs) with Inflammatory Bowel Disease (IBD) and comorbid depression.

OBJECTIVES

This pilot randomised controlled trial (RCT) aimed to evaluate feasibility and efficacy of an adapted MBCT program for AYA, aged 16-29, with IBD.

METHODS

Sixty-four AYAs were randomly allocated to MBCT (n = 33) or treatment as usual (TAU) (n = 31). Primary outcome measure was the depression score on Depression, Anxiety and Stress Scale. Secondary outcomes included anxiety, stress, IBD-related quality of life, coping, mindfulness, post-traumatic growth, medication adherence, IBD activity, inflammatory markers, microbiome characteristics and brain functional connectivity.

RESULTS

Study recruitment rate was 75%, retention rate 70%, and session attendance 92%. Intention to treat analyses revealed that, compared to TAU group, MBCT group had significantly lower depression (∆ = -6.0; 95%CI = -10.8 to -1.2; P = 0.015) and stress (∆ = -5.1; 95%CI = -10.1 to -0.0; P = 0.049), higher active coping (∆ = 1.0;95%CI = 0.1-1.9; P = 0.022), and total mindfulness scores (∆ = 10.9;95%CI = 1.1-20.8; P = 0.030) at 8 weeks (post-therapy), and improved coping by positive reframing (∆ = 1.1;95%CI = 0.0-2.2; P = 0.043) and planning (∆ = 0.9;95%CI = 0.0-1.9; P = 0.045), mindful awareness (∆ = 5.2.;95%CI = 2.0-8.5; P = 0.002) and total mindfulness scores (∆ = 10.8.;95%CI = 0.4-21.1; P = 0.042) at 20 weeks. On per protocol analysis, MBCT group had significantly lower depression (∆ = -6.3; 95%CI = -11.4 to -1.2; P = 0.015), stress (∆ = -6.0; 95%CI = -11.2 to -0.5; P = 0.032), increased active coping (∆ = 0.9;95%CI = 0-1.7; P = 0.05) at 8 weeks, and mindful awareness (∆ = 5.4; 95%CI = 2.1-8.6; P = 0.001) at 20 weeks.

CONCLUSION

In AYAs with IBD, MBCT is feasible and beneficial in improving depression, stress, mindfulness and adaptive coping. It holds promise as an important component of integrated IBD care. Trial registration number ACTRN12617000876392, U1111-1197-7370; Pre-results.

Outcomes of artery embolisation for cystic fibrosis patients with haemoptysis: a 20-year experience at a major Australian tertiary centre

There are no published data on Australian adult cystic fibrosis (CF) patient outcomes post bronchial arterial embolisation (BAE). We report 20 years of experience of BAE at a major Australian tertiary adult CF centre, where 46 patients underwent 100 BAE during this period. Mortality rate was comparable to previous studies (4% per year) and most who died had repeat BAE requirements. A higher proportion (9 out of 45) of patients were transplanted compared to previous publications. Repeat BAE was common and significantly higher in patients already on tranexamic acid.

A delicate balance: Psychotropic polypharmacy and anti-cholinergic use are correlated with fall incidence in Australian inpatients with dementia

BACKGROUND

Persons with dementia commonly experience a range of behavioural and psychological symptoms, including agitation, aggression, perceptual disturbances, and depression. While psychotropic medications are regularly prescribed to mitigate these symptoms, these agents also carry a broad adverse effect profile. This study aimed to characterize psychotropic medication use in patients with dementia, as well as identify prescribing factors associated with falls in this cohort.

METHODS

This retrospective study collected longitudinal demographic and medication data from all patients admitted to a neuro-cognitive unit at an Australian metropolitan hospital over a 2-year period. Psychotropic polypharmacy and psychotropic agent use per patient-fortnight were investigated for their association with inpatient falls.

RESULTS

All patients (n = 147) were prescribed at least one psychotropic medication, with 96% receiving anti-psychotic medications and 90% receiving benzodiazepines. Patient fall rate was significantly associated with anticholinergic drug use (Incidence rate ratio: 2.2; P < .001), as well as concomitant use of ≥5 daily psychotropic agents (Incidence rate ratio: 3.1; P = .001).

CONCLUSIONS

Patients with dementia are routinely prescribed a wide variety of psychotropic medications. Use of anticholinergic drugs and psychotropic polypharmacy are correlated with fall incidence in persons with dementia.

Differences in biomarkers of cardiac dysfunction in cord blood between normal pregnancies and pregnancies complicated by maternal diabetes

AIMS

The aim of this study was to compare biomarkers of cardiac dysfunction in cord blood in women with uncomplicated pregnancies and pregnancies complicated by maternal pre-gestational and gestational diabetes and to correlate these findings with fetal echocardiography parameters of cardiac function.

MATERIAL AND METHODS

Fetal echocardiographic assessment was performed longitudinally on 78 fetuses in the normal cohort and 32 in the diabetic cohort by measuring tricuspid annular plane systolic excursion, mitral annular plane systolic excursion, myocardial performance index, interventricular septum (IVS) thickness and left fractional shortening between July 2015 and December 2017. Cord blood samples were obtained at birth and levels of troponin I (TnI), B-type natriuretic peptide (BNP) and the amnio terminal segment of its prohormone measured.

RESULTS

Women with diabetes had significantly higher median body mass index and mean z-scores for BNP. Significant associations were observed between maternal diabetes and obesity and cord-blood BNP z-scores. The effect of diabetes on TnI levels were similar, with mean values higher in women with gestational diabetes compared to normal pregnancies; however, this difference did not reach statistical significance. These biomarker findings correlated with an increased IVS thickness in the diabetic group. No difference was demonstrated in the other cardiac function parameters measured.

CONCLUSION

Biochemical markers of cardiac dysfunction are elevated in infants of diabetic and obese mothers and correlated with increased IVS thickness.

The impact of an electronic hospital system on therapeutic drug monitoring

WHAT IS KNOWN AND OBJECTIVE

Australian hospitals have undergone a transformation with both a review and expansion of traditional roles of healthcare professionals and the implementation of an ieMR. The implementation of an ieMR brings large scale organizational change within the health system especially for staff with direct patient contact. This is changing the future of healthcare and the roles of healthcare professionals. There is minimal research on the impact of these electronic systems on the people and processes required to realise the improvements in patient care such as therapeutic drug monitoring (TDM) and the role of the pharmacist within the TDM process. The literature has discussed the use of computerised programs to assist with the interpretation of results and calculating of doses but the impact of an ieMR on the TDM process has not been discussed. This study undertook a retrospective analysis at an Australian tertiary hospital to investigate the impact of a digital hospital system on TDM within the facility.

METHODS

A 2-year retrospective audit was conducted on TDM at an Australian Tertiary Hospital. The periods were 2016 (a paper-based hospital) and 2018 (ieMR). Patients were identified using the pathology database. Patients were excluded if under the age of 18, in an outpatient setting or the emergency department. Progress notes, medication charts, ieMR and other relevant pathology were reviewed. They were assessed for appropriateness of the timing of collection, compliance to recommended TDM guidelines, and pharmacist documentation.

RESULTS AND DISCUSSION

A total of 2926 observations were included in the analysis. There was as similar percentage of appropriately collected samples between the paper-based system (2016) and the digital hospital system (2018) with 59% and 58% respectively. Results of logistic regression analysis models show the effect of year was not significant with regards to TDM for either a sample being appropriate or the dose adjustment being appropriate. Samples for TDM were more likely to be appropriate if the pharmacist had documented advice but less likely with regards to appropriate dose adjustment. This study considered the effect of introducing a hospital wide digital system on TDM processes. Overall, the results indicate no difference between the paper-based system and ieMR for appropriate samples and doses adjustments.

WHAT IS NEW AND CONCLUSION

To our knowledge, this is the first study of this kind looking at the impact of a digital hospital system on TDM. The introduction of a digital hospital system does not appear to have made improvement on the effective use of TDM. Inappropriate sampling as seen in this study can lead to ineffective clinical management of patients, inefficient use of time, and waste of financial resources. Further work is required to incorporate specific guidance and recommendations within the digital system to optimize TDM.

Safety and efficacy of high flow nasal cannula therapy in acute hypercapnic respiratory failure - a retrospective audit

BACKGROUND

While the role of high flow nasal cannulae (HFNC) in the management of respiratory failure continues to expand, few studies describe its use in acute hypercapnic respiratory failure.

AIMS

In this retrospective study we assessed the safety and efficacy of HFNC for treatment of acute hypercapnic respiratory failure.

METHODS

Admissions with acute hypercapnic respiratory failure to a thoracic medicine unit at a tertiary centre between January and August 2018 were included if treated with either HFNC or non-invasive ventilation (NIV). The primary outcome was post-treatment change in arterial pCO₂ . Demographics, comorbidities, length of stay, readmission rate and mortality were also collected.

RESULTS

64 patients were identified, comprising 69 presentations grouped according to initial treatment: HFNC (n=24) or NIV (n=45). Patients in the NIV group had more severe blood gas derangement. In both groups, mean arterial pCO₂ improved significantly (-10 (95% CI: -14 to -6) mmHg) from baseline with no evidence of a differential effect between groups. Six (25%) patients were transitioned from HFNC to NIV, of whom 3 had comorbid obesity and 2 had sleep disordered breathing. No significant differences in hospital length of stay, 30-day readmission rate or 90-day mortality were observed.

CONCLUSIONS

HFNC may be a reasonable initial treatment for patients with mild acute hypercapnic respiratory failure who do not have comorbid obesity or sleep disordered breathing. Prospective study may help identify clinical factors or phenotypes predictive of success with this treatment modality. This article is protected by copyright. All rights reserved.

Association between type of phototherapy management and hospital and patient-related outcomes in neonates with non-haemolytic jaundice at an Australian community hospital

AIM

To evaluate the associations between type of light-emitting diode phototherapy intervention and hospital and patient related outcomes in term neonates with non-haemolytic jaundice.

METHODS

A retrospective observational study in a community hospital within a disadvantaged area in Australia was conducted. Data was extracted from hospital systems and medical records regarding the use of three types of phototherapy surface-area exposure for term neonates ≤28 days with non-haemolytic neonatal jaundice. Associations between type of phototherapy management and length of stay (LOS), rate of serum bilirubin (SBR) decline and duration of phototherapy were estimated using the general linear mixed model or linear regression.

RESULTS

Of 102 neonates diagnosed with non-haemolytic jaundice between 1 June 2016 and 31 August 2017, 82 were included in final analyses. Neonates treated for jaundice during their first (birth) admission had a median LOS of 118 h for single-sided and 125 h for maximal double-sided phototherapy. Differences by phototherapy type were not statistically significant (P = 0.06). SBR rate of decline increased as surface-area of phototherapy increased (P < 0.001) with the fastest decline seen in maximal double-sided phototherapy. Estimated duration of phototherapy did not vary by phototherapy type but did vary by age at initiation of phototherapy (P = 0.006), with 16 fewer hours of phototherapy if commenced at ≥72 to <96 h versus ≥24 to 48 h of age (difference -16.4 h, 95% confidence interval -29.1 to -3.7 h).

CONCLUSIONS

LOS and phototherapy duration were not associated with phototherapy type. Older neonates with neonatal jaundice required shorter phototherapy duration. Double-sided phototherapy was associated with faster reduction in SBR.

Effects of omecamtiv mecarbil on failing human ventricular trabeculae and interaction with (-)-noradrenaline

Omecamtiv mecarbil (OM) is a novel medicine for systolic heart failure, targeting myosin to enhance cardiomyocyte performance. To assist translation to clinical practice we investigated OMs effect on explanted human failing hearts, specifically; contractile dynamics, interaction with the β₁–adrenoceptor (AR) agonist (−)‐noradrenaline and spontaneous contractions. Left and right ventricular trabeculae from 13 explanted failing hearts, and trabeculae from 58 right atrial appendages of non‐failing hearts, were incubated with or without a single concentration of OM for 120 min. Time to peak force (TPF) and 50% relaxation (t_50%) were recorded. In other experiments, trabeculae were observed for spontaneous contractions and cumulative concentration‐effect curves were established to (−)‐noradrenaline at β₁‐ARs in the absence or presence of OM. OM prolonged TPF and t_50% in ventricular trabeculae (600 nM, 2 µM, p < .001). OM had no significant inotropic effect but reduced time dependent deterioration in contractile strength compared to control (p < .001). OM did not affect the generation of spontaneous contractions. The potency of (−)‐noradrenaline (pEC₅₀ 6.05 ± 0.10), for inotropic effect, was unchanged in the presence of OM 600 nM or 2 µM. Co‐incubation with (−)‐noradrenaline reduced TPF and t_50%, reversing the negative diastolic effects of OM. OM, at both 600 nM and 2 µM, preserved contractile force in left ventricular trabeculae, but imparted negative diastolic effects in trabeculae from human failing heart. (−)‐Noradrenaline reversed the negative diastolic effects, co‐administration may limit the titration of inotropes by reducing the threshold for ischemic side effects.

Feasibility and Acceptability of a Smoking Cessation Smartphone App (My QuitBuddy) in Older Persons: Pilot Randomized Controlled Trial

Background

Although many smoking cessation smartphone apps exist, few have been independently evaluated, particularly in older populations. In 2017, of the 112 commercially available smoking cessation apps in Australia, only 6 were deemed to be of high quality, in that they partially adhered to Australian guidelines. Mobile health (mHealth) apps have the potential to modify smoking behavior at a relatively low cost; however, their acceptability in older smokers remains unknown. Rigorous scientific evaluation of apps is thus urgently needed to assist smokers and clinicians alike.

Objective

We conducted a pilot randomized controlled trial to evaluate the feasibility of a large-scale trial to assess the use and acceptability of a high-quality smoking cessation app in older smokers.

Methods

Adult inpatient and outpatient smokers with computer and smartphone access were recruited face to face and via telephone interviews from Metropolitan Hospitals in Brisbane, Australia. Participants were randomized 1:1 to the intervention (requested to download the “My QuitBuddy” smoking cessation app on their smartphone) or the control group (provided access to a tailored smoking cessation support webpage [Quit HQ]). The My QuitBuddy app is freely available from app stores and provides personalized evidenced-based smoking cessation support. Quit HQ offers regular email support over 12 weeks. No training or instructions on the use of these e-resources were given to participants. Outcomes at 3 months included recruitment and retention rates, use and acceptability of e-resource (User Version of the Mobile App Rating Scale [uMARS]), changes in quitting motivation (10-point scale), and self-reported smoking abstinence.

Results

We randomized 64 of 231 potentially eligible individuals (27.7%). The mean age of participants was 62 (SD 8). Nicotine dependence was moderate (mean Heaviness of Smoking Index [HSI] 2.8 [SD 1.2]). At 3 months the retention rate was (58/64, 91%). A total of 15 of 31 participants in the intervention arm (48%) used the app at least once, compared with 10 of 33 (30%) in the control arm. uMARS scores for e-resource use and acceptability were statistically similar (P=.29). Motivation to quit was significantly higher in the intervention arm compared with the control arm (median 6 [IQR 4-8] versus 4 [IQR 4-5], respectively, P=.02). According to the intention-to-treat analysis, smoking abstinence was nonsignificantly higher in the intervention group (4/31 [13%], 95% CI 4%-30%, versus 2/33 [6%], 95% CI 1%-20%; P=.42). The estimated number needed to treat was 14.

Conclusions

Internet and mHealth smoking cessation resources appear acceptable to a minority of older smokers. Smokers who engaged with the allocated e-resources rated them equally, and there were trends toward greater uptake, increased motivation, and higher abstinence rates in the app group; however, only the change in motivation reached statistical significance (median score 6 versus 4, respectively, P=.02). This results of this pilot study suggest that apps may improve quit outcomes in older adults who are willing to use them. Further research into user–app interactions should be undertaken to facilitate improvements in app design and consumer engagement. These favorable trends should be explored in larger trials with sufficient statistical power.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12619000159156; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376849&isReview=true

A prospective study investigating the efficacy and toxicity of definitive ChemoRadiation and ImmunOtherapy (CRIO) in locally and/or regionally advanced unresectable cutaneous squamous cell carcinoma

BACKGROUND

Patients with unresectable advanced cutaneous squamous cell carcinoma (cSCC) are generally treated with palliative intent. Immune checkpoint blockade has significant activity in the palliative setting in patients with recurrent or metastatic cSCC. This single arm phase 2 prospective study aims to investigate the combination of curative intent chemoradiation and durvalumab (anti-PD-L1 checkpoint inhibitor) for this patient cohort.

METHODS

Patients with unresectable locally and or regionally advanced pathologically confirmed cSCC (stage III-IVa) deemed fit for CRIO by consensus of the Multidisciplinary meeting will be eligible. In the first stage of a two-stage minimax design, we aim to recruit a total of 15 patients. If fewer than 7 patients achieved a complete response in the first stage, we will conclude the treatment is not more effective than standard treatment. The co-primary endpoints of CRIO are the safety of treatment (acute and late toxicities) and the rate of complete response. Secondary endpoints would include overall survival, progression free survival, and locoregional control. Translational research endpoints including biomarkers (CD73, CD39, PD-1, PD-L1) will also be explored utilising multiplex immunohistochemistry on tumour biopsy samples obtained prior to commencing treatment and during treatment (week 2). In addition, the utility of CXCR-4 PET/CT scan will be explored.

DISCUSSION

CRIO is a novel trial evaluating the combination of curative intent chemoradiotherapy with concurrent and adjuvant durvalumab for patients with unresectable stage III-IVa cSCC.

TRIAL REGISTRATION

Trial registered with the Australian New Zealand Clinical Trial Registry (ACTRN12618001573246).

Impact of diabetes self-management, diabetes management self-efficacy and diabetes knowledge on glycemic control in people with Type 2 Diabetes (T2D): A multi-center study in Thailand

We investigate the relationship of diabetes knowledge, diabetes management self-efficacy and diabetes self-management with blood glucose control among people with Thai type 2 diabetes mellitus (T2D). Seven hundred outpatients from diabetes clinics from large university and small community hospitals in two provinces of Thailand (Khon Kaen and Bangkok) were interviewed to evaluate their diabetes knowledge (DK), diabetes management self-efficacy (DMSE) and diabetes self-management (DSM). In addition, patient medical records were accessed to obtain other patient characteristics including patients’ HbA1c levels. Bivariate and multivariable logistic regression modelling was conducted and unadjusted and adjusted odds ratios obtained, respectively. Over half (52.4%) of the patients in our sample failed to control their blood glucose (HbA1c > 7%). All three psychometric measures (DK, DMSE and DSM) were identified as associated with blood glucose control in the bivariate analysis (OR_DK(unadj) = 0.89, 95%CI: 0.82, 0.96; OR_DSM(unadj) = 1.64, 95%CI: 1.46, 1.82; OR_DMSE(unadj) = 2.84; 95%CI: 2.43, 3.32). However, after mutual adjustment and adjustment for other patient characteristics, of the three psychometric measures, only diabetes management self-efficacy remained associated with blood glucose control (OR_DMSE(adj) = 2.67; 95%CI: 2.20, 3.25). Diabetes management self-efficacy is shown to be strongly associated with blood glucose control in the Thai Type 2 diabetes population. Current early diabetes interventions in Thailand tend to focus on disease knowledge. A stronger emphasis on enhancing patients’ disease management self-efficacy in these interventions is likely to lead to substantial improvement in both diabetes self-management and blood glucose control, thereafter reducing the risk, or prolonging the development, of chronic diabetes complications.

Hypophosphatemia Is Common After Intravenous Ferric Carboxymaltose Infusion Among Patients With Symptomatic Heart Failure With Reduced Ejection Fraction

Administration of intravenous ferric carboxymaltose (FCM) for iron-deficient patients suffering heart failure with reduced ejection fraction (HFrEF) has been associated with transient hypophosphatemia. We sought to investigate and model the effect of intravenous FCM on phosphate levels in iron-deficient patients with HFrEF. In this single-center retrospective study, serum phosphate levels, recorded for clinical reasons, were collected out to 60 days following intravenous FCM. Hypophosphatemia was defined as a nadir serum phosphate level <0.64 mmol/L. This was further categorized as severe (0.4 to <0.64 mmol/L) and extreme (<0.4 mmol/L). Factors associated with hypophosphatemia and change in serum phosphate over time were explored. Of 173 patients included, 47 (27%) experienced hypophosphatemia, 44 (25%) were classified as severe, and 3 (2%) extreme. Risk of hypophosphatemia was increased for patients with a creatinine clearance between 60 and <90 mL/min (odds ratio, 2.3; 95% confidence interval, 1.0-5.5), while <60 mL/min was protective. The median time to nadir in patients who experienced hypophosphatemia was 8 (interquartile range, 4-16) days, with a return to baseline levels at 6 weeks. Biochemically relevant hypophosphatemia is common following a single dose of intravenous FCM. The median time to nadir was 8 days, and creatinine clearance may influence phosphate levels following intravenous FCM. These observations support the need to increase awareness among clinicians administering intravenous FCM to iron-deficient patients with HFrEF.

A Cohort Study of Sleep Quality in Adult Patients with Acute Pulmonary Exacerbations of Cystic Fibrosis

INTRODUCTION

The impact of an acute pulmonary exacerbation of CF on sleep quality has not been established. Patients have greater burden of symptoms, higher intensity of therapy, and are often admitted to hospital outside of their usual sleeping environment.

METHODS

This prospective, observational study determined the prevalence of impaired sleep quality and associated factors in adult patients admitted to a single CF unit with an acute pulmonary exacerbation of CF. Sleep quality was defined by the Pittsburgh Sleep Quality Index (PSQI), with >5 indicating poor sleep quality. Data was obtained through patient questionnaires, chart review, and examination.

RESULTS

Sixty-six percent of patients had impaired sleep quality. Patients with poor sleep had more sleep disruption due to pain (median response "mild sleep disruption" vs "no sleep disruption" p=0.003) and insomnia (mean insomnia severity index (ISI) 13 vs 5, p<0.001). In patients with symptoms of restless legs, poor sleepers had worse symptoms (mean IRLSS 15 vs 5, p=0.029). Univariate modelling showed relationships between PSQI and symptoms of depression and anxiety as well as with sleep disruption due to pain, general noise, and nursing observations. In a multivariable model, ISI was the only variable that remained significantly associated with PSQI. Mean PSQI score increased 0.58 units for each 1 unit increase in ISI (95% CI 0.42-0.73, p<0.001).

CONCLUSIONS

Poor sleep quality is common among patients admitted with an acute exacerbation of CF and is strongly associated with insomnia symptoms in this cohort. This article is protected by copyright. All rights reserved.

Assessment of the Clinical Pulmonary Infection Scores for prediction of ventilator associated pneumonia in patients with out of hospital cardiac arrest

BACKGROUND

Patients suffering out-of-hospital cardiac arrest (OHCA) are at an increased risk of aspiration pneumonitis and development of subsequent aspiration pneumonia. The diagnostic uncertainty in this context can lead to a large proportion receiving broad spectrum antibiotics.

METHODS

This was a three-year, retrospective cohort study of consecutive patients admitted with OHCA. Data were collected in an Australian tertiary centre intensive care unit (ICU) between December 2016-December 2019. We assessed the incidence of Ventilator associated pneumonia (VAP), admission Clinical Pulmonary Infection Scores (CPIS) in patients with OHCA and its' association with VAP at day 3 [1]. We also assessed antibiotics prescribing (timing of initiation and drug choice) and intensive care mortality relative to the day 1 CPIS.

RESULTS

Over the three years, 100 patients were admitted with OHCA. The incidence of VAP was 6%. The CPIS on admission was not associated with development of VAP at day 3 (p = 0.75) and no significant association was found between choice of antibiotic regimens and VAP incidence. Timing of initiation of antibiotics was associated with VAP (12hrs vs 48hrs, p = 0.035) but not the choice of antibiotic (penicillin and cephalosporins vs antipseudomonal antibiotics). CPIS score at day 1 was not associated with ICU mortality in a multivariate analysis.

CONCLUSION

We demonstrated a very low incidence of VAP in OHCA patients in comparison to published studies. In this context, there was no evidence for an association between CPIS score and VAP at day 3. The CPIS may have utility as a decision support tool for targeted antibiotic prescribing in this cohort.

Sara Alert: An enduring national resource to support public health monitoring & disease containment

Background

Public health agencies had to respond swiftly to the novel coronavirus that emerged in 2019 (COVID-19) to try to contain the virus, which requires early identification of new cases. Monitoring exposed individuals is labor intensive and available tools are often limited. MITRE, a company that operates federally funded research and development centers for the U.S. government, rapidly developed a configurable monitoring tool that allows public health authorities to monitor potentially exposed individuals in their jurisdictions.

Methods

A team, including public health leaders, field epidemiologists, software engineers, and health communication specialists, was quickly assembled to design and develop an open source, disease-independent monitoring tool called Sara Alert. Outreach to key public health stakeholders, including partner organizations and local and state health departments, was conducted early for requirements gathering and to validate assumptions. Public health law experts were consulted regarding data privacy and security.

Results

By four weeks, a minimally viable monitoring tool was available for testing by public health partners. Exposed individuals can be enrolled and reminded daily to enter a temperature and any symptoms by web or mobile interface, SMS messaging or phone. Public health officials monitor and can quickly take action if symptoms consistent with COVID-19 are reported of if there is failure to report within a configurable time frame. Dashboards provide insight into aggregated data appropriate to level of view.

Conclusions

Sara Alert serves as a force multiplier that supports disease containment and allows resources to be directed where they are most needed. Successful development was possible because key stakeholders across public health practice were consulted early. Sara Alert is available, free, to state and local public health departments and serves as an enduring resource easily configured for the next public health emergency.

Key messages

Sara Alert serves as a force multiplier that supports disease containment and allows resources to be directed where they are most needed.

Sara Alert serves as an enduring resource easily configured for the next public health emergency.

Queensland smoking care in adult acute mental health inpatient units: Supporting practice change

OBJECTIVE

To review a clinical practice improvement approach to statewide implementation of smoking care in adult acute mental health inpatient units across public mental health services in Queensland.

METHOD

Queensland public mental health services, with adult acute inpatient units, joined a statewide collaborative to work together to increase the routine screening of smoking and delivery of a Smoking Cessation Clinical Pathway brief intervention to identified smokers.

RESULTS

Over a 2-year period, statewide improvements were demonstrated in the recording of smoking status (88-97%) and in the provision of a brief smoking cessation intervention to smokers (38-73%). In addition, all individual mental health services increased the delivery of a brief intervention to identified smokers and the recording of smoking status either improved or remained at high levels.

CONCLUSION

Smoking remains an ongoing challenge for mental health services and one of the most important physical health issues for people living with a mental illness. The ability to implement statewide smoking care in public mental health services is an important step in shifting poor health outcomes. The clinical practice change approach adopted in Queensland has demonstrated encouraging outcomes in improving the delivery of smoking care that has been sustained over a 2-year period.

Global longitudinal reference ranges for fetal myocardial deformation in the second half of pregnancy

PURPOSE

To construct longitudinal fetal reference ranges for global longitudinal myocardial deformation (strain and strain rate) of the left and right ventricles in the second half of pregnancy.

METHODS

A prospective, observational, longitudinal study of 120 women with uncomplicated singleton pregnancies. The participants underwent ultrasonographic scans every 4 weeks from enrolment (18-28 weeks) until delivery. Strain and strain rate were measured at each examination using velocity vector imaging. Changes in strain and strain rate as functions of gestational age (GA) were modeled using Bayesian mixed effects models.

RESULTS

A total of 406 assessments of global longitudinal strain and strain rate were performed for 120 women. Global longitudinal strain and strain rate decreased with increasing GA in the left ventricle. There was, however, no change in strain measurements of the right ventricle over the same gestational time frame. Posterior predictive distributions were used to derive reference centiles for each week of GA.

CONCLUSION

Assessment of myocardial deformation of the fetal heart is easily performed and may be useful for quantitative assessment of heart function, particularly in fetuses at risk of cardiac dysfunction.

Longitudinal Reference Ranges for Tricuspid Annular Plane Systolic Excursion and Mitral Annular Plane Systolic Excursion in Normally Grown Fetuses

OBJECTIVES

The aim of this study was to construct reference ranges for fetal tricuspid annular plane systolic excursion (TAPSE) and mitral annular plane systolic excursion (MAPSE) using conventional M-mode ultrasound (US) in the second half of pregnancy.

METHODS

Participants underwent US scans every 4 weeks from 18 weeks' gestation until delivery. The TAPSE and MAPSE were measured by conventional M-mode US at each examination. The relationships between TAPSE and MAPSE and gestational age and estimated fetal weight were modeled by Bayesian mixed effects linear regression.

RESULTS

Positive linear relationships were observed between both MAPSE and TAPSE and gestational age and estimated fetal weight. Reference centiles for TAPSE and MAPSE were developed.

CONCLUSIONS

This simple technique is a useful tool for assessing cardiac function and could be used for quantitative assessments of fetal cardiac function, particularly in high-risk pregnancies such as those complicated by maternal diabetes.

Late Potentials and Early Repolarisation Are Associated With Serious Mental Illness and May Portend Increased Arrhythmic Risk

BACKGROUND

Patients with serious mental illness (SMI) have an increased risk of sudden death. Higher rates of signal-averaged electrocardiogram (SAECG) abnormal late potentials (LP), which may be a predictor of sudden death risk, have been shown in patients with schizophrenia. We aimed to assess the prevalence and predictors of electrocardiograph (ECG) and SAECG abnormalities in a mixed SMI population.

METHODS

Consecutive consenting inpatients with SMI had 12-lead ECG and SAECG recorded in addition to demographics, diagnoses and medications. Standard criteria for abnormal SAECG were applied. Multivariate regression analysis was performed to determine predictors of SAECG abnormalities including diagnoses, body mass index, ECG parameters, psychotropic medication use, and medications associated with Long QT or Brugada syndromes.

RESULTS

Eighty (80) patients, 49% male, mean age 39±17 years were included. SAECG criteria abnormality for 1, 2 or 3 criteria were seen in 19, 3 and 5 cases (34% in total) respectively. Early repolarisation pattern was seen in 19% of patients. SAECG abnormality was associated with male gender (OR 7.3; 95% CI 2.3-23.4), and schizophrenia/schizoaffective disorder diagnosis (OR 7.4; 95% CI 1.9-29.0), but not with medication type or dose.

CONCLUSIONS

In the mixed SMI population studied, there was a high rate of SAECG-detected late potentials (34%) and early repolarisation pattern (19%). Schizophrenia/schizoaffective disorder diagnosis was the strongest multivariate predictor identified. Further studies are needed to define the mechanism and significance of these cardiac abnormalities in SMI patients.

Use of a limited-channel device for obstructive sleep apnoea diagnosis in a tertiary sleep disorders centre

BACKGROUND

A major impediment to the provision of obstructive sleep apnoea (OSA) treatment is reliance on labour-intensive and costly laboratory-based polysomnography (PSG).

AIMS

To investigate if measurement of oximetry and nasal flow through the ApneaLink device (AL) could identify patients with moderate-severe OSA among those referred for PSG to a tertiary sleep service.

METHODS

New referrals to The Prince Charles Hospital Sleep Disorders Centre were assessed for suitability. Demographics, anthropometrics, Epworth Sleepiness and OSA50 scores were collected. Exclusion criteria included age <18 years, pregnancy, significant cognitive impairment, poorly controlled psychiatric disorder, domiciliary oxygen and prior OSA treatment. Participants underwent concurrent type 1 PSG and AL assessments.

RESULTS

One hundred participants had a mean age of 55 years (standard deviation 17) and were 49% male. Forty-eight (48%) had moderate-severe OSA on PSG. Composite variable AL 3% oxygen desaturation index ≥16 and AL apnoea-hypopnoea index (AHI) ≥15 had receiver operator characteristic area under the curve of 0.87, sensitivity of 80% and specificity of 94% for PSG AHI ≥15. The three false-positives seen with this composite variable had PSG AHI 11-14 and Epworth Sleepiness Score 6-17. The various composites of AL, anthropometric and questionnaire variables did not improve the AUC or specificity but did improve sensitivity.

CONCLUSIONS

AL is useful in the diagnosis of moderate-severe OSA in patients referred to a tertiary sleep disorders centre. This could lessen reliance on PSG, expedite OSA care, lead to significant cost savings and make diagnosis of OSA more available in non-urban areas.

Frailty and hospital outcomes within a low socioeconomic population

BACKGROUND

Clinical frailty scales (CFS) predict hospital-related outcomes. Frailty is more common in areas of higher socioeconomic disadvantage, but no studies exclusively report on the impact of CFS on hospital-related outcomes in areas of known socioeconomic disadvantage.

AIMS

To evaluate the association of the CFS with hospital-related outcomes.

DESIGN

Retrospective observational study in a community hospital within a disadvantaged area in Australia (Social Economic Index for Areas = 0.1%).

METHODS

The CFS was used in the emergency department (ED) for people aged ≥ 75 years. Frailty was defined as a score of ≥4. Associations between the CFS and mortality, admission rates, ED presentations and length of stay (LOS) were analysed using regression analyses.

RESULTS

Between 11 July 2017 and 31 March 2018, there were 5151 ED presentations involving 3258 patients aged ≥ 75 years. Frail persons were significantly more likely to be older, represent to the ED and have delirium compared with non-frail persons. CFS was independently associated with 28-day mortality, with odds of mortality increasing by 1.5 times per unit increase in CFS (95% CI: 1.3-1.7). Frail persons with CFS 4-6 were more likely to be admitted (OR: 1.2; 95% CI: 1.0-1.5), have higher geometric mean LOS (1.43; 95% CI 1.15-1.77 days) and higher rates of ED presentations (IRR: 1.12; 95% CI 1.04-1.21) compared with non-frail persons.

CONCLUSIONS

The CFS predicts community hospital-related outcomes in frail persons within a socioeconomic disadvantage area. Future intervention and allocation of resources could consider focusing on CFS 4-6 as a priority for frail persons within a community hospital setting.

Lead-Specific Features Predisposing to the Development of Tricuspid Regurgitation After Endocardial Lead Implantation

Background

Endocardial lead in the right ventricle is recognized as a cause for tricuspid regurgitation (TR), but the mechanism remains elusive. We sought to evaluate lead-specific features on the development of TR after endocardial lead implantation.

Methods

This was a prospective single-center study. The patients underwent 2-dimensional echocardiograms before endocardial lead implantation and at follow-up visits at 4 to 6 weeks, 6 months, and 12 months. We assessed the position of the endocardial lead at the tricuspid annulus by 3-dimensional echocardiography, the tricuspid leaflet interference by the endocardial lead by both 2- and 3-dimensional echocardiography, and the degree of lead slack radiologically. Patient characteristics and lead-related factors were evaluated in the prediction of new or worse TR by univariable and multivariable analyses.

Results

New or increased TR was detected in 38 of 128 patients at the 12-month follow-up. The postero-septal commissure was the most common lead position, and tricuspid leaflet interference detected in 21 patients was associated with a noncommissural lead position. The implantation of an implantable cardioverter defibrillator lead was not associated with new TR compared with the implantation of a pacemaker lead. Tricuspid leaflet interference (P < 0.0001), but not lead position or lead slack, was the only lead-specific factor associated with the development of TR.

Conclusion

After right ventricle endocardial lead implantation, leaflet interference determined by echocardiography, but not the nature of the lead, the lead position at the tricuspid annulus, and the radiological lead slack, predicted TR development at 1 year postimplantation.

Sedatives, analgesics and antipsychotics in tracheostomised ICU patients - Is less more?

BACKGROUND

Sedation and anaesthesia are used universally to facilitate mechanical ventilation - with larger cumulative doses being used in those with prolonged ventilation. Transitioning from an endotracheal to a tracheostomy tube enables the depth of sedation to be reduced. Early use of speaking valves with tracheostomised patients has become routine in some intensive care units (ICU). The return of verbal communication has been observed to improve ease of patient care and increase patient and family engagement, with a perceived reduction in patient agitation.

OBJECTIVES

To investigate the potential impact of speaking valve (SV) use on requirements of sedatives, analgesics and antipsychotics in ICU patients with a tracheostomy.

METHODS

A retrospective data audit was undertaken for all tracheostomised patients in a cardio-respiratory ICU from 2011 to 2014. Use of sedative, analgesic and antipsychotic drugs was captured for endotracheal tube, tracheostomy and SV periods, including patient demographics, disease specifics and severity. Stratified Cox regression analysis was performed to determine the effects of SV on drug dosage.

RESULTS

Of 257 patients, 144 (56%) received an SV. Use of an SV was associated with reduced risk of being in the upper quartile of daily dosage of analgesics (HR: 0.6; 95% CI: 0.5-0.8; p < 0.001). In the final adjusted multivariable model, analgesic dose was additionally associated with age, and attendance to operating theatre during ICU. Sedative dose was associated with age, gender and SOFA score. Antipsychotic dose was associated with gender (less likely in females: HR 0.6, 95% CI: 0.4-0.8), age and APACHE score.

CONCLUSIONS

There was significantly less analgesic used in patients with an SV compared to those without. However, SV use in patients with tracheostomy was not found to be associated with reduced dose of sedatives or antipsychotics, despite the clinical impression. Future prospective studies are needed to more adequately investigate the association between drugs and patients' ability to verbally participate in their care.

Fresh frozen plasma and platelet concentrate storage duration not associated with in hospital mortality risk

BACKGROUND AND OBJECTIVES

To date, the effects of FFP and PC storage duration on mortality have only been studied in a few studies in limited patient subpopulations. The aim of the current study was to determine whether FFP and PC storage duration is associated with increased in hospital mortality risk across cardiac surgery, acute medicine, ICU and orthopaedic surgery patients.

MATERIALS AND METHODS

Two-stage individual patient data meta-analyses were performed to determine the effects of FFP and PC storage duration on in hospital mortality. Preset random effects models were used to determine pooled unadjusted and adjusted (adjusted for age, gender and units of product transfused) effect estimates.

RESULTS

The FFP storage duration analysis included 3625 patients across four studies. No significant association was observed between duration of storage and in hospital mortality in unadjusted analysis, but after adjusting for patient age, gender and units of product a small increased risk of in hospital mortality was observed for each additional month of storage (OR: 1·05, 95% CI: 1·01-1·08). This effect was no longer statistically significant when donor ABO blood group was incorporated into the random effects model on post hoc analyses. A total of 547 patients across five studies were incorporated in the PC storage duration analysis. No association was observed between PC storage duration and odds of in hospital morality (adjusted OR: 0·94, 95% CI: 0·79-1·11).

CONCLUSIONS

There is insufficient evidence to support shortening FFP or PC shelf life based on in hospital mortality.

Evaluating the prognostic significance of significant weight loss in patients with stage III non-small cell lung cancer (NSCLC) undergoing definitive chemoradiation (CRT) after FDG-PET staging

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Background: In the pre-PET era, weight loss is a harbinger of occult metastatic disease in patients with stage III NSCLC. Identifying the relationship between weight loss and pattern of relapse (POR), may enable stratification of patients into prognostic groups associated with increased risk of relapse. We sought to identify if weight loss remains a negative independent prognostic factor after FDG-PET staging. Methods: A retrospective audit (using web-based and electronic databases) was conducted in all patients with stage III NSCLC treated with definitive CRT between 01/07/2013 and 30/06/2018 at the Royal Brisbane and Women’s Hospital and The Prince Charles Hospital, Queensland, Australia. A descriptive analysis was applied to describe the primary end-point of PFS and secondary end-points of OS and POR, in relation to the percentage of pre-treatment weight loss (0-10% vs > 10-20% vs > 20%). A subset analysis looked at other prognostic factors identified in NSCLC to account for potential confounders. Results: Of the 127 patients (mean age 65 years, mean weight 76kg, 57% male, 42% current smokers) who commenced treatment during the study period, 24% lost > 10% and 3% lost > 20% weight. Median TTP for the entire cohort was 9 months. Based on multivariable modelling, risk of PD or death was 45% higher with > 10% loss of body weight (p = 0.004), and risk of death was 36% higher with > 10% of body weight (p = 0.05). Of the 54% that died during follow-up, 31 had distant PD, 18 had locoregional PD, 6 had local PD, and 10 had no PD. Males were at increased risk of PD. Conclusions: A prognostic link continues to be identified between significant (> 10%) weight loss and risk of progressive disease or death in stage III NSCLC treated with definitive CRT despite pre-treatment FDG-PET. These findings identify a sub-group of patients where weight loss could still be a surrogate for micro-metastases not detected on PET, or other adverse prognostic markers. Other treatment strategies or improved diagnostic strategies are warranted.

Protocol for a pilot randomised controlled trial of mindfulness-based cognitive therapy in youth with inflammatory bowel disease and depression

INTRODUCTION

Inflammatory bowel disease (IBD) is a chronic autoinflammatory disease of the gastrointestinal tract with peak age of onset during adolescence and young adulthood. Adolescents and young adults (AYAs) with IBD experience higher depression rates compared with peers who are well or have other chronic conditions. Mindfulness-based interventions are of particular interest because of their potential to improve both the course of IBD and depression.

METHODS AND ANALYSIS

This study is a parallel design, single-blind, pilot randomised controlled trial (RCT) of mindfulness-based cognitive therapy (MBCT) in AYAs with IBD and depression. The trial aims to recruit 64 participants who will be randomly allocated to MBCT or treatment as usual. The primary outcome measure is the depression subscale score from the Depression, Anxiety and Stress Scale. Secondary outcomes include anxiety, stress, post-traumatic growth, IBD-related quality of life, illness knowledge, medication adherence, mindfulness, IBD activity, inflammatory markers, microbiome and brain neuroconnectivity changes. All outcomes other than neuroimaging will be collected at three time points: at baseline, at therapy completion and at 20 weeks. Neuroimaging will be conducted at baseline and at therapy completion. Mixed-effects linear and logistic regression modelling will be used to analyse continuous and dichotomous outcomes, respectively. Participants' experiences will be explored through focus groups, and thematic analysis will be used to generate relevant themes.

ETHICS AND DISSEMINATION

The protocol has been approved by the Mater Hospital Human Research Ethics Committee (HREC) and University of Queensland HREC. Trial findings will be published in peer-reviewed journals and will be presented at scientific conferences.

TRIAL REGISTRATION NUMBER

ACTRN12617000876392, U1111-1197-7370; Pre-results.

Factors contributing to radiation dose for patients and operators during diagnostic cardiac angiography

INTRODUCTION

Diagnostic coronary angiography (CA) uses ionising radiation with relatively high doses, which impact on both patients and staff. This study sought to identify which patient and procedural factors impact patient and operator dose the most during CA.

METHODS

Patient and procedure related variables impacting on Kerma area product (PKA ) and operator dose (OD) were collected for 16 months. Procedures were separated into 10 different procedure categories. PKA was used for patient dose and OD was measured with an instantly downloadable dosimeter (IDD) - downloaded at the end of each procedure. High and low radiation dose was defined by binary variables based on the 75th percentile of the continuous measures. Univariate and multivariate regression were used to identify predictors.

RESULTS

Of 3860 patients included, the IDD was worn for 2591 (61.7%). Obesity (BMI > 30 compared to BMI < 25) was the strongest predictor for both a PKA (odds ratio (OR) = 19.1 (95% CI 13.5-26.9) P < 0.001) and OD (OR = 3.3 (2.4-4.4) P < 0.001) above the 75th percentile. Male gender, biplane imaging, the X-ray unit used, operator experience and procedure type also predicted a high PKA . Radial access, male gender, biplane imaging and procedure type also predicted a high OD.

CONCLUSION

Radiation dose during CA is multifactorial and is dependent on patient and procedure related variables. Many factors impact on both PKA and OD but obesity is the strongest predictor for both patients and operators to receive a high radiation dose.

A systematic review and meta-analysis of mindfulness based interventions and yoga in inflammatory bowel disease

BACKGROUND

Mindfulness interventions are increasingly used as a part of integrated treatment in inflammatory bowel disease (IBD) but there are limited data and a lack of consensus regarding effectiveness.

OBJECTIVES

We explored the efficacy of mindfulness interventions compared to treatment as usual (TAU), or other psychotherapeutic interventions, in treating physical and psychosocial symptoms associated with IBD.

METHODS

We conducted a systematic review and meta-analysis of relevant randomized controlled trials (RCTs). We included a broad range of mindfulness interventions including mindfulness-based interventions and yoga, with no restrictions on date of publication, participants' age, language or publication type. We searched the following electronic databases: MEDLINE, EMBASE, PsycINFO, CINAHL and WHO ICTRP database. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines in conducting the review.

RESULTS

We included eight studies in the meta-analysis. Mindfulness interventions showed a statistically significant effect on stress in both the short(SMD = -0.48; 95%CI:-0.97, 0.00; P = .05), and long term(SMD = -0.55; 95%CI:-0.78, -0.32; P < .00001), significant long term effects on depression (SMD = -0.36; 95%CI:-0.66, -0.07; P = .02) and quality of life (SMD = 0.38; 95%CI:0.08, 0.68; P = .01),and small but not statistically significant improvements in anxiety (SMD = -0.27; 95%CI:-0.65, 0.11; P = .16).Effects on physical outcomes were equivocal and not statistically significant.

CONCLUSIONS

Mindfulness interventions are effective in reducing stress and depression and improving quality of life and anxiety, but do not lead to significant improvements in the physical symptoms of IBD. Further research involving IBD-tailored interventions and more rigorously designed trials is warranted.