Anatomy and Neuroscience - Research Publications
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ItemNo Preview AvailableAerosol generation related to respiratory interventions and the effectiveness of a personal ventilation hood.(College of Intensive Care Medicine of Australia and New Zealand, 2020-09)OBJECTIVE: To quantify aerosol generation from respiratory interventions and the effectiveness of their removal by a personal ventilation hood. DESIGN AND SETTING: Determination of the aerosol particle generation (in a single, healthy volunteer in a clean room) associated with breathing, speaking, wet coughing, oxygen (O2) 15 L/min via face mask, O2 60 L/min via nasal prongs, bilevel non-invasive positive-pressure ventilation (BiPAP) and nebulisation with O2 10 L/min. INTERVENTIONS: Aerosol generation was measured with two particle sizer and counter devices, focusing on aerosols 0.5-5 μm (human-generated aerosols), with and without the hood. An increase from baseline of less than 0.3 particles per mL was considered a low level of generation. MAIN OUTCOME MEASURES: Comparisons of aerosol generation between different respiratory interventions. Effectiveness of aerosol reduction by a personal ventilation hood. RESULTS: Results for the 0.5-5 μm aerosol range. Quiet breathing and talking demonstrated very low increase in aerosols (< 0.1 particles/mL). Aerosol generation was low for wet coughing (0.1 particles/mL), O2 15 L/min via face mask (0.18 particles/mL), and high flow nasal O2 60 L/min (0.24 particles/mL). Non-invasive ventilation generated moderate aerosols (29.7 particles/mL) and nebulisation very high aerosols (1086 particles/mL); the personal ventilation hood reduced the aerosol counts by 98% to 0.5 particles/mL and 8.9 particles/mL respectively. CONCLUSIONS: In this human volunteer study, the administration of O2 15 L/min by face mask and 60 L/min nasal therapy did not increase aerosol generation beyond low levels. Non-invasive ventilation caused moderate aerosol generation and nebulisation therapy very high aerosol generation. The personal ventilation hood reduced the aerosol counts by at least 98%.
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ItemApproaches to palliative oxygen therapy in chronic obstructive pulmonary disease: a multi-national survey of specialists(WILEY, 2019-02)As palliative oxygen therapy (POT) is beneficial only to a minority of patients with chronic breathlessness, it is no longer routinely recommended. This multi-national, online survey of respiratory and palliative medicine specialists, with 440 participants, identified that prescription of POT has decreased over the past decade; however a sizeable proportion of doctors, particularly within palliative care, still support and recommend POT. Further education and research regarding the optimal management of chronic breathlessness are required.
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ItemAntimicrobial prescription in patients dying from chronic obstructive pulmonary disease(WILEY, 2019-01)BACKGROUND: Despite rising antimicrobial resistance, treatment guidelines for chronic obstructive pulmonary disease (COPD) exacerbations are frequently ignored. Patients with terminal conditions are often prescribed antimicrobials despite the goal of care to reduce burdensome treatments. The appropriate use of antimicrobials in patients who die from an exacerbation of COPD is unknown. AIM: To review antimicrobial prescription during the final admission in patients who died from an acute exacerbation of COPD. METHODS: A retrospective medical record audit was performed for 475 patients who died over 12 years (2004-2015). Patients were analysed within three groups: Group 1 - pneumonia on chest radiograph, Group 2 - infective exacerbation of COPD +/- raised inflammatory markers (white cell count, C-reactive protein) and Group 3 - non-infective exacerbation of COPD. RESULTS: A total of 221 patients died from COPD. The median age was 80 years, and 136 (60%) were male. Median respiratory function: forced expiratory volume in 1 s 0.8 L (41.0%), forced vital capacity 2.0 L (74.0%) and diffusing capacity for carbon monoxide 8 (40.5%). A total of 109 (49.3%) patients used home oxygen and 156 (70.6%) were ex-smokers. Of the cohort, 90.5% received antimicrobials. In Groups 1, 2 and 3, 68 (94.4%), 108 (92.3%) and 24 (75.0%) patients received antimicrobials respectively. Guideline-concordant therapy was administered to 31.7% of patients (Group 1: 79.2%, Group 2: 4.3%, Group 3: 25.0%), 60.2% of patients received ceftriaxone and 44.8% received azithromycin. The median duration of therapy was 4 days and 27.1% received antimicrobials at the time of death. CONCLUSION: Antimicrobials are overprescribed, and non-guideline antimicrobials are overused in patients who die from COPD. Further education of medical staff, regular medication reviews and the use of disease severity scores or clinical pathways may improve antimicrobial stewardship.
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ItemThe 2016 Melbourne thunderstorm asthma epidemic: Risk factors for severe attacks requiring hospital admission(WILEY, 2019-01)BACKGROUND: The world's most catastrophic and deadly thunderstorm asthma epidemic struck Melbourne, Australia, on November 21, 2016. OBJECTIVE: Among thunderstorm-affected patients presenting to emergency rooms (ERs), we investigated risk factors predicting severe attacks requiring admission to hospital. METHODS: Thunderstorm-affected patients were identified from ER records at the eight major Melbourne health services and interviewed by telephone. Risk factors for hospital admission were analyzed. RESULTS: We interviewed 1435/2248 (64%) of thunderstorm-affected patients, of whom 164 (11.4%) required hospital admission. Overall, rhinitis was present in 87%, and current asthma was present in 28%. Odds for hospital admission were higher with increasing age (odds ratio 1.010, 95% CI 1.002, 1.019) and among individuals with current asthma (adjusted odds ratio [aOR] 1.87, 95% CI 1.26, 2.78). Prior hospitalization for asthma in the previous 12 months further increased the odds for hospital admission (aOR 3.16, 95% CI 1.63, 6.12). Among patients of Asian ethnicity, the odds for hospital admission were lower than for non-Asian patients (aOR 0.59, 95% CI 0.38, 0.94), but higher if born in Australia (OR = 5.42, 95% CI 1.56, 18.83). CONCLUSIONS: In epidemic thunderstorm asthma patients who presented to the ER, higher odds for hospital admission among patients with known asthma were further amplified by recent asthma admission, highlighting the vulnerability conferred by suboptimal disease control. Odds for hospital admission were lower in Asian patients born overseas, but higher in Asian patients born locally, than in non-Asian patients; these observations suggest susceptibility to severe thunderstorm asthma may be enhanced by gene-environment interactions.
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ItemRare manifestation of Neurofibromatosis type 1: A plexiform neurofibroma involving the mediastinum and lungs with endobronchial neurofibromata(WILEY, 2019-02)Neurofibromatosis type 1 (NF1) is a multisystem phakomatosis. The intrathoracic manifestations of NF1 are protean. We describe a rare case of a plexiform neurofibroma infiltrating the mediastinum and lungs with multiple endobronchial neurofibromata. To our knowledge, a mediastinal plexiform neurofibroma extending into the lungs on CT has not been reported.
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ItemPulmonary function testing for the early detection of drug-induced lung disease: a systematic review in adults treated with drugs associated with pulmonary toxicity(WILEY, 2020-11)Pulmonary function tests (PFT) are sometimes monitored during treatment with known pulmonary toxic drugs to detect asymptomatic drug-induced interstitial lung disease (DILD). We conducted a systematic review to assess the accuracy of PFT, including the diffusing capacity for carbon monoxide (DLCO), for early detection of DILD in a range of drugs. Using a pre-specified, registered review protocol, OvidMEDLINE and EMBASE were searched from 1946 to February 2018. Two reviewers independently screened abstracts and reviewed full-text articles for inclusion. Included studies were assessed for risk of bias using adapted QUADAS-2 domains and primary outcome data were extracted and entered into RevMan5 to estimate sensitivity and specificity with 95% confidence intervals (CI). The search identified 4065 citations and included 42 studies. The most commonly studied drugs were bleomycin and amiodarone. Due to clinical heterogeneity between studies, a pooled analysis was not performed. Sensitivity of monitoring with DLCO varied between 0 and 100%, with the majority of studies finding a sensitivity of <80%. CI were wide for the majority of studies. Specificity was less than 90% in all studies. Risk of bias was high for the majority of studies for the quality domain of reference standard. The findings of this review do not support routine PFT for early detection of DILD. Due to methodological limitations, the relatively small number of participants and the low prevalence of DILD in the included studies, there remains significant uncertainty about the sensitivity of PFT to screen for DILD.
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ItemNo Preview AvailableAerosol generation related to respiratory interventions and the effectiveness of a personal ventilation hood.(College of Intensive Care Medicine of Australia and New Zealand, 2020-09)OBJECTIVE: To quantify aerosol generation from respiratory interventions and the effectiveness of their removal by a personal ventilation hood. DESIGN AND SETTING: Determination of the aerosol particle generation (in a single, healthy volunteer in a clean room) associated with breathing, speaking, wet coughing, oxygen (O2) 15 L/min via face mask, O2 60 L/min via nasal prongs, bilevel non-invasive positive-pressure ventilation (BiPAP) and nebulisation with O2 10 L/min. INTERVENTIONS: Aerosol generation was measured with two particle sizer and counter devices, focusing on aerosols 0.5-5 μm (human-generated aerosols), with and without the hood. An increase from baseline of less than 0.3 particles per mL was considered a low level of generation. MAIN OUTCOME MEASURES: Comparisons of aerosol generation between different respiratory interventions. Effectiveness of aerosol reduction by a personal ventilation hood. RESULTS: Results for the 0.5-5 μm aerosol range. Quiet breathing and talking demonstrated very low increase in aerosols (< 0.1 particles/mL). Aerosol generation was low for wet coughing (0.1 particles/mL), O2 15 L/min via face mask (0.18 particles/mL), and high flow nasal O2 60 L/min (0.24 particles/mL). Non-invasive ventilation generated moderate aerosols (29.7 particles/mL) and nebulisation very high aerosols (1086 particles/mL); the personal ventilation hood reduced the aerosol counts by 98% to 0.5 particles/mL and 8.9 particles/mL respectively. CONCLUSIONS: In this human volunteer study, the administration of O2 15 L/min by face mask and 60 L/min nasal therapy did not increase aerosol generation beyond low levels. Non-invasive ventilation caused moderate aerosol generation and nebulisation therapy very high aerosol generation. The personal ventilation hood reduced the aerosol counts by at least 98%.
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ItemDiagnostic performance of 19-gauge endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in suspected lymphoma: A prospective cohort study(WILEY, 2020-09)Introduction Endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) represents a minimally invasive approach in the evaluation of mediastinal/hilar lymphadenopathy. Diagnostic performance of EBUS‐TBNA in lymphoma using standard 22‐gauge (22G) needle is limited by sample volumes that are often inadequate for histopathological assessment. Objectives To evaluate the diagnostic utility of 19‐gauge (19G) EBUS‐TBNA needle in the evaluation of suspected lymphoma. Methods We prospectively collected clinical and procedural information for patients undergoing EBUS‐TBNA with 19G needle at Royal Melbourne Hospital for investigation of mediastinal/hilar lymphadenopathy, where lymphoma was considered in the differential diagnosis. All consecutive patients between June 15, 2016 and July 10, 2019 were included. If definitive diagnosis was not achieved on EBUS‐TBNA, final diagnosis was determined through subsequent investigation or a minimum of 6 months radiologic surveillance. Results Thirty‐nine patients underwent EBUS‐TBNA using 19G needle for evaluation of suspected lymphoma. Thirteen patients had a prior diagnosis of lymphoma (33%). Lymphoma was ultimately diagnosed in 23 patients (59%). Of these, 10 had a prior diagnosis of lymphoma (43%). 19G EBUS‐TBNA demonstrated lymphoma in 19 patients, with a sensitivity of 83% (95% CI 66‐93) for detection of lymphoma. Four patients required surgical biopsy to definitively characterise lymphoma subtype. Therefore, sensitivity of 19G EBUS‐TBNA for definitive diagnosis of lymphoma was 65% (95% CI 45‐81). In patients with a prior diagnosis of lymphoma, sensitivity for definitive diagnosis of lymphoma was 80% (95% CI 48‐95). Conclusion Diagnostic performance of 19G EBUS‐TBNA appears similar to standard 22G needle in detection and definitive diagnosis of lymphoma. Further invasive testing remains necessary following non‐diagnostic EBUS‐TBNA procedures.
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ItemInvestigation and diagnostic imaging of suspected pulmonary embolism during pregnancy and the puerperium: A review of the literature(WILEY, 2020-08)Pulmonary embolism (PE) is a leading cause of maternal mortality with women at increased risk of PE during pregnancy and the early postpartum period. Clinical assessment of suspected PE during pregnancy is challenging as signs and symptoms associated with PE overlap with physiological changes of pregnancy. Clinical tests and rules commonly used to assess pre-test probability of PE were historically not well validated in the pregnant population. The challenges of clinical assessment in the pregnant and postpartum population result in a lowered threshold for diagnostic imaging. Computed tomographic pulmonary angiography (CTPA) and nuclear medicine lung scintigraphy or ventilation/perfusion (V/Q) scans are the main types of diagnostic imaging for suspected PE. Both methods are associated with small levels of ionising radiation exposure to mother and foetus. Accuracy of the diagnostic imaging tests is paramount. Haemodynamic changes of pregnancy, including increased heart rate, increased blood volume and altered flow velocity in the pulmonary arteries, may influence the quality of imaging. This comprehensive review examines the literature and evidence for the investigation and diagnostic imaging of suspected pulmonary embolism during pregnancy with CTPA and V/Q. Clinical decision-making tools, biomarkers and diagnostic imaging during pregnancy and postpartum will be considered with a focus on diagnostic accuracy and yield, radiation dose exposure (maternal-foetal) and protocol modifications. Current practice guideline recommendations and recent literature on diagnostic pathways are also presented.
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ItemHealth impacts of bushfire smoke exposure in Australia(WILEY, 2020-05)Smoke exposure from bushfires, such as those experienced in Australia during 2019-2020, can reach levels up to 10 times those deemed hazardous. Short-term and extended exposure to high levels of air pollution can be associated with adverse health effects, although the most recent fires have brought into sharp focus that several important knowledge gaps remain. In this article, we briefly identify and discuss the existing Australian evidence base and make suggestions for future research.