Medicine (Northwest Academic Centre) - Research Publications

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    Enablers and barriers to the use of antibiotic guidelines in the assessment and treatment of community-acquired pneumonia-A qualitative study of clinicians' perspectives
    Sedrak, A ; Anpalahan, M ; Luetsch, K (WILEY, 2017-06-01)
    BACKGROUND: Community-acquired pneumonia (CAP) is a common condition and a number of guidelines have been developed for its assessment and treatment. Adherence to guidelines by clinicians varies and particularly the prescribing of antibiotics often remains suboptimal. OBJECTIVE: The aim of this study was to elucidate potential barriers and enablers to the adherence to antibiotic guidelines by clinicians treating CAP in an Australian hospital. METHODS: Semi-structured interviews were conducted with purposively recruited senior prescribers who regularly treat CAP in an Australian hospital. Thematic analysis identified a number of themes and subthemes related to their knowledge, attitudes and behaviours associated with the use of CAP guidelines. RESULTS: Thematic saturation was reached after 10 in-depth interviews. Although similar barriers to the use of guidelines as previously described in the literature were confirmed, a number of novel, potential enablers were drawn from the interviews. Clinicians' acceptance and accessibility of guidelines emerged as enabling factors. Generally positive attitudes towards antimicrobial stewardship services invite leveraging what was described as the relationship-based and hierarchical nature of medical practice to provide personalised feedback and updates to clinicians. CONCLUSIONS: Adding a social and personalised approach of antimicrobial stewardship to policy- and systems-based strategies may lead to incremental improvements in guideline adherent practice when assessing and treating CAP.
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    Pyrexia of unknown origin associated with rosuvastatin
    Liew, KC ; Anpalahan, M ; Wadhwa, V (WILEY-BLACKWELL, 2016-10-01)
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    Successful use of "Choice Architecture" and "Nudge Theory" in a quality improvement initiative of analgesia administration after Caesarean section
    Shakespeare, T ; Fehlberg, M ; Slejko, T ; Taylor, J ; Srbinovska, I ; Bolsin, S (WILEY, 2019-02-01)
    BACKGROUND: Regular, routine, multimodal analgesia provides better pain relief following Caesarean section than reliance on "as required" opiate dosing. This quality improvement report describes the effective use of an education programme coupled with a highlighted, preprinted medication chart, employing "Nudge Theory" principles to achieve significant improvements in the administration of analgesic medications to patients after Caesarean section operations. PROBLEM: An acute pain service audit identified a serious deficiency with delivery of regular postoperative analgesic medications to patients following Caesarean section operations. METHODS: An audit of pain medication delivery to patients following Caesarean section demonstrated that postoperative analgesia was not being administered in line with local prescribing guidelines. Two interventions were planned: Education sessions for anaesthetic recovery and ward staff. Introduction of a new preprinted and highlighted medication chart. A postintervention audit was then conducted. RESULTS: There were statistically significant improvements in all medications administered to patients following the two interventions. For analgesic medications, the rate of administration of drugs in compliance with guidelines rose from 39.6% to 89.9% (P < 0.001 using 2-sample z test). Each subgroup of medications also showed statistically significant improvements in administration compliance. CONCLUSION: A combined approach, including application of "Nudge Theory" to the administration of analgesic medication after Caesarean section, considerably improved delivery of medications prescribed for postoperative analgesia.
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    Getting RID of the blues: Formulating a Risk Index for Depression (RID) using structural equation modeling
    Dipnall, JF ; Pasco, JA ; Berk, M ; Williams, LJ ; Dodd, S ; Jacka, FN ; Meyer, D (SAGE PUBLICATIONS LTD, 2017-11-01)
    OBJECTIVE: While risk factors for depression are increasingly known, there is no widely utilised depression risk index. Our objective was to develop a method for a flexible, modular, Risk Index for Depression using structural equation models of key determinants identified from previous published research that blended machine-learning with traditional statistical techniques. METHODS: Demographic, clinical and laboratory variables from the National Health and Nutrition Examination Study (2009-2010, N = 5546) were utilised. Data were split 50:50 into training:validation datasets. Generalised structural equation models, using logistic regression, were developed with a binary outcome depression measure (Patient Health Questionnaire-9 score ⩾ 10) and previously identified determinants of depression: demographics, lifestyle-environs, diet, biomarkers and somatic symptoms. Indicative goodness-of-fit statistics and Areas Under the Receiver Operator Characteristic Curves were calculated and probit regression checked model consistency. RESULTS: The generalised structural equation model was built from a systematic process. Relative importance of the depression determinants were diet (odds ratio: 4.09; 95% confidence interval: [2.01, 8.35]), lifestyle-environs (odds ratio: 2.15; 95% CI: [1.57, 2.94]), somatic symptoms (odds ratio: 2.10; 95% CI: [1.58, 2.80]), demographics (odds ratio:1.46; 95% CI: [0.72, 2.95]) and biomarkers (odds ratio:1.39; 95% CI: [1.00, 1.93]). The relationships between demographics and lifestyle-environs and depression indicated a potential indirect path via somatic symptoms and biomarkers. The path from diet was direct to depression. The Areas under the Receiver Operator Characteristic Curves were good (logistic:training = 0.850, validation = 0.813; probit:training = 0.849, validation = 0.809). CONCLUSION: The novel Risk Index for Depression modular methodology developed has the flexibility to add/remove direct/indirect risk determinants paths to depression using a structural equation model on datasets that take account of a wide range of known risks. Risk Index for Depression shows promise for future clinical use by providing indications of main determinant(s) associated with a patient's predisposition to depression and has the ability to be translated for the development of risk indices for other affective disorders.
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    Feasibility and impact of a post-discharge geriatric evaluation and management service for patients from residential care: the Residential Care Intervention Program in the Elderly (RECIPE)
    Harvey, P ; Storer, M ; Berlowitz, DJ ; Jackson, B ; Hutchinson, A ; Lim, WK (BMC, 2014-04-16)
    BACKGROUND: Geriatric evaluation and management has become standard care for community dwelling older adults following an acute admission to hospital. It is unclear whether this approach is beneficial for the frailest older adults living in permanent residential care. This study was undertaken to evaluate (1) the feasibility and consumer satisfaction with a geriatrician-led supported discharge service for older adults living in residential care facilities (RCF) and (2) its impact on the uptake of Advanced Care Planning (ACP) and acute health care service utilisation. METHODS: In 2002-4 a randomised controlled trial was conducted in Melbourne, Australia comparing the geriatrician-led outreach service to usual care for RCF residents. Patients were recruited during their acute hospital stay and followed up at the RCF for six months. The intervention group received a post-discharge home visit within 96 hours, at which a comprehensive geriatric assessment was performed and a care plan developed. Participants and their families were also offered further meetings to discuss ACPs and document Advanced Directives (AD). Additional reviews were made available for assessment and management of intercurrent illness within the RCF. Consumer satisfaction was surveyed using a postal questionnaire. RESULTS: The study included 116 participants (57 intervention and 59 controls) with comparable baseline characteristics. The service was well received by consumers demonstrated by higher satisfaction with care in the intervention group compared to controls (95% versus 58%, p = 0.006).AD were completed by 67% of participants/proxy decision makers in the intervention group compared to 13% of RCF residents prior to service commencement. At six months there was a significant reduction in outpatient visits (intervention 21 (37%) versus controls 45 (76%), (p < 0.001), but no difference in readmissions rates (39% intervention versus 34% control, p = 0.6). There was a trend towards reduced hospital bed-day utilisation (intervention 271 versus controls 372 days). CONCLUSION: It is feasible to provide a supported discharge service that includes geriatrician assessment and care planning within a RCF. By expanding the service there is the potential for acute health care cost savings by decreasing the demand for outpatient consultation and further reducing acute care bed-days.
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    Relationship between health-related quality of life, comorbidities and acute health care utilisation, in adults with chronic conditions
    Hutchinson, AF ; Graco, M ; Rasekaba, TM ; Parikh, S ; Berlowitz, DJ ; Lim, WK (BMC, 2015-05-29)
    BACKGROUND: There is increased interest in developing multidisciplinary ambulatory care models of service delivery to manage patients with complex chronic diseases. These programs are expensive and given limited resources it is important that care is targeted effectively. One potential screening strategy is to identify individuals who report the greatest decrement in health related quality of life (HRQoL) and thus greater need. The aim of this study was to explore the relationship between HRQoL, comorbid conditions and acute health care utilisation. METHODS: A prospective, longitudinal cohort design was used to evaluate the impact of HRQoL on acute care utilisation rates over three-years of follow-up. Participants were enrolled in chronic disease management programs run by a metropolitan health service in Australia. Baseline data was collected from 2007-2009 and follow-up data until 2012. Administrative data was used to classify patients' primary reasons for enrolment, number of comorbidities (Charlson Score) and presentations to acute care. At enrolment, HRQoL was measured using the Assessment of Quality of Life (AQoL) instrument, for analysis AQoL scores were dichotomised at two standard deviations below the population norm. RESULTS: There were 1999 participants (54 % male) with a mean age of 63 years (range 18-101), enrolled in the study. Participants' primary health conditions at enrolment were: diabetes 915 (46 %), chronic respiratory disease 463 (23 %), cardiac disease 260 (13 %), peripheral vascular disease, and 181 (9 %) and aged care 180 (9 %). At 1-year multivariate logistic regression models demonstrated that AQOL utility score was not predictive of acute care presentations after adjusting for comorbidities. Over 3-years an AQoL utility score in the lowest quartile was predictive of both ED presentation (OR 1.58, 95 % CI, 1.16-2.13, p = 0.003) and admissions (OR 1.67, 95 % CI.1.21 to 2.30, p = 0.002) after adjusting for differences in age and comorbidities. CONCLUSION: This study found that both HRQoL and comorbidities were predictive of subsequent acute care attendance over 3-years of follow-up. At 1-year, comorbidities was a better predictor of acute care representation than HRQoL. To maximise benefits, programs should initially focus on medical disease management, but subsequently switch to strategies that enhance health independence and raise HRQoL.
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    Familial Mesial Temporal Lobe Epilepsy and the Borderland of Deja Vu
    Perucca, P ; Crompton, DE ; Bellows, ST ; McIntosh, AM ; Kalincik, T ; Newton, MR ; Vajda, FJE ; Scheffer, IE ; Kwan, P ; O'Brien, TJ ; Tan, KM ; Berkovic, SF (WILEY, 2017-08-01)
    OBJECTIVE: The cause of mesial temporal lobe epilepsy (MTLE) is often unknown. We ascertained to what extent newly diagnosed nonlesional MTLE actually represents familial MTLE (FMTLE). METHODS: We identified all consecutive patients presenting to the Austin Health First Seizure Clinic with MTLE and normal magnetic resonance imaging (MRI) or MRI evidence of hippocampal sclerosis over a 10-year period. Patients' first-degree relatives and pairwise age- and sex-matched controls underwent a comprehensive epilepsy interview. Each interview transcript was reviewed independently by 2 epileptologists, blinded to relative or control status. Reviewers classified each subject as follows: epilepsy, specifying if MTLE; manifestations suspicious for epilepsy; or unaffected. Physiological déjà vu was noted. RESULTS: Forty-four patients were included. At the Clinic, MTLE had been recognized to be familial in 2 patients only. Among 242 subjects interviewed, MTLE was diagnosed in 9 of 121 relatives versus 0 of 121 controls (p = 0.008). All affected relatives had seizures with intense déjà vu and accompanying features; 6 relatives had not been previously diagnosed. Déjà vu experiences that were suspicious, but not diagnostic, of MTLE occurred in 6 additional relatives versus none of the controls (p = 0.04). Physiological déjà vu was common, and did not differ significantly between relatives and controls. After completing the relatives' interviews, FMTLE was diagnosed in 8 of 44 patients (18.2%). INTERPRETATION: FMTLE accounts for almost one-fifth of newly diagnosed nonlesional MTLE, and it is largely unrecognized without direct questioning of relatives. Relatives of patients with MTLE may experience déjà vu phenomena that clinically lie in the "borderland" between epileptic seizures and physiological déjà vu. Ann Neurol 2017;82:166-176.
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    Discharge Patterns of Human Tensor Palatini Motor Units during Sleep Onset
    Nicholas, CL ; Jordan, AS ; Heckel, L ; Worsnop, C ; Bei, B ; Saboisky, JP ; Eckert, DJ ; White, DP ; Malhotra, A ; Trinder, J (OXFORD UNIV PRESS INC, 2012-05-01)
    STUDY OBJECTIVES: Upper airway muscles such as genioglossus (GG) and tensor palatini (TP) reduce activity at sleep onset. In GG reduced muscle activity is primarily due to inspiratory modulated motor units becoming silent, suggesting reduced respiratory pattern generator (RPG) output. However, unlike GG, TP shows minimal respiratory modulation and presumably has few inspiratory modulated motor units and minimal input from the RPG. Thus, we investigated the mechanism by which TP reduces activity at sleep onset. DESIGN: The activity of TP motor units were studied during relaxed wakefulness and over the transition from wakefulness to sleep. SETTING: Sleep laboratory. PARTICIPANTS: Nine young (21.4 ± 3.4 years) males were studied on a total of 11 nights. INTERVENTION: Sleep onset. MEASUREMENTS AND RESULTS: Two TP EMGs (thin, hooked wire electrodes), and sleep and respiratory measures were recorded. One hundred twenty-one sleep onsets were identified (13.4 ± 7.2/subject), resulting in 128 motor units (14.3 ± 13.0/subject); 29% of units were tonic, 43% inspiratory modulated (inspiratory phasic 18%, inspiratory tonic 25%), and 28% expiratory modulated (expiratory phasic 21%, expiratory tonic 7%). There was a reduction in both expiratory and inspiratory modulated units, but not tonic units, at sleep onset. Reduced TP activity was almost entirely due to de-recruitment. CONCLUSIONS: TP showed a similar distribution of motor units as other airway muscles. However, a greater proportion of expiratory modulated motor units were active in TP and these expiratory units, along with inspiratory units, tended to become silent over sleep onset. The data suggest that both expiratory and inspiratory drive components from the RPG are reduced at sleep onset in TP.
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    Socioeconomic status and quality of life in population-based Australian men: data from the Geelong Osteoporosis Study
    Brennan, SL ; Williams, LJ ; Berk, M ; Pasco, JA (WILEY, 2013-06-01)
    OBJECTIVE: To investigate the relationship between socioeconomic status (SES) and reported perceptions of quality of life (QOL) in a cross-sectional population-based analysis of a representative sample of Australian men. METHODS: In 917 randomly recruited men aged 24-92 years, we measured QoL in the domains of physical health, psychological health, environment and social relationships, using the Australian World Health Organization Quality of Life Instrument (WHOQOL-BREF). Residential addresses were cross-referenced with Australian Bureau of Statistics 2006 census data to ascertain SES. Participants were categorised into lower, mid, or upper SES based on the Index of Relative Socioeconomic Disadvantage and Advantage (IRSAD), the Index of Economic Resources (IER), and the Index of Education and Occupation (IEO). Lifestyle and health information was self-reported. RESULTS: Males of lower SES reported poorer satisfaction with physical health (OR=0.6, 95%CI 0.4-0.9, p=0.02), psychological health (OR=0.4, 95%CI 0.3-0.7, p<0.001) and environment (OR=0.5, 95%CI 0.3-0.7, p<0.001), although not social relationships (p=0.59). The poorest QOL for each domain was observed in the lower and upper SES groups, representing an inverse U-shaped pattern of association; however, statistical significance was only observed for psychological health (OR=0.5, 95%CI 0.4-0.7, p<0.001). These relationships were similar for IEO and IER. CONCLUSIONS: Men from lower and upper SES groups have lower QOL compared to their counterparts in the mid SES group.
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    Weight loss on stimulant medication: how does it affect body composition and bone metabolism? - A prospective longitudinal study
    Poulton, A ; Briody, J ; McCorquodale, T ; Melzer, E ; Herrmann, M ; Baur, LA ; Duque, G (BIOMED CENTRAL LTD, 2012-01-01)
    UNLABELLED: OBJECTIVE: Children treated with stimulant medication for attention deficit hyperactivity disorder (ADHD) often lose weight. It is important to understand the implications of this during growth. This prospective study was designed to quantify the changes in body composition and markers of bone metabolism on starting treatment. METHODS: 34 children (29 boys) aged 4.7 to 9.1 years newly diagnosed with ADHD were treated with dexamphetamine or methylphenidate, titrating the dose to optimise the therapeutic response. Medication was continued for as long as clinically indicated. Body composition and bone density (dual-energy X-ray absorptiometry) were measured at baseline, 6 months and 3 years; changes were analysed in Z-scores based on data from 241 healthy, local children. Markers of bone turnover were measured at baseline, 3 months and 3 years. RESULTS: Fat loss of 1.4±0.96kg (total fat 5.7±3.6 to 4.3±3.1kg, p<0.001) occurred in the first 6 months. There were significant reductions over 3 years in the sex and height corrected Z-scores for lean tissue, bone mineral content, bone mineral density and ratio of central to total fat (-0.84±0.86, p=0.003; -0.55±0.31, p<0.0001; -0.41±0.28, p<0.0001 and -0.55±0.62, p=0.006 respectively). Propeptide of type I collagen indicated a significant reduction in bone turnover after 3 months (564±202 to 458±96ng/ml, p=0.019), which was fully recovered after 3 years (619±276ng/ml). CONCLUSIONS: Stimulant medication was associated with early fat loss and reduced bone turnover. Lean tissue including bone increased more slowly over 3 years of continuous treatment than would be expected for growth in height. There was long-term improvement in the proportion of central fat for height. This study shows that relatively minor reductions in weight on stimulant medication can be associated with long-term changes in body composition. Further study is required to determine the effects of these changes on adult health.