Medical Education - Research Publications
Now showing items 1-36 of 1252
Insights into the complexity of presentation and management of patients: the Sport and Exercise Physician's perspective
(BMJ Publishing Group, 2021-11-01)
Objectives Sport and Exercise Physicians represent a relatively new specialty focusing on exercise in complex diseases including musculoskeletal diseases. Our objective was to describe the characteristics, type and complexity of patient presentations, their management strategies and referral information in Australian practice. Methods A cross-sectional study including a cohort of 11 senior Sport and Exercise Physicians in Australia studied all new patient consultations within an 8-week period. Data were analysed relating to presentation, referral source, follow-up referrals, and patient management strategies. Results Data from 419 patients were recorded. The majority, 97% (n=406), had musculoskeletal conditions, 53% (n=222) had one or more associated comorbidities and 47% (n=195) had ongoing symptoms for >12 months. Most patients, 82% (n=355), were referred by general practitioners. Prior consultations included physiotherapy 72% (n=301) and orthopaedic 20% (n=85). A multidisciplinary network of referrals from Sport and Exercise Physicians was observed, including 210 referrals to 9 allied health specialities and 61 referrals to 17 medical specialities. Over 74% (n=311) of patients received exercise-based intervention as part of the treatment plan, including 57% (n=240) physician managed exercise interventions. Conclusion Our work shines a light on the nature and complexity of the role of Sport and Exercise Physicians in an Australian practice context. Findings will assist in implementing measures to promote patient care at the community level in managing musculoskeletal conditions. Sport and exercise medicine stakeholders and government policy makers can use this information in developing appropriate programmes to support patients and create integrated sport and exercise medicine services for the community.
Pilot multi-centre randomised trial of the impact of pre-operative focused cardiac ultrasound on mortality and morbidity in patients having surgery for femoral neck fractures (ECHONOF-2 pilot)
Hip fracture surgery is common, usually occurs in elderly patients who have multiple comorbidities, and is associated with high morbidity and mortality. Pre-operative focused cardiac ultrasound can alter diagnosis and management, but its impact on outcome remains uncertain. This pilot study assessed feasibility and group separation for a proposed large randomised clinical trial of the impact of pre-operative focused cardiac ultrasound on patient outcome after hip fracture surgery. Adult patients requiring hip fracture surgery in four teaching hospitals in Australia were randomly allocated to receive focused cardiac ultrasound before surgery or not. The primary composite outcome was any death, acute kidney injury, non-fatal myocardial infarction, cerebrovascular accident, pulmonary embolism or cardiopulmonary arrest within 30 days of surgery. Of the 175 patients screened, 100 were included as trial participants (screening:recruitment ratio 1.7:1), 49 in the ultrasound group and 51 as controls. There was one protocol failure among those recruited. The primary composite outcome occurred in seven of the ultrasound group patients and 12 of the control group patients (relative group separation 39%). Death, acute kidney injury and cerebrovascular accident were recorded, but no cases of myocardial infarction, pulmonary embolism or cardiopulmonary arrest ocurred. Focused cardiac ultrasound altered the management of 17 participants, suggesting an effect mechanism. This pilot study demonstrated that enrolment and the protocol are feasible, that the primary composite outcome is appropriate, and that there is a treatment effect favouring focused cardiac ultrasound - and therefore supports a large randomised clinical trial.
Models of care for non-invasive ventilation in the Acute COPD Comparison of three Tertiary hospitals (ACT3) study
BACKGROUND AND OBJECTIVE: Non-invasive ventilation (NIV) improves clinical outcomes in hypercapnic acute exacerbations of COPD (AECOPD), but the optimal model of care remains unknown. METHODS: We conducted a prospective observational non-inferiority study comparing three models of NIV care: general ward (Ward) (1:4 nurse to patient ratio, thrice weekly consultant ward round), a high dependency unit (HDU) (1:2 ratio, twice daily ward round) and an intensive care unit (ICU) (1:1 ratio, twice daily ward round) model in three similar teaching tertiary hospitals. Changes in arterial blood gases (ABG) and clinical outcomes were compared and corrected for differences in AECOPD severity (Blood urea > 9 mmol/L, Altered mental status (Glasgow coma scale (GCS) < 14), Pulse > 109 bpm, age > 65 (BAP-65)) and co-morbidities. An economic analysis was also undertaken. RESULTS: There was no significant difference in age (70 ± 10 years), forced expiratory volume in 1 s (FEV1 ) (0.84 ± 0.35 L), initial pH (7.29 ± 0.08), partial pressure of CO2 in arterial blood (PaCO2 ) (72 ± 22 mm Hg) or BAP-65 scores (2.9 ± 1.01) across the three models. The Ward achieved an increase in pH (0.12 ± 0.07) and a decrease in PaCO2 (12 ± 18 mm Hg) that was equivalent to HDU and ICU. However, the Ward treated more patients (38 vs 28 vs 15, P < 0.001), for a longer duration in the first 24 h (12.3 ± 4.8 vs 7.9 ± 4.1 vs 8.4 ± 5.3 h, P < 0.05) and was more cost-effective per treatment day ($AUD 1231 ± 382 vs 1745 ± 2673 vs 2386 ± 1120, P < 0.05) than HDU and ICU. ICU had a longer hospital stay (9 ± 11 vs 7 ± 7 vs 13 ± 28 days, P < 0.002) compared with the Ward and HDU. There was no significant difference in intubation rate or survival. CONCLUSION: In acute hypercapnic Chronic obstructive pulmonary disease (COPD) patients, the Ward model of NIV care achieved equivalent clinical outcomes, whilst being more cost-effective than HDU or ICU models.
Behavioural assessment unit improves outcomes for patients with complex psychosocial needs
OBJECTIVE: We aimed to assess the impact of a new model of care for patients presenting to the ED with acute behavioural disturbance. METHODS: This pre-/post-intervention study involved creating a dedicated, highly resourced six bed unit, the behavioural assessment unit (BAU). Co-located with the ED at the Royal Melbourne Hospital, the unit was designed to fast-track the admission of patients affected by intoxication, mental illness or psychosocial crisis and provide front-loaded interventions. RESULTS: In 12 months from 1 April 2016, 2379 patients were admitted to the BAU. They were compared with a similar cohort of 3047 patients from the entire 2015 ED population. The BAU resulted in a decreased wait to be seen (40 min [interquartile range (IQR): 17-86] vs 68 min [IQR: 24-130], P < 0.001), a decreased wait for a mental health review (117 min [IQR: 49-224] vs 139 min [IQR: 57-262], P = 0.001) and a decreased ED length of stay (180 min [IQR: 101-237] vs 328 min [IQR: 227-534], P < 0.001). Patients admitted to the BAU were less likely to have a security code (349 (14.7%) vs 538 (17.7%), P = 0.003) and less likely to have mechanical restraint (156 episodes (6.6%) vs 275 (9.0%), P < 0.001) or therapeutic sedation (156 episodes (6.6%) vs 250 (8.2%), P < 0.001). CONCLUSION: A unit specifically designed to improve the care of patients requiring prolonged ED care due to mental illness and/or intoxication reduces the time spent in the ED and the use of some restrictive interventions. We recommend this model of care to EDs that care for this complex and challenging group of patients.
Combined treatment approach to chronic anal fissure with associated anal fistula
BACKGROUND: Anal fistula in association with chronic anal fissure (fissure-fistula) is infrequently described. Recognizing this association and managing both components may help prevent some treatment failures seen with chronic anal fissure. This study aims to report on the outcomes of 20 consecutive patients with fissure-fistula managed with fistulotomy and injection of botulinum A toxin. METHODS: The study is a retrospective, observational study, assessing the success of symptom resolution following fistulotomy with botulinum A toxin, in patients identified as having a chronic anal fissure with associated anal fistula. The study included all patients with this condition treated with combination treatment by a single surgeon at a tertiary care hospital between January 2013 and January 2016. RESULTS: Twenty patients with fissure-fistula treated with fistulotomy and botulinum toxin A were identified. The median cohort age was 44 years (range 25-78), with a predominance of males (80%) and posterior fissure position (80%). The most common presenting symptoms were anal pain (70%), rectal bleeding (55%), anal discharge (35%) and anal pruritus (35%). Mean follow-up was 10.5 weeks and all patients who attended follow-up appointments reported resolution of symptoms. There were no cases of incontinence and none of the cohort required further surgical intervention for the condition. CONCLUSION: Chronic anal fissure with associated anal fistula can be successfully managed with fistulotomy and injection of botulinum toxin A. Further studies would be helpful in determining if recognition and management of the fistula component in isolation with fistulotomy is as effective as fistulotomy plus botulinum A toxin.
Postoperative outcomes following cardiac surgery in non-anaemic iron-replete and iron-deficient patients - an exploratory study
Iron deficiency anaemia is strongly associated with poor outcomes after cardiac surgery. However, pre-operative non-anaemic iron deficiency (a probable anaemia precursor) has not been comprehensively examined in patients undergoing cardiac surgery, despite biological plausibility and evidence from other patient populations of negative effect on outcome. This exploratory retrospective cohort study aimed to compare an iron-deficient group of patients undergoing cardiac surgery with an iron-replete group. Consecutive non-anaemic patients undergoing elective coronary artery bypass grafting or single valve replacement in our institution between January 2013 and December 2015 were considered for inclusion. Data from a total of 277 patients were analysed, and were categorised by iron status and blood haemoglobin concentration into iron-deficient (n = 109) and iron-replete (n = 168) groups. Compared with the iron-replete group, patients in the iron-deficient group were more likely to be female (43% vs. 12%, iron-replete, respectively); older, mean (SD) age 64.4 (9.7) vs. 63.2 (10.3) years; and to have a higher pre-operative EuroSCORE (median IQR [range]) 3 (2-5 [0-10]) vs. 3 (2-4 [0-9]), with a lower preoperative haemoglobin of 141.6 (11.6) vs. 148.3 (11.7) g.l-1 . Univariate analysis suggested that iron-deficient patients had a longer hospital length of stay (7 (6-9 [2-40]) vs. 7 (5-8 [4-23]) days; p = 0.013) and fewer days alive and out of hospital at postoperative day 90 (83 (80-84 [0-87]) vs. 83 (81-85 [34-86]), p = 0.009). There was no evidence of an association between iron deficiency and either lower nadir haemoglobin or higher requirement for blood products during inpatient stay. After adjusting the model for pre-operative age, sex, renal function, EuroSCORE and haemoglobin, the mean increase in hospital length of stay in the iron-deficient group relative to the iron-replete group was 0.86 days (bootstrapped 95%CI -0.37 to 2.22, p = 0.098). This exploratory study suggests there is weak evidence of an association between non-anaemic iron deficiency and outcome after cardiac surgery after controlling for potentially confounding variables.
Review article: Critical Care Airway Management eLearning modules
The Australasian College for Emergency Medicine (ACEM) has recently launched the Critical Care Airway Management eLearning modules to support emergency medicine trainees in developing their airway management skills in the ED. A team of emergency physicians and trainees worked collaboratively to develop the eLearning resources ensuring extensive stakeholder consultation. A comprehensive resource manual was written to provide learners with knowledge that underpins the modules. ACEM provided project coordination as well as administrative and technical team support to the production. Although specifically developed with early ACEM trainees in mind, it is envisaged the resources will be useful for all emergency clinicians. The project was funded by the Australian Commonwealth Department of Health.
Monitoring, imperfect detection, and risk optimization of a Tasmanian devil insurance population
Most species are imperfectly detected during biological surveys, which creates uncertainty around their abundance or presence at a given location. Decision makers managing threatened or pest species are regularly faced with this uncertainty. Wildlife diseases can drive species to extinction; thus, managing species with disease is an important part of conservation. Devil facial tumor disease (DFTD) is one such disease that led to the listing of the Tasmanian devil (Sarcophilus harrisii) as endangered. Managers aim to maintain devils in the wild by establishing disease-free insurance populations at isolated sites. Often a resident DFTD-affected population must first be removed. In a successful collaboration between decision scientists and wildlife managers, we used an accessible population model to inform monitoring decisions and facilitate the establishment of an insurance population of devils on Forestier Peninsula. We used a Bayesian catch-effort model to estimate population size of a diseased population from removal and camera trap data. We also analyzed the costs and benefits of declaring the area disease-free prior to reintroduction and establishment of a healthy insurance population. After the monitoring session in May-June 2015, the probability that all devils had been successfully removed was close to 1, even when we accounted for a possible introduction of a devil to the site. Given this high probability and the baseline cost of declaring population absence prematurely, we found it was not cost-effective to carry out any additional monitoring before introducing the insurance population. Considering these results within the broader context of Tasmanian devil management, managers ultimately decided to implement an additional monitoring session before the introduction. This was a conservative decision that accounted for uncertainty in model estimates and for the broader nonmonetary costs of mistakenly declaring the area disease-free.
Comparison between site and central radiological assessments for patients with recurrent glioblastoma on a clinical trial
AIM: Assessment of magnetic resonance imaging (MRI) in glioblastoma can be challenging. For patients with recurrent glioblastoma managed on the CABARET trial, we compared disease status assessed at hospitals and subsequent blinded central expert radiological review. METHODS: MRI results and clinical status at specified time points were used for site and central assessment of disease status. Clinical status was determined by the site. Response Assessment in Neuro-Oncology (RANO) criteria were used for both assessments. Site and central assessments of progression-free survival (PFS) and response rates were compared. Inter-rater variability for central review progression dates was assessed. RESULTS: Central review resulted in shorter PFS in 45% of 89 evaluable patients (n = 40). Median PFS was 3.6 (central) versus 3.9 months (site) (hazard ratio 1.5, 95% confidence interval 1.3-1.8, P < 0.001). Responses were documented more frequently by sites (n = 16, 18%) than centrally (n = 11, 12%). Seven of 120 patients continued on trial without site-determined progression for more than 6 months beyond the central review determination of progression. Of scans reviewed by all three central reviewers, 33% were fully concordant for progression date. CONCLUSION: While the difference between site and central PFS dates was statistically significant, the 0.3-month median difference is small. The variability within central review is consistent with previous studies, highlighting the challenges in MRI interpretation in this context. A small proportion of patients benefited from treatment well beyond the centrally determined progression date, reinforcing that clinical status together with radiology results are important determinants of whether a therapy is effective for an individual.
Attitudes of patients with metastatic cancer towards research biopsies
AIM: To evaluate the attitudes of patients with different cancers towards research biopsies outside a clinical trial. METHODS: Patients with metastatic cancer completed a questionnaire that assessed patients' willingness to consider research biopsies. Research biopsies were divided into two groups: biopsies performed as stand-alone procedures (research purposes only biopsy, RPOB) or performed during a clinically indicated biopsy (additional pass biopsy, APB). Factors analyzed included biopsy timing, biopsy site, sociodemographic information and information about prior trial participation. Univariate and multivariable analyses were conducted using random-effects logistic regression. RESULTS: One hundred and sixty-five patients with cancer (40 melanoma, 37 colorectal, 32 breast, 30 lung, 26 prostate) completed the questionnaire. Patients with melanoma demonstrated the greatest willingness to consider a research biopsy compared to patients with other cancer types (P < 0.05). Patients' ethnicity, time since previous biopsies, time since metastatic diagnosis, and previous trial enrolment were all statistically significant for willingness to consider a research biopsy on univariate analysis. When adjusting for statistically significant variables on univariate analysis, the odds of patients considering APBs were 14.6 times greater than RPOBs (P < 0.0001). Patients were also more willing to consider having blood or skin taken for research purposes (P < 0.0001) compared to liver and bone biopsies. CONCLUSIONS: Patients with cancer show a greater willingness to consider APBs compared to RPOBs, and biopsies performed at less invasive body sites. There are differences in the attitudes of patients with different cancers towards research biopsies. Further research addressing motivations and barriers to research biopsies should be considered to increase the availability of this important resource.
"Sounds a Bit Crazy, But It Was Almost More Personal:" A Qualitative Study of Patient and Clinician Experiences of Physical Therapist-Prescribed Exercise For Knee Osteoarthritis Via Skype
OBJECTIVE: To explore the experience of patients and physical therapists with Skype for exercise management of knee osteoarthritis (OA). METHODS: This was a qualitative study. The Donabedian model for quality assessment in health care (structure, process, and outcomes) informed semistructured individual interview questions. The study involved 12 purposively sampled patients with knee OA who received physical therapist-prescribed exercise over Skype, and all therapists (n = 8) who delivered the intervention in a clinical trial were interviewed about their experiences. Interviews were audio recorded and transcribed. Two investigators undertook coding and analysis using a thematic approach. RESULTS: Six themes arose from both patients and therapists. The themes were Structure: technology (easy to use, variable quality, set-up assistance helpful) and patient convenience (time efficient, flexible, increased access); Process: empowerment to self-manage (facilitated by home environment and therapists focusing on effective treatment) and positive therapeutic relationships (personal undivided attention from therapists, supportive friendly interactions); and Outcomes: satisfaction with care (satisfying, enjoyable, patients would recommend, therapists felt Skype more useful as adjunct to usual practice) and patient benefits (reduced pain, improved function, improved confidence and self-efficacy). A seventh theme arose from therapists regarding process: adjusting routine treatment (need to modify habits, discomfort without hands-on, supported by research environment). CONCLUSION: Patients and physical therapists described mostly positive experiences using Skype as a service delivery model for physical therapist-supervised exercise management of moderate knee OA. Such a model is feasible and acceptable and has the potential to increase access to supervised exercise management for people with knee OA, either individually or in combination with traditional in-clinic visits.
Magnetic resonance imaging of the upper airway in patients with quadriplegia and obstructive sleep apnea
The aim of this study was to investigate upper airway anatomy in quadriplegics with obstructive sleep apnea. Fifty subjects were recruited from three hospitals in Australia: people with quadriplegia due to spinal cord injury and obstructive sleep apnea (n = 11), able-bodied people with obstructive sleep apnea (n = 18), and healthy, able-bodied controls (n = 19). All underwent 3-Tesla magnetic resonance imaging of their upper airway. A subgroup (n = 34) received a topical vasoconstrictor, phenylephrine and post-phenylephrine magnetic resonance imaging. Mixed-model analysis indicated no significant differences in total airway lumen volume between the three groups (P = 0.086). Spinal cord injury-obstructive sleep apnea subjects had a significantly larger volume of soft palate (P = 0.020) and retroglossal lateral pharyngeal walls (P = 0.043) than able-bodied controls. Able-bodied-obstructive sleep apnea subjects had a smaller mandible volume than spinal cord injury-obstructive sleep apnea subjects and able-bodied control subjects (P = 0.036). No differences were seen in airway length between groups when controlling for height (P = 0.055). There was a marginal increase in velopharyngeal volume across groups post-phenylephrine (P = 0.050), and post hoc testing indicated the difference was confined to the able-bodied-obstructive sleep apnea group (P < 0.001). No other upper airway structures showed significant changes with phenylephrine administration. In conclusion, people with obstructive sleep apnea and quadriplegia do not have a structurally smaller airway than able-bodied subjects. They did, however, have greater volumes of soft palate and lateral pharyngeal walls, possibly due to greater neck fat deposition. The acute response to upper airway topical vasoconstriction was not enhanced in those with obstructive sleep apnea and quadriplegia. Changes in upper airway anatomy likely contribute to the high incidence in obstructive sleep apnea in quadriplegic subjects.
Relationship between urinary sodium-to-potassium ratio and ambulatory blood pressure in patients with diabetes mellitus
Previous studies investigating the relationship between sodium intake and blood pressure have mostly relied on dietary recall and clinic blood pressure measurement. In this cross-sectional study, we aimed to investigate the relationship between 24 hour urinary sodium and potassium excretion, and their ratio, with 24 hour ambulatory blood pressure parameters including nocturnal blood pressure dipping in patients with type 1 and 2 diabetes. We report that in 116 patients with diabetes, systolic blood pressure was significantly predicted by the time of day, age, the interaction between dipping status with time, and 24 hour urinary sodium-to-potassium ratio (R2 = 0.83) with a relative contribution of 53%, 21%, 20% and 6%, respectively. However, there was no interaction between urinary sodium-to-potassium ratio and dipping status.
The supervisory encounter and the senior GP trainee: managing for, through and with
OBJECTIVE: Help-seeking supervisory encounters provide important learning experiences for trainees preparing for independent practice. Although there is a body of expert opinion and theories on how supervisor encounters should happen, supporting empirical data are limited. This is particularly true for the senior general practice (GP) trainee. Without knowing what happens during these encounters, we cannot know how to maximise their educational potential. This study aimed to understand what happens when senior GP trainees call on their supervisor when caring for patients and how learning can be enhanced when this occurs. METHODS: This is an analysis of data from a multi-case study of five GP supervisory pairs, each with a GP registrar and their supervisor. The data are recordings of 45 supervisory encounters, 78 post-encounter reflections and six interviews. We used Wenger's communities of practice theory and rhetorical genre theory as analytical lenses. RESULTS: The supervisory encounters followed a consistent format, which fitted the form of a genre. Within this genre, three dominant interactional patterns were identified, which we labelled 'managing for', 'managing through' and 'managing with'. Each pattern presented different opportunities and drew on different skills. The primary agenda was always developing a plan for the patient. Education agendas included acquiring knowledge, developing skills and achieving independence. Other agendas were issues of control, credibility and relationship building. Both supervisor and trainee could be purposeful in their supervisory engagement. CONCLUSIONS: For supervisors and trainees to achieve the educational potential of their supervisory encounters they require flexibility. This depends on understanding the genre of the supervisory encounter, the agendas at play, the options they have in engaging and having the skills to utilise these options. Educators can facilitate supervisors and trainees in acquiring this understanding and these skills. We recommend further research into the genre of the supervisory encounter.
Clinical characteristics of Australian osteopaths who teach: A national sample
(AUSTRALIAN NZ ASSOC HEALTH PROFESSIONAL EDUCATORS-ANZAHPE, 2021-01-01)
Background: Health professionals involved in teaching future practitioners have been studied to some extent, but our knowledge of their clinical characteristics is variable. Our study sought to profile the clinical characteristics of osteopaths who teach in the three Australian universities delivering pre-professional osteopathy education.Materials: This study is a secondary analysis of data collected via the Australian Osteopathy Research and Innovation Network (ORION) project. Descriptive statistics were generated for each of the 27-item questionnaire variables. For binary responses, unadjusted odds ratios were calculated, and for continuous variables, independent t-tests were used. Backward step-wise regression modelling was used to identify significant characteristics associated with university teaching in osteopathy. Results: The survey demonstrated 9.9% of Australian osteopaths reported being involved in university teaching. Compared to non-teaching survey respondents, the osteopaths involved in university teaching were more likely to be female (OR 1.56), older (p 0.01) and in clinical practice for longer (p 0.01) but report fewer patient care hours (p 0.01) and patient visits per week (p 0.01). Osteopaths involved in university teaching were also more likely to be involved in research (OR 18.54) and clinical supervision (OR 12.39). They also reported a broader range of patient presentations and therapeutic modalities than their counterparts.Conclusions: This nationally representative survey demonstrates a small percentage of the Australian osteopathy profession are engaged in university teaching. Our secondary analysis has highlighted several characteristics associated with involvement in university teaching that begin to shed light on the composition of the Australian osteopathy teaching workforce. This data may inform development of a skilled and experienced teaching workforce.
Multiple feedback sources in learning clinical history-taking skills: Developing evaluative judgement
(AUSTRALIAN NZ ASSOC HEALTH PROFESSIONAL EDUCATORS-ANZAHPE, 2021-01-01)
Introduction: Contemporary feedback models emphasise the value of multiple feedback opportunities. Effective feedback participation requires evaluative judgement—the ability to discern the quality of one’s own and others’ work. Self and peer assessment may enable repeated practice and feedback for developing evaluative judgement. However, attitudes to self and peer assessment may present a barrier to effective implementation. This study explored whether congruence between marks from self and peer assessment improved with assessment task participation. Participants’ attitudes towards self and peer assessment and approaches to learning were also evaluated.Methods: Participants undertook simulated history-taking tasks in semester 2, 2018. Group 1 undertook formative and summative assessments and participated in self and peer assessment . Group 2 undertook formative and summative assessment. Group 3 undertook only summative assessment. All groups received faculty feedback for each submitted assessment. Participants completed the modified Study Process Questionnaire (mSPQ) and the Peer Perception of Assessment (PPA) before (T1) and after the formative task (T2) and after the summative task (T3).Results: Summative task scores improved for group 1 (n = 9, p 0.01) and group 2 (n = 26, p 0.01). Within-group (p = 0.02) and between-group differences (p = 0.01) were identified for surface learning approaches. All groups’ perceptions of peer assessment decreased significantly (p 0.01) across all three time periods.Conclusions: Participants receiving self and peer assessment and faculty feedback improved performance and increased congruence of their self- and peer-assessment marks, potentially developing their evaluative judgment skills. Peer assessment perception became less positive, while surface learning approaches increased. Future research should assess the role of self and peer assessment in developing evaluative judgment.
Hepatic cystic echinococcosis in Australia: an update on diagnosis and management
BACKGROUND: Echinococcosis is an uncommonly encountered zoonotic disease caused by the taeniid Echinococcus. The only endemic species in Australia, Echinococcus granulosus, forms cysts in the liver in 70% of cases. The aim of this study was to review the literature to provide an evidence-based narrative update on the diagnosis and management of hepatic cystic echinococcosis in Australia. METHODS: We reviewed the literature, utilizing multiple research databases and citation tracking. Original research and review articles examining the diagnosis and management of hydatid disease in adults, published prior to 2016 and in the English language were included in our review. RESULTS: Ultrasound is the gold-standard screening test, whilst computed tomography has a role in emergency presentations and screening for multi-organ involvement. Magnetic resonance imaging is the preferred second-line imaging and better demonstrates biliary involvement. Medical therapy or PAIR (percutaneous aspiration, irrigation with scolicide and re-aspiration) may be appropriate in selected cases; however, surgery remains the definitive treatment for active, large (>5 cm), symptomatic or complicated cysts. A variety of surgical techniques have been described, including conservative, radical and minimally invasive procedures. There is currently no consensus approach; surgical modality should be tailored to patient factors, relevant anatomy, local facilities and surgeons' expertise. CONCLUSION: Diagnosis and therapy in hepatic hydatid cysts have been significantly advanced by imaging, interventional radiology and surgical approaches in recent years. Surgery remains the mainstay of treatment for large, active, complicated or symptomatic hepatic hydatid cysts.
Taking the challenge: A protocolized approach to optimize Pneumocystis pneumonia prophylaxis in renal transplant recipients
While trimethoprim-sulfamethoxazole is considered first-line therapy for Pneumocystis pneumonia prevention in renal transplant recipients, reported adverse drug reactions may limit use and increase reliance on costly and less effective alternatives, often aerosolized pentamidine. We report our experience implementing a protocolized approach to trimethoprim-sulfamethoxazole adverse drug reaction assessment and rechallenge to optimize prophylaxis in this patient cohort. We retrospectively reviewed 119 patients receiving Pneumocystis pneumonia prophylaxis prior to and after protocol implementation. Forty-two patients (35%) had 48 trimethoprim-sulfamethoxazole adverse drug reactions documented either at baseline or during the prophylaxis period, of which 83% were non-immune-mediated and 17% were immune-mediated. Significantly more patients underwent trimethoprim-sulfamethoxazole rechallenge after protocol implementation (4/22 vs 23/27; P = .0001), with no recurrence of adverse drug reactions in 74%. In those who experienced a new or recurrent reaction (26%), all were mild and self-limiting with only 1 recurrence of an immune-mediated reaction. After protocol implementation, aerosolized pentamidine-associated costs were reduced. The introduction of a standard approach to trimethoprim-sulfamethoxazole rechallenge in the context of both prior immune and non-immune-mediated reactions was safe and successful in improving the uptake of first-line Pneumocystis pneumonia prophylaxis in renal transplant recipients.
Variability of Liver Shear Wave Measurements Using a New Ultrasound Elastographic Technique
OBJECTIVES: A new 2-dimensional (2D) shear wave elastographic (SWE) device has been developed for the noninvasive assessment of liver fibrosis. Guidelines on measurement acquisition parameters are not yet well established for this technique. Our study aimed to assess 2D SWE measurement variability and to determine the number of measurements required per patient to reliably assess liver stiffness. METHODS: Two-dimensional SWE was assessed in 55 patients with mixed-etiology chronic liver disease on an Aplio 500 ultrasound system (Toshiba Medical Systems Corporation, Tochigi, Japan). Ten measurements were obtained per patient by an operator blinded to all preceding readings. Results were analyzed with clinical information obtained from medical records. RESULTS: The median interquartile range/median ratio for 2D SWE was 0.131 (quartiles 1-3, 0.089-0.174). Five readings provided an approximation within 0.11 m/s, or 4.2% of the median velocity of 10 measurements. Factors associated with increased measurement variability included body mass index (ρ = 0.388; P = .01), increased skin-to-liver capsule distance (ρ = 0.426; P = .002), and measurements taken within 1.5 cm of the liver capsule (P < .001). Measurements with heterogeneous shear wave profiles (indicated by a region of interest [ROI] SD/speed ratio > 0.15) showed greater deviation from the set's median velocity than those with an ROI SD/speed ratio of 0.15 or lower (0.42 versus 0.22 m/s; P = .001). CONCLUSIONS: Two-dimensional SWE showed low overall measurement variability, with a minimum of 5 readings providing equivalent precision to the existing method using 10 samples. Obesity, increasing abdominal wall thickness, subcapsular measurements and an ROI SD/speed ratio of greater than 0.15 were all associated with increased measurement variability. The ROI SD/speed ratio warrants further evaluation as a quality assessment metric, to allow objective operator assessment of individual 2D SWE measurement reliability in real time.
Taming the zebra: Unravelling the barriers to diagnosing aortic dissection
Aortic dissection is a lethal cardiovascular emergency that continues to pose a diagnostic dilemma to the emergency physician. The condition is rare, can present atypically and is associated with a cumulative mortality for every hour that passes. While it is a recognised differential of acute chest pain, its prevalence in comparison to other causes often leads to the diagnosis being overlooked. The ED is a busy environment with high patient turnover and varying degrees of complexity and acuity. This increases susceptibility to cognitive bias and error-producing conditions that can lead to delayed or missed diagnosis. In reported cases where aortic dissection has been missed, clinician awareness of the disease was not the primary issue but failure to respond to clinical cues suggestive of aortic dissection was. To improve patient outcomes for this condition, it is important for clinicians to be aware of pertinent cognitive bias and error-producing conditions.
Comparison of perioperative, renal and oncologic outcomes in robotic-assisted versus open partial nephrectomy
BACKGROUND: To compare perioperative, renal and oncological outcomes after robotic-assisted partial nephrectomy (RAPN) versus open partial nephrectomy (OPN) for the treatment of renal tumours. METHODS: All partial nephrectomies performed at a Metropolitan Urology Centre between 2010 and 2016 were analysed. Baseline data was collected for patient demographics, tumour characteristics (tumour size, laterality and polarity, RENAL scores), and perioperative variables (e.g. warm ischaemic time, operation time, estimated blood loss (EBL), length of stay). Tumour characteristics included malignancy, clinical stage, Fuhrman nuclear grade and surgical margin status. Day-1 post-operative serum creatinine, estimated glomerular filtration rate (eGFR) and 6-month eGFR stage were used for assessing renal function. RESULTS: Two hundred patients underwent partial nephrectomy between 2010 and 2016 (n = 200; 55 OPN versus 145 RAPN). Baseline data was similar between groups, except for lower age (P = 0.0001) and higher RENAL scores (P = 0.001) in the RAPN group. RAPN demonstrated significantly lower complication rates (P = 0.015), lesser EBL (P = <0.0001), shorter hospital stays (P = <0.001) and reduced positive tumour resection margins (P = 0.039). There was no significant difference in mean operation time between RAPN and OPN (137.2 (±48.0) OPN versus 146.07 (±35.91) RAPN; P = 0.16). No statistical difference was shown for post-operative eGFR stage between groups at Day-1 and 6-month post-surgery (P = 0.15 and P = 0.861, respectively). CONCLUSION: We present the largest reported Australian series on partial nephrectomy, confirming that a robotic-assisted approach is equivalent to OPN, with reduced complications, EBL, length of hospital stays and fewer positive margins, even when resecting more complex tumours.
Changing face of robot-assisted radical prostatectomy in Melbourne over 12 years
BACKGROUND: This study aims to characterize the trends in disease presentation for robot-assisted radical prostatectomy (RARP) over a 12-year period in Melbourne, Australia. METHODS: All patients undergoing an RARP between 2004 and October 2016 while under the care of six high-volume surgeons were included in this study. Data were collected prospectively regarding patient demographics and clinical details of their cancer. RESULTS: Over the 12-year time span of the study, 3075 men underwent an RARP with a median age of 63.01 years. Temporal analysis demonstrated that the median age of patients undergoing prostatectomy advanced with time with the median age in 2016 being 65.51 years compared with 61.0 years in 2004 (P < 0.001). There was also a significant trend to increased D'Amico risk groups over time with the percentage procedures for high-risk patients increasing from 12.6% to 28.10% from 2004 to 2016 (P < 0.001). Upgrade rates between biopsy and pathological Gleason grade scoring significantly trended down over the period of the study (P < 0.001). There was also a shift to increased pathological stage over the 12 years with 22.1% of men having T3 disease in 2004 compared with 49.8% in 2016. CONCLUSION: Our analysis demonstrates increasing treatment of older men with higher risk tumours, consistent with international trends. While this largely reflects a shift in case selection, further work is needed to assess whether the stage shift may relate partially to a decline in screening and increased presentation of higher risk disease.
Impaired bone and muscle development in young people treated with antiepileptic drugs
OBJECTIVE: Antiepileptic drugs (AEDs) are associated with reduced bone density, balance impairment, and increased fracture risk in adults. However, pediatric data are limited. Therefore, we aimed to examine bone, muscle, and balance outcomes in young patients taking AEDs. METHODS: We undertook a case-control study utilizing an AED exposure-discordant matched-pair approach. Subjects were aged 5-18 years with at least 12 months of AED exposure. Pairs were twins, nontwin siblings and first cousins, sex- and age-matched (to within 2 years), allowing for greater power than with unrelated control subjects. Dual energy x-ray absorptiometry (DXA), peripheral quantitative computed tomography (pQCT), and muscle force/balance were tested, with questionnaires were administered for bone health and epilepsy details. RESULTS: Twenty-three pairs were recruited, (median age 12.9 years [subjects] and 13.5 years [controls])-7 twin, 14 sibling, and 2 cousin pairs. Those taking AEDs had an increased prevalence of fractures (15 fractures in 8 subjects, compared with 4 fractures in 3 controls, p < 0.01). Trabecular volumetric bone mineral density (vBMD) measured by pQCT at the 4% site (tibia) was reduced by 14% (p = 0.03) in subjects. Subjects exerted a decreased maximum force compared to body weight (Fmax total/g) at the tibia. There were no differences seen in either bone mineral parameters measured by DXA or balance measures. SIGNIFICANCE: Young people taking AEDs reported more fractures and had reductions in tibial vBMD and lower limb muscle force compared to their matched controls. These findings suggest that further exploration of bone health issues of young patients on AED therapy is required. Longitudinal studies are required to confirm these changes in the muscle-bone unit and to further explore the clinical outcomes.
Antibiotic complications during the treatment of Mycobacterium ulcerans disease in Australian patients
BACKGROUND: Antibiotics are the recommended first-line treatment for Mycobacterium ulcerans disease. Antibiotic toxicity is common in Australian patients, yet antibiotic complication rates and their risk factors have not been determined. AIM: To determine the incidence rate and risk factors for antibiotic toxicity in Australian patients treated for M. ulcerans disease. METHODS: An analysis of severe antibiotic complications was performed using data from a prospective cohort of M. ulcerans cases managed at Barwon Health from 1 January 1998 to 30 June 2016. A severe antibiotic complication was defined as an antibiotic adverse event that required its cessation. Antibiotic complication rates and their associations were assessed using a Poisson regression model. RESULTS: A total of 337 patients was included; 184 (54.6%) males and median age 57 years (interquartile range (IQR) 36-73 years). Median antibiotic treatment duration was 56 days (IQR 49-76 days). Seventy-five (22.2%) patients experienced severe antibiotic complications after a median 28 days (IQR 17-45 days) at a rate of 141.53 per 100 person-years (95% confidence interval (CI) 112.86-177.47). Eleven (14.7%) patients required hospitalisation. Compared with rifampicin/clarithromycin combinations, severe complication rates were not increased for rifampicin/ciprofloxacin (rate ratio (RR) 1.49, 95% CI 0.89-2.50, P = 0.13) or rifampicin/moxifloxacin (RR 2.54, 95% CI 0.76-8.50, P = 0.13) combinations, but were significantly increased for 'other' combinations (RR 2.53, 95% CI 1.13-5.68, P = 0.03). In a multivariable analysis, severe complication rates were significantly increased with reduced estimated glomerular filtration rates (EGFR) (adjusted rate ratio (aRR) 2.65, 95% CI 1.24-5.65 for EGFR 60-89 mL/min and aRR 1.31, 95% CI 0.49-3.53 for EGFR 0-59 mL/min compared with EGFR ≥90 mL/min, P < 0.01) and female gender (aRR 2.15, 95% CI 1.38-3.30, P < 0.01). CONCLUSIONS: Severe antibiotic complications during M. ulcerans treatment are high with increased rates independently associated with reduced renal function and female gender.
Tensions in post-examination feedback: information for learning versus potential for harm
OBJECTIVE: Self-regulation is recognised as being a requisite skill for professional practice This study is part of a programme of research designed to explore efficient methods of feedback that improve medical students' ability to self-regulate their learning. Our aim was to clarify how students respond to different forms and content of written feedback and to explore the impact on study behaviour and knowledge acquisition. METHODS: Year 2 students in a 4-year graduate entry medical programme completing four formative progress tests during the academic year were randomised into three groups receiving different feedback reports. All reports included proportion correct overall and by clinical rotation. One group received feedback reports including lists of clinical presentations relating to questions answered correctly and incorrectly; another group received reports containing this same information in combination with response certitude. The final group received reports involving normative comparisons. Baseline progress test performance quartile groupings (a proxy for academic ability) were determined by results on the first progress test. A mixed-method approach with triangulation of research findings was used to interpret results. Outcomes of interest included progress test scores, summative examination results and measures derived from study diaries, questionnaires and semi-structured interviews. RESULTS: Of the three types of feedback provided in this experiment, feedback containing normative comparisons resulted in inferior test performance for students in the lowest performance quartile group. This type of feedback appeared to stimulate general rather than examination-focused study. CONCLUSIONS: Medical students are often considered relatively homogenous and high achieving, yet the results of this study suggest caution when providing them with normative feedback indicating poorer performance relative to their peers. There is much need for further work to explore efficient methods of providing written feedback that improves medical students' ability to self-regulate their learning, particularly when giving feedback to those students who have the most room for improvement.
Acknowledging medical students' reports of intimidation and humiliation by their teachers in hospitals
AIM: The continuing existence of 'teaching by humiliation' of medical students and junior doctors in Australia has recently been highlighted in a number of research publications and media reports. This study investigates medical students' experiences of being intimidated or humiliated during their clinical rotations in Australian hospitals in paediatrics and adult medicine. METHODS: From factors identified in earlier research, a two-page survey was developed for administration at two Australian medical schools. Administered in Semester 2 of 2014, students were invited to add their own free-text comments at the conclusion of 17 closed questions. Using thematic analysis of the qualitative data, the researchers identified the common themes in the students' free-text comments, which are reported in this paper. RESULTS: We found five main themes in the qualitative data: a spectrum of interpretations of and responses to 'teaching by humiliation', an accepted means of enculturating the young, teachers' techniques for asking questions, the victims and perpetrators of mistreatment and the variance of prevalence in different contexts. CONCLUSION: Research shows the persistence of 'teaching by humiliation', even in paediatrics, particularly when doctors are questioning students in ways that shame them for their lack of knowledge. Given the many personal and professional costs of these practices, this cycle of mistreatment needs to be brought to an end. There is a need for students' reports of intimidation and humiliation to be acknowledged; the offending practices need to be interrupted, and more effective and respectful approaches to teaching need to be adopted.
Importance of preoperative diagnosis for management of patients with suspected retroperitoneal sarcoma
Soft tissue sarcoma is an umbrella term which encompasses over 60 histological tumour types. Approximately 15% of soft tissue sarcomas arise in the retroperitoneum. This complex group of tumours poses unique management challenges due to their often large size, histological heterogeneity and complexity of anatomical relationships. This review discusses the management of retroperitoneal tumours including the need for preoperative diagnosis, the evidence for neoadjuvant radiotherapy, the role of multivisceral resection and the importance of a multidisciplinary team approach.
Survey of practices around pharmaceutical company funding for continuing professional development among medical oncologists and trainees in Australia
BACKGROUND: The completion of continuing professional development (CPD) is mandatory for medical oncologists and trainees (MO&T). Pharmaceutical companies may fund some CPD activities, but there is increasing debate about the potential for conflicts of interest (COI). AIM: To assess current practices around funding to attend CPD activities. METHODS: An electronic survey was distributed to Australian MO&T. The survey asked questions about current practices, institutional policies and perceptions about attending CPD funded by pharmaceutical companies. The design looked at comparing responses between MO&T as well as their understanding of and training around institutional and ethical process. RESULTS: A total of 157 of 653 (24%) responses was received, the majority from MO (76%). Most CPD activities attended by MO&T were self-funded (53%), followed by funding from institutions (19%), pharmaceutical companies (16%) and salary award (16%). Most institutions allowed MO&T to receive CPD funding from professional organisations (104/157, 66%) or pharmaceutical companies (90/157, 57%). A minority of respondents (13/157, 8%) reported that the process to use pharmaceutical funds had been considered by an ethics committee. Although 103/157 (66%) had received pharmaceutical funding for CPD, most (109/157, 69%) reported never receiving training about potential COI. The lack of education was more noticeable among trainees (odds ratio (OR) 8.61, P = 0.02). MO&T acknowledged the potential bias towards a pharmaceutical product (P = 0.05) but believed there was adequate separation between themselves and pharmaceutical companies (P < 0.01). CONCLUSION: Majority of CPD attended by MO&T is self-funded. There is lack of clarity in institutional policies regarding external funding support for CPD activities. Formal education about potential COI is lacking.
Autoantibodies against voltage-gated potassium channel and glutamic acid decarboxylase in psychosis: A systematic review, meta-analysis, and case series.
Antibodies to the voltage-gated potassium channel (VGKC) complex and glutamic acid decarboxylase (GAD) have been reported in some cases of psychosis. We conducted the first systematic review and meta-analysis to investigate their prevalence in people with psychosis and report a case series of VGKC-complex antibodies in refractory psychosis. Only five studies presenting prevalence rates of VGKC seropositivity in psychosis were identified, in addition to our case series, with an overall prevalence of 1.5% (25/1720) compared to 0.7% in healthy controls (12/1753). Meta-analysis established that the pooled prevalence of GAD65 autoantibodies was 5.8% (95% confidence interval [CI]: 2.0-15.6%; I2 = 91%; nine studies) in psychotic disorders, with a prevalence of 4.6% (95%CI: 1.2-15.9%; nine studies; I2 = 89%) and 6.2% (95%CI: 1.2-27.0%; two studies; I2 = 69%) in schizophrenia and bipolar disorder, respectively. People with psychosis were more likely to have GAD65 antibodies than controls (odds ratio [OR], 2.24; 95%CI: 1.28-3.92%; P = 0.005; eight studies; I2 = 0%). Among 21 participants with treatment-resistant psychosis, none had VGKC antibodies. The prevalence of VGKC antibodies is low in psychosis. Our preliminary meta-analysis suggests that GAD autoantibodies are more common in people with psychosis than in controls, although few studies accounted for the possibility of co-existing type 1 diabetes mellitus and the clinical significance of reported GAD titers remains unclear. The paucity of studies reporting thresholds for defining GAD abnormality and rates of comorbid type 1 diabetes mellitus precludes interpretations regarding the influence of GAD antibodies on the development of psychotic disorders and may have led to an overestimate of the prevalence of GAD. Our case series fails to support the hypothesis that VGKC antibodies are linked to treatment resistance in psychosis, but the literature to date is remarkably sparse.