Publications by authors named "Alexandra Gorelik"

108 Publications

Evolution of surgical management for phaeochromocytoma over a 17-year period: an Australian perspective.

ANZ J Surg 2021 Apr 12. Epub 2021 Apr 12.

Department of General Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia.

Background: Minimally invasive adrenalectomy and advances in anaesthetic techniques have transformed surgery for phaeochromocytoma. This 17-year review describes the evolution of phaeochromocytoma care in our unit.

Methods: We performed a retrospective cohort review of all patients who underwent adrenalectomy for phaeochromocytoma from 2000 to 2016. Patients were divided into three time periods, early: 2000-2005 (n = 17), middle: 2006-2010 (n = 15) and late: 2011-2016 (n = 24). The posterior retroperitoneoscopic adrenalectomy was introduced in 2011. Demographics and clinicopathological details were extracted. Median values for nominal data were compared using Mann-Whitney U-test. A chi-squared test was used to compare categorical data.

Results: Sixty-one adrenalectomies were performed on 56 patients: 19 open, 17 laparoscopic and 20 posterior retroperitoneoscopic adrenalectomies. The median length of operation decreased from 135 to 90 min from the early to the late time period (P > 0.05). Length of stay decreased from a median of 5 days in the early group to 1 day in the late group (P = 0.01). A total of 94.1% of the early period patients were admitted to the intensive care unit compared to 30.4% of the late group (P = <0.01). Need for post-operative vasopressors and blood transfusions was significantly reduced.

Conclusion: Over the 17-year period, the choice of operative technique has transitioned towards posterior retroperitoneoscopic adrenalectomy. Operative time, rate of intensive care unit admission, and admission length have all decreased without any increase in rates of complications.
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http://dx.doi.org/10.1111/ans.16847DOI Listing
April 2021

Risk of Fractures and Other Injuries in Children Treated with Antiseizure Medications for Epilepsy.

Calcif Tissue Int 2021 Apr 7. Epub 2021 Apr 7.

Department of Medicine (RMH), University of Melbourne, Melbourne, VIC, Australia.

This study aimed to investigate the prevalence of fractures and non-fracture injuries, including associated risk factors, in children with epilepsy prescribed antiseizure medications (ASM). A controlled, cross-sectional study was conducted in a hospital outpatient setting, comparing children with epilepsy prescribed ASMs with their non-epileptic siblings. Information was collected by questionnaire included history of fractures, non-fracture injuries and epilepsy, comorbidities and ASM use. 261 participants completed the questionnaire, 133 children with epilepsy (aged 10.7 ± 3.5 years, mean ± SD) and 128 siblings (10.1 ± 3.7 years). There were 49 non-seizure-related fractures in 34 ASM patients while prescribed ASMs, compared with 21 lifetime fractures in 15 controls, giving a 2.7 (95% CI 1.3-5.3, p = 0.007) times greater fracture prevalence in children treated with ASMs compared to healthy siblings. The rates of non-fracture injuries were similar across groups, except that concussion was more common in children taking ASMs (9.0% vs 1.6%, p = 0.026). Duration of ASM use and generalized tonic-clonic seizures (GTCS) were independent predictors of fractures (OR 1.55; 95% CI 1.03-2.31, p = 0.03; OR 2.50; 95% CI 1.05-5.94, p = 0.04, respectively). Fewer than 20% of participants and/or their families were aware that ASM use was related to bone health. Children with epilepsy treated with ASMs had a higher fracture prevalence than their sibling controls. Duration of ASM treatment and GTCS were associated with fracture risk. Longitudinal prospective studies are required to further explore risk and the direct impact of epilepsy on bone health.
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http://dx.doi.org/10.1007/s00223-021-00842-3DOI Listing
April 2021

Mainstreaming genomics: training experience of hospital medical officers at the Royal Melbourne Hospital.

Intern Med J 2021 Feb;51(2):268-271

Department of Genomic Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.

The rapid evolution and wide applicability of genomic testing means that medical practitioners outside the field are not appropriately skilled to understand the utility of genomics for their patients. Rotating junior doctors through genomic medicine provides them with the hands-on experience necessary to understand the complexities in this field. In this study, we analysed the training experience of 12 hospital medical officers who rotated through genomic medicine at the Royal Melbourne Hospital. Here, we demonstrate that immersion in clinical genomics aids in mainstreaming genomics knowledge.
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http://dx.doi.org/10.1111/imj.15185DOI Listing
February 2021

Relationship between procedural volume and complication rates for catheter ablation of atrial fibrillation: a systematic review and meta-analysis.

Europace 2021 Feb 17. Epub 2021 Feb 17.

Department of Cardiology, Royal Melbourne Hospital, Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Royal Parade. 300 Grattan Street, Parkville, Melbourne, VIC 3050, Australia.

Aims: There are conflicting data as to the impact of procedural volume on outcomes with specific reference to the incidence of major complications after catheter ablation for atrial fibrillation. Questions regarding minimum volume requirements and whether these should be per centre or per operator remain unclear. Studies have reported divergent results. We performed a systematic review and meta-analysis of studies reporting the relationship between either operator or hospital atrial fibrillation (AF) ablation volumes and incidence of complications.

Methods And Results: Databases were searched for studies describing the relationship between operator or hospital AF ablation volumes and incidence of complications which were published prior to 12 June 2020. Of 1593 articles identified, 14 (315 120 patients) were included in the meta-analysis. Almost two-thirds of the procedures were performed in low-volume centres. Both hospital volume of ≥50 and ≥100 procedures/year were associated with a significantly lower incidence of complications compared to <50/year (4.2% vs. 5.5%, OR = 0.58, 95% CI 0.50-0.66, P < 0.001) or <100/year (5.5% vs. 6.2%, OR = 0.62, 95% CI 0.53-0.73, P < 0.001), respectively. Hospitals performing ≥50 procedures/year demonstrated significantly lower mortality compared with those performing <50 procedures/year (0.16% vs. 0.55%, OR = 0.33, 95% CI 0.26-0.43, P < 0.001). A similar relationship existed between proceduralist volume of <50/year and incidence of complications [3.75% vs. 12.73%, P < 0.001; OR = 0.27 (0.23-0.32)].

Conclusion: There is an inverse relationship between both hospital and proceduralist AF ablation volume and the incidence of complications. Implementation of minimum hospital and operator AF ablation volume standards should be considered in the context of a broader strategy to identify AF ablation Centers of Excellence.
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http://dx.doi.org/10.1093/europace/euaa415DOI Listing
February 2021

Can adequate analgesia be achieved in patients with cirrhosis without precipitating hepatic encephalopathy? A prospective study.

Clin Exp Hepatol 2020 Sep 30;6(3):243-252. Epub 2020 Sep 30.

Department of Gastroenterology, Eastern Health, Australia.

Aim Of The Study: Analgesic use in patients with liver cirrhosis can be associated with increased morbidity and mortality and presents clinicians with a significant and challenging management issue. We evaluated the efficacy of opiate analgesia in patients with cirrhosis, while closely monitoring the side effect profile.

Material And Methods: This prospective cohort pilot study compared inpatients with cirrhosis who required regular opiate analgesia to non-cirrhotic patients requiring opiates and patients with cirrhosis who did not require opiates. Participants completed daily surveys to assess for analgesic efficacy and encephalopathy.

Results: Fifty-two patients were initially recruited, of whom 50 patients were analysed in three groups (40 male, 10 female, median age 52 years). These included 13 cirrhotic patients (69% Child-Pugh B or C) requiring regular opiate analgesia, 18 cirrhotic patients (67% Child-Pugh B or C) not receiving regular opiate analgesia, and 19 non-cirrhotic controls. Two patients were excluded due to past stroke and acquired brain injury. All cirrhotic patients received regular lactulose. There was no statistical difference in the adequacy of analgesia between the three groups. The modified orientation log score for encephalopathy remained in the normal range in all but two cirrhotic patients receiving regular opiate analgesia.

Conclusions: Effective pain control is achievable with opiate analgesia in most patients with advanced liver disease without precipitating hepatic encephalopathy.
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http://dx.doi.org/10.5114/ceh.2020.99521DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592086PMC
September 2020

Clinical Prediction Tool To Identify Adults With Type 2 Diabetes at Risk for Persistent Adverse Glycemia in Hospital.

Can J Diabetes 2021 Mar 10;45(2):114-121.e3. Epub 2020 Jun 10.

Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine, University of Melbourne and Royal Melbourne Hospital, Parkville, Victoria, Australia.

Objectives: Given the high incidence of hyperglycemia and hypoglycemia in hospital and the lack of prediction tools for this problem, we developed a clinical tool to assist early identification of individuals at risk for persistent adverse glycemia (AG) in hospital.

Methods: We analyzed a cohort of 594 consecutive adult inpatients with type 2 diabetes. We identified clinical factors available early in the admission course that were associated with persistent AG (defined as ≥2 days with capillary glucose <4 or >15 mmol/L during admission). A prediction model for persistent AG was constructed using logistic regression and internal validation was performed using a split-sample approach.

Results: Persistent AG occurred in 153 (26%) of inpatients, and was associated with admission dysglycemia (odds ratio [OR], 3.65), glycated hemoglobin ≥8.1% (OR, 5.08), glucose-lowering treatment regimen containing sulfonylurea (OR, 3.50) or insulin (OR, 4.22), glucocorticoid medication treatment (OR, 2.27), Charlson Comorbidity Index score and the number of observed days. An early-identification prediction tool, based on clinical factors reliably available at admission (admission dysglycemia, glycated hemoglobin, glucose-lowering regimen and glucocorticoid treatment), could accurately predict persistent AG (receiver-operating characteristic area under curve = 0.806), and, at the optimal cutoff, the sensitivity, specificity and positive predictive value were 84%, 66% and 53%, respectively.

Conclusions: A clinical prediction tool based on clinical risk factors available at admission to hospital identified patients at increased risk for persistent AG and could assist early targeted management by inpatient diabetes teams.
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http://dx.doi.org/10.1016/j.jcjd.2020.06.006DOI Listing
March 2021

Mid-life predictors of late-life depressive symptoms; determining risk factors spanning two decades in the Women's Heathy Ageing Project.

Womens Midlife Health 2020 4;6. Epub 2020 Mar 4.

4Department of Psychiatry, University of Melbourne, Melbourne, Victoria Australia.

Background: Data available from longitudinal studies of adequate duration to explore midlife risk factors for late life higher depressive symptom scores in women is lacking. This study examines midlife (mean ages 50 years and 60 years) predictors of late life (mean age 70 years) depressive symptom scores to enrich our understanding of the role of changing risk factors across the lifespan.

Methods: This investigation was an assessment of the long-term impact of lifestyle and health variables on depressive symptoms. Data were drawn from an epidemiological prospective study of women's healthy ageing spanning two decades. Variables included assessment of mood, demographics, physical health, smoking status, attitudes towards ageing and menopause, alcohol consumption and employment. Analysis was conducted to determine the set of strongest predictors assessed in 1992 (mean age 50 years) and in 2002 (mean age 60 years) in relation to higher CESD-SF scores measured in 2012 (mean aged 70 years ( = 249)). A cross-sectional analysis determining concurrent associations at mean age 70 years was also conducted.

Results: An increase in positive mood at 50 and 60 years was associated with a 0.3 (95% CI 0.1-0.5) and 0.4 (95%CI 0.1-0.8) point reduction in CESD score at 70 years respectively. An increase in Hassles score at age 50 was associated with a 0.18-point increase in CESD (95% CI 0.01-0.05) 20 years later. However, no relationship was observed between Hassles score at 60 and CESD 10 years later. Analysis of concurrent risk factors demonstrated that bothersome symptom frequency and higher anxiety were associated with higher depressive symptom scores when women were 70 years.

Conclusion: Low levels of positive mood were consistently associated with depressive symptoms scores 10 and 20 years later, suggesting clinical interventions aimed at improving positive affect may be particularly useful across the midlife.
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http://dx.doi.org/10.1186/s40695-020-00050-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7055082PMC
March 2020

Skin-Liver Distance and Interquartile Range-Median Ratio as Determinants of Interoperator Concordance in Acoustic Radiation Force Impulse Imaging.

J Med Ultrasound 2019 Oct-Dec;27(4):177-180. Epub 2019 May 17.

Department of Radiology, Royal Melbourne Hospital, Victoria, Australia.

Context And Aims: The accuracy of acoustic radiation force impulse (ARFI) ultrasound compared to liver biopsy is higher when there is concordance between F-scores of two or more operators. We hypothesized that when the first operator interquartile range/median-velocity ratio (IMR) is <0.3 and skin-liver distance (SLD) is <2.5 cm, there is greater interoperator concordance and a second operator is not necessary.

Subjects And Methods: Two-operator ARFI ultrasound measurements (F-score, SLD, and IMR) were recorded for 927 consecutive patients. Chi-squared testing compared interoperator concordance for SLD <2.5 cm versus SLD ≥2.5 cm and IMR <0.3 versus IMR ≥0.3 when SLD <2.5 cm, in each of the F-score groups of 0/1, 2, 3, and 4.

Results: Statistically significant differences were demonstrated between SLD <2.5 cm and SLD ≥2.5 cm groups for F-scores 0/1 or 4 ( = 0.005) and F-scores 2 or 3 ( < 0.001). Concordance, when SLD measured <2.5 cm, was more than 85% for all F-score groups. In the SLD <2.5 cm group, concordance fell below 85% when IMR ≥0.3, for all F-scores except F2. Specifically, values comparing IMR <0.3 and IMR ≥0.3 in the various first operator F-score groups were = 0.040 for F0/F1, = 0.580 for F2, = 0.342 for F3, and < 0.001 for F4.

Conclusions: ARFI measurements from one operator can be considered acceptable when SLD <2.5 cm and IMR <0.3. Otherwise, adding a second operator can improve confidence in the result.
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http://dx.doi.org/10.4103/JMU.JMU_124_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6905253PMC
May 2019

Quantifying Use of a Health Virtual Community of Practice for General Practitioners' Continuing Professional Development: A Novel Methodology and Pilot Evaluation.

J Med Internet Res 2019 11 27;21(11):e14545. Epub 2019 Nov 27.

Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia.

Background: Health care practitioners (HPs), in particular general practitioners (GPs), are increasingly adopting Web-based social media platforms for continuing professional development (CPD). As GPs are restricted by time, distance, and demanding workloads, a health virtual community of practice (HVCoP) is an ideal solution to replace face-to-face CPD with Web-based CPD. However, barriers such as time and work schedules may limit participation in an HVCoP. Furthermore, it is difficult to gauge whether GPs engage actively or passively in HVCoP knowledge-acquisition for Web-based CPD, as GPs' competencies are usually measured with pre- and posttests.

Objective: This study investigated a method for measuring the engagement features needed for an HVCoP (the Community Fracture Capture [CFC] Learning Hub) for learning and knowledge sharing among GPs for their CPD activity.

Methods: A prototype CFC Learning Hub was developed using an Igloo Web-based social media software platform and involved a convenience sample of GPs interested in bone health topics. This Hub, a secure Web-based community site, included 2 key components: an online discussion forum and a knowledge repository (the Knowledge Hub). The discussion forum contained anonymized case studies (contributed by GP participants) and topical discussions (topics that were not case studies). Using 2 complementary tools (Google Analytics and Igloo Statistical Tool), we characterized individual participating GPs' engagement with the Hub. We measured the GP participants' behavior by quantifying the number of online sessions of the participants, activities undertaken within these online sessions, written posts made per learning topic, and their time spent per topic. We calculated time spent in both active and passive engagement for each topic.

Results: Seven GPs participated in the CFC Learning Hub HVCoP from September to November 2017. The complementary tools successfully captured the GP participants' engagement in the Hub. GPs were more active in topics in the discussion forum that had direct clinical application as opposed to didactic, evidence-based discussion topics (ie, topical discussions). From our knowledge hub, About Osteoporosis and Prevention were the most engaging topics, whereas shared decision making was the least active topic.

Conclusions: We showcased a novel complementary analysis method that allowed us to quantify the CFC Learning Hub's usage data into (1) sessions, (2) activities, (3) active or passive time spent, and (4) posts made to evaluate the potential engagement features needed for an HVCoP focused on GP participants' CPD process. Our design and evaluation methods for ongoing use and engagement in this Hub may be useful to evaluate future learning and knowledge-sharing projects for GPs and may allow for extension to other HPs' environments. However, owing to the limited number of GP participants in this study, we suggest that further research with a larger cohort should be performed to validate and extend these findings.
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http://dx.doi.org/10.2196/14545DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6906624PMC
November 2019

Effect of a 24-month physical activity program on brain changes in older adults at risk of Alzheimer's disease: the AIBL active trial.

Neurobiol Aging 2020 05 27;89:132-141. Epub 2019 May 27.

Department of Medicine and Radiology, The University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia.

White matter hyperintensities (WMHs) are a risk factor for cognitive decline. Physical activity (PA) is associated with lower WMH. Whether long-term exposure to PA programs has beneficial effects on WMH progression in older adults with memory complaints and comorbid conditions has had limited exploration. This study explored whether a 24-month moderate-intensity PA intervention can delay the progression of WMH and hippocampus loss in older adults at risk for cognitive decline. Data acquired on magnetic resonance imaging were used to measure the progression of WMH and hippocampus loss. The results of this study showed no effect of intervention on either the primary outcome measure "WMH" or the secondary outcome measure "hippocampal volume." In addition, neither beta amyloid status nor the adherence to the intervention had any effect on the outcome. In this cohort of subjective memory complaints and mild cognitive impairment participants with vascular risk factors, there was no effect of long-term moderate-intensity PA on WMH or hippocampal loss.
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http://dx.doi.org/10.1016/j.neurobiolaging.2019.02.030DOI Listing
May 2020

Associations Between Serum Sodium Concentration and Bone Health Measures in Individuals Who Use Antiepileptic Drugs: A Pilot Study.

J Clin Densitom 2020 Jul - Sep;23(3):364-372. Epub 2019 Mar 23.

University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Parkville, Australia; Bone and Mineral Medicine, Royal Melbourne Hospital, Parkville, Australia.

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http://dx.doi.org/10.1016/j.jocd.2019.03.007DOI Listing
March 2019

Compliance with screening for and recommended management of maternal group B streptococcus carriage in pregnancy.

Aust N Z J Obstet Gynaecol 2019 12 25;59(6):837-842. Epub 2019 Apr 25.

Department of Microbiology and Infectious Disease, Royal Women's Hospital, Melbourne, Australia.

Background: Universal screening of pregnant women at 35-37 weeks gestation is recommended for detection of anogenital group B streptococcus carriage. Intrapartum chemoprophylaxis is prescribed to carriers to prevent transmission to babies, reducing early-onset neonatal group B streptococcal sepsis.

Aims: To review compliance with, and the effects of education on group B streptococcus screening and intrapartum chemoprophylaxis practices at The Royal Women's Hospital, Melbourne, Australia.

Materials And Methods: A retrospective audit of women delivering in February 2016 and February-March 2017 was conducted. In February 2017, updated early-onset group B streptococcal disease prevention guidelines were released and promoted with targeted education of clinical staff. Compliance was considered appropriate if practices followed up-to-date local protocols.

Results: Screening rate for group B streptococcus was 84.4% (599/710) and carriage rate 19.5% (109/558), while intrapartum antibiotic prophylaxis was optimal in 83% of those labouring greater than four hours (39/47). There was no significant difference in compliance between 2016 and 2017. Of 113 women with unknown group B streptococcal status at delivery, only five of 33 (15%) with clinical risk factors for early-onset neonatal disease received intrapartum prophylaxis.

Conclusions: Compliance remained stable, with no change during or after implementation of new protocols. Compliance with protocols was low for cases with unknown group B streptococcal status at delivery but with the presence of one or more clinical risk factors for early-onset group B streptococcal sepsis.
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http://dx.doi.org/10.1111/ajo.12977DOI Listing
December 2019

Practice Patterns in Parathyroid Surgery: A Survey of Asia-Pacific Parathyroid Surgeons.

World J Surg 2019 08;43(8):1964-1971

Endocrine Surgery Unit, Department of Surgery, The Royal Melbourne Hospital, Epworth Freemason's Hospital, Melbourne University, 300 Grattan Street, Parkville, VIC, 3050, Australia.

Background: Practice variations exist amongst parathyroid surgeons depending on their expertise and resources. Our study aims to elucidate the choice of surgical techniques and adjuncts used in parathyroid surgery by surgeons in the Asia-Pacific region.

Methods: A 25-question online survey was sent to members of five endocrine surgery associations. Questions covered training background, practice environment and preferred techniques in parathyroid surgery. Respondents were divided into three regions: Australia/New Zealand, South/South East Asia and East Asia, and responses were analysed according to region, specialty, case volume and years in practice.

Results: One hundred ninety-six surgeons returned the questionnaire. Most surgeons (98%) routinely perform preoperative imaging, with 75% preferring dual imaging with Tcsestamibi and ultrasound. Ten per cent of surgeons use parathyroid 4DCT as first-line imaging, more commonly in East Asia (p = 0.038). Minimally invasive parathyroidectomy is the favoured technique of choice (97%). Most surgeons reporting robotic or endoscopic approaches are from East Asia. Rapid intraoperative parathyroid hormone is accessible to just under half of the surgeons but less available in Australian/New Zealand (p < 0.001). The use of intraoperative neuromonitoring is not commonly used, even less so amongst Asian surgeons (p = 0.048) and surgeons with low case load (p = 0.013).

Conclusion: Dual localisation techniques are the preferred choice of investigations in preparation for parathyroid surgery, with minimally invasive surgery without neuromonitoring the preferred approach. Use of adjuncts is sporadic and limited to certain centres.
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http://dx.doi.org/10.1007/s00268-019-04990-4DOI Listing
August 2019

Early Intervention for Diabetes in Medical and Surgical Inpatients Decreases Hyperglycemia and Hospital-Acquired Infections: A Cluster Randomized Trial.

Diabetes Care 2019 05 28;42(5):832-840. Epub 2019 Mar 28.

Royal Melbourne Hospital, Parkville, Victoria, Australia

Objective: To investigate if early electronic identification and bedside management of inpatients with diabetes improves glycemic control in noncritical care.

Research Design And Methods: We investigated a proactive or early intervention model of care (whereby an inpatient diabetes team electronically identified individuals with diabetes and aimed to provide bedside management within 24 h of admission) compared with usual care (a referral-based consultation service). We conducted a cluster randomized trial on eight wards, consisting of a 10-week baseline period (all clusters received usual care) followed by a 12-week active period (clusters randomized to early intervention or usual care). Outcomes were adverse glycemic days (AGDs) (patient-days with glucose <4 or >15 mmol/L [<72 or >270 mg/dL]) and adverse patient outcomes.

Results: We included 1,002 consecutive adult inpatients with diabetes or new hyperglycemia. More patients received specialist diabetes management (92% vs. 15%, < 0.001) and new insulin treatment (57% vs. 34%, = 0.001) with early intervention. At the cluster level, incidence of AGDs decreased by 24% from 243 to 186 per 1,000 patient-days in the intervention arm ( < 0.001), with no change in the control arm. At the individual level, adjusted number of AGDs per person decreased from a mean 1.4 (SD 1.6) to 1.0 (0.9) days (-28% change [95% CI -45 to -11], = 0.001) in the intervention arm but did not change in the control arm (1.8 [2.0] to 1.5 [1.8], -9% change [-25 to 6], = 0.23). Early intervention reduced overt hyperglycemia (55% decrease in patient-days with mean glucose >15 mmol/L, < 0.001) and hospital-acquired infections (odds ratio 0.20 [95% CI 0.07-0.58], = 0.003).

Conclusions: Early identification and management of inpatients with diabetes decreased hyperglycemia and hospital-acquired infections.
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http://dx.doi.org/10.2337/dc18-2342DOI Listing
May 2019

Robust norms for neuropsychological tests of verbal episodic memory in Australian women.

Neuropsychology 2019 May 4;33(4):581-595. Epub 2019 Mar 4.

Department of Medicine (Royal Melbourne Hospital).

Objective: Robust norms for neuropsychological tests may offer superior clinical utility to conventional norms, in their ability to distinguish normal cognitive aging from prodromal dementia. However, the availability of robust norms from midlife, where cognitive changes in those at risk of disease may arise, is limited. This study presents demographically stratified robust norms for tests of verbal memory in Australian women.

Method: Participants were from the population-based Women's Healthy Ageing Project. Baseline (1999 to 2002; n = 368; age range = 53-67years) and follow-up (2012 to 2014; n = 291; age range = 65-80years) measures of word-list and story recall were administered at least 10 years apart. Four samples were identified: conventional (derived from a cross-sectional sample), robust (derived from a longitudinal sample), mild cognitive impairment (MCI) or Alzheimer's disease (AD), and lost to follow-up. Area under the curve (AUC) values were generated to assess the diagnostic ability of conventional and robust norms using 1 standard deviation and 1.5 standard deviation cut-offs.

Results: There were differences between conventional Australian and American normative data for the Consortium to Establish a Registry for Alzheimer's Disease word-list recall. Individuals who declined to MCI/AD over the follow-up displayed poorer performance at baseline, however no differences in classification ability of robust (AUC range .54 to.64) and conventional (AUC range .51 to .65) norms were observed.

Conclusion: Neuropsychological performance in midlife predicted clinical cognitive decline 1 decade later, but conventional and robust norms was similarly predictive of conversion to disease in this cohort. The use of country-specific, representative conventional norms remains a valuable tool for neuropsychologists to assess cognitive performance throughout midlife. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/neu0000522DOI Listing
May 2019

Using Mobile Technology to Improve Bone-Related Lifestyle Risk Factors in Young Women With Low Bone Mineral Density: Feasibility Randomized Controlled Trial.

JMIR Form Res 2019 Feb 25;3(1):e9435. Epub 2019 Feb 25.

Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia.

Background: Poor bone health in adolescent and young adult females is a growing concern. Given the widespread use of mobile phones in this population, mobile health (mHealth) interventions may help improve health behaviors related to bone health in young women.

Objective: The goal of the study was to determine the acceptability and feasibility of an mHealth intervention called Tap4Bone in improving health behaviors associated with the risk of osteoporosis in young women.

Methods: The Tap4Bone mHealth intervention comprised the use of mobile phone apps, short messaging service (text messaging), and Web emails to encourage health behavior changes. The education group received osteoporosis prevention education leaflets. Changes in the bone health-related behaviors exercise, smoking, and calcium intake were assessed. User experiences and acceptance of the app were collected through focus group interviews.

Results: A total of 35 (22 completed, mean age 23.1 [SD 1.8] years) were randomized to either the mobile phone (intervention n=18) or education (control n=17) group. Although there were trends toward improvement in calcium intake, sports activity, and smoking behaviors in the mHealth intervention group compared to the education group, these were not statistically significant.

Conclusions: The Tap4Bone mHealth intervention was shown to be acceptable and feasible in subsets of the participants. The intervention should be improved upon using participant feedback to improve functionality. Findings from this study may aid in the development and modification of health care apps to reduce participant attrition.
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http://dx.doi.org/10.2196/formative.9435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6409511PMC
February 2019

The projected burden of primary total knee and hip replacement for osteoarthritis in Australia to the year 2030.

BMC Musculoskelet Disord 2019 Feb 23;20(1):90. Epub 2019 Feb 23.

Department of Surgery, Epworth HealthCare, The University of Melbourne, 89 Bridge Road, Richmond, Victoria, 3121, Australia.

Background: Comprehensive national joint replacement registries with well-validated data offer unique opportunities for examining the potential future burden of hip and knee osteoarthritis (OA) at a population level. This study aimed to forecast the burden of primary total knee (TKR) and hip replacements (THR) performed for OA in Australia to the year 2030, and to model the impact of contrasting obesity scenarios on TKR burden.

Methods: De-identified TKR and THR data for 2003-2013 were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Population projections and obesity trends were obtained from the Australian Bureau of Statistics, with public and private hospital costs sourced from the National Hospital Cost Data Collection. Procedure rates were projected according to two scenarios: (1) constant rate of surgery from 2013 onwards; and (2) continued growth in surgery rates based on 2003-2013 growth. Sensitivity analyses were used to estimate future TKR burden if: (1) obesity rates continued to increase linearly; or (2) 1-5% of the overweight or obese population attained a normal body mass index.

Results: Based on recent growth, the incidence of TKR and THR for OA is estimated to rise by 276% and 208%, respectively, by 2030. The total cost to the healthcare system would be $AUD5.32 billion, of which $AUD3.54 billion relates to the private sector. Projected growth in obesity rates would result in 24,707 additional TKRs totalling $AUD521 million. A population-level reduction in obesity could result in up to 8062 fewer procedures and cost savings of up to $AUD170 million.

Conclusions: If surgery trends for OA continue, Australia faces an unsustainable joint replacement burden by 2030, with significant healthcare budget and health workforce implications. Strategies to reduce national obesity could produce important TKR savings.
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http://dx.doi.org/10.1186/s12891-019-2411-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6387488PMC
February 2019

A prospective study of the incidence of drug-induced liver injury by the modern volatile anaesthetics sevoflurane and desflurane.

Aliment Pharmacol Ther 2019 04 13;49(7):940-951. Epub 2019 Feb 13.

Melbourne Medical School, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.

Background: Volatile anaesthetics are known to cause drug-induced liver injury, a hepatotoxic reaction characterised by antibodies to trifluoroacetylated lipid and protein adducts and cytochrome p450 2E1. The incidence of volatile anaesthetic drug-induced liver injury from older agents has been described, but modern agents have not been prospectively studied.

Aim: To determine prospectively the incidence of volatile anaesthetic drug-induced liver injury from sevoflurane and desflurane.

Methods: Adult surgical patients with a predicted post-operative stay of at least 4 days were recruited. If volatile anaesthetic was administered, liver biochemistry was performed regularly. Medications, observations and other investigations were documented. Patients with abnormal liver biochemistry were classified as likely volatile anaesthetic drug-induced liver injury or not based on clinical assessment, Roussel Uclaf Causality Assessment Method score, and the absence of other likely pathology. Some patients were also tested for antibodies to both trifluoroacetylated lipid and protein adducts, and cytochrome p450 2E1.

Results: A total of 209 patients were recruited, of which 121 were included for analysis. Post-operative liver biochemistry was abnormal in 62 patients (51.2%); further classified as not volatile anaesthetic drug-induced liver injury in 47 cases (38.8%), and likely volatile anaesthetic-drug induced liver injury in 15 cases (12.4%). Of the likely volatile anaesthetic drug-induced liver injury patients, only one had severe disease with alanine transaminase greater than five times the upper limit of normal, while four cases had moderate disease with alanine transaminase greater than three times the upper limit of normal. Thus, the incidence of clinically significant volatile anaesthetic drug-induced liver injury was 4.1%. No risk factors were identified.

Conclusions: Volatile anaesthetic drug-induced liver injury from modern agents seems to be as common (4.1%) as previously reported with older agents (3%), and may identify patients at risk of severe acute liver injury with subsequent re-exposure.
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http://dx.doi.org/10.1111/apt.15168DOI Listing
April 2019

Symptom burden in malignant and non-malignant disease on admission to a palliative care unit.

BMJ Support Palliat Care 2019 Feb 4. Epub 2019 Feb 4.

Department of Palliative Care, The Royal Melbourne Hospital, Parkville, Victoria, Australia.

Background: There is increasing recognition that patients with non-malignant diseases have comparable physical and psychosocial symptom burden to patients with cancer. There is currently limited data directly comparing symptom burden between these patient groups.

Objective: To investigate differences in symptom burden between patients with malignant and non-malignant conditions admitted to a palliative care unit (PCU).

Method: A cross-sectional study involving 186 patients admitted to a PCU was undertaken. Patients were dichotomised into malignant or non-malignant disease categories. Symptom burden at admission was assessed using the Symptom Assessment Scale and Palliative Care Problem Severity Score. Group differences in symptoms were analysed using univariate and multivariate approaches.

Results: One hundred patients (53.8%) had cancer, with upper gastrointestinal the most common type (18.0%). Among the 86 patients with non-malignant disease, neurological conditions were most prevalent (40.7%). Patients admitted with non-malignant diseases were older, more functionally impaired and more likely to be deteriorating or terminal. A malignant diagnosis was associated with a higher likelihood of clinician-assessed pain, patient-assessed pain, fatigue, psychological/spiritual symptoms and other symptoms. However, when adjusted for confounders, disease category ceased to be a significant predictor of symptom burden. Younger patients experienced worse pain and patients in terminal phase experienced less symptom burden.

Conclusion: Symptom burden was similar between patients with malignant and non-malignant disease after adjustment for confounders. Further research is needed to understand the palliative care needs of patients with non-malignant disease.
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http://dx.doi.org/10.1136/bmjspcare-2018-001560DOI Listing
February 2019

Apolipoprotein E4 Mediates the Association Between Midlife Dyslipidemia and Cerebral Amyloid in Aging Women.

J Alzheimers Dis 2019 ;68(1):105-114

Healthy Ageing Organisation, Melbourne, Parkville, VIC, Australia.

Cerebral amyloid-β (Aβ) plaques are the hallmark biomarker of Alzheimer's disease (AD) and are detectable decades before clinical symptoms. Modifying risk factors associated with Aβ accrual offers an opportunity for AD prevention. While midlife vascular health is linked to AD; there is minimal longitudinal evidence regarding the effect of midlife lipids on Aβ. We examined the association between midlife lipids and Aβ 20 years later. One hundred and twenty-two women had serum lipid profiles in midlife (1992, 45-57 years), and cerebral imaging, genotyping, and cognition measured 20 years later (2012/13, 66-77 years). Imaging was performed in 2012/13 via F-18 Florbetaben positron emission tomography (PET) and standard uptake value ratios (SUVR) were calculated. Lipid profiles and other predictors of high PET-SUVR levels (>1.2) were evaluated using multivariable logistic regression. Increases in low-density lipoprotein (LDL) cholesterol in midlife were associated with Aβ, adjusting for age, education, cholesterol medication, and cognition (AdjOR1.81, 95% CI 1.08-3.01, p = 0.024), but attenuated on adjustment for apolipoprotein E4 (APOE ɛ4). Aβ risk increased in women with APOE ɛ4 and midlife cholesterol >6.2 mmol/L (AdjOR9.59, 95% CI 2.94-31.31, p < 0.001), APOE ɛ4 and LDL >3.3 mmol/L (AdjOR9.00, 95% CI 2.89-28.03, p < 0.001), and APOE ɛ4 and cholesterol to high-density lipoprotein ratio ≥3.25 (AdjOR8.32, 95% CI 2.32-29.89, p < 0.001). Presence of APOE ɛ4 and midlife dyslipidemia compounded the risk for Aβ deposition, although no independent effect of midlife lipids was found. Lipid-modifying treatment in midlife could mitigate the risk of Aβ in women with a genetic predisposition for AD. To better inform prevention, future consideration should be given toward managing dyslipidemia in women carrying the APOE ɛ4 allele.
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http://dx.doi.org/10.3233/JAD-180815DOI Listing
June 2020

Diet and biomarkers of Alzheimer's disease: a systematic review and meta-analysis.

Neurobiol Aging 2019 04 27;76:45-52. Epub 2018 Dec 27.

Faculty of Health Sciences, School of Psychology, Australian Catholic University, Melbourne, Australia; Institute for Health & Ageing, Australian Catholic University, Melbourne, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Melbourne, Australia. Electronic address:

Alzheimer's disease (AD) risk increases with age and lacks efficacious pharmacological options. Summaries of the existing evidence reveal an association between Mediterranean-style diet adherence and reduced AD incidence; however, no review has investigated this relationship with respect to the hallmark AD biomarkers (tau and beta-amyloid) that manifest decades before clinical symptomatology. MEDLINE, PubMed, PsycINFO, Google Scholar, and SCOPUS databases were systematically searched to identify peer-reviewed articles investigating diet and AD biomarkers in the last 2 decades. Two thousand seven hundred twenty-six records were extracted, quality assessed, and double-blind screened by 2 authors. Fifteen studies met the inclusion criteria and 13 studies found a significant relationship. Of these, 4 studies found a high-glycemic load was related to an increase in AD biomarker burden; 6 found adherence to a Mediterranean or "AD-protective" dietary pattern conferred a reduction in AD biomarker burden. Meta-analysis revealed a small but significant effect of diet on AD biomarkers (β = 0.11 [95% CI 0.04-0.17], p = 0.002). This systematic review supports the notion that diet and nutrition display potential for nonpharmacological AD prevention.
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http://dx.doi.org/10.1016/j.neurobiolaging.2018.12.008DOI Listing
April 2019

Risk factors for candidaemia and their cumulative effect over time in a cohort of critically ill, non-neutropenic patients.

Crit Care Resusc 2018 12;20(4):313-319

Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Vic, Australia.

Objectives: There is an increasing incidence of invasive candidal infections in critically ill patients worldwide, which has prompted development of various risk prediction rules, both clinical and microbiological. To date, however, there is a lack of research into how cumulative risk factors over time affect transition to candidaemia. The aim of this study was to investigate the association of risk factor accumulation over time with candidaemia in a cohort of critically ill, non-neutropenic adult patients.

Design, Setting And Participants: A single centre, retrospective, matched case-control study in a tertiary referral intensive care unit (ICU). Data were retrieved and analysed from 108 patients (54 cases and 54 controls) admitted between 1 January 2008 and 1 August 2016.

Main Outcome Measures: Primary outcome was the association between time-dependent risk factors and candidaemia. Secondary outcomes were ICU and inhospital mortality.

Results: Baseline demographic and clinical factors were similar across both groups. Time dependent univariate factors associated with candidaemia were days of mechanical ventilation, systemic antibiotic use, renal replacement therapy, central venous access, total parenteral nutrition (TPN), systemic inflammatory response syndrome, site colonisation and number of surgeries. Factors persisting on multivariate analysis were days of TPN use (odds ratio [OR], 1.8; 95% CI, 1.02-3.22; = 0.041) and total site colonisation days (OR, 2.41; 95% CI, 1.30-4.46; = 0.005). Mortality and length of stay (LOS) was greater in patients with candidaemia control patients (ICU mortality, 15 [28%] 10 [19%]; = 0.254; hospital mortality, 26 [48%] 16 [30%]; = 0.048; ICU LOS median, 13 days [interquartile range (IQR), 5-29 days] 2 days [IQR, 1-5 days]; < 0.001; hospital LOS median, 36 days [IQR,19- 63 days] 13 days [IQR, 6-28 days]; < 0.001).

Conclusion: This study demonstrates an association between TPN use, colonisation and cumulative risk over time of developing candidaemia.
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December 2018

The effect of midlife cardiovascular risk factors on white matter hyperintensity volume and cognition two decades later in normal ageing women.

Brain Imaging Behav 2020 Feb;14(1):51-61

Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Melbourne, VIC, 3010, Australia.

Cerebral White Matter Hyperintensity (WMH) lesions have been identified as markers of cerebrovascular diseases and they are associated with increased risk of cognitive impairment. In this study, we investigated the relationship between midlife cardiovascular risk factors and late life WMH volumes two decades later, and examined their association with cognitive performance. 135 participants from the Women's Healthy Ageing Project had completed midlife cardiovascular risk measurement in 1992 and late life brain MRI scan and cognitive assessment in 2012. In these community-dwelling normal aging women, we found that higher midlife Framingham Cardiovascular Risk Profile (FCRP) score was associated with greater WMH volume two decades later, and was predominantly driven by the impact of HDL cholesterol level, controlling for age, education and APOE ε4 status. Structural equation modelling demonstrated that the relationship between midlife FCRP score and late life executive function was mediated by WMH volume. These findings suggest intervention strategies that target major cardiovascular risk factors at midlife might be effective in reducing the development of WMH lesions and thus late life cognitive decline.
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http://dx.doi.org/10.1007/s11682-018-9970-5DOI Listing
February 2020

Increasing frequency of critically ill patient turns is associated with a reduction in pressure injuries.

Crit Care Resusc 2018 Sep;20(3):217-222

Melbourne EpiCentre, Royal Melbourne Hospital, Melbourne, Vic, Australia.

Objective: Pressure injuries are a significant problem for critically ill patients; they increase morbidity, cost, and duration of hospitalisation. Prolonged immobility is a major risk factor, but evidence guiding how frequently patients should be turned to prevent this complication is limited. We aimed to determine the impact of changing from 5-hourly to 3-hourly turns on pressure injury incidence in critically ill patients.

Design: We conducted a pre-post intervention evaluation study, comparing a 6-month period during which patient turns were 5-hourly (1 July 2015 - 31 December 2015) with a 6-month period during which turns were 3-hourly (1 February 2016 - 31 August 2016). These periods were separated by a 3-week wash-in period.

Setting: Intensive care unit in a metropolitan tertiary referral hospital.

Participants: All patients admitted during the pre-intervention and post-intervention periods were included.

Intervention: A change in turn frequency for critically ill patients from 5-hourly to 3-hourly.

Main Outcome Measures: The primary outcome was the number of patients diagnosed with a pressure injury. Secondary outcomes were the total number of pressure injuries, and the number of decubitus injuries.

Results: In the pre-intervention period, 1094 patients were admitted; in the post-intervention period, 1165 were admitted. Thirty-eight pre-intervention patients (3.5%) and 23 post-intervention patients (2.0%) developed a pressure injury ( =0.028). The incidence of decubitus injuries was markedly reduced in the post-intervention period (36 8 injuries, P < 0.001). After adjusting for Acute Physiology and Chronic Health Evaluation (APACHE) III score, duration of intubation and age, the odds ratio for developing a pressure injury in the post-intervention period was 0.51 (95% CI, 0.27-0.97) ( =0.041). For mechanically ventilated patients, the adjusted odds ratio for developing a decubitus pressure injury in the post-intervention period was 0.22 (95% CI, 0.06-0.85) ( =0.029).

Conclusions: A change in turn frequency from 5-hourly to 3-hourly was associated with a halved incidence of pressure injuries. Critically ill patients may benefit from more frequent turns.
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September 2018

Preoperative Staging by EBUS in cN0/N1 Lung Cancer: Systematic Review and Meta-Analysis.

J Bronchology Interv Pulmonol 2019 Jul;26(3):155-165

Department of Medicine, University of Melbourne.

Background: Performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for staging the radiologically normal mediastinum has been reported with inconsistent findings. We assessed the sensitivity of systematic staging using EBUS-TBNA for detection of radiologically occult mediastinal metastases in cN0/N1 lung cancer.

Methods: Studies evaluating EBUS-TBNA for systematic mediastinal staging in cN0/N1 lung cancer were identified by systematic review. Data extracted included: participant age and sex; EBUS-TBNA protocol; stage determined by radiology, EBUS-TBNA and surgery; 2×2 tables. Primary outcome was diagnostic accuracy of EBUS-TBNA for detection of unsuspected N2/N3 disease.

Results: We identified 1173 articles. In total, 13 were included in a qualitative review and 9 (1146 patients) in a quantitative meta-analysis. Mean prevalence of N2/N3 disease was 15% (6% to 24%). EBUS-TBNA had pooled sensitivity of 49% [95% confidence interval (CI), 41%-57%], pooled specificity of 100% (95% CI, 99%-100%), mean negative predictive value 91% (82% to 100%) for detection of unsuspected N2/N3 metastases. Number needed to test to detect occult N2/N3 disease was 14 (95% CI, 10.8-16.3), which halved with addition of per-esophageal endoscopic ultrasound.

Conclusion: Preoperative systematic staging by EBUS-TBNA of early lung cancer can reduce postoperative upstaging. Sensitivity for detection of radiologically occult mediastinal metastases seems lower than selective sampling of pathologic lymph nodes. Verification of negative results by mediastinoscopy in selected cases remains of value.
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http://dx.doi.org/10.1097/LBR.0000000000000545DOI Listing
July 2019

Factors influencing reoperation following breast-conserving surgery.

ANZ J Surg 2018 09 15;88(9):922-927. Epub 2018 May 15.

The Breast Service, The Royal Melbourne and The Royal Women's Hospital, Melbourne, Victoria, Australia.

Background: Reoperation rates after breast-conserving surgery are highly variable and the best techniques for optimizing margin clearance are being evaluated. The aim was to identify the reoperation rate at our centre and identify influential factors, including a change in guidelines on margin recommendations and the introduction of in-theatre specimen X-ray.

Methods: A retrospective review of medical records was undertaken to identify 562 patients who underwent breast conservation at The Royal Melbourne Hospital and Royal Women's Hospital between 2013 and 2015. All cases that underwent subsequent re-excision or total mastectomy were captured and factors influencing margin excision recorded.

Results: Reoperation was undertaken in 19.5% of patients (110; 86 re-excisions and 24 total mastectomies). There was a reduction in reoperation rate from 25% to 17% (P = 0.01) with adoption of the margin guidelines in 2014, but no significant reduction with the introduction of in-theatre specimen X-ray in 2015 (21% versus 16%, P = 0.14). On multivariate analysis, factors that significantly influenced reoperation rates were the presence of multifocality on mammogram (odds ratio (OR): 5.3, 95% confidence interval (CI): 1.6-16.7, P < 0.01); lesion size on mammogram (OR: 2.2 per 10 mm, 95% CI: 1.4-3.6, P < 0.01); smaller excision specimen weight (OR: 0.5 per 25 g of resection, 95% CI: 0.3-0.8, P < 0.01); and pure ductal carcinoma in situ on final pathology (OR: 5.9, 95% CI: 1.9-16.7, P < 0.01).

Conclusion: Optimizing reoperation rates following breast-conserving surgery remains a surgical challenge, particularly in patients with in situ or multifocal disease. Adoption of international margin guidelines reduced reoperation rates at our centre; however, introduction of intraoperative specimen X-ray had no influence.
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http://dx.doi.org/10.1111/ans.14467DOI Listing
September 2018

Examination of the relationship between disease activity and patient-reported outcome measures in an inflammatory bowel disease cohort.

Intern Med J 2018 Oct;48(10):1234-1241

Department of Gastroenterology, The Austin Hospital, Melbourne, Victoria, Australia.

Background: The extent to which disease activity impacts patient-reported outcomes (PRO) is unclear.

Aims: To examine the relationship between disease activity and PRO.

Methods: Adult inflammatory bowel disease (IBD) patients attending a tertiary clinic from May to June 2015 were included. Assessment of disease activity (Simple Clinical Colitis Activity Index (SCCAI), Harvey Bradshaw Index (HBI)), IBD knowledge (CCKNOW), medication adherence (MMAS8), psychological distress (Hospital Anxiety and Depression Scale (HADS)), work productivity (WPAI) and quality of life (IBDQ) was performed to investigate any correlations between disease activity and PRO.

Results: A total of 81 participants was included: 49% female, 57% Crohn disease (CD), 38% ulcerative colitis (UC) and 5% IBD-unclassified, with a median age of 34 years. At least mild levels of depression were present in 21 of 81 (26%) of patients; 37 of 81 (46%) expressed some level of anxiety. A moderate-to-strong correlation was found between disease activity and depression in UC (r = 0.84, P = 0.002) but not in CD (r = 0.53, P = 0.29). Disease activity correlated with: overall work impairment due to health (r = 0.85, P = 0.001), health-related impairment while working (r = 0.76, P = 0.02) and percentage of activity impaired due to health (r = 0.83, P = 0.002) in UC only.

Conclusions: Disease activity significantly affects mood and work productivity in patients with UC. Monitoring patients' ability to function and work, rather than minimising disease activity alone, should become a routine part of IBD care.
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http://dx.doi.org/10.1111/imj.13937DOI Listing
October 2018

Breathlessness and palliative oxygen therapy in advanced chronic obstructive pulmonary disease.

Intern Med J 2018 Apr;48(4):483-484

Centre for Palliative Care, St Vincent's Hospital, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1111/imj.13748DOI Listing
April 2018

Influence of ward round order on critically ill patient outcomes.

J Crit Care 2018 06 3;45:110-113. Epub 2018 Feb 3.

Intensive Care Unit, Royal Melbourne Hospital, Grattan St, Parkville, Melbourne, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.

Purpose: To examine the effect of order in which patients are seen on an Intensive Care Unit (ICU) ward round on ICU length of stay (LOS), mortality and duration of mechanical ventilation.

Materials And Methods: Retrospective observational study in a tertiary metropolitan ICU over a 12month period. All patients who occupied the first and last three bed spaces of the ICU ward round, without having moved bed spaces during admission, were included. Separate analyses were performed for the absolute first and last patients.

Results: 681 patients were included. There was no difference in the primary outcome, ICU LOS [median (IQR) 50 (23-102) hours for the first three patients seen vs. 51 (25-110) hours for the last three patients, p=0.594]. No differences were found in any secondary outcomes (hospital LOS, ICU mortality or duration of mechanical ventilation).

Conclusions: The order in which patients were seen on an ICU ward did not affect ICU LOS nor related outcomes.
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http://dx.doi.org/10.1016/j.jcrc.2018.02.003DOI Listing
June 2018

Assessment of Bronchoscopic Dexterity and Procedural Competency in a Low-fidelity Simulation Model.

J Bronchology Interv Pulmonol 2018 Jul;25(3):198-203

Departments of Respiratory Medicine.

Background: Assessment of competency in bronchoscopy has traditionally been undertaken in clinical settings, however, recent recognition of increased procedural complications and learner anxiety have led to interest in simulation-based competency assessment. The aim of this study was to determine if low-fidelity simulation-based assessment allows discrimination of competency based on prior experience between bronchoscopists.

Methods: Forty-four participants were allocated to 3 groups based on prior bronchoscopic experience [novices (n=31) with no prior experience, intermediates (n=7) with prior experience of 5 to 10 bronchoscopies, and expert bronchoscopists (n=6) with minimum 200 prior bronchoscopies performed]. Participants performed bronchoscopy in a 3D-printed anatomic airway model and were assessed according to time required to navigate to a target bronchus. Bronchoscopic dexterity was measured using a modified version of the validated Bronchoscopy Skills and Tasks Assessment Tool.

Results: Competency based on successful navigation to a target bronchus differed significantly between each group [experts, 12/12 (100%); intermediates, 9/14 (64%); novices, 19/62 (31%); P<0.001]. Bronchoscopic dexterity as measured by modified Bronchoscopy Skills and Tasks Assessment Tool also differed significantly between groups with experts achieving consistently higher scores compared with other 2 groups [median (interquartile range) scores: novices, 3.5 (2.5 to 5); intermediate, 5 (4.5 to 7); experts, 8 (7.5 to 8); P<0.0.001).

Conclusions: Multiple measures demonstrate that low-fidelity simulation-based assessment may reliably discriminate between different levels of skill in performing bronchoscopic navigation and airway inspection. Procedural dexterity of trainees may be assessed in a 0-risk simulation environment.
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http://dx.doi.org/10.1097/LBR.0000000000000481DOI Listing
July 2018