Publications by authors named "Fergus Gardiner"

31 Publications

Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a systematic review and individual participant data meta-analysis.

Lancet Gastroenterol Hepatol 2021 Jul 27;6(7):547-558. Epub 2021 Apr 27.

Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA.

Background: Ursodeoxycholic acid is commonly used to treat intrahepatic cholestasis of pregnancy, yet its largest trial detected minimal benefit for a composite outcome (stillbirth, preterm birth, and neonatal unit admission). We aimed to examine whether ursodeoxycholic acid affects specific adverse perinatal outcomes.

Methods: In this systematic review and individual participant data meta-analysis, we searched PubMed, Web of Science, Embase, MEDLINE, CINAHL, Global Health, MIDIRS, and Cochrane without language restrictions for relevant articles published between database inception, and Jan 1, 2020, using search terms referencing intrahepatic cholestasis of pregnancy, ursodeoxycholic acid, and perinatal outcomes. Eligible studies had 30 or more study participants and reported on at least one individual with intrahepatic cholestasis of pregnancy and bile acid concentrations of 40 μmol/L or more. We also included two unpublished cohort studies. Individual participant data were collected from the authors of selected studies. The primary outcome was the prevalence of stillbirth, for which we anticipated there would be insufficient data to achieve statistical power. Therefore, we included a composite of stillbirth and preterm birth as a main secondary outcome. A mixed-effects meta-analysis was done using multi-level modelling and adjusting for bile acid concentration, parity, and multifetal pregnancy. Individual participant data analyses were done for all studies and in different subgroups, which were produced by limiting analyses to randomised controlled trials only, singleton pregnancies only, or two-arm studies only. This study is registered with PROSPERO, CRD42019131495.

Findings: The authors of the 85 studies fulfilling our inclusion criteria were contacted. Individual participant data from 6974 women in 34 studies were included in the meta-analysis, of whom 4726 (67·8%) took ursodeoxycholic acid. Stillbirth occurred in 35 (0·7%) of 5097 fetuses among women with intrahepatic cholestasis of pregnancy treated with ursodeoxycholic acid and in 12 (0·6%) of 2038 fetuses among women with intrahepatic cholestasis of pregnancy not treated with ursodeoxycholic acid (adjusted odds ratio [aOR] 1·04, 95% CI 0·35-3·07; p=0·95). Ursodeoxycholic acid treatment also had no effect on the prevalence of stillbirth when considering only randomised controlled trials (aOR 0·29, 95% CI 0·04-2·42; p=0·25). Ursodeoxycholic acid treatment had no effect on the prevalence of the composite outcome in all studies (aOR 1·28, 95% CI 0·86-1·91; p=0·22), but was associated with a reduced composite outcome when considering only randomised controlled trials (0·60, 0·39-0·91; p=0·016).

Interpretation: Ursodeoxycholic acid treatment had no significant effect on the prevalence of stillbirth in women with intrahepatic cholestasis of pregnancy, but our analysis was probably limited by the low overall event rate. However, when considering only randomised controlled trials, ursodeoxycholic acid was associated with a reduction in stillbirth in combination with preterm birth, providing evidence for the clinical benefit of antenatal ursodeoxycholic acid treatment.

Funding: Tommy's, the Wellcome Trust, ICP Support, and the National Institute for Health Research.
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http://dx.doi.org/10.1016/S2468-1253(21)00074-1DOI Listing
July 2021

Pregnancy-related aeromedical retrievals in rural and remote Australia: national evidence from the Royal Flying Doctor Service.

BMC Health Serv Res 2021 Apr 26;21(1):390. Epub 2021 Apr 26.

Royal Flying Doctor Service of Australia, Canberra, ACT, Australia.

Background: Inequalities in the availability of maternity health services in rural Australia have been documented, but not the impact on aeromedical retrievals. This study aims to examine the prevalence of pregnancy-related aeromedical retrievals, the most common conditions (overall and in specific age groups), and their distribution according to operation area and demographic characteristics.

Methods: Cross-sectional study using administrative data from the Royal Flying Doctors Service (RFDS) including all pregnant women aged 15-49 years retrieved by the RFDS between 2015 and 2019. All pregnancy-related aeromedical retrievals were classified according to the International Classification of Diseases, Tenth Revision (ICD-10, chapter XV). The distribution of pregnancy-related conditions was presented overall and stratified by age group (i.e. < 20 years, 20-34 years and 35+ years). Retrieval and receiving sites were geographically mapped with Tableau mapping software® based on postcode numbers of origin and destination.

Results: A total of 4653 pregnancy-related retrievals were identified (mean age 27.8 ± 6.1 years), representing 3.1% of all RFDS transfers between 2015 and 18 and 3.5% in 2018-19 (p-value 0.01). The highest proportion of pregnancy-related retrievals (4.8%) occurred in Western operation. There was an apparent increase in pregnancy-related retrievals in South Australia and the Northern Territory (Central Operation) in 2018-19. Preterm labour/delivery was responsible for 36.4% of all retrievals (40.7% among women aged 15-19 years) and premature rupture of membranes for 14.9% (19.4% among women aged 35-49 years). Inter-hospital transfers represented 87.9% of all retrievals, with most patients relocated from rural and remote regions to urban hospitals; most retrievals occurred during the day, with a median distance of 300 km. Adolescents and Aboriginal and Torres Strait Islander were overrepresented in the sample (four and eight times higher than their metropolitan counterparts, respectively).

Conclusions: The proportion of pregnancy-related aeromedical retrievals varies geographically across Australia. Overall, one-third of retrievals were related to preterm/delivery complications, especially among adolescents. Most retrievals performed by the RFDS are susceptible to public health strategies aimed at improving antenatal care and preventing unintended pregnancies among adolescents and Aboriginal and Torres Strait Islander women. Greater capacity to manage pregnancy conditions in rural hospitals could reduce the requirement for aeromedical inter-hospital transfers.
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http://dx.doi.org/10.1186/s12913-021-06404-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8077896PMC
April 2021

Characteristics and in-hospital outcomes of patients requiring aeromedical retrieval for pregnancy, compared to non-retrieved metropolitan cohorts.

Aust N Z J Obstet Gynaecol 2021 Jan 10. Epub 2021 Jan 10.

Australian National University Medical School, College of Health and Medicine, The Australian National University, Canberra, Australian Capital Territory, Australia.

Background: Limited access to obstetrics and gynaecology (O&G) services in rural and remote Australia is believed to contribute to suboptimal birth outcomes.

Aims: To describe the characteristics of pregnancy aeromedical transfers, in-hospital outcomes, and patient access to O&G services, as compared to whole of Australia data.

Materials And Methods: We conducted a cohort study of women who required aeromedical retrieval for pregnancy-related issues between the 1 January 2015 and 31 December 2017.

Results: Hospital outcome data were collected on 2171 (65.2%) mothers and 2438 (100.0%) babies. The leading retrieval reason was threatened preterm labour and delivery (n = 883; 40.7%). Most patients were retrieved from rural and remote areas (n = 2224; 93.0%). Retrieved patients were significantly younger (28.0 vs 30.0 years, 95% CI 27.7-28.3), more likely to be overweight or obese (52.2% vs 45.1%, 95% CI 47.5-56.9) and to have smoked during their pregnancy (14.0% vs 9.9%, 95% CI 12.5-15.5) compared to Australian pregnant women overall. Over one-third of transferred women gave birth by Caesarean section (n = 812; 37.4%); the median gestational age at birth was 33.0 (95% CI 32.7-33.3) weeks. Early gestation is associated with low birth weights (median = 2579.5 g; 95% CI 2536.1-2622.9), neonatal resuscitation (35.4%, 95% CI 33.5-37.3), and special care nursery admission (41.2%, 95% CI 39.3-43.2). There were 42 (1.7%, 95% CI 1.2-2.2) stillbirths, which was significantly higher than seen Australia-wide (n = 6441; 0.7%).

Conclusion: This study found that pregnant women retrieved by the Royal Flying Doctor Service were younger, with higher rates of obesity and smoking.
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http://dx.doi.org/10.1111/ajo.13308DOI Listing
January 2021

Western Australia.

Lancet Psychiatry 2021 01;8(1):22

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http://dx.doi.org/10.1016/S2215-0366(20)30520-4DOI Listing
January 2021

Mental Health Care for Rural and Remote Australians During the Coronavirus Disease 2019 Pandemic.

Air Med J 2020 Nov - Dec;39(6):516-519. Epub 2020 Sep 8.

The Rural Clinical School of Western Australia, University of Western Australia, Albany, Western Australia, Australia.

The aims of this article are to comment on pre-coronavirus disease 2019 (COVID-19) mental health activity in rural and remote Australia, including related air medical retrievals; to discuss how the current pandemic is likely to impact on this vulnerable population's mental health; and to provide potential solutions. The COVID-19 pandemic has resulted in significant air medical activity from rural and remote Australia. COVID-19 and the necessary public health and socioeconomic interventions are likely to significantly compound mental health problems for both the general public and the mental health workforce servicing rural and remote communities. However, the COVID-19 crisis provides a window of opportunity to develop, support, and build novel and sustainable solutions to the chronic mental health service vulnerabilities in rural and remote areas in Australia and other countries.
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http://dx.doi.org/10.1016/j.amj.2020.08.008DOI Listing
December 2020

Aeromedical retrieval diagnostic trends during a period of Coronavirus 2019 lockdown.

Intern Med J 2020 12;50(12):1457-1467

Federation Office, The Royal Flying Doctor Service, Canberra, Australian Capital Territory, Australia.

Background: Little is known on the trends of aeromedical retrieval (AR) during social isolation.

Aim: To compare the pre, lockdown, and post-lockdown AR patient characteristics during a period of Coronavirus 2019 (COVID-19) social isolation.

Methods: An observational study with retrospective data collection, consisting of AR between 26 January and 23 June 2020.

Results: There were 16 981 AR consisting of 1983 (11.7%) primary evacuations and 14 998 (88.3%) inter-hospital transfers, with a population median age of 52 years (interquartile range 29.0-69.0), with 49.0% (n = 8283) of the cohort being male and 38.0% (n = 6399) being female. There were six confirmed and 230 suspected cases of COVID-19, with the majority of cases (n = 134; 58.3%) in the social isolation period. As compared to pre-restriction, the odds of retrieval for the restriction and post-restriction period differed across time between the major diagnostic groups. This included, an increase in cardiovascular retrieval for both restriction and post-restriction periods (odds ratio (OR) 1.12, 95% confidence interval (CI) 1.02-1.24 and OR 1.18 95%, CI 1.08-1.30 respectively), increases in neoplasm in the post restriction period (OR 1.31, 95% CI 1.04-1.64) and increases for congenital conditions in the restriction period (OR 2.56, 95% CI 1.39-4.71). Cardiovascular and congenital conditions had increased rates of priority 1 patients in the restriction and post restriction periods. There was a decrease in endocrine and metabolic disease retrievals in the restriction period (OR 0.72, 95% CI 0.53-0.98). There were lower odds during the post-restriction period for retrievals of the respiratory system (OR 0.78, 95% CI 0.67-0.93), and disease of the skin (OR 0.78, 95% CI 0.6-1.0). Distribution between the 2019 and 2020 time periods differed (P < 0.05), with the lockdown period resulting in a significant reduction in activity.

Conclusion: The lockdown period resulted in increased AR rates of circulatory and congenital conditions.
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http://dx.doi.org/10.1111/imj.15091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675287PMC
December 2020

Mental Health Crises in Rural and Remote Australia: An Assessment of Direct Medical Costs of Air Medical Retrievals and the Implications for the Societal Burden.

Air Med J 2020 Sep - Oct;39(5):343-350. Epub 2020 Jul 15.

The Rural Clinical School of Western Australia, The University of Western Australia, Western Australia, Australia.

Objective: Adequate mental health service provision in rural and remote Australian communities is problematic because of the tyranny of distance. The Royal Flying Doctor Service provides air medical retrieval for people in rural and remote areas. The economic impact on both the Royal Flying Doctor Service and the public hospital system for mental health-related air medical retrievals is unknown. We aimed to estimate the direct medical costs associated with air medical retrievals and subsequent hospitalizations for mental and behavioral disorders for the 2017 calendar year.

Methods: All patients with a primary working diagnosis of International Statistical Classification of Diseases and Related Health Problems, 10th Version, Australian Modification F00 to F99 (mental and behavioral disorders) who underwent an air medical retrieval were included in this cost analysis. International Statistical Classification of Diseases and Related Health Problems, 10th Edition, Australian Modification codes were mapped to Australian Refined Diagnosis Related Group codes, with hospital costs applied from the National Hospital Cost Data Collection (2016/2017). All costs are reported in 2017 Australian dollars (AUDs).

Results: One hundred twenty-two primary evacuations and 926 interhospital transfers occurred with an in-flight diagnosis of F00 to F99, most commonly psychotic disorders, including schizophrenia and schizotypal disorders. The total direct medical costs were estimated to be AUD $20,070,527. Costs for primary evacuations accounted for 13% (AUD $2,611,260), with the majority of this associated with the subsequent hospital admission (AUD $1,770,139). Similarly, the majority of the costs associated with interhospital transfers (total costs = AUD $17,459,267) were also related to hospital costs (AUD $13,569,187).

Conclusion: Direct medical costs associated with air medical retrievals for people experiencing a mental health crisis are substantial. The majority of costs are associated with hospital admission and treatment; however, the indirect (loss of productivity) and intangible (quality of life) costs are likely to be far greater.
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http://dx.doi.org/10.1016/j.amj.2020.06.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7362830PMC
July 2020

Aeromedical Retrieval for Stroke in Australia.

Cerebrovasc Dis 2020 24;49(3):334-340. Epub 2020 Jun 24.

Royal Melbourne Hospital, Parkville, Melbourne, Victoria, Australia.

Introduction: Rural, remote, and Indigenous stroke patients have worse stroke outcomes than urban Australians. This may be due to lack of timely access to expert facilities.

Objectives: We aimed to describe the characteristics of patients who underwent aeromedical retrieval for stroke, estimate transfer times, and investigate if flight paths corresponded with the locations of stroke units (SUs) throughout Australia.

Methods: Prospective review of routinely collected Royal Flying Doctor Service (RFDS) data. Patients who underwent an RFDS aeromedical retrieval for stroke, July 2014-June 2018 (ICD-10 codes: I60-I69), were included. To define the locations of SUs throughout Australia, we accessed data from the 2017 National Stroke Audit. The main outcome measures included determining the characteristics of patients with an in-flight diagnosis of stroke, their subsequent pickup and transfer locations, and corresponding SU and imaging capacity.

Results: The RFDS conducted 1,773 stroke aeromedical retrievals, consisting of 1,028 (58%) male and 1,481 (83.5%) non-Indigenous and 292 (16.5%) Indigenous patients. Indigenous patients were a decade younger, 56.0 (interquartile range [IQR] 45.0-64.0), than non-Indigenous patients, 66.0 (IQR 54.0-76.0). The most common diagnosis was "stroke not specified," reflecting retrieval locations without imaging capability. The estimated median time for aeromedical retrieval was 238 min (95% confidence interval: 231-244). Patients were more likely to be transferred to an area with SU and imaging capability (both p < 0.0001).

Conclusion: Stroke patients living in rural areas were younger than those living in major cities (75 years, Stroke Audit Data), with aeromedically retrieved Indigenous patients being a decade younger than non-Indigenous patients. The current transfer times are largely outside the time windows for reperfusion methods. Future research should aim to facilitate more timely diagnosis and treatment of stroke.
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http://dx.doi.org/10.1159/000508578DOI Listing
November 2020

Rural and remote dental care: Patient characteristics and health care provision.

Aust J Rural Health 2020 Jun 27;28(3):292-300. Epub 2020 May 27.

The Royal Flying Doctor Service, Canberra, ACT, Australia.

Objective: To describe the characteristics of patients who used the Royal Flying Doctor Service dental clinics and determine Royal Flying Doctor Service and non-Royal Flying Doctor Service dental service provision in mainland Australia.

Design: A prospective cohort study.

Setting: All Royal Flying Doctor Service dental clinics located throughout rural and remote Australia.

Participants: All patients who accessed an Royal Flying Doctor Service dental clinic from April 2017 to September 2018.

Interventions: Royal Flying Doctor Service mobile dental clinics.

Main Outcome Measures: Patient demographics and dental procedures conducted (by age, sex and Indigenous status); and the dental service provision and coverage (Royal Flying Doctor Service and non-Royal Flying Doctor Service) within mainland rural and remote Australia.

Results: There were 8992 patient episodes comprising 3407 individual patients with 27 897 services completed. There were 920 (27%) Indigenous and 1465 (43%) non-Indigenous patients (n = 1022 missing ethnicity data). The mean (SD) age was 31.5 (24.8) years; the age groups 5-9 years and 10-14 years received 17.6% and 15.1% of the services, respectively. There were 1124 (33%) men and 1295 (38%) women (n = 988 with missing sex data). Women were more likely (all P < .05) to receive preventive services, diagnostic services, restorative services, general services, endodontics and periodontics. Men were more likely (both P < .05) to receive oral surgery and prosthodontics. There are many rural and remote people required to travel more than 60 minutes by vehicle to access dental care.

Conclusion: Without increasing dental provision and preventive services in rural areas, it seems likely that there are and will be unnecessary oral emergencies and hospitalisations.
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http://dx.doi.org/10.1111/ajr.12631DOI Listing
June 2020

Aeromedical retrievals for gastrointestinal disorders in rural and remote Australia: the need for improved access to specialist advice.

Intern Med J 2020 05;50(5):619-623

Department of Gastroenterology and Hepatology, RAH and University of Adelaide, Adelaide, Australia.

The Royal Flying Doctor Service (RFDS) provides medical care to populations without access to traditional health-care services. From 2014 to 2018 the RFDS conducted 6007 (≈1201/year) aeromedical retrievals for gastrointestinal (GI) disorders. More detailed research is needed to determine specific GI disorders that contributed to this caseload, and in particular inform whether the establishment of a GI specialist service is justified.
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http://dx.doi.org/10.1111/imj.14822DOI Listing
May 2020

Royal Flying Doctor Service Coronavirus Disease 2019 Activity and Surge Modeling in Australia.

Air Med J 2020 Sep-Oct;39(5):404-409. Epub 2020 May 16.

Department of Medicine at Austin Health, The University of Melbourne, Melbourne, Australia.

Objective: There is a coronavirus disease 2019 (COVID-19) pandemic. We aimed to describe the characteristics of patients transported by the Royal Flying Doctor Service (RFDS) for confirmed or suspected COVID-19 and to investigate the surge capacity of and operational implications for the RFDS in dealing with COVID-19.

Methods: This was a prospective cohort study. To determine the characteristics of patients transported for confirmed or suspected COVID-19, we included patient data from February 2, 2020, to May 6, 2020. To investigate the surge capacity and operational implications for the RFDS in dealing with COVID-19, we built and validated an interactive operations area-level discrete event simulation decision support model underpinned by RFDS air medical activity data from 2015 to 2019 (4 years). This model was subsequently used in a factorial in silico experiment to systematically investigate both the supply of RFDS air medical services and the increased rates of demand for these services for diseases of the respiratory system.

Results: The RFDS conducted 291 patient episodes of care for confirmed or suspected COVID-19. This included 288 separate patients, including 136 men and 119 women (sex missing = 33), with a median age of 62.0 years (interquartile range, 43.5-74.9 years). The simulation decision support model we developed is capable of providing dynamic and real-time support for RFDS decision makers in understanding the system's performance under uncertain COVID-19 demand. With increased COVID-19-related demand, the ability of the RFDS to cope will be driven by the number of aircraft available. The simulation model provided each aviation section with estimated numbers of aircraft required to meet a range of anticipated demands.

Conclusion: Despite the lack of certainty in the actual level of COVID-19-related demand for RFDS services, modeling demonstrates that the robustness of meeting such demand increases with the number of operational and medically staffed aircraft.
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http://dx.doi.org/10.1016/j.amj.2020.05.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7229980PMC
October 2020

Nurse-led psychological intervention reduces anxiety symptoms and improves quality of life following percutaneous coronary intervention for stable coronary artery disease.

Aust J Rural Health 2020 Apr 20;28(2):124-131. Epub 2020 Jan 20.

Department of Cardiology and Nursing, Liaocheng People's Hospital, Liaocheng City, China.

Objective: To study the effect of nurse-led counselling on the anxiety symptoms and the quality of life following percutaneous coronary intervention for stable coronary artery disease.

Design: Randomised control trial.

Setting: Rural and remote China.

Participants: Rural and remote patients were consecutively recruited from a medical centre located in China between January and December 2014.

Interventions: The control group received standard pre-procedure information from a ward nurse on the processes of the hospitalisation and percutaneous coronary intervention, and post-procedural care. The intervention group received a structured 30-minute counselling session the day before and 24 hours after the percutaneous coronary intervention, by nurse consultants with qualifications in psychological therapies and counselling. The health outcomes were assessed by a SF-12 scale and the Seattle Angina Questionnaire at 6 and 12 months after percutaneous coronary intervention. The anxiety and depression symptoms were evaluated by a Zung anxiety and depression questionnaire.

Main Outcome Measures: Cardiac outcomes, quality of life and mental health status.

Results: Eighty patients were randomly divided into control (n = 40) and intervention groups (n = 40). There was a significant increase in the scores of the three domains of Seattle Angina Questionnaire 12 months after percutaneous coronary intervention in the intervention group (P < .01). The mental health and physical health scores also increased (P < .01). In the control group, the mean scores of Zung self-rating anxiety scale 12 months following percutaneous coronary intervention were higher than the baseline scores, and higher than in the intervention group (P < .01).

Conclusions: Counselling by a clinician qualified in psychological therapies and counselling significantly reduces anxiety symptoms and improves quality of life.
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http://dx.doi.org/10.1111/ajr.12587DOI Listing
April 2020

Poor access to kidney disease management services in susceptible patient populations in rural Australia is associated with increased aeromedical retrievals for acute renal care.

Intern Med J 2020 08;50(8):951-959

The Royal Flying Doctor Service, Australia.

Background: Inequalities in access to renal services and acute care for rural and remote populations in Australia have been described but not quantified.

Aim: To describe: the coverage of renal disease management services in rural and remote Australia; and the characteristics of patients who had an aeromedical retrieval for renal disease by Australia's Royal Flying Doctor Service (RFDS).

Methods: Data from the RFDS, the Australian Bureau of Statistics, and Health Direct were used to estimate provision of renal disease management services by geographic area. RFDS patient diagnostic data were prospectively collected from 2014 to 2018.

Results: Many rural and remote areas have limited access to regular renal disease management services. Most RFDS retrievals for renal disease are from regions without such services. The RFDS conducted 1636 aeromedical retrievals for renal disease, which represented 1.6% of all retrievals. Among retrieved patients, there was a higher proportion of men than women (54.6% vs 45.4%, P < 0.01), while indigenous patients (n = 546, 33.4%) were significantly younger than non-indigenous patients (40.9 vs 58.5, P < 0.01). There were significant differences in underlying diagnoses triggering retrievals between genders, with males being more likely than females to be transferred with acute renal failure, calculus of the kidney and ureter, renal colic, obstructive uropathy, and kidney failure (all P < 0.01). Conversely, females were more likely to have chronic kidney disease, disorders of the urinary system, acute nephritic syndrome, tubulo-interstitial nephritis, and nephrotic syndrome (all P < 0.01).

Conclusion: Aeromedical retrievals for acute care were from rural areas without regular access to renal disease prevention or management services.
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http://dx.doi.org/10.1111/imj.14716DOI Listing
August 2020

Faecal calprotectin testing for identifying patients with organic gastrointestinal disease: systematic review and meta-analysis.

Med J Aust 2019 11 3;211(10):461-467. Epub 2019 Nov 3.

Mater Hospital Brisbane, Brisbane, QLD.

Objectives: To assess the clinical effectiveness of faecal calprotectin (FC) testing for distinguishing between organic gastrointestinal diseases (organic GID), such as inflammatory bowel disease (IBD), and functional gastrointestinal disorders (functional GIDs).

Study Design: Studies that assessed the accuracy of FC testing for differentiating between IBD or organic GID and functional GIDs were reviewed. Articles published in English during January 1998 - June 2018 that compared diagnostic FC testing in primary care and outpatient hospital settings with a reference test and employed the standard enzyme-linked immunosorbent FC assay method with a cut-off of 50 or 100 μg/g faeces were included. Study quality was assessed with QUADAS-2, an evidence-based quality assessment tool for diagnostic accuracy studies.

Data Sources: MEDLINE and EMBASE; reference lists of screened articles.

Data Synthesis: Eighteen relevant studies were identified. For distinguishing patients with organic GID (including IBD) from those with functional GIDs (16 studies), the estimated sensitivity of FC testing was 81% (95% CI, 74-86%), the specificity 81% (95% CI, 71-88%); area under the curve (AUC) was 0.87. For distinguishing IBD from functional GIDs (ten studies), sensitivity was 88% (95% CI, 80-93%), specificity 72% (95% CI, 59-82%), and AUC 0.89. Assuming a population prevalence of organic GID of 1%, the positive predictive value was 4.2%, the negative predictive value 100%. The difference in sensitivity and specificity between FC testing cut-offs of 50 μg/g and 100 μg/g faeces was not statistically significant (P = 0.77).

Conclusions: FC testing is clinically useful for distinguishing organic GID (including IBD) from functional GIDs, and its incorporation into clinical practice for evaluating patients with lower gastrointestinal symptoms could lead to fewer patients with functional GIDs undergoing colonoscopy, reducing costs for both patients and the health system.

Prospero Registration: CRD4201810507.
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http://dx.doi.org/10.5694/mja2.50384DOI Listing
November 2019

The prevalence and pregnancy outcomes of intrahepatic cholestasis of pregnancy: A retrospective clinical audit review.

Obstet Med 2019 Sep 25;12(3):123-128. Epub 2018 Oct 25.

The Canberra Hospital, Canberra, Australia.

Background: To determine the prevalence and outcomes of intrahepatic cholestasis of pregnancy.

Methods: A review comparing intrahepatic cholestasis of pregnancy pregnancies to all other pregnancies in three tertiary care Australian hospitals over a 36-month period.

Results: There were 43,876 pregnancies. The prevalence of intrahepatic cholestasis of pregnancies ( = 319) was 0.7%. There were differences between intrahepatic cholestasis of pregnancy and non-intrahepatic cholestasis of pregnancy mothers including higher prevalence of South Asian (22.6% versus 3.1%, p < 0.001), Indigenous Australian (3.8% versus 1.8%, p < 0.05), and Asian ethnicity (8.4% versus 5.7%, p < 0.05), mothers with a body mass index >35 kg/m (10.6% versus 5.5%, p < 0.001), those with diabetes mellitus (25.7% versus 9.8%, p < 0.001), and those with twin births (8.7% versus 2.2%, p < 0.001). The primary clinical outcomes of intrahepatic cholestasis of pregnancy included a median gestational age at delivery of 36.4 (SE 0.09) weeks compared to 38.6 (SE 0.01) weeks (p < 0.001), a lower birth weight (3.12 (SE 0.03) versus 3.31 kg (SE 0.03), p < 0.001), and an increase in special care nursery admissions (44.5% versus 15.3%, p < 0.001).

Conclusion: Treated intrahepatic cholestasis of pregnancy in the population described here had similar mortality outcomes although increased special care nursery admission as compared to the general population.
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http://dx.doi.org/10.1177/1753495X18797749DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6734627PMC
September 2019

Aeromedical retrievals of people for mental health care and the low level of clinical support in rural and remote Australia.

Med J Aust 2019 10 25;211(8):351-356. Epub 2019 Jul 25.

Royal Flying Doctor Service of Australia, Canberra, ACT.

Objectives: To characterise the people retrieved by the Royal Flying Doctor Service (RFDS) for treatment of mental and behavioural disorders, and to assess mental health care provision in rural and remote areas.

Design: Prospective review of routinely collected RFDS and Health Direct data.

Setting, Participants: RFDS aeromedical retrievals of patients from anywhere in Australia except Tasmania during 1 July 2014 - 30 June 2017 for the treatment of mental or behavioural disorders.

Main Outcome Measures: Retrievals by ICD-10 mental and behavioural disorder diagnoses.

Results: 2257 patients were retrieved by the RFDS for treatment of mental or behavioural disorders, including 1394 males (62%) and 863 females (38%); 60% of patients were under 40 years of age, 35% identified as Indigenous Australians. The most frequent mental and behavioural disorders were schizophrenia (227 retrievals, 16.5% of retrievals with ICD diagnoses), bipolar affective disorder (185, 13.5%), and depressive episodes (153, 11.2%). Psychoactive substance misuse triggered 194 retrievals (14.2%), including misuse of multiple drugs (85, 6.2%), alcohol (61, 4.5%), and cannabinoids (25, 1.8%). The mean age of patients retrieved for treatment of substance misuse (29.6 years; SD, 11.6 years) was lower than for retrieved patients overall (37.0 years; SD, 19.3 years); 38 of 194 patients retrieved after psychoactive substance misuse (19.6%) were under 19 years of age. Most retrieval sites were rural and remote communities with low levels of mental health care support.

Conclusion: Mental and behavioural disorders are an important problem in rural and remote communities, and acute presentations trigger a considerable number of RFDS retrievals.
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http://dx.doi.org/10.5694/mja2.50272DOI Listing
October 2019

A nurse-led structured education program improves self-management skills and reduces hospital readmissions in patients with chronic heart failure: a randomized and controlled trial in China.

Rural Remote Health 2019 05 22;19(2):5270. Epub 2019 May 22.

Department of Cardiology, Liaocheng People's Hospital, Liaocheng, Shandong, 252000, China; and School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW 2650, Australia

Introduction: Patient self-management skills are an important part of heart failure (HF) management. However, there is a lack of knowledge about the effectiveness of nurse-led education on patient self-management and the associated clinical outcomes of rural Chinese patients with chronic heart failure (CHF). As such, this study was designed to evaluate the impact of a nurse-led education program on patient self-management and hospital readmissions in rural Chinese patients with CHF.

Methods: Ninety-six patients in the eastern Chinese province of Shandong with CHF were randomly divided into intervention and control groups. A structured education program was delivered to the intervention group during hospitalization and after discharge. Control group patients were managed as per clinical guidelines without structured education. Medication adherence, dietary modifications, social support, and symptom control were assessed 12 months after the educational intervention.

Results: The mean score of medication adherence, dietary modifications, social support and symptom control in the intervention group was higher than in the control group at the end of the study (p<0.01). The readmission rates for HF in the intervention and control group were 10.4% and 27.1%, respectively (p=0.036).

Conclusions: This study has demonstrated that a structured education program was associated with a significant improvement in medication adherence, dietary modifications, social support, and symptom control in rural CHF patients. Furthermore, this program was associated with a significant reduction in hospital readmission. This study indicates that implementation of a nurse-led education program improves self-management and clinical outcomes of rural CHF patients, who may not have regular access to cardiac management services as per metropolitan populations.
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http://dx.doi.org/10.22605/RRH5270DOI Listing
May 2019

Periodontal pathogens in the placenta and membranes in term and preterm birth.

Placenta 2018 08 30;68:40-43. Epub 2018 Jun 30.

The Canberra Hospital, Garran, ACT, 2605, Australia; The Australian National University Medical School, Canberra, ACT, 0200, Australia.

Introduction: Preterm birth is a common cause of adverse neonatal and childhood outcomes. It is commonly associated with infection of the maternal-fetal interface. The relationship between periodontitis and preterm labour is controversial.

Methods: Control placental tissues from uncomplicated term births were compared with those from spontaneous preterm births for incidence of common periodontal bacteria. A chi-square analysis was used to compare the populations, with significance determined at p=<0.05.

Results: The study group comprised 29 control women who had an uncomplicated term birth, 25 delivered by caesarean section and 4 vaginal deliveries, and 36 women with a spontaneous preterm labour and subsequent delivery at less than 34 weeks gestation. There were significant (p=<0.05) differences between the preterm and term groups maternal age with 28.7 compared to 32.0 years old respectively. There was no significant (p=>0.05) differences between the groups fetal risk factors or co-morbidities, except the preterm group had a significantly higher (p=<0.05) rate of premature rupture of membrane (PROM). There were significantly (p=<0.01) more Fusobacterium spp. in the placentas from term births than preterm births.

Discussion: This study found that the common periodontal pathogen, Fusobacterium spp., is not detected more in placentas from preterm birth and may potentially be lower, possibly resulting from bacterial ecological factors in term placentas.
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http://dx.doi.org/10.1016/j.placenta.2018.06.310DOI Listing
August 2018

Does a hospital diabetes inpatient service reduce blood glucose and HbA1c levels? A prospective cohort study.

Ann Med Surg (Lond) 2018 Feb 27;26:15-18. Epub 2017 Dec 27.

School of Biomedical Sciences, Charles Sturt University, Australia.

Background: Diabetes education is believed to bring about sustained benefits in diabetes mellitus (DM) patient outcomes. These benefits have not been widely studied in an inpatient hospital setting, and as such the aim was to determine whether a hospital diabetes in-service, and specifically diabetes education, results in reduced blood glucose and HbA1c levels after hospital discharge.

Methods And Materials: A cohort review was performed at a large teaching hospital, in Canberra, Australia. Sixty seven patients comprising 35 males and 32 females who were referred upon discharge to the Diabetes Services as having a history of uncontrolled DM from February 1st 2015 until January 31st 2016 were evaluated. The retrospective discharge blood glucose level (BGL) was compared to prospective BGL 3 months after hospital discharge. HbA1c was prospectively taken before and 3 months after Diabetes Service education. A between subjects -Test was used to compare patients' glucose and HbA1c averages.

Results: The average discharge BGL result was 13.3 mmol/L, compared to the post-discharge result of 11.2 mmol/L, indicating a significant decrease ( = < 0.01). The average pre-HbA1c result was 10.45%, and decreased to the post-HbA1c result of 8.96%, which was significant ( = <0.05).

Conclusion: This study is the first to measure the direct glucose adherence benefits associated DM education within Australia and provides evidence on the effectiveness of a Diabetes Service in reducing patient BGLs. Utilisation of Diabetes Services to control glycaemia encourages ongoing efforts and translates to reduced micro and macro cardiovascular risk factors associated with DM.
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http://dx.doi.org/10.1016/j.amsu.2017.12.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5904764PMC
February 2018

Similarities between military and medical service: stigma of seeking mental health assistance.

BMJ Mil Health 2020 Jun 16;166(3):181-182. Epub 2018 May 16.

Emergency Department, Calvary Public Hospital, Canberra, Australian Capital Territory, Australia.

Studies have identified that there are many barriers to treatment of mental health illnesses in military populations, including the negative-associated stigma. One such barrier includes perceptions of weakness, leading to concerns about leadership and competency and being seen as malingering. Furthermore, similarities can be seen in civilian health professionals, where concerns of negative perceptions can limit reporting and treatment of mental health illnesses. Despite the frequency of stressful events, military and health professionals do not become immune to stress and are often ill prepared to cope with acute stressors that can often build on each other until emotional exhaustion and/or crisis point. Even with targeted internal programmes, the stigma of seeking mental health assistance in the military and medicine is poor and is believed to contribute to poor outcomes, such as the potential of increased suicide prevalence.
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http://dx.doi.org/10.1136/jramc-2018-000975DOI Listing
June 2020

An Effective Risk Minimization Strategy Applied to an Outdoor Music Festival: A Multi-Agency Approach.

Prehosp Disaster Med 2018 Apr 21;33(2):220-224. Epub 2018 Mar 21.

2St John Ambulance (ACT),Canberra,Australian Capital Territory,Australia.

Specific Event Identifiers a. Event type: Outdoor music festival. b. Event onset date: December 3, 2016. c. Location of event: Regatta Point, Commonwealth Park. d. Geographical coordinates: Canberra, Australian Capital Territory (ACT), Australia (-35.289002, 149.131957, 600m). e. Dates and times of observation in latitude, longitude, and elevation: December 3, 2016, 11:00-23:00. f. Response type: Event medical support. Abstract Introduction Young adult patrons are vulnerable to risk-taking behavior, including drug taking, at outdoor music festivals. Therefore, the aim of this field report is to discuss the on-site medical response during a music festival, and subsequently highlight observed strategies aimed at minimizing substance abuse harm.

Method: The observed outdoor music festival was held in Canberra (Australian Capital Territory [ACT], Australia) during the early summer of 2016, with an attendance of 23,008 patrons. First aid and on-site medical treatment data were gained from the relevant treatment area and service.

Results: The integrated first aid service provided support to 292 patients. Final analysis consisted of 286 patients' records, with 119 (41.6%) males and 167 (58.4%) females. Results from this report indicated that drug intoxication was an observed event issue, with 15 (5.1%) treated on site and 13 emergency department (ED) presentations, primarily related to trauma or medical conditions requiring further diagnostics.

Conclusion: This report details an important public health need, which could be met by providing a coordinated approach, including a robust on-site medical service, accepting intrinsic risk-taking behavior. This may include on-site drug-checking, providing reliable information on drug content with associated education. Luther M , Gardiner F , Lenson S , Caldicott D , Harris R , Sabet R , Malloy M , Perkins J . An effective risk minimization strategy applied to an outdoor music festival: a multi-agency approach. Prehosp Disaster Med. 2018;33(2):220-224.
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http://dx.doi.org/10.1017/S1049023X18000195DOI Listing
April 2018

Adherence to blood pressure and glucose recommendations in chronic kidney disease hospital inpatients: Clinical inertia and patient adherence.

Diabetes Metab Syndr 2018 May 16;12(3):291-300. Epub 2017 Dec 16.

School of Biomedical Sciences, Charles Sturt University, Australia.

Aims: To determine the extent to which targets for blood pressure (BP) (<140.90 mmHg) and random blood glucose level (BGL) (<7.7 mmol/L) control in patients with chronic kidney disease (CKD) are achieved; and the extent clinical inertia affects BP and glucose control in CKD and diabetes mellitus (DM).

Methods: Data was collected from the 1st January 2015 until 31st December 2015 on key patient pathology, admission reason, final discharge diagnosis, and information concerning clinical guideline adherence.

Results: Eighty-seven (n = 87) CKD patients were included. The average hospital BP for all CKD patients was 134.3/73.4 mmHg, adhering to recommendations of <140/90 mmHg. The average CKD patient pre-admission BP was 134.8/72.2 mmHg compared to the discharge BP of 129.8/72.2 mmHg. At admission, 63.3% and 93.1% of patients adhered to systolic and diastolic BP recommendations, which significantly (p = < .05) increased at discharge to a systolic and diastolic BP adherence of 83.9% and 98.8%, respectively. The average random hospital BGL was 7.7 mmol/L, indicating good control, whereas the pre-hospital HbA1c average was 7.58%, indicating poor control (>7.0% >53 mmol/mol). There were 21 cases of clinical inertia, affecting 18 out of 87 patients (20.7%), with significant adverse hospital discharge differences (p = <.05) between clinical inertia and non- clinical inertia patient systolic BP (144.2 vs. 132.8 mmHg), deranged BGL (66.7% vs. 35.3%), and reduction in kidney function (83.3% vs. 30.9%).

Conclusion: Adherence appears to be related to inpatient clinical inertia and outpatient patient health literacy and empowerment.
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http://dx.doi.org/10.1016/j.dsx.2017.12.007DOI Listing
May 2018

Services aimed at achieving desirable clinical outcomes in patients with chronic kidney disease and diabetes mellitus: A narrative review.

SAGE Open Med 2017 17;5:2050312117740989. Epub 2017 Nov 17.

School of Biomedical Sciences, Charles Sturt University, Canberra, ACT, Australia.

There is a large number of patients with chronic kidney disease (CKD), diabetes mellitus (DM), and hypertension (HT) but whether the targets on blood pressure (BP) control in patients with DM and/or CKD are met is not clear. This narrative review therefore investigated evidence on services aimed at achieving desirable clinical results in patients with CKD and DM, and HT in Australia. Literature pertaining to pathology diagnosis and management of these patients as well as the complexities in management were considered. This involved evidence from PubMed-listed articles published between 1993 and 2016 including original research studies, focusing on randomised controlled trials and prospective studies where possible, systematic and other review articles, meta- analyses, expert consensus documents and specialist society guidelines, such as those from the National Heart Foundation of Australia, American Diabetes Association, the Department of Health, The Royal College of Pathologists of Australasia, and The Australasian College of Emergency Medicine. Based on the literature reviewed, it is yet unknown as to how effective programs, such as diabetes inpatient services, endocrine out-patient services, and cardiac rehabilitation services, are at achieving guideline recommendations. It is also not clear how or whether clinicians are encumbered by complexities in their efforts of adhering to DM, HT, and glucose control recommendations, and the potential reasons for clinical inertia. Future studies are needed to ascertain the extent to which required BP and glucose control in patients is achieved, and whether clinical inertia is a barrier.
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http://dx.doi.org/10.1177/2050312117740989DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5697580PMC
November 2017

Blood glucose and pressure controls in diabetic kidney disease: Narrative review of adherence, barriers and evidence of achievement.

J Diabetes Complications 2018 01 15;32(1):104-112. Epub 2017 Sep 15.

School of Biomedical Sciences, Charles Sturt University, Australia.

Aims: To review the epidemiology and the clinical evidence regarding achieving blood pressure (BP) and blood glucose control in patients with chronic kidney disease (CKD) and diabetes mellitus (DM), with emphasis on adherence and barriers within the context of Australian clinical guidelines. This article then considers Australian services aimed at BP, DM, and CKD, guideline adherence and control.

Methods: Evidence from PubMed-listed articles published between 1994 and 2016 is considered, including original research, focusing on randomised controlled trials and prospective studies, review articles, meta- analyses, expert and professional bodies' guidelines as well as our experience.

Results: There have been no Australian studies that consider adherence to BP control in DM and CKD patients. This is a major limitation in preventing DM and renal disease progression. It is possible that Australian clinicians are not adhering to DM, hypertension (HT), and glucose recommendations, thus resulting in reduced patient outcomes.

Conclusions: It is hoped that future studies ascertain the extent to which the required BP and glucose control in patients is achieved, and the potential barriers to adherence. The significance of this is immense since the impact of failure to control blood glucose levels and BP leads to renal damage.
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http://dx.doi.org/10.1016/j.jdiacomp.2017.09.008DOI Listing
January 2018

Outpatient cardiac rehabilitation: Effects on patient improvement outcomes.

Diabetes Metab Syndr 2017 Dec 27;11 Suppl 2:S1025-S1030. Epub 2017 Jul 27.

School of Biomedical Sciences, Charles Sturt University, Australia.

Objective: To determine if the Cardiac rehabilitation (CR) program had positive effects on the patient medically as well as effects on pathological risk factors, functional capacity, and mental health; and the extent to which targets for blood pressure (BP) control in patients with hypertension (HT) and diabetes mellitus (DM) are achieved.

Methodology: CR participant data was collected from 1st June 2014 until 31st December 2015 (19 months), which included: demographics, medical history, social history, medications, lipid profiles and anthropometric measurements. Additional data was collected on The Patient Health Questionnaire (PHQ-9) factors, and on the participants 6min walk test (6MWT). Study participants were eligible to participate in the study if they attended 10 or more CR program sessions out of 12 at the Calvary Public Hospital Canberra.

Results: Seventy nine (79) participants participated in the study. Significant reductions in BP (n=79) (p=<0.05), blood LDL cholesterol levels (n=26) (p=<0.05), and improvements in participants PHQ-9 scores (n=79) (p=<0.001), and their 6MWT (n=78) (p=<0.001) were noted. Participants were also able to better manage their medication (p=<0.05). Importantly, results indicated that significant improvements (p=<0.05) were made in DM patients (n=18) diastolic BP, physical ability and depression and anxiety.

Conclusion: A CR program can reduce risk factors associated with CVD, and improves mental health and physical fitness of participants.

Results: Indicated that the CR program reduces DM patient risk factors through improved physical fitness and reductions in depression and anxiety, leading to reduced risk of future cardiovascular and renal disease.
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http://dx.doi.org/10.1016/j.dsx.2017.07.034DOI Listing
December 2017

The Cost-Effectiveness of a Stroke Unit in Providing Enhanced Patient Outcomes in an Australian Teaching Hospital.

J Stroke Cerebrovasc Dis 2017 Oct 13;26(10):2362-2368. Epub 2017 Jun 13.

Calvary Hospital, Bruce, Canberra, Australia; Australian National University, Canberra, Australia.

Background: Stroke is one of the leading causes of disability and mortality. Patients who receive organized inpatient care in a stroke unit (SU) have better clinical outcomes. However, evidence on the cost analysis of an SU is lacking. The objective of this study was to assess the performance and analyze the cost-effectiveness of an SU.

Methods: A retrospective observational study was conducted comparing the acute stroke patient care in a 6-month period before and after the establishment of an acute SU at Calvary Hospital in 2013-2014.

Results: There were 103 patients included in the pre-SU period, as compared to 186 patients in the post-SU period. In the pre- and post-SU groups, 54 and 87 patients, respectively, had ischemic stroke, with significant trends in improved morbidity and mortality in the post-SU group (P = .01). The average length of stay (LOS) for patients was reduced from 9.7 days to 4.6 days in the post-SU group (P = .001). There was a reduction of cost per admission from $6382 Australian dollars (AUD) with conventional ward care as compared to $6061 (AUD) with SU care.

Conclusion: This study confirmed that the establishment of an SU not only improves treatment outcomes but also shortens LOS, thereby achieving cost-effectiveness.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2017.05.025DOI Listing
October 2017

Are all after-hours diagnostic imaging appropriate? An Australian Emergency Department pilot study.

Ann Med Surg (Lond) 2016 Dec 24;12:75-78. Epub 2016 Nov 24.

Calvary Health Care Australia, Calvary Hospital Canberra, Cnr Belconnen Way & Haydon Drive, Bruce, ACT, 2617, Australia.

Background: This study was aimed at determining the extent to which after-hours diagnostic imaging is appropriate within the case hospital's Emergency Department. This was amid growing concerns of the inappropriateness of some medical investigations within the Australian health-care system.

Methods: After-hours referral data and patient notes were used in reviewing the clinical case. Diagnostic imaging was deemed appropriate if reflective of clinical guidelines, and if not reflective, whether the investigation changed the patient's ongoing management.

Results: Results indicated that 96.37% of after-hours diagnostic imaging adhered to clinical guidelines and was appropriately requested, with 95.85% changing the ongoing management of the patient. The most sought after diagnostic imaging procedures were Chest X-Ray (30.83%), and CT Brain (16.58%), with 99.16% and 98.44 appropriateness respectively. Chest pain (14.49%) and motor vehicle accidents (8.12%) were the leading reason for ordering after-hours imaging.

Conclusion: This study provided an Emergency Department example as it relates to after-hours diagnostic imaging appropriateness. This study found that most after-hours referrals were appropriate.
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http://dx.doi.org/10.1016/j.amsu.2016.11.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5134081PMC
December 2016

The art of self-knowledge and deduction in clinical practice.

Ann Med Surg (Lond) 2016 Sep 13;10:19-21. Epub 2016 Jul 13.

Medical Education and Research Officer, Calvary Hospital Bruce, Australia.

Clinical reasoning involves interviewing the patient, taking a history, and carefully scrutinising objects in the environment, via a physical examination, and the interpretation of medical results. Developments in medicine are trending towards the routine use of sophisticated diagnostic tools. While important, these trends may be leading clinicians to rely on expensive tests, while not using or improving the art of clinical deduction. The ideal clinician knows themselves and their environment, truly observes, imagines the possibilities, deduces from what they observe, and continually learns. This allows the clinician to use all of their senses, while not primarily relying on a diagnostic test.
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http://dx.doi.org/10.1016/j.amsu.2016.07.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4961678PMC
September 2016