Repatriation General Hospital Research Articles

Hypogammaglobulinemia and infection risk in myotonic dystrophy type 1.

Hypogammaglobulinemia is a common yet under-recognized feature of myotonic dystrophy type 1 (DM1). The aims of our study were to determine the frequency of immunoglobulin G (IgG) deficiency in our cohort, to examine the association between immunoglobulin levels and cytosine-thymine-guanine (CTG) repeat length in the DMPK gene, and to assess whether IgG levels are associated with an increased risk of infection in DM1 patients. We conducted a single-center, retrospective cross-sectional study of 65 adult patients with DM1 who presented to the Neuromuscular Clinic at Concord Repatriation General Hospital, Sydney, Australia, between January 2002 and January 2022. We systematically collected and analyzed clinical, laboratory, and genetic data for all patients with available serum electrophoresis and/or IgG level results. Forty-one percent of DM1 patients had IgG deficiency despite normal lymphocyte counts, IgA, IgM, and albumin levels. There was an association between CTG repeat expansion size and the degree of IgG deficiency (F = 6.3, p = .02). There was no association between IgG deficiency and frequency of infection in this group (p = .428). IgG deficiency is a frequent occurrence in DM1 patients and is associated with CTG repeat expansion size. Whether hypogammaglobulinemia is associated with increased infection risk in DM1 is unclear. A prospective multicenter cohort study is needed to evaluate this.

Prevalence of Coronary Vasomotor Disorders in Patients With Angina and Nonobstructive Coronary Arteries: A Sydney Experience

Patients with angina and non-obstructive coronary arteries (ANOCA) frequently have coronary vasomotor disorders (CVaD), characterised by transient pathological vasoconstriction and/or impaired microvascular vasodilatation. Functional coronary angiography is the gold standard for diagnosing CVaD. Despite recommendations, testing is only available at a limited number of Australian and New Zealand centres. This study aimed to determine the prevalence of CVaDs in an Australian ANOCA population and identify predictive factors associated with specific endotypes. Functional coronary angiography was performed in patients with suspected ANOCA. Vasoreactivity testing was performed using intracoronary acetylcholine provocation. A pressure-temperature sensor guidewire was used for coronary physiology assessment. Comprehensive clinical data on patient characteristics, cardiac risk factors, and symptom profiles was collected before testing. This prospective observational study at Royal Prince Alfred and Concord Repatriation General Hospital included 110 patients (58±13 years with 63.6% women), with 81.8% (90/110) having a CVaD. Regarding specific ANOCA endotypes, microvascular angina (MVA) occurred in 31.8% (35/110) of cases, vasospastic angina (VSA) in 25.5% (28/110) and a mixed presentation of MVA and VSA in 24.5% (27/110) of patients. Patients with CVaD were found to be older (59±11 vs 51±15, p=0.024), overweight (61.1% vs 15.0%, p<0.001) and had a worse quality of life (EuroQol 5 Dimensions-5 Levels; 0.61 vs 0.67, p=0.043). MVA was associated with being overweight (odds ratio [OR] 4.2 [95% confidence interval [CI] 1.9-9.3]; p=0.015) and ischaemia on stress testing (OR 2.4 [95% CI 1.1-4.3]; p=0.028), while VSA was associated with smoking (OR 9.1 [95% CI 2.21-39.3]; p=0.007). Coronary vasomotor disorders are highly prevalent among ANOCA patients. This study highlights the importance of increasing national awareness and the use of functional coronary angiography to evaluate and manage this unique cohort.

Prehabilitation Before Gastrointestinal Cancer Surgery: Protocol for an Implementation Study.

Surgery remains the standard curative treatment for early-stage colorectal and upper gastrointestinal cancer. Reduced preoperative functional capacity, nutritional status, and psychological well-being are associated with poor postoperative outcomes. Prehabilitation aims to improve preoperative functional reserves through physical, nutritional, and psychological interventions. Yet, how it transitions from a trial setting to being integrated into a real-world health setting is unknown. The primary aim is to evaluate the implementation of a multimodal (supervised exercise, nutrition, and nursing support) prehabilitation program into standard care for patients with gastrointestinal cancer (colorectal and upper gastrointestinal cancer) scheduled for curative intent surgery. The secondary aim is to determine the impact of a multimodal prehabilitation program on functional capacity, nutritional and psychological status, and surgical outcomes. This is an implementation study that will investigate a multimodal prehabilitation intervention, in a nonblinded, nonrandomized, single-group, pre-post design. Patients diagnosed with colorectal and upper gastrointestinal cancer scheduled for potentially curative intent surgery at Concord Repatriation General Hospital, with ≥14 intervention days prior to surgery and are medically cleared to exercise will be eligible. The study will be evaluated using the Reach, Effectiveness, Adoption, Implementation, and Maintenance Evaluation Framework. The protocol was approved in December 2019 by the Concord Repatriation General Hospital Human Research Ethics Committee (reference number 2019/PID13679). Recruitment commenced in January 2020. In response to the COVID-19 pandemic, recruitment was paused in March 2020 and reopened in August 2020 with remote or telehealth intervention adaptations. Recruitment ended on December 31, 2021. Over the 16-month recruitment period, a total of 77 participants were recruited. Prehabilitation represents an opportunity to maximize functional capacity and improve surgical outcomes. The study will provide guidance and contribute to the evidence on the integration of prehabilitation into standard care using adaptive models of health care delivery including telehealth. Australian and New Zealand Clinical Trials Registry ACTR 12620000409976; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378974&isReview=true. RR1-10.2196/41101.

Tinzaparin for venous thromboembolism in patients with renal impairment: a single-centre, prospective pilot study.

Low molecular weight heparins (LMWH) are used extensively for prophylaxis and treatment of venous thromboembolism (VTE), bridging therapy for warfarin and standard of care in cancer-associated VTE (CA-VTE). Tinzaparin has the highest molecular weight of all LMWH and relies least on renal clearance to Cockcroft-Gault creatinine clearance (CrCl) of 20 mL/min. Previous pharmacological studies have demonstrated safety and effectiveness in elderly patients. Prospective clinical trials have confirmed these findings to CrCl 20 mL/min and in CA-VTE. We describe the pilot program developed at Concord Repatriation General Hospital for tinzaparin. We aim to confirm the deliverability of tinzaparin in patients with renal insufficiency. Twenty patients were established on tinzaparin as therapeutic anticoagulation with CrCl or CKD-EPI estimated glomerular filtration rate (eGFR) 20-50 mL/min with an indication for anticoagulation. Tinzaparin was given as a subcutaneous injection at 175 units/kg as a single daily dose, rounded to the nearest vial size. Tinzaparin anti-Xa levels were tested at Days 2, 7 and 14 (±1 day) and transition to oral anticoagulants were allowed at clinician discretion. No accumulation of tinzaparin was seen into Day 14. Two patients required dose-adjustment, five patients had bleeding complications (two major, three minor) and four patients died during follow-up, all attributable to patients' comorbidities. CrCl and body surface area-standardised CrCl were significantly correlated with tinzaparin anti-Xa level only on Day 2, and this effect was lost when patients with CrCl >50 mL/min were excluded. Data from our cohort confirm the deliverability of therapeutic tinzaparin in patients with CrCl or CKD-EPI eGFR 20-50 mL/min. Bleeding and death outcomes were also comparable to other trials using tinzaparin in CA-VTE. For patients with renal insufficiency, tinzaparin represents an attractive alternative anticoagulant with once-daily administration in a range of potential indications.

Weight gain during the menopause transition: Evidence for a mechanism dependent on protein leverage.

Weight gain during the menopause transition: Evidence for a mechanism dependent on protein leverage.

Hypothalamic‐pituitary‐adrenal axis activity and vascular function in healthy adults

The objective of this study is to assess the relationship between hypothalamic-pituitary-adrenal (HPA) axis activity, vascular function and insulin sensitivity in healthy adults. Open observational study. Thirty healthy adults were studied at the Endocrine Research Unit, Repatriation General Hospital, Adelaide, SA, Australia. HPA activity was assessed from the serum cortisol 30 min after 1 µg ACTH1-24 (Novartis Pharmaceuticals). Subjects with a cortisol below (n = 15) and above (n = 15) the median were categorized as low and high responders, respectively. Reactive hyperaemia index (RHI) was measured fasting to estimate endothelial function. Matsuda index was calculated from glucose and insulin concentrations collected fasting and 30 minutely for 2 h after a mixed meal (10 kcal/kg, 45% carbohydrate, 15% protein, 40% fat). The primary endpoint was the difference in RHI between low and high responders. There were no significant differences in age (61 ± 9 vs. 64 ± 7 years, p = .19), body mass index (BMI; 26 ± 3 vs. 24 ± 4 kg/m2 , p = .25) and sex (p = .71) between low and high responders. High responders had a lower RHI (2.1 ± 0.2 vs. 2.6 ± 0.2, p = .04) than low responders and there was a negative association between RHI and peak cortisol post ACTH1-24 (β = -.56, p < .01). There were no significant differences in Matsuda index (15.0 ± 2.4 vs. 22.7 ± 5.2, p = .19) between high and low responders. In healthy adults, endothelial dysfunction is likely to contribute to the association between HPA hyperactivity and increased cardiovascular risk. As insulin sensitivity was not different in high and low responders, endothelial dysfunction is not primarily secondary to insulin resistance.

Increased self-immolation frequency and severity during the COVID-19 pandemic

ObjectiveTo determine whether the increased restrictions, isolation and stressors associated with COVID-19 led to an increase in rates or severity of self-immolation burn injuries. DesignRetrospective review of a prospectively-collected database of New South Wales burn patients, comparing 2020 data with the preceding 5 years. SettingBoth adult units in the New South Wales Statewide Burn Injury Service (Concord Repatriation General Hospital and Royal North Shore Hospital). ParticipantsAll adult patients in New South Wales with self-inflicted burn injuries between 1st January 2015 and 31st December 2020. Outcome measuresDemographic information, precipitating factors, burn severity, morbidity and mortality outcomes. ResultsWe found18 episodes of self-immolation in 2020, compared to an average of 10 per year previously. Burn size significantly increased (43% total body surface area vs 28%) as did revised Baux score (92 vs 77). Most patients had a pre-existing psychiatric illness. Family conflict and acute psychiatric illness were the most common precipitating factors. Conclusion2020 saw an increase in both the frequency and severity of self-inflicted burn injuries in New South Wales, with psychiatric illness a major factor.

Exploding power: a statewide review of lithium battery related burns

Introduction: With the increase of lithium battery devices, including electronic cigarettes and battery power banks, there has been a steady rise in burn injuries secondary to device malfunction. These devices may cause chemical or flame burns. Our aim was to identify and classify epidemiological trends of explosions from lithium battery devices across the state of New South Wales (NSW), Australia. Methods: A review of the NSW Burn Injury Service (SBIS) database from January 2005–December2019, together with medical records from the burns units at the Children’s Hospital at Westmead (CHW), the Concord Repatriation General Hospital (CRGH) and the Royal North Shore Hospital (RNSH) was conducted. All patients who suffered a burn secondary from a lithium battery device were included and data was extracted on mechanism of injury, severity of injury and management. This study was approved by the ethics committees of CHW, RNSH and CRGH [2020/PID00179]. Results: Of the 24 patients identified, six were paediatric and 18 were adults. The majority were male (7:1) with a mean age of 29.0 (+/- 16.6 years). The mean total body surface area burnt was 2.5% (+/- 0.9) [range 0.1–21.0%]. The majority occurred after 2014 and involved spontaneous explosions. Their injuries ranged from partial to full thickness burns with flame being the most common type (n=15). Three quarters of the cases (n=18) occurred in a home setting. Conclusions: Lithium battery device explosions can result in a mix of burn depth injuries from flame, contact and electrical, or chemical burns. Consumers need to be made more aware of the potential risks associated with use of lithium battery powered devices.

In Hospital Outcomes for High-Risk Percutaneous Coronary Intervention (PCI) in Patients Referred From a Rural Centre to Metropolitan Sites

Cardiac Society of Australia and New Zealand (CSANZ) guidelines recommend elective high-risk percutaneous coronary intervention (PCI) is not performed in sites greater than 1 hour from cardiac surgery. In hospital outcomes for all patients from Orange Health Service (OHS) from January 2017 to January 2020 who were transferred electively to tertiary centres in Sydney for high risk PCI were examined. One hundred and fourteen (114) patients were identified, with 1,259 PCIs performed at OHS over the same period without transfer. The mean age of these 114 patients was 71 years, with 74.6% male. Receiving hospitals were Royal Prince Alfred Hospital, Sydney, NSW (66.7%), Concord Repatriation General Hospital, Concord, NSW (19.3%) and Strathfield Private Hospital, Strathfield, NSW (14%). The definition of high risk and indication for transfer included at least one of: moderate or greater calcification of the target lesion or proximal segment (34%), single or multiple target lesions that in aggregate jeopardised over 50% of remaining viable myocardium (27%), degenerated saphenous vein grafts (14.8%), chronic total occlusions (7.0%) and severe left ventricular (LV) impairment (3.9%). American Heart Society/American College of Cardiology (AHA/ACC) lesion types were A (1%), B1 (4.2%), B2 (40.2%), and C (54.6%). PCI was performed via the femoral route in 96.2%. The mean procedure duration was 72 minutes, mean combined fluoroscopy time was 19 minutes and mean radiation dose as defined by Reference Air Kerma was 1,630mGy. Complications occurred in 13 patients and were: acute vessel dissection requiring stenting (4), perforation (2), acute vessel closure (4), puncture site related (1), and life-threatening arrhythmia (2). There were no cases of emergent coronary artery bypass graft (CABG) or death. This contemporary cohort of high-risk patients transferred electively from a regional PCI centre to a tertiary cardiac unit underwent lengthy PCI procedures, with high radiation doses, and a modest rate of peri-procedural complications, but had otherwise excellent procedural and clinical outcomes.

Short-term multimodal prehabilitation improves functional capacity for colorectal cancer patients prior to surgery.

Evaluate feasibility and outcomes of a multimodal prehabiliation program in patients with stage I-III colorectal cancer (CRC) awaiting surgery. Patients scheduled for elective CRC resection at Concord Repatriation General Hospital were recruited from pre-admission clinic between January and November 2018. Participants received a 2-4week prehabilitation program consisting of supervised exercise sessions, nurse-led phone support, and written nutritional information. Participants were assessed at baseline, pre-surgery, and 4 weeks post-surgery. Twenty-two patients participated in the program: 55% male; median age 73 (56-86) years. Six (28%) required an interpreter. At baseline, 19 of 22 (86%) had at least one comorbidity. Median intervention length was 11.5 days (range 7-29). Participants attended 79% of scheduled exercise sessions (range 33-100%, mean 3.5 sessions) and 66% of nurse support calls (range 0-100%, mean 2.6 sessions). Between baseline and pre-surgery, participants reported increasing mean unsupervised moderate-intensity aerobic exercise from 17 (range 0-210) to 73 minutes/week (range 0-276) and mean vigorous-intensity aerobic exercise from 0 to 24 minutes/week (range 0-300). Resistance exercise sessions increased from 0.6 to 2.6 times/week. Mean 6-minute walk test distance increased by 48 meters (435-483m) and 30-second "sit to stand" by 1.6 repetitions. Small improvements were seen in global quality of life and fatigue. Nutritional status and body composition remained unchanged. All participants were satisfied/strongly satisfied with the program and would recommend it to others. Our multimodal prehabilitation program was feasible in CRC patients inclusive of those from non-English speaking backgrounds, with improvement in functional capacity before CRC surgery.

Five Year Survival Outcomes of Prospectively Recorded Cohort Data for Older Adults versus Younger Adults with Resected Primary Rectal Cancer

Background: Rectal cancer predominantly occurs in older adults. We aimed to compare the long-term outcomes of older adults (≥70 years) versus younger adults (Methods: Consecutive patients who had resection of a primary rectal cancer between January 1, 2000 and December 31, 2010 were identified from a prospective database at the Concord Repatriation General Hospital and stratified into two age groups: ences in patients, cancer, and treatment characteristics were determined by Chi-square tests. 5-year Overall Survival (OS) and Cancer-Specific Survival (CSS) were determined by the Kaplan-Meier method and by multivariable Cox regression analysis. Results: Of 714 included patients, the mean age was 65.8 years (range, 21 - 92 years). 407 (57%) patients were aged 70 years. Older age (>70 years) predicted more comorbidity (p 70 years), compared with younger adults (Conclusion: Older adults who had had a resection of stage I-IV primary rectal cancer received less neoadjuvant and adjuvant therapy and had worse OS and CSS than their younger counterparts.

Efficacy and Safety of Zanubrutinib in Patients with Treatment-Naïve (TN) Chronic Lymphocytic Leukemia (CLL) or Small Lymphocytic Lymphoma (SLL) with del(17p): Follow-up Results from Arm C of the SEQUOIA (BGB-3111-304) Trial

Efficacy and Safety of Zanubrutinib in Patients with Treatment-Naïve (TN) Chronic Lymphocytic Leukemia (CLL) or Small Lymphocytic Lymphoma (SLL) with del(17p): Follow-up Results from Arm C of the SEQUOIA (BGB-3111-304) Trial

The effect of humidified warmed CO2 during open colorectal surgery on body temperature and postoperative pain: a randomized controlled trial.

IntroductionOpen abdominal surgery exposes the intestine to negative ventilation (20°C, 0-5% RH), which along with the large surface area of peritoneum has the potential to cause loss of body heat. This study examined whether the warmed, humidified CO2 (WHCO2) can reduce heat loss and reduce postoperative pain.MethodsA randomized controlled trial was performed at a tertiary colorectal unit (Concord Repatriation General Hospital, The University of Sydney, Australia). The study group received WHCO2 at a rate of 10L/min. The control group did not receive any insufflation during the operation. Patients were over 18 years of age undergoing elective open colorectal operations. Core body temperature measurement was made every 15 minutely with a trans-oesophageal probe. Postoperative pain was assessed via: (1) duration of use of patient controlled analgesia (PCA), (2) total oral morphine equivalent daily dose (oral MEDD).Results39 Patients were recruited in the study, with 20 patients receiving WHCO2. There was no difference in the core body temperature between the WHCO2 and the Control group (36.1 vs. 35.9°C, p=0.35). There was no difference in the % of the operating time where core body temperature dropped below the lower limit of normal of 35.8°C (28.4% vs 35.8%, p=0.51), or to the level of hypothermia of 35°C (7.7% vs. 13.4%, p=0.50). No difference in postoperative PCA duration, as well as MEDD, were noted between the CO2 group and control group.ConclusionWHCO2 had no effect on core body temperature during open colorectal surgery and the postoperative pain experienced.

25. Strumal carcinoid – When two become one

Background: Strumal carcinoid is the rare coexistence of both struma ovarii and carcinoid. Recognition of this essentially benign entity avoids misdiagnosis and over-treatment. Aims: To present the macroscopic, microscopic, immunohistochemical, and ultrastructural findings of a case of strumal carcinoid. Methods: A 51-year-old female presented with a 4 cm left adnexal mass that was resected and received by the Anatomical Pathology Department at Concord Repatriation General Hospital. Macroscopic examination, light microscopy, immunohistochemistry, and electron microscopy were performed. Results and conclusions: Macroscopically, the specimen consisted of a 40 mm cystic lesion lined by dark-brown granular material, with a 14 mm brown-and-spongy intramural nodule including a colloid-like area. By light microscopy, the cyst was a haemorrhagic corpus luteum and the nodule was a biphasic tumour composed of thyroid tissue and rosette-forming/trabecular areas. By immunohistochemistry, the rosette-forming/trabecular areas were positive for CD56 and NSE—though negative for chromogranin and synaptophysin. By electron microscopy, the rosette-forming/trabecular areas contained ‘salt-and-pepper’ nuclear chromatin and cytoplasmic single-membrane bound dense core granules. Therefore, the biphasic tumour was concluded to be composed of both thyroid and neuroendocrine tissue and a diagnosis of strumal carcinoid was made. Strumal carcinoid is the intimate association of thyroid and carcinoid tissue, seen in 25% of primary ovarian carcinoid. It is a unilateral lesion, 1–20 cm, beefy-red to yellow, and can be near-pure or part of a cystic teratoma. The morphologic and immunohistochemical features are predictable. The prognosis is almost invariably benign and local disease is treated by salpingo-oopherectomy, however a study of 50 cases reported one incident of peritoneal metastasis and death. In this same study, strumal carcinoid had been misdiagnosed as malignant transformation of struma ovarii in 4 of 50 cases. The diagnostic pitfall today is to over-interpret the frequently present mucinous epithelium of strumal carcinoid as representing mucinous (goblet cell) carcinoid.

Regional pain management for oesophagectomy: Cohort study suggests a viable alternative to a thoracic epidural to enhance recovery after surgery

Ivor Lewis oesophagectomy (ILO) is associated with significant acute postsurgical pain and persistent chronic pain. The purpose of this study was to compare the Concord technique, which involves a combination of a surgeon-inserted paravertebral catheter, a single injection of intrathecal morphine and surgeon-inserted bilateral preperitoneal catheters, with the other available analgesic techniques. The study was designed as a retrospective cohort study and performed at the Concord Repatriation General Hospital, a tertiary teaching hospital affiliated with Sydney University. The participants comprised 60 consecutive patients in whom ILO was undertaken from January 1, 2011 to December 31, 2017, who were retrospectively analysed according to analgesic technique. The maximum, minimum and average pain numerical rating scale (NRS) scores were prospectively recorded daily for 3 days, opioid use for 3 days, and hospital length of stay, intensive care unit (ICU) length of stay, 30-day mortality and postoperative complications were also recorded. The Concord regional anaesthetic technique group had an average NRS pain scores which appeared favourable for day 0 (0.90 vs. 1.42), but no statistical differences were found between either group on day 1 (1.34 vs. 1.54), day 2 (0.94 vs. 1.13) or day 3 (0.94 vs. 1.00). The 30-day mortality, length of stay in hospital and ICU, and postoperative complications were comparable. The Concord regional technique for ILO analgesia appears to provide a simple alternative to other forms of analgesia, with similar analgesic efficacy and with no differences in postoperative complications. This may provide a pathway to enhanced recovery and is suitable to be evaluated in a Randomised control trial (RCT) of techniques.

Reflections on a bowel cancer support group 6 years from inception

The intention of this paper is to offer insight into the establishment, facilitation, challenges and outcomes of a bowel cancer support group at Concord Repatriation General Hospital in Sydney. The...

Ablative fractional resurfacing with laser‐facilitated steroid delivery for burn scar management: Does the depth of laser penetration matter?

To investigate whether the depth of ablative fractional CO2 laser (CO2 -AFL) penetration of pathological burn scars influences clinical outcomes. All patients presenting to the Concord Repatriation General Hospital (CRGH) Scar Clinic received ultrasound measurement at the thickest point of their burn scars. Subsequently, the effect of various CO2 -AFL settings (energy which correlates to penetration depths) on different outcome parameters was analysed. Patients were divided into five groups depending on minimal scar penetration depth. Seventy-eight patients (158 scars) had complete data allowing for analysis. Median scar thickness was 3,400 μm and median laser scar penetration depth was 900 μm. Scar penetration categories were as follows: 0-25% (n = 40), 25-50% (n = 67), 50-75% (n = 31), 75-100% (n = 8), >100% (n = 3) of scar thickness. The median reduction in maximum scar thickness was 800 μm following one treatment (P < 0.001). However, this effect depended on scar penetration depth, whereby scars that were penetrated ≥75% showed no significant improvement in scar thickness and those penetrated >100% indicated a tendency to become worse. Other assessed outcome parameters included: the Vancouver Scar Scale, the Patient and Observer Scar Assessment Scale, a neuropathic pain score (DN4 Pain Questionnaire), and a pruritus score (modified D4 Pruritus Score). All these factors showed significant improvement in the categories up to 75% scar penetration depth. CO2 -AFL scar penetration depth significantly influences subjective and objective pathologic burn scar modulation. The penetration depth of 51-75% achieves the greatest reduction in scar thickness. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Retrospective pharmaceutical financial benefits and cost avoidance analysis of clinical trial participation in the Australian haematology setting.

Clinical trial participants receiving investigational new drugs, which subsequently become approved by a medicines regulatory authority for its trialled indication, effectively gain free early access to efficacious treatment. Participants may also benefit from receiving approved, but unsubsidised medicines. These financial benefits of clinical trial participation have not previously been defined or quantified. Additionally, there are limited Australian pharmaceutical cost avoidance studies quantifying government savings through sponsored clinical trials. To calculate pharmaceutical financial benefits and cost avoidance of clinical trial participation at a single Clinical Research Unit. Recruiting clinical trials between 1 January 2006 and 31 December 2017 conducted at the Haematology Clinical Research Unit, Concord Repatriation General Hospital, Sydney were reviewed. Dispensing records were used to quantitate the pharmaceuticals dispensed to every participant. Financial calculations were based on Pharmaceutical Benefits Scheme (PBS) pricing, or from UpToDate for non-PBS listed agents. Thirty-six eligible clinical trials involving 245 participants accrued AU$3 971 357 in financial benefit from early access to subsequently approved investigational new drugs, AU$12 209 538 in financial benefit from accessing approved medications not PBS listed, and AU$6 728 576 in government cost avoidance. These findings totalled AU$22 909 471, 89% of which was derived in the past 5 years. Pharmaceutical financial benefit is a previously unquantified aspect of clinical trial participation, its assigned value reflecting a measure of the quality and quantity of life delivered to patients. These data, albeit from a single discipline and institution, suggest that financial benefit represents a greater value than cost avoidance, and that its inclusion in cost-analyses may better reflect the monetary benefits of accessing efficacious pharmaceutical agents through clinical trials.

Retrospective chart review to assess domains of quality of death (recognition of dying, appropriate limitations, symptom monitoring, anticipatory prescribing) of patients dying in the acute hospital under the care of a nephrology service with renal supportive care support over time.

To explore the quality of deaths in an acute hospital under a nephrology service at two teaching hospitals in Sydney with renal supportive care services over time. Retrospective chart review of all deaths in the years 2004, 2009 and 2014 at St George Hospital (SGH) and in 2014 at the Concord Repatriation General Hospital. Domains assessed were recognition of dying, invasive interventions, symptom assessment, anticipatory prescribing, documentation of spiritual needs and bereavement information for families. End-of-life care plan (EOLCP) use was also evaluated at SGH. Over 90% of patients were recognized to be dying in all 3 years at SGH. Rates of interventions in the last week of life were low and did not differ across the 3 years. There was a significant increase in the prescription of anti-psychotic, anti-emetic and anti-cholinergic medication over the years at SGH. Use of EOLCP was significantly higher at SGH, and their use improved several quality domains. Of all deaths, 68% were referred to palliative care at SGH and 33% at Concord Repatriation General Hospital (not significant). Cessation of observations and non-essential medications and documentation of bereavement information given to families was low across both sites in all years, although this significantly improved when EOLCP were used. While acute teams are good at recognizing dying, they need support to care for dying patients. The use of EOLCP in acute services can facilitate improvements in caring for the dying. Renal supportive care services need time to become embedded in the culture of the acute hospital.

A 10-year retrospective cohort study of the management of toxic epidermal necrolysis and Stevens-Johnson syndrome in a New South Wales state referral hospital from 2006 to 2016.

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are life-threatening severe cutaneous drug reactions. There have been no Australian data published since 2007. To explore whether there is an association between prognosis and the type of systemic immune-modulation treatment administered in a cohort of patients with SJS, SJS-TEN overlap, and TEN at the New South Wales State SJS/TEN referral center - Concord Repatriation General Hospital. This is a retrospective, single center, cohort study of patients admitted with SJS/TEN from January 1, 2006, to December 31, 2016, at Concord Repatriation General Hospital. Data on demographic information, the causative agent, treatment, and final survival outcome were analyzed. Forty-two patients included: 26 (62%) with TEN, six (14%) with SJS/TEN overlap, and 10 (24%) with SJS. Overall mortality was 19% (n=8), and seven suffered TEN. The average age of those who died was 60years. Eighty-one percent of patients were managed within the burn unit. Twenty-nine patients (70%) received IVIG within this group; 13 individuals also received systemic corticosteroids. Seven (17%) were managed with corticosteroid therapy alone. The incidence of death was 0% in the combined IVIG and corticosteroid group. This series of 42 patients contributes valuable information to a serious condition with low global incidence and high mortality. There appears to be an apparent reduced mortality in the group of SJS/TEN patients managed with combined IVIG and corticosteroid. Larger cohorts are required to validate this relationship due to the risk of bias inherent to the retrospective study design and small sample size.