Royal Brisbane And Women's Hospital Research Articles

Fred J Boyd Oration 2021

Fred J Boyd Oration 2021

Delivering inflammatory bowel disease care across distance.

BackgroundInflammatory bowel disease (IBD) patients living in regional or remote Queensland are often disadvantaged by limited access to IBD specialist care. Telehealth clinics could potentially address this disparity and improve patient outcomes.AimWe report the impact of the Royal Brisbane and Women's Hospital (RBWH) IBD telehealth clinics from March 2011 to December 2017, including patient satisfaction and healthcare activity.MethodsPatient satisfaction surveys were collected prospectively between March 2011 and March 2012. Healthcare activity was assessed through occasions of service (OOS), number of enrolled patients on biologics and IBD related admissions to RBWH.ResultsOverall, 3764 OOS were completed including 576 new patient and 3188 follow‐up visits. Mean age at first telehealth visit was 44 years (range: 16–87 years). The IBD telehealth clinics were well accepted with 99% of the first 153 patients surveyed choosing to continue with telehealth and 94% rated the telehealth experience as very good or excellent. The net number of patients under active review increased from 125 patients in 2011 to 345 patients in 2017. Enrolled patients on biologics also increased from 9 patients in 2011 to 63 patients in 2017. There was an initial dip in annual IBD related admissions to RBWH in 2011 but these have progressively increased over time although the average length of inpatient stay annually has remained stable.ConclusionThe RBWH IBD telehealth clinics have shown that telemedicine is well received and can be used successfully to deliver IBD specialist care to patients living in regional or remote areas.

Does earlier arrival of the retrieval team improve short-term outcomes in outborn extremely premature infants?

The risk of mortality and morbidity is increased in outborn, extremely premature infants. We aim to determine whether earlier arrival of the retrieval team after the birth of infants less than 29 weeks gestation improves short-term mortality and morbidity. This is a retrospective analysis of a cohort of infants less than 29 weeks gestation who were retrieved to the Royal Brisbane and Women's Hospital (RBWH) over a 5-year period. Demographic information regarding the infant and mother, retrieval team arrival time and outcome data was collected. Primary outcomes investigated were mortality prior to discharge from hospital or a composite of mortality or severe intraventricular haemorrhage (IVH). Data on 105 infants were analysed; 88 infants (83.8%) survived to discharge home, and 79 (75.2%) survived to discharge without severe IVH. On univariate analysis, there was no significant association between age at arrival of the retrieval team and death prior to discharge (P = 0.94) or death prior to discharge or severe IVH (P = 0.83). On logistic regression analysis, age at arrival of retrieval team remained non-significant for a reduction in death prior to discharge and composite of death or severe IVH (P = 0.70 and P = 0.99, respectively). The earlier arrival of the retrieval team is not associated with improved short-term outcomes in outborn, extremely preterm infants who are retrieved and admitted to a tertiary neonatal intensive care unit - for infants where the retrieval team arrived within about 8 h of birth.

Pre-oncall key conditions training for first-year radiology registrars.

The Royal Australian and New Zealand College of Radiology (RANZCR) recognised the importance of experience in on-call and emergency radiology for first-year registrars by introducing 'Key conditions in Year 1 training'. This list of common radiological pathologies can help to focus preparations for new registrars as they prepare for after-hours duties. The Royal Brisbane and Women's Hospital (RBWH) implemented a 12-week formal training programme, based on this curriculum, for new registrars prior to commencing after-hours work. Its impact was assessed by an image recognition and interpretation examination that was administered to registrars before and after training. Examination results revealed that the prescribed training programme significantly increased both the rate and accuracy of reporting, and that improvements in speed were not at the expense of accuracy. Furthermore, it showed that a 12-week training programme was able to improve novice radiology registrars' ability to detect radiological abnormalities above that of experienced emergency department clinicians. Performances of consultant radiologists were used as a 'gold standard' control. This research demonstrates the value of a formal training programme in preparing registrars for extended after-hours reporting duties and contributing to important departmental service provision.

Dysphagia screening in subacute care settings using the Italian version of the Royal Brisbane and Women's Hospital (I-RBWH) dysphagia screening tool.

SUMMARYThe large majority of the available dysphagia screening tools has been developed for the stroke population. Only few screening tools are suitable for heterogeneous groups of patients admitted to a subacute care unit. The Royal Brisbane and Women's Hospital (RBWH) dysphagia screening tool is a nurse-administered, evidence-based swallow screening tool for generic acute hospital use that demonstrates excellent sensitivity and specificity. No Italian version of this tool is available to date. The aim of this study was to determine the reliability and screening accuracy of the Italian version of the RBWH (I-RBWH) dysphagia screening tool. A total of 105 patients consecutively admitted to a subacute care unit were enrolled. Using the I-RBWH tool, each patient was evaluated twice by trained nurses and once by a speech and language pathologist (SLP) blind to nurses' scores. The SLP also performed standardised clinical assessment of swallowing using the Mann assessment of swallowing ability (MASA). During the first and the second administration of the I-RBWH by nurses, 28 and 27 patients, respectively, were considered at risk of dysphagia, and 27 were considered at risk after SLP assessment. Intra- and inter-rater reliability was satisfactory. Comparison between nurse I-RBWH scores and MASA examination demonstrated a sensitivity and specificity of the I-RBWH dysphagia screening tool up to 93% and 96%, respectively; the positive and negative predictive values were 90% and 97%, respectively. Thus, the current findings support the reliability and accuracy of the I-RBWH tool for dysphagia screening of patients in subacute settings. Its application in clinical practice is recommended.

Review of peripartum hysterectomy rates at a tertiary Australian hospital.

Peripartum hysterectomy is commonly performed for catastrophic postpartum haemorrhage uncontrolled by conservative medical and surgical therapies. Currently, information about the incidence and indications for peripartum hysterectomy are not well defined in Australia. Evaluate the incidence and indications of peripartum hysterectomy in the Royal Brisbane and Women's Hospital (RBWH) between 2000 and 2014. A 15-year retrospective cohort study of peripartum hysterectomies at RBWH was conducted. The incidence of this event was calculated. Risk factors for abnormal placentation were explored using univariate analyses. Statistical significance was declared at α < 0.05. A total of 83 cases of peripartum hysterectomy were reviewed. The incidence of peripartum hysterectomy was 0.60 per 1000 births after discounting the 44 (53%) cases of peripheral regional hospital referrals. Abnormal placentation and uterine atony constituted the majority of the indications for peripartum hysterectomy. Abnormal placentation included placenta praevia, accrete, increta and percreta. In this cohort with peripartum hysterectomy, previous caesarean section was strongly associated with abnormal placentation (P < 0.001, OR 11.4, 95% CI 3.6-35.8). No maternal mortality was recorded, although 63% of patients encountered complications. A planned peripartum hysterectomy resulted in significantly fewer red blood cell (P = 0.011) and platelet transfusions (P = 0.001). The incidence of peripartum hysterectomy recorded in our tertiary institution between 2000 and 2014 is 0.60 per 1000 births. Abnormal placentation is the commonest indication leading to severe postpartum haemorrhage requiring peripartum hysterectomy.

TO INVESTIGATE THE EFFECT OF THE PASTEURISATION PROCESS ON TRACE ELEMENTS IN DONOR BREAST MILK

AimTo investigate the effect of the pasteurisation process on trace elements in donor breast milk.MethodPremature infants often receive donor breast milk when the mother is unable to produce sufficient breast...

A two-center study for the quality control of [(18)F]FDG using FASTlab phosphate cassettes.

The GE FASTlab radiosynthesis module is routinely used for the production of [(18)F]FDG, utilizing the commercially available phosphate cassettes. Because of the observation of a white precipitate in the product vial before the product expiry time, we re-examined the quality of the produced [(18)F]FDG solution. Phosphate buffered [(18)F]FDG solution was synthesized on the FASTlab and analyzed at both National Taiwan University Hospital (NTUH) of Taiwan and Royal Brisbane and Women's Hospital (RBWH) of Australia. In addition to the standard product quality control (QC), the concentration of aluminum (Al(3+)) as probable cause of the precipitations in the [(18)F]FDG solution was analyzed by inductively coupled plasma mass spectrometry (ICP-MS at RBWH) and inductively coupled plasma optical emission spectrometry (ICP-OES at NTUH), and using three semi-quantitative methods at NTUH, Advantec(®) Alumi Check Test Strip, Quantofix(®) Aluminum Test Strip and MColortest™ Aluminum Test kit. The precipitates were observed in the [(18)F]FDG solution within 24 (NTUH) and 6 (RBWH) hours after the end of synthesis in 38-100% of the batches, dependent on the batch of the FASTlab cassettes. Addition of metal-free HCl(aq) to aliquots of [(18)F]FDG containing precipitate, followed by ICP-MS analysis revealed Al(3+) concentrations of 70-80ppm. Al(3+) concentrations of 10-12ppm were detected in [(18)F]FDG batches that did not show any precipitation. In contrast, less than 5ppm of the residual Al(3+) was detected by semi-quantitative methods in all batches. The US (USP), British (BP), European (EP) and Japanese (JP) pharmacopeias demand that [(18)F]FDG for injection should be clear and particulate free within the given shelf-life/expiration time. To avoid Al-phosphate precipitation within the product expiry time, FASTlab citrate cassettes, rather than phosphate cassettes, should be used for [(18)F]FDG production. Although testing for Al(3+) is not listed in the [(18)F]FDG monographs of the USP, BP and EP, residual Al(3+) levels should be considered in the interests of patient safety.

Feasibility of a stepped wedge cluster RCT and concurrent observational sub-study to evaluate the effects of modified ward night lighting on inpatient fall rates and sleep quality: a protocol for a pilot trial

BackgroundFalls among hospitalised patients impose a considerable burden on health systems globally and prevention is a priority. Some patient-level interventions have been effective in reducing falls, but others have not. An alternative and promising approach to reducing inpatient falls is through the modification of the hospital physical environment and the night lighting of hospital wards is a leading candidate for investigation. In this pilot trial, we will determine the feasibility of conducting a main trial to evaluate the effects of modified night lighting on inpatient ward level fall rates. We will test also the feasibility of collecting novel forms of patient level data through a concurrent observational sub-study.Methods/designA stepped wedge, cluster randomised controlled trial will be conducted in six inpatient wards over 14 months in a metropolitan teaching hospital in Brisbane (Australia). The intervention will consist of supplementary night lighting installed across all patient rooms within study wards. The planned placement of luminaires, configurations and spectral characteristics are based on prior published research and pre-trial testing and modification. We will collect data on rates of falls on study wards (falls per 1000 patient days), the proportion of patients who fall once or more, and average length of stay. We will recruit two patients per ward per month to a concurrent observational sub-study aimed at understanding potential impacts on a range of patient sleep and mobility behaviour. The effect on the environment will be monitored with sensors to detect variation in light levels and night-time room activity. We will also collect data on possible patient-level confounders including demographics, pre-admission sleep quality, reported vision, hearing impairment and functional status.DiscussionThis pragmatic pilot trial will assess the feasibility of conducting a main trial to investigate the effects of modified night lighting on inpatient fall rates using several new methods previously untested in the context of environmental modifications and patient safety. Pilot data collected through both parts of the trial will be utilised to inform sample size calculations, trial design and final data collection methods for a subsequent main trial.Trial registrationAustralian New Zealand Clinical Trials Register (ANZCTR): ACTRN12614000615684 (cluster RCT) and ACTRN12614000616673 (observational sub-study).Date Registered: 10 June 2014 (both studies).Protocol version: 1.2 (Dated: 01 June 2014)Anticipated completion: September 2015Role of Trial Sponsor: The named sponsor for this investigator-initiated trial was the Director of the Royal Brisbane and Women’s Hospital (RBWH) Safety and Quality Unit (Therese Lee, Phone: +61 7 3646 8111). The principal investigators, SC and MA, are employed by the RBWH Safety and Quality Unit. The trial sponsor has no involvement in any aspects of study design, conduct or decision to submit the report for publication. AM and MD are employed by other departments in the same organisation.

Orbitozygomatic Fracture Repairs: Are Antibiotics Necessary?

Orbitozygomatic fractures are one of the most common maxillofacial injuries encountered. This study aims to investigate and review the management and complications of orbitozygomatic fractures at the Royal Brisbane and Women's Hospital (RBWH). Specifically the postoperative infection rate will be closely examined to determine whether adjunctive antibiotics are necessary in its surgical management. A retrospective case selection study of all patients with orbitozygomatic fractures treated at the RBWH in 2011 was performed. The cases were collected from the maxillofacial database. Chart review of the admission with consecutive follow-up of up to 6 weeks including clinical and radiological assessment and consecutive data analysis was performed. A total of 160 patients with orbitozygomatic fractures were managed at the RBWH with three complications. Eighty-five (53.1%) cases were treated surgically and 155 (97.5%) cases had follow-up until 6 weeks postoperatively. Twenty-six surgical cases (16.3%) were treated via elevation without fixation. A further 26 surgical cases (16.3%) were treated with one fixation point, 19 cases (11.9%) with two fixation points, 12 cases (7.5%) with three fixation points, and 2 cases (1.3%) treated with four fixation points. The three complications (1.9%) returned for surgical correction without further consequence; two were due to inadequate cosmesis and one was due to exposure of the fixation plate. No early postoperative infections were seen. This study presents an excellent outcome with minimal early complications of orbitozygomatic fractures treated at the RBWH, a trauma center with high caseload. All operatively treated cases received perioperative antibiotic prophylaxis as per the unit's protocol. With a nil infection rate at the RBWH, future studies should focus on whether the use of prophylactic antibiotics is appropriate.

Teaching and learning in an era of time-based access targets: Impact of a new model of care on junior medical officers.

Teaching and learning in an era of time-based access targets: Impact of a new model of care on junior medical officers.

Abdominal aortic aneurysm calcification and thrombus volume are not associated with outcome following endovascular abdominal aortic aneurysm repair.

Aortic calcification and thrombus have been postulated to worsen outcome following endovascular abdominal aortic aneurysm repair (EVAR). The purpose of this study was to assess the association of abdominal aortic aneurysm (AAA) calcification and thrombus volume with outcome following EVAR using a reproducible, quantifiable computed tomography (CT) assessment protocol. Patients with elective EVAR performed between January 2002 and 2012 at the Townsville Hospital, Mater Private Hospital (Townsville) and Royal Brisbane and Women's Hospital (RBWH) were included if preoperative CTAs were available for analysis. AAA calcification and thrombus volume were measured using a semiautomated workstation protocol. Outcomes were assessed in terms of clinical failure, endoleak (type I, type II) and reintervention. Univariate and multivariate analyses were performed. Median follow-up was 1.7 years and the interquartile range 1.0-3.8 years. One hundred thirty-four patients undergoing elective EVAR were included in the study. Rates of primary clinical success and freedom from reintervention were 82.8% and 88.9% at the 24-month follow-up. AAA calcification and thrombus volume were not associated with clinical failure, type I endoleak, type II endoleak or reintervention. AAA calcification and thrombus volume were not associated with poorer outcome after EVAR in this study. • The association of calcification and thrombus volumes with EVAR outcome is unclear • Quantifiable methods for assessing calcification and thrombus were not used previously • This study used reproducible methods for assessing AAA calcification and thrombus volumes.

Patterns of Retreatment by Radiotherapy

AimsTo describe patterns of treatment for those who receive more than one episode of megavoltage radiotherapy (retreatment) by cancer type for better service planning and benchmarking. Materials and methodsInstitutional databases of all patients who received their first megavoltage radiotherapy for any type of cancer at the Liverpool and Macarthur Cancer Therapy Centres (LM), New South Wales, Australia, Royal Brisbane and Women's Hospital (RBWH), Queensland, Australia and Radiotherapeutic Institution Friesland (RIF), Leeuwarden, the Netherlands, over the period 1991–2009 were examined. Radiotherapy retreatment was defined as any radiotherapy episode, to any body site, after an initial episode of radiotherapy, for the same cancer diagnosis. The total retreatment rate was defined as the number of retreatment episodes of radiotherapy divided by the number of cases in the cohort. ResultsIn total, 62 270 patients (RBWH 38581, LM 9654, RIF 14035) received 77 762 episodes of radiotherapy, giving a total retreatment rate of 0.25; 52 351 patients (84%) received only one episode of treatment and 9919 (16%) received two or more episodes of treatment. Overall retreatment rates for LM, RBWH and RIF were 0.24, 0.25 and 0.26, respectively. For the five most common cancer types treated, the median time between treatment episodes was longest for breast cancer (11.3 months), then head and neck cancer (9.7 months), colorectal cancer (7.2 months), prostate cancer (4.4 months) and lung cancer (4.1 months). Ninety-one per cent of all fractions were delivered in the first episode of treatment. ConclusionsThe retreatment rate was very similar between the three facilities, suggesting agreement about the indications for retreatment.

CKD.QLD: chronic kidney disease surveillance and research in Queensland, Australia.

BackgroundChronic kidney disease (CKD) is recognized as a major public health problem in Australia with significant mortality, morbidity and economic burden. However, there is no comprehensive surveillance programme to collect, collate and analyse data on CKD in a systematic way.MethodsWe describe an initiative called CKD Queensland (CKD.QLD), which was established in 2009 to address this deficiency, and outline the processes and progress made to date. The foundation is a CKD Registry of all CKD patients attending public health renal services in Queensland, and patient recruitment and data capture have started.ResultsWe have established through early work of CKD.QLD that there are over 11 500 CKD patients attending public renal services in Queensland, and these are the target population for our registry. Progress so far includes conducting two CKD clinic site surveys, consenting over 3000 patients into the registry and initiation of baseline data analysis of the first 600 patients enrolled at the Royal Brisbane and Women's Hospital (RBWH) site. In addition, research studies in dietary intake and CKD outcomes and in models of care in CKD patient management are underway.ConclusionsThrough the CKD Registry, we will define the distribution of CKD patients referred to renal practices in the public system in Queensland by region, remoteness, age, gender, ethnicity and socioeconomic status. We will define the clinical characteristics of those patients, and the CKD associations, stages, co-morbidities and current management. We will follow the course and outcomes in individuals over time, as well as group trends over time. Through our activities and outcomes, we are aiming to provide a nidus for other states in Australia to join in a national CKD registry and network.

Dinoprostone vaginal pessary for induction of labour: Safety of use for up to 24 h

Cervidil(®) (dinoprostone) intravaginal pessaries are used for induction of labour and maintain serum prostaglandin levels for up to 24 h. The Therapeutic Goods Administration approves Cervidil(®) for 12-h use. However, twenty-four-hour use of Cervidil(®) is supported in Europe, New Zealand, America and some Australian hospitals. To assess the safety of Cervidil(®) use for up to 24 h for induction of labour in nulliparous women. A retrospective cohort study of 269 consecutive women receiving Cervidil(®) at the Royal Brisbane and Women's Hospital (RBWH) between July 2007 and December 2008 was performed. The primary outcome measures were frequency of, and time to, uterine tachysystole with or without fetal heart rate (FHR) changes. Secondary outcome measures included frequency of maternal (intrapartum temperature, postpartum haemorrhage) and neonatal (low Apgars, resuscitation, nursery admission) morbidity. Morbidity outcomes of those who received Cervidil(®) for less than or equal to 12 h were compared with those who received Cervidil(®) for more than 12 h. Uterine tachysystole occurred in 9.3% of patients receiving Cervidil(®) , with a mean time to tachysystole of 10 h. The majority of cases (68%) occurred within 12 h of use. There was no increase in maternal or neonatal morbidity for those who received Cervidil(®) for longer than 12 h. Twenty-four-hour use of Cervidil(®) is likely as safe as 12-h use for induction of labour in nulliparous women.

Predictors of outcome after elective endovascular abdominal aortic aneurysm repair and external validation of a risk prediction model

Endovascular abdominal aortic aneurysm (AAA) repair (EVAR) has been associated with lower operative mortality and morbidity than open surgery but comparable long-term mortality and higher delayed complication and reintervention rates. Attention has therefore been directed to identifying preoperative and operative variables that influence outcomes after EVAR. Risk-prediction models, such as the EVAR Risk Assessment (ERA) model, have also been developed to help surgeons plan EVAR procedures. The aims of this study were (1) to describe outcomes of elective EVAR at the Royal Brisbane and Women's Hospital (RBWH), (2) to identify preoperative and operative variables predictive of outcomes after EVAR, and (3) to externally validate the ERA model. All elective EVAR procedures at the RBWH before July 1, 2009, were reviewed. Descriptive analyses were performed to determine the outcomes. Univariate and multivariate analyses were performed to identify preoperative and operative variables predictive of outcomes after EVAR. Binomial logistic regression analyses were used to externally validate the ERA model. Before July 1, 2009, 197 patients (172 men), who were a mean age of 72.8 years, underwent elective EVAR at the RBWH. Operative mortality was 1.0%. Survival was 81.1% at 3 years and 63.2% at 5 years. Multivariate analysis showed predictors of survival were age (P = .0126), American Society of Anesthesiologists (ASA) score (P = .0180), and chronic obstructive pulmonary disease (P = .0348) at 3 years and age (P = .0103), ASA score (P = .0006), renal failure (P = .0048), and serum creatinine (P = .0022) at 5 years. Aortic branch vessel score was predictive of initial (30-day) type II endoleak (P = .0015). AAA tortuosity was predictive of midterm type I endoleak (P = .0251). Female sex was associated with lower rates of initial clinical success (P = .0406). The ERA model fitted RBWH data well for early death (C statistic = .906), 3-year survival (C statistic = .735), 5-year survival (C statistic = .800), and initial type I endoleak (C statistic = .850). The outcomes of elective EVAR at the RBWH are broadly consistent with those of a nationwide Australian audit and recent randomized trials. Age and ASA score are independent predictors of midterm survival after elective EVAR. The ERA model predicts mortality-related outcomes and initial type I endoleak well for RBWH elective EVAR patients.

Randomised Controlled Trial to determine the appropriate time to initiate peritoneal dialysis after insertion of catheter to minimise complications (Timely PD study)

BackgroundThe most appropriate time to initiate dialysis after surgical insertion of Tenckhoff catheters is not clear in the literature. There is the possibility of peritoneal dialysis (PD) complications such as leakage and infection if dialysis is started too soon after insertion. However, much morbidity and expense could be saved by reducing dependency on haemodialysis (HD) by earlier initiation of PD post catheter insertion. Previous studies are observational and mostly compare immediate with delayed use. The primary objective is to determine the safest and shortest time interval between surgical placement of a Tenckhoff catheter and starting PD.Methods/DesignThis is a randomised controlled trial of patients who will start PD after insertion of Tenckhoff catheter at Royal Brisbane and Women's Hospital (RBWH) or Rockhampton Base Hospital (RBH) who meet the inclusion criteria. Patients will be stratified by site and diabetic status. The patients will be randomised to one of three treatment groups. Group 1 will start PD one week after Tenckhoff catheter insertion, group 2 at two weeks and group 3 at four weeks. Nurses and physicians will be blinded to the randomised allocation. The primary end point is the complication rate (leaks and infection) after initiation of PD.DiscussionThe study will determine the most appropriate time to initiate PD after placement of a Tenckhoff catheter.Trial RegistrationACTRN12610000076077

The Eating Disorders Outreach Service: Enabling Clinicians Statewide to Treat Eating Disorders

The aim of this paper is to describe the Eating Disorders Outreach Service (EDOS), which supports clinicians in the treatment and management of eating disorder patients across Queensland. EDOS's mandate is to facilitate intake to the specialist inpatient and outpatient services at the Royal Brisbane and Women's Hospital (RBWH) and to provide eating disorders education and consultation liaison to clinicians statewide. EDOS provides services in four key areas: intake facilitation, service development, education and training, and consultation liaison. Each area is described in detail. EDOS has grown since its inception to currently comprise a full-time team manager and a number of specialist clinician positions in psychiatry, nursing, dietetics, social work and psychology. The Service has become an integral part of the RBWH Adult Eating Disorders Service, providing statewide assessment and treatment recommendations, consultation liaison services and specialist intervention programs. EDOS has been successful in facilitating patient access to local general medical and psychiatric facilities. EDOS also plays a significant leadership role in the development of effective statewide networking forums for clinicians and key stakeholders, in inservice delivery and in the provision of evidence-based educational opportunities, each of which has contributed to improved access to services for eating disorder patients.

Outcomes of salvage therapy for acute severe ulcerative colitis: Cyclosporin versus Infliximab

Acute severe ulcerative colitis (ASUC) is a common and serious complication of UC. For those cases refractory to intravenous steroid therapy Cyclosporin or, more recently, Infliximab therapy is the current standard of care. Although there have been no published studies comparing and contrasting these agents, clinical experience has previously indicated their effectiveness to be equable in this clinical context. A prospective study of 72 consecutive presentations of steroid refractory ASUC at the Royal Brisbane and Women's Hospital (RBWH) from 1996-2009 was con-ducted to assess the relative efficacy of Cyclosporin and Infliximab in this clinical setting. All study participants satisfied the Truelove and Witts criteria for acute severe colitis (≥6 bloody stools/day with one or more of the following: temperature >37.8°C; pulse rate >90/min; haemoglobin <10.5g/dl; or erythrocyte sedimentation rate (ESR) >30mm/hr) and were prevalent or incident cases of ulcerative colitis as confirmed by histological analysis. Primary endpoints measured were: outcome at discharge and outcome at 12 months after discharge; specifically whether these cases proceeded to total colectomy or were amenable to continuing medical management. The 72 steroid refractory acute colitis events were generated by 68 UC patients from north Brisbane, Queensland. Salvage therapy was instituted with either Cyclosporin in 44(61%) cases or Infliximab in the remaining 28(39%) patients. Of those patients who received Cyclosporin 52% (23/44) proceeded to total colectomy before discharge while this figure was only 18% (5/28) for those administered Infliximab as a salvage therapy. This finding was found to be statistically significant (p = 0.003). Twelve month follow-up data are currently available for 69/72 cases. At this timepoint 68% (30/44) and 44% (11/25) of cases treated with Cyclosporin and Infliximab, respectively, had required surgery for recurrent severe disease (p = 0.049). This study is of significance because it presents longitudinal outcomes data from a large, prospectively studied series of patients with refractory acute severe UC, selected on the basis of validated severity criteria. While it is clear that Infliximab salvage therapy is more efficacious than Cyclosporin in the short term in avoiding surgical intervention, the significance and duration of this benefit remain to be conclusively evaluated. We recognise that a randomised controlled trial is in progress in the United Kingdom that has been designed to answer this question and we await its findings.

Fetal macrosomia and pregnancy outcomes

Pregnancies with a macrosomic fetus comprise a subgroup of high-risk pregnancies. There is uncertainty in the clinical management and outcomes of such pregnancies. We sought to examine clinical management and maternal and fetal outcomes in pregnancies with macrosomic infants at Royal Brisbane and Women's Hospital (RBWH). Data from 276 macrosomic births (weighing > or = 4500 g) and 294 controls (weighing 3250-3750 g) delivered during 2002-2004 at RBWH were collected from the hospital database. Univariate and logistic regression analyses were performed for maternal risk factors and maternal and neonatal outcomes that were associated with fetal macrosomia. Macrosomia was more than two times likely in women with body mass index (BMI) of > 30 kg/m(2) (odds ratio (OR) 2.41, 95% confidence interval (CI) 1.26-4.61) and in male infant sex (OR 2.05, 95% CI 1.35-3.12), and four times more likely in gestation of > 40 weeks (OR 3.93, 95% CI 1.99-7.74). Maternal smoking reduced the risk of fetal macrosomia (OR 0.27, 95% CI 0.14-0.51). Macrosomia was associated with nearly two times higher risk of emergency caesarean section (OR 1.75, 95% CI 1.02-2.97) and maternal hospital stay of > 3 days (OR 1.66, 95% CI 1.11-2.50), and four times higher risk of shoulder dystocia (OR 4.08, 95% CI 1.62-10.29). Macrosomic infants were twice as likely to have resuscitation (OR 2.21, 95% CI 1.46-3.34) and intensive care nursery admission (OR 1.89, 95% CI 1.03-3.46). Macrosomia was associated with an increased risk of adverse maternal and neonatal health outcomes. Optimal management strategies of macrosomic pregnancies need evaluation.