Royal Perth Hospital Research Articles

Cemented vs Cementless Stems for Reverse Shoulder Arthroplasty for Proximal Humerus Fractures: A Registry Analysis with Patient-Reported Outcomes from a Level 1 Trauma Centre

BackgroundReverse total shoulder arthroplasty (rTSA) is being increasingly used in the treatment of comminuted or unreconstructible proximal humerus fractures. It is currently unclear if cementless rTSA have equivocal revision rates, mortality and functional outcomes compared to cemented or cementless rTSA. MethodsTwo data sources were used for this study. All rTSA performed for proximal humerus fractures between 1 January 2010 and 1 January 2020 recorded on the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) were used to determine revision rate and mortality between cemented and cementless rTSA. Patient-reported outcome measurements (PROM) including the American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score (OSS) and Single Assessment Numerical Value (SANE) were obtained via telephone from Royal Perth Hospital (RPH) patients between 01 January 2010 and 10 February 2021. ResultsThe study included 83 patients who underwent rTSA for proximal humerus fractures at Royal Perth Hospital. There were 4,335 rTSA procedures identified at other hospitals nationally. Of these, 54% of rTSA used cementless humeral stems. There was no significant difference in revision rate or mortality between cemented and cementless humeral stems adjusted for age and gender. For the RPH cohort, PROM scores included ASES score of 65.9 (CI: 60.6 - 71.2), OSS of 34.6 (CI: 31.9 - 37.2) and SANE value of 68.8 (CI: 61.8 - 75.8). ConclusionRevision rates and mortality are similar between cemented and cementless humeral stems used for rTSA for proximal humerus fractures. For appropriate patients, cementless humeral stems may be an acceptable first line treatment for proximal humerus fractures.

Assessing the Sympatholytic Effects of SGLT2 Inhibitors in Anuric Haemodialysis Patients Using Microneurography: Study Protocol for a Mechanistic Proof-of-Concept Trial

Introduction: Sodium-glucose co-transporter 2 inhibitors (SGLT2is) have been shown to provide effective cardiorenal protection, reducing mortality in conditions such as heart failure and chronic kidney disease. While several mechanisms have been identified, recent research has shed light on the drug’s ability to attenuate sympathetic nervous system (SNS) activity. Controversy exists on whether this is due to the extra-renal effects of the drug, or simply due to its renoprotective effects. However, recent trials have highlighted the persistent efficacy of SGLT2i despite declining renal function. Therefore, investigating the ability of SGLT2i to attenuate the SNS independently of the kidney could lead to more insight into its mechanism of action. So far, there has been limited research done on investigating the extra-renal effects of SGLT2i in human subjects on dialysis where the glycosuric renal effects of SGLT2i are negligible. This current study therefore aims to investigate the effects of SGLT2i on the SNS in anuric haemodialysis patients. Methods: We developed a protocol for a mechanistic study to investigate the extra-renal effects of SGLT2i on the SNS. The study will be an investigator-led, open-label, prospective study involving 20 adult (aged ≥18 years) haemodialysis patients with a residual urine output of ≤250 mL/day. Participants will be administered empagliflozin 25 mg/day for 6 weeks. Baseline SNS activity will be measured before and after administration by microneurography to assess central SNS outflow. Secondary outcomes such as changes from baseline in SNS stressor response, heart rate variability, and endothelial function will also be examined. We hypothesize that the use of empagliflozin will result in reduced sympathetic drive in anuric haemodialysis patients. Discussion: This will be the first study evaluating the effects of SGLT2i on the SNS in haemodialysis subjects. This study aims to enhance our understanding of the potential role of SGLT2i-induced SNS reduction in the setting of markedly reduced renal function. The study has received ethics approval from the Royal Perth Hospital Human Research Ethics Committee (RGS0000003840) (Australian New Zealand Clinical Trials Registry [ANZCTR] ID: ACTRN12623001237673).

A Dedicated Menopausal After Cancer Clinic May Improve Adherence to Endocrine Therapy For Breast Cancer: A Population Based Study

PurposeTo examine utilization of a dedicated menopause symptoms after cancer clinic (MSAC) and to determine whether women referred to the MSAC for management of severe hot flush symptoms are more likely to adhere to endocrine therapy compare to those with severe symptoms not referred to MSAC. Patients and methodsBreast cancer patients prescribed endocrine therapy with a diagnosis of estrogen-receptor positive breast cancer between January 2003 and December 2011 were identified from the Royal Perth Hospital Breast Unit database. Details of breast cancer pathology, endocrine therapy, endocrine therapy related side effects, referral to MSAC and patient reported adherence to endocrine therapy for up to 4 years were ascertained from the database and medical records systems. For those with severe vasomotor symptoms, total duration of endocrine therapy was compared between women referred to MSAC and those who were not referred to MSAC. ResultsAbout 1275 women were identified from the database, with the cohort followed up until Dec 2016. Of these women, 120 (9.4%) were referred to MSAC and 1155 (90.1%) received usual care. In total, 147 reported severe vasomotor symptoms of whom almost half (71) were referred to MSAC. Women with severe vasomotor symptoms managed by MSAC were less likely to discontinue endocrine therapy (15.5%) compared with those managed with usual care (26.3%). However, this difference was not statistically significant (chi-square test statistic = 2.584, 1df, P = .1). ConclusionManagement of severe vasomotor symptoms at a dedicated menopause clinic may increase adherence to endocrine therapy for breast cancer.

Infective endocarditis outcomes at a tertiary hospital in Western Australia: a retrospective cohort study from 2016 to 2021.

Infective endocarditis (IE) is a severe infection with considerable mortality. It is associated with geographical variation, complicating diagnosis and treatment of patients in a standardised manner. To evaluate the characteristics and management outcomes of patients with IE in Royal Perth Hospital (RPH). A single-centre, retrospective cohort study. Data were collected from medical records of 131 patients with a diagnosis of IE admitted to RPH between 2016 and 2021. Eighty-four patients with definite IE were included for analysis. The median age of patients was 51.5 years and 77.4% were male. Compared to the general Australian population, there was disproportionately greater representation of Indigenous Australians (21.4%), those with a history of injecting drug use (IDU) (27.4%), rheumatic heart disease (14.3%) and previous IE (13.1%). The most commonly affected valve was the mitral valve in 46.4% of patients, and the most common pathogen was Staphylococcus aureus in 47.6% of patients. Twelve-month mortality was 16.7%, with significantly increased mortality in those treated non-surgically (25.6% vs 7.3%, P = 0.025). Factors associated with undergoing surgery included the presence of aortic valve disease, perivalvular extension of infection and infection with Enterococcus faecalis, whereas IDU, tricuspid valve disease and S. aureus infection were associated with non-surgical management. Adherence to multidisciplinary team review was 75.0%, and surgical management was performed in 70.7% of patients meeting an indication for surgery. IE mortality rates remain high, particularly in patients who do not undergo surgical management. Streamlined MDT assessment and referral for surgical management where appropriate is necessary to improve outcomes.

Evaluation of geographic variations in appendicectomy outcomes within Western Australia assessing the impact of surgical wait times and rate of negative appendicectomies in both urban and rural locations statewide

PurposeSurgery wait times after diagnosis of appendicitis are an important factor influencing the success of a patient’s treatment. The proposed study will be a quantitative multicenter retrospective cohort design with the primary aim of assessing the difference between appendicectomy wait times between rural and urban hospitals in Western Australia and the effect of this on operative outcomes. Selected outcome measures will be examined by time from initial presentation at an emergency department to the patient being diagnosed and then time of diagnosis to surgery being performed. The secondary aim is to compare rates of negative appendicectomies between hospitals.MethodsAppendicectomy patients will be identified from operating room register by medical student data collectors; then, each respective hospital’s emergency room data collection will subsequently be accessed to complete case report forms based on demographics and clinical findings, pre-operative investigations, and management and follow-up. Case report forms with > 95% completeness will be accepted for pooled analysis. The expected duration of retrospective data collection will be 8 months. This study RGS6483 has received HREC approval by the Royal Perth Hospital HREC Ethics Committee, with a waiver of consent obtained and the HREC was notified of amendments to the protocol made on April 21, 2024.Dissemination of results.Data will be collected and stored online through a secure server running the Research Electronic Data Capture (REDCap) web application. No patient-identifiable data will be entered into the system. Results will subsequently be shared via scientific journal publication and presentation at relevant meetings.

A case series of the Royal Perth Hospital cannula-first approach in the 'can't intubate, can't oxygenate' scenario.

At the Royal Perth Hospital, we have been developing and teaching a can't intubate, can't oxygenate (CICO) rescue algorithm for over 19 years, based on live animal simulation. The algorithm involves a 'cannula-first' approach, with jet oxygenation and progression to scalpel techniques if required in a stepwise fashion. There is little reported experience of this approach to the CICO scenario in humans. We present eight cases in which a cannula-first Royal Perth Hospital approach was successfully implemented during an airway crisis. We recommend that institutions teach and practice this approach; we believe it is effective, safe and minimally invasive when undertaken by clinicians who have been trained in it and have immediate access to the requisite equipment. The equipment is low cost, comprising a 14G Insyte cannula, saline, 5 ml syringe and a Rapid-O2. Training can be provided using low-fidelity manikins or part-task trainers.

A Retrospective Cohort Study on One-Year Mortality Following Emergency Laparotomy: A Tertiary Centre Experience From Western Australia.

Background Emergency laparotomy is a common general surgical procedure associated with a high mortality and morbidity profile. While short-term outcomes following emergency laparotomy have been increasingly described, there remains a paucity of literature on long-term outcomes in Australia. We report our one-year mortality following emergency laparotomy at Royal Perth Hospital, Australia. Methodology A retrospective observational series of emergency laparotomies performed during 2019 and 2020 at Royal Perth Hospital was collected. The primary endpoint is the one-year mortality, and the secondary endpoints are patient demography, COVID-19 status, ASA classification, surgical category, operative indication, primary surgical pathology, procedure and surgical duration, ICU stay, post-operative destination, length of stay, 30-day mortality, and 90-day mortality. Subgroup analysis was performed for years 2019 and 2020. Results A total of 272 emergency laparotomies were performed during the two-year study period. The average age was 61 years (range 18- 98, SD ± 18.32). The majority of patients were in the ASA classification III (n= 134, 49.26%). The average length of patients' stay was 14.17 days (median 10, IQR 11). Moreover, 31.98% of patients were admitted directly to the ICU following emergency laparotomy. One year mortality was 16.6%. However, a significant difference in the long-term mortality rates was observed between the two calendar years, 24.6% in 2019 and 8.66% in 2020. The one-month mortality rate was 7.33%, and the three-month mortality rate was 10.85%. Conclusion The one-year mortality rate observed is high and considerable and similar to experiences published elsewhere. The significant reduction in mortality during the study period warrants further investigation and may reflect improved planning and attitudes around these high-risk surgeries.

High value healthcare analysis of “triggers” in deteriorating patients

Objective: To review “triggers” for deteriorating patients who required intervention by a medical emergency response team (MET). In addition, to assess whether these “triggers” differed by medical or surgical governance of these patients. A secondary objective was to report laboratory investigations performed via the MET, with particular interest in tests duplicating haemoglobin (Hb) values and their degree of concordance within the context of low-cost, high value inpatient care.Methods: This quality improvement initiative involved a prospective observational cohort of inpatients, who were attended to by the MET at Royal Perth Hospital in Perth, Western Australia over a 2-year period between 2020 and 2022.Results: The mean number of MET calls for inpatients under surgical governance was slightly higher than for those patients under medical governance (1.34 vs. 1.25 calls respectively p = .03). Hypotension triggered a MET call in 184 (40.9%) surgical patients compared to 154 (28%) under medical governance (p < .001). Comparing haemoglobin values obtained from FBP and VBG, Lin’s concordance correlation coefficient (CCC) was found to be 0.986, 95%CI: 0.983, 0.989. The Bland-Altman limits of agreement suggest that the haemoglobin value on a VBG ranges from 9.55 g/L higher than the FBP to 4.7 g/L lower than the FBP.Conclusions: Significant differences in the frequency of triggers for patients under medical vs surgical governance highlight the need for proactive planning around hypotension management of patients under surgical governance. In addition, understanding the nuances between haemoglobin values obtained from FBP and VBG can help with value-based health care and efficiencies in patient care, since measuring haemoglobin values is one of the key components in hypotension management.

The Utility of Renal Mass Biopsy in Large Renal Masses.

The role of needle core renal biopsy in large renal masses, defined as lesions larger than 4 cm, is debatable, as larger renal masses are associated with malignant histology. We aim to review the safety and impact of renal biopsy on the management of large renal masses. A retrospective, single-center review of all renal biopsies performed between January 2011 and December 2020 at Royal Perth Hospital was conducted. Indications for biopsy, complications and final management plans were correlated to assess the value of biopsies in large renal masses. In total, 126 biopsies were performed. Indeterminate imaging findings and comorbidities were the main indications for biopsies. We identified 116 (92.1%) diagnostic biopsies and 10 (8.0%) non-diagnostic biopsies due to insufficient samples or inflammatory tissue. Of the diagnostic biopsies, 99 (78.6%) were malignant and 17 (13.5%) were benign. Unnecessary extirpative surgery was avoided in 17 patients. Histology included renal cell carcinoma (96%) and other malignancies such as urothelial carcinoma (3%) and non-Hodgkin's lymphoma (1%). Benign biopsies identified histology including angiomyolipoma (35.3%) and oncocytoma (52.5%). The median follow-up time was 68 months (range 19-132 months). Renal biopsies in large renal masses may aid in preventing unnecessary surgery, especially in situations where imaging findings are equivocal or in patients with many comorbidities.

Establishing a Functional Coronary Angiogram Program at Royal Perth Hospital

Establishing a Functional Coronary Angiogram Program at Royal Perth Hospital

Subcorneal pustular dermatosis treated successfully with apremilast.

Australasian Journal of DermatologyEarly View LETTER Subcorneal pustular dermatosis treated successfully with apremilast Lori Zhang MD, Corresponding Author Lori Zhang MD [email protected] orcid.org/0009-0008-9403-0812 Royal Perth Hospital, Perth, Western Australia, Australia Correspondence Lori Zhang, Royal Perth Hospital, Perth, WA, Australia. Email: [email protected]Search for more papers by this authorKurt Gebauer MBBS, FACD, FACP, Kurt Gebauer MBBS, FACD, FACP University of Western Australia, Perth, Western Australia, Australia Probity Health Care, Waterloo, Ontario, Canada Fremantle Dermatology, Fremantle, Western Australia, AustraliaSearch for more papers by this author Lori Zhang MD, Corresponding Author Lori Zhang MD [email protected] orcid.org/0009-0008-9403-0812 Royal Perth Hospital, Perth, Western Australia, Australia Correspondence Lori Zhang, Royal Perth Hospital, Perth, WA, Australia. Email: lori.zhan[email protected]Search for more papers by this authorKurt Gebauer MBBS, FACD, FACP, Kurt Gebauer MBBS, FACD, FACP University of Western Australia, Perth, Western Australia, Australia Probity Health Care, Waterloo, Ontario, Canada Fremantle Dermatology, Fremantle, Western Australia, AustraliaSearch for more papers by this author First published: 27 May 2023 https://doi.org/10.1111/ajd.14073 The photographs in this letter were obtained with the informed consent of the patient, and there are no identifying markings or words in the images. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Early ViewOnline Version of Record before inclusion in an issue RelatedInformation

Elective surgery after COVID19 infection: long exclusion times may not be justified in a highly vaccinated population and milder strains of the virus.

Since the publication of an increase in perioperative morbidity and mortality up to 6 weeks after infection with COVID-19 by the COVIDSurg Collaborative,1 many hospitals worldwide have adopted policies of post COVID waiting periods before elective surgery may be performed. However, the introduction of such ‘exclusion times’ has the potential to significantly interrupt the flow of elective surgery,2 and the postponement of surgery due to COVID has been shown to have a negative impact on emotional wellbeing and the perception of the quality of life.3 The findings of the COVIDSurg group included a heterogenous group of patients, many of whom likely infected with either the original COVID strain or the Delta variant, and many patients were either unvaccinated or only partially vaccinated. This invites the question whether in a highly vaccinated population and with the predominance of the Omicron variant outcomes after surgery may be different. The current vaccination rate for 2 or 3 doses of a COVID vaccine in Australia's general population is approx. 96% and 72%, respectively. Western Australia experienced a surge of COVID (vast majority Omicron) infections between February and September 2022. At the Royal Perth Hospital (RPH), the trauma centre of Western Australia, some patients underwent surgery during their active COVID infection due to the urgency of their condition. The aim of an audit done by us at the end of 2022 (approved by the Royal Perth Hospital on 14/10/2022, approval number 47637) was to identify all cases operated at RPH during this period. We then followed up their postoperative outcomes in order to identify whether the acute COVID infection was associated with an increase in postoperative morbidity or mortality. Patients were counted as COVID positive if either a positive rapid antigen test or a polymerase chain reaction test had been performed prior to their surgery. Patients undergoing cardiac or pulmonary interventions were excluded. Thirty-eight patients (median age 42 years) were identified. Two percent of patients had received four COVID vaccines, 50% percent of the patients were triple vaccinated, 32% double vaccinated, and 16% had received a single dose. Sixty-one percent of patients were classified as ASA 3 or 4, with 63% of patients having at least 2 cardio-pulmonary significant co-morbidities. Fifty-five percent presented with a fever (≥38°C) and cough. Seventy-four percent of the patients underwent surgery within 4 days of their COVID-19 diagnosis, with the majority having surgery on day two of the COVID-19 diagnosis. Eighty-two percent of the patients underwent general anaesthesia, with the seven remaining cases comprised of five regional blocks, one neuraxial anaesthesia and one case done under infiltration (local) anaesthesia. Of interest, only one of the 38 patients suffered a likely COVID-related complication, manifested as postoperatively diagnosed COVID pneumonitis. This patient was a 48-year-old female (active smoker with a past medical history of chronic obstructive pulmonary disease) who developed increasing oxygen requirements shortly after surgery. However, the patient recovered after a short course of anti-viral treatment. All 38 patients who underwent surgery during an active COVID infection were successfully discharged from the hospital. Though all but one patient had no complication after surgery, our follow-up ended at the time of hospital discharge. Hence, complications may have been missed if only occurring after this time point. However, on 30-day follow-up the mortality in our cohort was 0 %, at least indicating no extremes of impaired outcomes were missed. We conclude that the rate of postoperative complications in a relatively co-morbid cohort of patients with active COVID infection at the time of their emergency/urgent surgery was very low. Though our relatively small case series may not allow final conclusions, it may at least introduce the hypothesis that, in a highly vaccinated population and predominance of a milder COVID strain, the currently frequently observed 6–8 weeks after COVID infection until elective surgery can be performed may be overly cautious, and that an increase in surgical wait times may ultimately adversely affect patient physical and emotional health. Open access publishing facilitated by The University of Western Australia, as part of the Wiley - The University of Western Australia agreement via the Council of Australian University Librarians. Calvin Lo: Conceptualization; data curation; investigation; methodology; project administration; software; writing – review and editing. Thomas Ledowski: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; supervision; writing – original draft; writing – review and editing.

JS-ECCR/HBPRCA-2: HOMOCYSTEINE AND LIPOPROTEIN (A) AS A DETERMINANT OF ARTERIAL STIFFNESS AND A PREDICTOR OF HYPERTENSION MEDIATED TARGET ORGAN DAMAGE (HMOD)

Background: Despite advances in modern medicine, cardiovascular disease (CVD) remains a leading cause of global mortality. Among the many CVD determinants, hypertension is a leading modifiable risk factor and blood pressure control and prevention of hypertension mediated target organ damage (HMOD) has become the hallmark of cardiovascular risk management. Homocysteine and lipoprotein (a) are independent CVD risk factors, proposed to contribute to vascular compromise by facilitating thrombogenesis and atherosclerosis. Aims: We sought to determine in a real-world clinical setting whether these risk factors interact to facilitate vascular organ damage in hypertension. Methods: We performed a cross-sectional analysis of prospectively collected data in 131 hypertensive patients referred to our tertiary hypertension clinic at Royal Perth Hospital. The Lipoprotein (a), homocysteine and other biochemical parameters studied were assayed in the central hospital laboratory. We analysed the effect of the interaction between Lipoprotein (a) and homocysteine (Lpa-Hcy) on markers of HMOD including arterial stiffness, as assessed by pulse wave velocity (PWV). Results: The average age of participants was 56 ± 0.9 years, and there was a greater proportion of males than females (62% vs. 38%). The regression analysis demonstrated that Lp(a)-Hcy interaction was significantly associated with PWV [beta = 0.33; 95% CI 0.12, 0.55; p < 0.005], 24 h urinary protein excretion [beta = -10.9; 95% CI -14.5, -7.4; p < 0 .001], and estimated glomerular filtration rate [beta = 103.9; 95% CI 93.9, 113.8; p < 0.001], which persisted after adjusting for potential confounders such as age, sex, 24 h BP, inflammation, smoking, diabetes mellitus and other metabolic risk factors. Interaction analysis showed that increasing homocysteine and lipoprotein (a) concentration was associated with increasing arterial stiffness. Hcy levels does not affect the PWV if Lp(a) levels are normal and the knowledge of both Lp(a) and Hcy are necessary to determine arterial damage. Furthermore, Lp(a)-Hcy product exhibited a positive predictive relationship with every unit increase in Lp(a)-Hcy product associated with a 0.3 m/s increase in PWV which may represent a useful marker for cardiovascular risk stratification and may suggest the need for rigorous treatment to minimise HMOD progression. These clinical findings provide novel insights into the potential interaction between Lp(a) and Hcy in the pathogenesis of hypertension mediated vascular damage

Editorial introductions.

Current Opinion in Lipidology was launched in 1990. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of lipidology is divided into six sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editor for this issue. SECTION EDITOR Erik StroesErik StroesErik S. G. Stroes is Chair of the Department of Vascular Medicine at the Academic Medical Center, Amsterdam, The Netherlands. After gaining his Doctor of Medicine degree from Erasmus University, Rotterdam, The Netherlands, he then specialized in internal medicine at University Medical Center, Utrecht, The Netherlands, and later in vascular medicine at the Academic Medical Center, Amsterdam. Professor Stroes’ research interests include the role of the vessel wall in atherosclerosis development and lipid disorders in relation to atherogenesis. He has been an investigator in numerous lipid-lowering trials using various surrogate markers, such as intima-media thickness and flow-mediated dilation, and more recently 3T magnetic resonance imaging as a surrogate marker for vascular disease progression. He has also been involved in the development of novel therapeutic moieties for dyslipidemia, such as lipoprotein lipase gene therapy, antisense oligonucleotide inhibition of apolipoprotein B synthesis, and reconstituted high-density lipoprotein infusion. He has been the recipient of numerous research grants and several awards. Professor Stroes is Chair of the Dutch Atherosclerosis Society, member of the Vascular Biology Working Group, member of the American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology, and former Chair of the Dutch Internist Vascular Society. He has published more than 300 papers in various peer-reviewed journals and authored several book chapters in the field. Gerald F WattsGerald F WattsGerald F Watts (DSc DM PhD FRCP FRACP) trained at Imperial College (St Mary's Hospital) and King's College (St Thomas’ Hospital) in the University of London. He is a consultant physician, specializing in lipid disorders and cardiovascular medicine, within the department of cardiology at Royal Perth Hospital, as well as Winthrop Professor of Cardiometabolic Medicine in the University of Western Australia. He is Chair of The Familial Hypercholesterolaemia (FH)-Australasia Network and executive board member of the International Atherosclerosis Society. His research interests include lipid disorders and cardiovascular prevention, with clinical interest focusing on delivering improved health care for patients and families with FH. Professor Watts is actively involved in undergraduate medical education and supervisors PhD students and post-doctoral fellows. He has authored over 500 published works, including scientific articles, reviews, book chapters and monographs, and is associate editor of Atherosclerosis, Journal Clinical Lipidology and Metabolism.

External validity of four risk scores predicting 30-day mortality after surgery.

Surgical risk prediction tools can facilitate shared decision-making and efficient allocation of perioperative resources. Such tools should be externally validated in target populations before implementation. Predicted risk of 30-day mortality was retrospectively derived for surgical patients at Royal Perth Hospital from 2014 to 2021 using the Surgical Outcome Risk Tool (SORT) and the related NZRISK (n=44 031, 53 395 operations). In a sub-population (n=31 153), the Physiology and Operative Severity Score for the enumeration of Mortality (POSSUM) and the Portsmouth variant of this (P-POSSUM) were matched from the Copeland Risk Adjusted Barometer (C2-Ai, Cambridge, UK). The primary outcome was risk score discrimination of 30-day mortality as evaluated by area-under-receiver operator characteristic curve (AUROC) statistics. Calibration plots and outcomes according to risk decile and time were also explored. All four risk scores showed high discrimination (AUROC) for 30-day mortality (SORT=0.922, NZRISK=0.909, P-POSSUM=0.893; POSSUM=0.881) but consistently over-predicted risk. SORT exhibited the best discrimination and calibration. Thresholds to denote the highest and second-highest deciles of SORT risk (>3.92% and 1.52-3.92%) captured the majority of deaths (76% and 13%, respectively) and hospital-acquired complications. Year-on-year SORT calibration performance drifted towards over-prediction, reflecting a decrease in 30-day mortality over time despite an increase in the surgical population risk. SORT was the best performing risk score in predicting 30-day mortality after surgery. Categorising patients based on SORT into low, medium (80-90th percentile), and high risk (90-100th percentile) might guide future allocation of perioperative resources. No tools were sufficiently calibrated to support shared decision-making based on absolute predictions of risk.

Evaluation of the ‘Talking Together’ simulation communication training for ‘goals of patient care’ conversations: a mixed-methods study in five metropolitan public hospitals in Western Australia

IntroductionIn partnership with Cancer Council Western Australia (WA), the East Metropolitan Health Service in Perth, WA has developed a clinical simulation training programme ‘Talking Together’ using role play scenarios with...

Evolution of trauma care and the trauma registry in the West Australian health system.

Trauma care is evolving throughout the world to meet the demand resulting from rapidly increasing rates of mortality and morbidity related to external injuries. The State Major Trauma Service was designated to Royal Perth Hospital in 2004 to provide comprehensive care for trauma patients in Western Australia (WA), which is the largest state by area in the country. The State Major Trauma Unit, which was established in 2008, functions as a level I center and admits over 1,000 major trauma patients per year, making it the second busiest trauma center in Australia. The importance of recording data related to trauma was identified by the trauma service in WA to inspire higher standards of patient care and injury prevention. In 1994, the service established a trauma registry, which has undergone significant changes over the last two decades. The current State Trauma Registry is linked to a statewide database called the Data Linkage System. The linked data are available for policy development, quality assurance, and research. This article discusses the evolution of the trauma service and the registry database in the WA health system. The State Trauma Registry has enormous potential to contribute to research and quality improvement studies along with its ability to link with other databases.

Cannula cricothyroidotomy in the impalpable neck: An observational study of simulated 'can't intubate, can't oxygenate' scenarios by teams following a cannula-first algorithm in live anaesthetised pigs.

Live animal models can be used to train anaesthetists to perform emergency front-of-neck-access. Cannula cricothyroidotomy success reported in previous wet lab studies contradicts human clinical data. This prospective, observational study reports success of a cannula-first 'can't intubate, can't oxygenate' algorithm for impalpable anatomy during high fidelity team simulations using live, anaesthetised pigs.Forty-two trained anaesthesia teams were instructed to follow the Royal Perth Hospital can't intubate, can't oxygenate algorithm to re-oxygenate a desaturating pig with impalpable neck anatomy (mean (standard deviation, SD) 16.2 (3.5) kg); mean (SD) tracheal internal diameter 11 (1.4) mm. Teams were informed that failure would prompt veterinary-led euthanasia.All teams performed percutaneous cannula cricothyroidotomy as the initial technique, with a median (interquartile range, IQR (range)) start time of 42 (35-50 (24-93)) s. First-pass percutaneous cannula success was 29% to both insufflate tracheal oxygen and re-oxygenate. Insufflation success improved with repeated percutaneous attempts (up to three), but prolonged hypoxia time increasingly necessitated euthanasia (insufflation 57%; re-oxygenation 48%). First, second and third percutaneous attempts achieved insufflation at median (IQR (range)) 74 (64-91 (46-110)) s, 111 (95-136 (79-150)) s and 141 (127-159 (122-179)) s, respectively. Eighteen teams failed with percutaneous cannulae and performed scalpel techniques, predominantly dissection cannulation (n = 17) which achieved insufflation in all cases (insufflation 100%; re-oxygenation 47%). Scalpel attempts were started at median (IQR (range)) 142 (133-218 (97-293)) s and achieved insufflation at 232 (205-303 (152-344)) s.While percutaneous cannula cricothyroidotomy could rapidly re-oxygenate, the success rate was low and teams repeated attempts beyond the recommended 60 s time frame, delaying transition to the more successful dissection cannula technique. We recommend this 'cannula-first' can't intubate, can't oxygenate algorithm adopts a 'single best effort' strategy for percutaneous cannula, with failure prompting a scalpel technique.

Is Asymptomatic Severe Aortic Stenosis Still a Waiting Game?

Is Asymptomatic Severe Aortic Stenosis Still a Waiting Game?

Evaluating the Efficacy, Toxicity and Pharmacokinetic Profile of Oral Busulfan in Allogeneic Stem Cell Transplant Patients.

Oral busulfan and intravenous cyclophosphamide (Bu/Cy) are common myeloablative preparations used in allogeneic hematopoietic stem cell transplantation (HSCT). Herein, we investigated the safety of (Bu/Cy) administration during HSCT. Patients administered Bu/Cy for allogeneic HSCT at Royal Perth Hospital and Fiona Stanley Hospital between 2007 and 2017 were reviewed for inclusion in the study. We performed busulfan pharmacokinetic (PK) testing for a subset of patients and allometric scaling modeling to assess the best method of busulfan dosing in patients at extremes of weight. Sixty-nine patients were included in the clinical outcome analysis. The median follow-up period was 32 months (range, 9-114 months). The three-year overall survival rate was 62% (95% confidence interval (CI), 51%-75%), and transplant-related mortality was 4% at 6 months (95% CI, 1-7%), with a low rate of sinusoidal obstruction syndrome of the liver being observed. In addition, relapse was 38% (95% CI, 30%-44%) at 3 years. The PK information of 15 patients receiving busulfan was available after oral dosing. The average per-dose busulfan exposure was 1,350 μmol.min/L (range, 878-1,717 μmol.min/L), and the within target range was 1,000-1,500 μmol.min/L in 73% of patients. Of the size measures investigated, ideal and adjusted body weight (ABW40) provided the best fit. No association was observed between busulfan exposure, toxicity, and relapse. Overall, Bu/Cy administration appeared safe when dosed in relation to weight, showing a low early transplant-related mortality rate following adequate busulfan exposure in majority of the cases. Body size measures, such as ideal body weight or ABW40, are likely more suitable for use during busulfan dosing, particularly at high extremes of the body mass index classification.