Sir Charles Gairdner Research Articles

EDITORIAL

EDITORIAL

Survey of consent practices for inpatient colonoscopy and endoscopic retrograde cholangiopancreatography at a tertiary referral center

The purpose of the present paper was to determine informed consent practices for inpatient, open-access colonoscopy and endoscopic retrograde cholangiopancreatography (ERCP) at a tertiary referral center. A two-part prospective study incorporating (i) an audit of consent practices for colonoscopy and ERCP; and (ii) a questionnaire directed at gastroenterologists and interns regarding information imparted to patients in the process of acquiring informed consent, was undertaken at Sir Charles Gairdner Hospital, Western Australia. Study subjects consisted of inpatients undergoing open-access colonoscopy and/or ERCP at the study center commencing May 2003; and gastroenterologists and interns at the study center. Written consent was obtained by junior medical staff in 89% of cases. Response rates for the questionnaire was 100% from interns, and 91% from gastroenterologists. Of interns surveyed, 93% had witnessed a colonoscopy, and 59% had witnessed an ERCP. For 12% of interns, colonoscopic bleeding or perforation were not always mentioned. Colonoscopy failure rate and perforation were overestimated by 51% and 63% of interns, respectively. Only 56% of interns always mentioned pancreatitis as a complication of ERCP. The rate of post-ERCP pancreatitis was overestimated by 25% of interns. Only 40% of gastroenterologists always provided additional information to patients whose consent was obtained by someone else. Written material was not routinely provided for patients. Consent was usually obtained on the day of the procedure. Written consent for inpatients undergoing open-access colonoscopy and ERCP is rarely obtained by the proceduralist. There is substantial variability in the information provided to patients. Guidelines are required to ensure best practice in this area.

Teaching on the run tips 12: planning for learning during clinical attachments

Education Centre, Faculty of Medicine and Dentistry, University of Western Australia, Nedlands, WA. Fiona R Lake, MB BS, FRACP, MD, Senior Lecturer in Medicine and Associate Dean (Teaching and Learning). Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA. Gerard Ryan, MB BS, FRACP, Respiratory Physician. Reprints will not be available from the authors. Correspondence: Associate Professor Fiona R Lake, Education Centre, Faculty of Medicine and Dentistry, University of Western Australia, 1st Floor, N Block, QEII Medical Centre, Verdun Street, Nedlands, WA 6009. flake@cyllene.uwa.edu The Medical Journal of Australia ISSN: 0025729X 6 March 2006 184 5 238-239 ©The Medical Journal of Australia 2006 www.mja.com.au Teaching on the run during the attachment.

A half‐day each month for quality and safety activities

Medical Journal of AustraliaVolume 183, Issue 10 p. 545-546 Matter Arising A half-day each month for quality and safety activities R James Aitken, R James Aitken S Sir Charles Gairdner Hospital, Hollywood Specialist Centre, 95 Monash Avenue, Nedlands, WA 6090.Search for more papers by this author R James Aitken, R James Aitken S Sir Charles Gairdner Hospital, Hollywood Specialist Centre, 95 Monash Avenue, Nedlands, WA 6090.Search for more papers by this author First published: 21 November 2005 https://doi.org/10.5694/j.1326-5377.2005.tb07166.xRead 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 Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume183, Issue10November 2005Pages 545-546 RelatedInformation

810 ORAL Risk and risk factors of renal impairment in hormone refractory prostate cancer (HPRC) patients with bone metastases (BM) treated with Zoledronic Acid (ZA)

Interobserver variation in the histological grading of breast carcinoma was investigated using the hypothesis that optimal fixation, more precise grading guidelines, some experience, the use of training and test sets, and a comparison of results with an expert group might allow higher levels of agreement. For the training sets sections from 50 consecutive cases of breast carcinoma received at the Sir Charles Gairdner Hospital (SCGH) and fixed in both B5 and buffered formal saline (BFS) were graded by consensus of three pathologists at the SCGH and independently by consensus of two pathologists at the Nottingham City Hospital (NCH) using a modified Scarff-BloomRichardson histological grading system with guidelines as suggested by NCH pathologists. The section quality and degree of preservation of nuclear morphology were judged by NCH pathologists to be superior for B5-fixed material. Complete agreement in grade between SCGH and NCH results was achieved for 83.3% of B5-fixed cases and 73.5% of BFS-fixed cases (P = .05) with relative disagreement rates (RDRs) of 0.15 and 0.29 and kappa statistic values of 0.73 and 0.58, respectively. Approximately 80% complete agreement was achieved for tubule formation, nuclear score, and mitotic count, with RDRs ranging from 0.19 to 0.27 and kappa values from 0.46 to 0.69. There was a consistent bias in the SCGH results toward a higher tubule score in both B5- and BFS-fixed material because of a difference in interpretation of cribriform or complex gland patterns and a consistent bias in SCGH results toward a lower nuclear size/pleomorphism score for B5 and BFS material. For the test set sections from 50 further consecutive cases of breast cancer fixed in B5 were examined using similar criteria but taking into account the sources of error shown by the training set. Approximately 80% complete agreement was again achieved for grade components and grade (RDRs, 0.18 and 0.72). Systematic bias was reduced in the test set, but no other improvement was observed. Of the tumors designated as grade I by NCH, 87.5% were called grade I tumors by SCGH in the B5 training set, 84.6% in the B5 test set, and 66.6% in the BFS training set. The levels of agreement shown in both the training and test sets were satisfactory and represented a significant improvement over our previous study, suggesting that experience and precise grading guidelines are of value. The similar levels of agreement in training and test sets suggest that reasonable results can be achieved without direct training by expert groups. The value of optimal fixation may be the most important variable noted by the study.

Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis

Medical Journal of AustraliaVolume 182, Issue 7 p. 365-368 Letter Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis David J Blacker, Corresponding Author David J Blacker Neurologist and Stroke Physician David.blacker@health.wa.gov.au Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009.Correspondence: David.blacker@health.wa.gov.auSearch for more papers by this author David J Blacker, Corresponding Author David J Blacker Neurologist and Stroke Physician David.blacker@health.wa.gov.au Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009.Correspondence: David.blacker@health.wa.gov.auSearch for more papers by this author First published: 04 April 2005 https://doi.org/10.5694/j.1326-5377.2005.tb06741.xRead 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 Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume182, Issue7April 2005Pages 365-368 RelatedInformation

Airway remodeling in asthma

This overview summarizes some the more recent studies of remodeling in patients with asthma, studies using animal models to study the interaction of cell types and mediators, and studies using in vitro models to assess the effects of mitogenic stimuli, including mechanical strain, on mesenchymal cells and extracellular matrix proteins. The aim is to demonstrate how the term remodeling is becoming increasingly less specific as reductionism is applied to this field of study. Specific areas of recent interest include plasticity of airway smooth muscle and fibroblast phenotype; the role of the extracellular matrix and its relation to the function of the airway smooth muscle and the mechanical properties of the airway wall; mitogenic stimuli arising from damaged epithelium, fibroblasts, smooth muscle cells, mast cells, eosinophils, and mechanical stress; extracellular and intracellular signaling in fibroblasts and smooth muscle cells; and therapeutic targets among the many pathways of remodeling-pathways that may be distinct from those involved in inflammation. The potential functional consequences of some of these findings call into question the role of remodeling. In some respects, it may represent a continuum from inflammation to scarring, but it may also be a protective response to altered airway mechanics caused by ongoing tissue damage or by abnormal airway structure present from early in life. The diverse areas of research in this field are increasingly making the term remodeling as useful (or not) as the word asthma, because both can be used to describe simultaneously a large number of processes that may or may not be related to each other.

Problems with contracting out government services: lessons from orderly services at SCGH

This paper identifies and discusses the problems associated with contracting out labor-intensive government services. It examines in detail the contracting out of the orderly service at Sir Charles Gairdner Hospital (SCGH) in Western Australia and its subsequent return to in-house delivery. When the orderly service was contracted out, the result was poor in terms of cost, quality and externalities. Subsequent return of the service to in-house provision reduced costs and improved quality. The problems that led to failure of contracting out and subsequent success of in-house provision can be explained in terms of transaction cost economics. Copyright 2004, Oxford University Press.

Acute radiation toxicity assessment of a 3-D conformal head and neck radiation treatment technique.

Patients undergoing radiation treatment for head and neck cancer have many critical structures within or adjacent to the treatment area. Avoiding these critical structures is more efficient and easier using 3-D conformal planning. At Sir Charles Gairdner Hospital an investigation into the acute radiation toxicity was undertaken when the head and neck treatment technique was changed from the conventional 2-D plan to the conformal 3-D plan. Although the primary target volume (PTV), fraction size and overall dose remain the same for the two techniques, differing beam configurations mean that treatment fields enter and exit through different parts of the head and neck. Ten patients were initially assessed to gain a baseline appearance of their head and neck region, and then graded weekly according to the toxicity criteria during treatment and at 4, 8 and 12 weeks after treatment. The results of the assessment indicate that there is no increase in toxicity as a result of treating using the conformal head and neck technique.

Teaching on the run tips 4: teaching with patients.

Education Centre, Faculty of Medicine and Dentistry, University of Western Australia, Nedlands, WA. Fiona R Lake, MD, FRACP, Associate Professor in Medicine and Medical Education. Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA. Gerard Ryan, MB BS, FRACP, Respiratory Physician. Reprints will not be available from the authors. Correspondence: Associate Professor Fiona R Lake, Education Centre, Faculty of Medicine and Dentistry, University of Western Australia, First Floor, N Block, QEII Medical Centre, Verdun Street, Nedlands, WA 6009. flake@cyllene.uwa.edu.au The Medical Journal of Australia ISSN: 0025729X 2 August 2004 181 3 158-159 ©The Medical Journal of Australia 2004 www.mja.com.au Teaching on the run tions by junior staff at the bedside significantly incr doctors spend with patients, and such patients are m be satisfied with their inpatient stay. They prefer ha present t ir history in fro t of them than outside th Teaching with patients allows the important doma to be integrated through teaching, observation and ling. These domains include: There should be no teaching without the patient for a text, and the best teaching is often that taught by the patient himself.

Enrolled nurse medication administration

This paper describes an initiative undertaken at Sir Charles Gairdner Hospital in Perth, Western Australia to enhance the professional development of enrolled nurses to allow them to administer medications without the direct supervision of a registered nurse. This practice change proved to be a positive step for the hospital and for enrolled nurses. Benefits for patients were identified as greater continuity of care and increased timeliness of medication administration. The benefits for enrolled nurses were increased job satisfaction, improved morale and self esteem while the main benefit for registered nurses was decreased stress and workload.

Iodine-125 brachytherapy for prostate cancer: first published Australian experience.

With the emergence of new imaging and implant techniques, prostate brachytherapy has become increasingly popular over the last decade. Brachytherapy promises to deliver twice the biologically effective dose as conventional external beam treatments without increasing the dose to tissues surrounding the prostate. However, there are few or no published Australian series of its efficacy in the clinic. We present the experience of one of the first centres in Australia to offer this service to its patients: a series from Sir Charles Gairdner Hospital in Western Australia. We present data on the efficacy of brachytherapy in maintaining prostate specific antigen levels, as well as the rate of urinary, rectal and sexual complications. Our results compare favourably with other brachytherapy and external beam treatment series. We believe that with the increasing trend towards dose escalation and novel therapies, standardized measurements of success and failure need to be better defined, and that randomized trials comparing modalities are needed to improve the management of prostate cancer.

High-order aberrations in pseudophakia with different intraocular lenses

Purpose: To compare high-order aberrations in patients who had cataract surgery and implantation of different types of intraocular lenses (IOLs). Setting: Sir Charles Gairdner Hospital and Lions Eye Institute, University of Western Australia, Perth, Australia. Methods: Fifty eyes of 48 patients were included in this study. The optical aberrations were measured with the Hartmann-Shack wavefront sensor (Zyoptix, Bausch & Lomb) before and after surgery using a 5.0 mm wavefront aperture diameter for all comparisons. The eyes were divided into 4 groups according to the type of IOL (material and curvature). A fifth group of 10 eyes of 6 elderly patients with normal crystalline lenses had the same examination. Results: There was no statistical difference in high-order aberrations between the 2 acrylic IOL groups with different curvatures ( P>.05) or between the silicone and poly(methyl methacrylate) (PMMA) IOL groups ( P>.05). However, the measured high-order aberrations were significantly higher (3rd through 5th order) in the 2 acrylic IOL groups than in the PMMA and silicone IOL groups ( P<.05). Conclusions: An increase in IOL high-order aberrations contributed to the decline in retinal image quality. An IOL modifies the entire aberration pattern of the eye. There was a statistically significant increase in aberrations in patients with an acrylic IOL compared to those with a silicone or PMMA IOL. The exact mechanism is uncertain. Further study is required to optimize IOL design.

Emergency department presentations of naltrexone-accelerated detoxification.

To analyze emergency department (ED) presentations after naltrexone-accelerated detoxification. This was a retrospective cohort analysis of patient presentations to Sir Charles Gairdner Hospital Emergency Department over a six-month period (November 2000 to April 2001). During the six-month study period, 42 patients presented to the ED after naltrexone-accelerated detoxification. This represented 7% of patients treated at a single clinic over the same period. Presentation occurred within 24 hours in 40% of cases and within 48 hours in 74%. Clinical features on presentation included gastrointestinal (GI) symptoms (vomiting, 60%; abdominal pain, 55%; diarrhea, 45%), central nervous system [CNS] symptoms (excessive drowsiness, 55%; agitation requiring sedation, 50%), and respiratory symptoms (tachypnea, 33%; respiratory difficulties, 19%). Gastrointestinal symptoms were managed adequately with supportive therapy in most cases (intravenous fluids; antiemetics). Agitation sometimes required large doses of intravenous benzodiazepines (up to 730 mg in 44 hours), one-to-one nursing, and security staff. Two of 14 patients presenting with predominantly CNS disturbance required intubation (14%). Mean in-hospital stay for all patients was 18 hours (range 1 to 92 hours). A few patients undergoing outpatient naltrexone-accelerated detoxification during a six-month period subsequently required ED management. The clinical features encountered in this group of patients can be subdivided into GI or CNS predominance, with different management strategies. Most presentations can be managed in the ED or an associated observation ward, but departmental resources must be available for one-to-one nursing and security personnel. Patients presenting with agitation should be sedated with benzodiazepines; large doses may be required. Close monitoring of respiratory function is mandatory, and advanced airway management may be required.

Emergency Department Presentations of Naltrexone‐accelerated Detoxification

Abstract Objectives: To analyze emergency department (ED) presentations after naltrexone‐accelerated detoxification. Methods: This was a retrospective cohort analysis of patient presentations to Sir Charles Gairdner Hospital Emergency Department over a six‐month period (November 2000 to April 2001). Results: During the six‐month study period, 42 patients presented to the ED after naltrexone‐accelerated detoxification. This represented 7% of patients treated at a single clinic over the same period. Presentation occurred within 24 hours in 40% of cases and within 48 hours in 74%. Clinical features on presentation included gastrointestinal (GI) symptoms (vomiting, 60%; abdominal pain, 55%; diarrhea, 45%), central nervous system [CNS] symptoms (excessive drowsiness, 55%; agitation requiring sedation, 50%), and respiratory symptoms (tachypnea, 33%; respiratory difficulties, 19%). Gastrointestinal symptoms were managed adequately with supportive therapy in most cases (intravenous fluids; antiemetics). Agitation sometimes required large doses of intravenous benzodiazepines (up to 730 mg in 44 hours), one‐to‐one nursing, and security staff. Two of 14 patients presenting with predominantly CNS disturbance required intubation (14%). Mean in‐hospital stay for all patients was 18 hours (range 1 to 92 hours). Conclusions: A few patients undergoing outpatient naltrexone‐accelerated detoxification during a six‐month period subsequently required ED management. The clinical features encountered in this group of patients can be subdivided into GI or CNS predominance, with different management strategies. Most presentations can be managed in the ED or an associated observation ward, but departmental resources must be available for one‐to‐one nursing and security personnel. Patients presenting with agitation should be sedated with benzodiazepines; large doses may be required. Close monitoring of respiratory function is mandatory, and advanced airway management may be required.

Colonoscopic surveillance after surgery for colorectal cancer.

Intensive colonoscopic surveillance after resection of colorectal cancer (CRC) has been shown not to improve outcome. The National Health and Medical Research Council of Australia (NHMRC) has recently published guidelines recommending appropriate surveillance intervals after CRC resection. The aims of the present study were to assess current and past patterns of postoperative CRC surveillance and to determine the yield of neoplasia from such surveillance. An audit was performed of all patients who underwent colonoscopy following surgical resection of CRC from 1989 to 2001. Two groups were assessed: (i) all patients undergoing surveillance colonoscopies; and (ii) all patients diagnosed with CRC at Sir Charles Gairdner Hospital (SCGH) who subsequently had postoperative colonoscopies. Patients who had their index colonoscopy at the study centre and who subsequently underwent surveillance colonoscopies were studied in detail. Yield for neoplasia, patterns of surveillance and concordance with NHMRC recommendations were determined. There were 990 surveillance examinations performed and colorectal adenomas were identified in 184. However, only one case of recurrent cancer was detected. There were a total of 161 patients who had CRC diagnosed and underwent surveillance at SCGH. Of these patients, 75% underwent colonoscopy at 12 months after resection and 48% of these cases underwent a further examination within 12 months. Only 23% of examinations concurred with NHMRC recommendations and practice has not changed with release of these guidelines. Resectable CRC recurrences are rarely detected at colonoscopic surveillance. Surveillance colonoscopies are -performed too frequently and release of NHMRC guidelines has failed to change practice.

Secondary and tertiary prevention in the management of low-trauma fracture

A significant risk factor for osteoporotic fracture is a previous atraumatic fracture. The objective of this study was to investigate whether patients with Colles fracture from minimal trauma were subsequently identified, assessed and treated for their elevated risk of fracture. Medical records at Sir Charles Gairdner Hospital in Perth, Western Australia, from August 1999 to July 2000 were audited and 111 patients who had sustained a Colles fracture from minimal trauma were identified. Questionnaires were subsequently posted to participants to determine whether any assessment or treatment was undertaken outside the hospital system. According to documentation in the medical records, 9% (10/111) had their bone mineral density assessed, 15% (17/111) were receiving medical therapy for osteoporosis, 7% (8/111) had their falls risk assessed and 51% (58/111) were seen by a physiotherapist. Of the 58 who received physiotherapy, 76% (44/58) received upper limb exercises and 19% (11/58) received lower limb or balance exercises. Follow-up questionnaires one to two years after the fracture were returned by 43% (48/111) of the sample. By this time, 37% (18/48) had BMD assessed and 27% (13/48) were receiving medical therapy for osteoporosis. Thirty-five per cent (17/48) of patients recalled being advised to increase their calcium intake. Of those who reported more than one fall during the past 12 months, 62% (8/13) had been seen by a physiotherapist, 46% (6/13) reported having their balance assessed and 54% (7/13) reported having a home visit for assessment of rails etc. Despite the availability of effective treatments, a substantial proportion of patients with Colles fracture from minimal trauma are not all being identified, assessed or treated for their elevated risk of subsequent osteoporotic fracture.

Probiotics and Clostridium difficile-associated diarrhoea

Clostridium difficile is now recognised as the major cause of hospital acquired infectious diarrhoea. Data from Sir Charles Gairdner Hospital (SCGH) in Perth, Western Australia, is typical of many similar hospitals in developed countries. SCGH is a 600 bed adult university teaching hospital. During the period 1983 to 1992, C. difficile was detected in 917 patients who were being investigated for diarrhoeal illness. Up to 120 patients a year were infected, most of these being elderly females. Incidence rates increased from 23/100,000 occupied bed days in 1983 to 56/100,000 occupied bed days in 1990.

Extent of nodal involvement in Stage III colorectal carcinoma: relationship to clinicopathologic variables and genetic alterations.

Recent evidence from our laboratory suggests that the factors of tumor site, patient gender, microsatellite instability, and mutations are important determinants in the survival benefit associated with adjuvant chemotherapy in Stage III colorectal carcinoma. In the present study we investigated whether these factors, as well as Ki- mutations, were also associated with the extent of nodal involvement in Stage III cancers. Nodal involvement was retrospectively evaluated in a series of 645 patients with Stage III colorectal cancer from Sir Charles Gairdner Hospital. The number of involved nodes was correlated with the clinicopathologic features of gender, age, tumor site, and histologic grade, as well as to the genetic alterations of mutation, Ki- mutation, and microsatellite instability. The median number of nodes examined per tumor was 11 (range, 1-53). Forty-nine percent of cases had one or two involved nodes and 51 percent had three or more involved nodes, the latter feature being associated with significantly reduced patient survival. No differences in the extent of nodal involvement were apparent with respect to tumor site, patient gender, or or Ki- mutation status. Tumors from younger patients (P = 0.025) or with poorly differentiated histology (P = 0.007), were associated with significantly higher nodal burden, whereas the microsatellite instability phenotype was associated with less extensive nodal involvement (P = 0.020). Survival benefits from the use of chemotherapy were apparent for both the low and high nodal involvement groups, although the latter seemed to obtain relatively more benefit. Multivariate analysis of patients treated with chemotherapy found that gender, grade, and microsatellite instability, but not nodal involvement, were independently prognostic for survival. The extent of nodal involvement in Stage III colorectal cancer is related to patient age, tumor grade, and microsatellite instability status, but not to tumor site, patient gender, or Ki- mutation. These results indicate that differences in metastatic nodal burden cannot explain previously observed site, gender, and mutation differences in the response to chemotherapy.

Effectiveness of a Participatory Workplace Risk Assessment Team in Reducing the Risk and Severity of Musculoskeletal Injury

Effectiveness of a Participatory Workplace Risk Assessment Team in Reducing the Risk and Severity of Musculoskeletal Injury: Philip J.W. Carrivick, et al. Department of Occupational Health, Sir Charles Gairdner Hospital, Australia— This study evaluates the effectiveness of a participatory workplace risk assessment team (the intervention) in reducing the rate and severity of musculoskeletal and non‐musculoskeletal injuries among a cohort of 137 cleaners within a hospital setting. The date, workers’ compensation claims cost and hours lost from work were obtained for each injury occurring during the 4‐yr pre‐intervention and 3‐yr post‐intervention period. The age, gender and hours worked during the study period, were ascertained for every cleaner whether injured or not. For musculoskeletal injuries, the intervention was associated with significant reductions of two‐thirds in injury rate, 65% in workers’ compensation claims cost per hour worked, and 40% in hours lost per hour worked. Cleaners also experienced a significant two‐ third post‐intervention reduction in non‐musculoskeletal injury rate; but the corresponding changes in severity rates were not significant. The intervention supports the adoption of a participatory approach to reducing the rate and consequence of musculoskeletal injuries in the workplace.