Teaching Hospitals In Perth Research Articles

Emphasizing the Clinical Diagnosis of Acute Appendicitis Amidst Technological Advancements.

Background The clinical diagnosis of acute appendicitis (AA) can be challenging. This study aimed to evaluate the significance of this diagnosis amidst technological progress. It compared clinical diagnosis to radiology-aided diagnostic outcomes and negative appendicectomy rates (NAR). Methodology This study conducted a single-center retrospective and prospective cohort observational study on all adult patients presenting with suspected AA in 2018 at a major tertiary teaching hospital in Perth, Western Australia. Key demographics, clinicopathological, radiology, and operative reports were reviewed. Data were analyzed using SPSS v.27. Results Of 418 patients with suspected AA, 234 (56%) were in the retrospective group. The median age was 35 (IQR=26), and 224 (54%) were female. The overall NAR was 18.6% (95% CI (14.8-22.4)) and 20.8% for clinical diagnosis. Notably, the NAR for ultrasound (USS)-reported AA (false positive) was 17.6% (95% CI (10.6-27.4)). Three-quarters of the patients, 298 (71.3%), had radiological imaging. The most common modality was CT 176 (59.1%), and 33 (7.9%) had both CT and USS imaging performed. Compared with final histopathology, no significant difference was found in the accuracy of clinically diagnosed and USS-diagnosed cases, with rates of 83.5% and 82.5%, respectively (p=0.230). CT had the best positive predictive value at 82.1%. Single-modality imaging did not cause a significant surgical delay (p=0.914), but multi-modal imaging showed a non-significant trend toward delay (p=0.065). When surgeons assessed an appendix as normal, 54 (12.9%), the histopathological assessment revealed pathology in 28 (51.9%). The inter-observer agreement was only fair to moderate, Kappa=0.46 (95% CI (0.33-0.58); p<0.001). The intraoperative identification of a normal appendix inversely correlated to the grade of the primary surgeon, which was likely related to the number of surgical personnel in the theater (p<0.001). Conclusion This study showed that clinical diagnosis matches the diagnostic accuracy of imaging technologies. Utilizing diagnostic imaging methods promptly and appropriately did not lead to considerable delays in surgery. Surgeons' capability to diagnose appendicitis during surgery is moderately accurate. Most patients underwent imaging, with CT scans being the most common. Moving forward, practitioners must minimize excessive reliance on imaging techniques as this can be resource-intensive, especially in developing countries. Future clinical practice should balance embracing technological advancements and preserving essential clinical diagnostic expertise, for medicine is both a science and an art.

Practice Implications of Colonoscopic Investigation of Microscopic Colitis in Patients Above 50 Years of Age Presenting With Chronic Diarrhoea: A Multi-Centre Review.

Background Patients with an unknown cause for chronic diarrhoea will usually undergo a colonoscopy as part of the investigative work-up, and it is acceptable practice for the patients to undergo random biopsies. The optimum number of biopsies has yet to be established.This study investigated the implications of routine random biopsies for diagnosing microscopic colitis in patients 50 years and older who presented with chronic diarrhoea. Methodology A retrospective cohort study of a prospectively maintained internal hospital database across three tertiary teaching hospitals in Perth, Western Australia, on participants >50 years old who presented for an elective colonoscopy to investigate chronic diarrhoea between January 2016 and June 2019. Data was captured from medical records, imaging, colonoscopy, and histopathology reports, and patient follow-up was analysed using SPSS v.29 (IBM Corp., Armonk, NY). Results There were 216 patients, with the majority female (67%) and a mean age of 64.6 (SD±9.9).Microscopic colitis was identified in 7.4% (95% CI = 3.9-10.9%). Most positive biopsies (81.3%) were from the left colon. The median number of biopsies per case was seven (IQR=5). The median procedure duration and scope withdrawal time were 23 and eight minutes, respectively. Most of the procedures were done by a consultant (77%). Bowel was adequately prepped in 76.9% of the cases. Univariate analysis demonstrated that the rate of identification of microcolitis was associated with the number of biopsies taken; microcolitis positivity had a higher mean number of biopsies, 10.8 vs 6.7 (p<0.001). Key complications were a 30-day readmission rate, seven-day re-presentation with acute colitis, post-procedure bleeding,requiring further imaging or angioembolisation and increased length of stay on readmission. Conclusion The prevalence of positive biopsies for microcolitis is low (7.4%). Biopsies during colonoscopy are associated with clinically significant morbidity and health care costs. Most positive biopsies were attained from the left colon. It may be time to standardise practice in investigating microscopic colitis as a cause of chronic diarrhoea in patients > 50 years old.

Antithrombotic Therapy in Atrial Fibrillation Management in Western Australia: Temporal Trends and Evidence-Treatment Gaps

To describe temporal trends in appropriate antithrombotic therapy use in hospitalised atrial fibrillation (AF) patients and identify evidence-treatment gaps in clinical practice. Retrospective cohort study from January 2009-March2016. Tertiary and secondary teaching hospitals in Perth, Western Australia. Hospitalised adults with non-valvular AF. We identified 11,294 index AF admissions, with a mean age of 76.9 years, 45.8% women and 86.3% at high risk of stroke (CHA2DS2-VASc score ≥2 in men and ≥3 in women). In high risk subjects use of appropriate antithrombotic therapy improved over time with increasing oral anticoagulant (OAC) use and declining sole antiplatelet use (both trend p<0.001). However, by study end only 45.3% of high-risk patients were receiving OAC therapy. In low risk patients, receipt of OAC therapy was steady throughout the study at 40.5% (trend p=0.10). The gender gap in OAC use narrowed over time, with no significant differencebetween high risk men and women by study end. Use of OAC therapy in elderly patients (age ≥75 years) remained lower than younger patients (age <65 years) over the entire period, with only 31% of elderly patients receiving OAC therapy at study end. From 2012 onwards use of non-vitamin K oral anticoagulants (NOACs) doubled each year with declining warfarin use (both trend p<0.001). Despite substantial uptake of NOACs, OAC therapy in AF patients at high risk of stroke remains under-utilised in Western Australia and over-utilised in low risk patients. Further work is required to reduce treatment-risk mismatch for stroke prevention in AF patients.

Predicting sequential bilateral cochlear implantation performance in postlingually deafened adults; A retrospective cohort study.

To identify which preoperative patient characteristics influence sequential bilateral cochlear implantation performance and to create a statistical model that predicts benefit. Multicentre retrospective cohort study. All patients were operated in four academic teaching hospitals in Perth, Australia, and followed up by audiologists of the Ear Science Institute Australia. A total of 92 postlingually deafened adult patients who had undergone sequential cochlear implantations between 19 June 1990 and 14 March 2016 were included. Patients were excluded if the 12-month follow-up consonant-nucleus-consonant (CNC) phoneme score was missing. The effect of 18 preoperative factors on the CNC phoneme score in quiet (at 65 dB SPL) with the second cochlear implant (CI2) one year after implantation. Two factors were positively correlated to speech understanding with CI2: Wearing a hearing aid (HA) before receiving CI2 (r = 0.46, P = 0.00) and the maximum CNC phoneme score with the first CI (CI1) (r = 0.21, P = 0.05). Two factors were negatively correlated: the length of hearing loss before CI2 in the second implanted ear (r = -0.25, P = 0.02) and preoperative pure tone average (PTA) (0.5, 1, 2 kHz) before CI2 in the second implanted ear (r = -0.27, P = 0.01). The following model could be created: predicted CNC phoneme score with CI2 (%) = 16 + (44 * HA use before CI2 (yes)) - (0.22 * length of hearing loss before CI2 (years)) + (0.23 * CNC phoneme score with CI1 (%)). Because the effect of HA use before implantation played such a major role, we also created a model after exclusion of the HA factor: Predicted CNC phoneme score with CI2 (%) = 82 - (0.17 * length of hearing loss before CI2 (years)) - (0.27 * PTA in second implanted ear before CI2 (0.5, 1, 2 kHz)) + (0.20 * CNC phoneme score with CI1 (%)). Advanced age or a long interval between implantations does not necessarily lead to poor CI2 results. Patients who are successful HA users before CI2, who have a low PTA before CI2, a high CNC phoneme score with CI1 and a limited length of hearing loss before CI2, are likely to be successful CI2 recipients.

An investigation of nurse education service models in acute care metropolitan hospitals across Australia.

This paper outlines a study that was undertaken to investigate the different nurse education service models being utilised in acute care metropolitan hospitals across Australia with a view to make recommendations for future nurse education service delivery within healthcare organisations. This research study used a mixed methods approach comprising three phases. Phase one involved interviews and focus groups with nurse educators at one tertiary teaching hospital in Perth, Western Australia (WA). Phase two involved focus groups and interviews with nurse educators and coordinators of nurse education services in acute care metropolitan hospitals in W.A. Phase three of the study consisted of the development of a survey tool from the findings of the previous phases and a national survey of nurse educators in acute care metropolitan hospitals across Australia. The findings of this study demonstrate that a centralised nurse education service model undertakes more functions than, and delivers significant advantages over, the decentralised and combination models.

A Randomized, Placebo-Controlled, Double-Blind Efficacy Study of Nefiracetam to Treat Poststroke Apathy

To evaluate the efficacy of treatment with nefiracetam compared to placebo in poststroke apathy. A parallel group, randomized, placebo-controlled, double-blind two-center trial in patients with recent stroke and apathy was conducted in 2 tertiary teaching hospitals in Perth, Western Australia, between March 2010 and October 2014. Consenting patients hospitalized with stroke were screened for participation at the time of hospitalization and, if diagnosed with apathy 8-36 weeks later, they were randomized to 12 weeks of 900 mg/day nefiracetam or placebo. The primary efficacy parameter was change in apathy at 12 weeks defined by the 14-item Apathy Scale (AS). Of 2514 patients screened, only 377 (15%) were eligible for the study after the first screening, 233 declined further participation, and 144 were assessed for apathy at 8-36 weeks post stroke to confirm eligibility. Twenty patients out of 106 with a complete psychiatric assessment had apathy (19%). Of this sample, 13 patients were randomized. Overall, the AS score decreased by a mean of 7.0 points (95% CI = -14.6 to .6), but there was no significant between-group difference at week 12 (mean paired t-tests, P > .14). Treatment with nefiracetam did not prove to be more efficacious than placebo in ameliorating apathy in stroke. The main limitation was the very small sample randomized, highlighting the limitations of conducting drug trials for behavioral problems among stroke patients. Pharmacological studies of apathy in stroke will require a large multicenter study and a massive sample of patients.

Characteristics and Outcomes of MI Patients with and without Chest Pain: A Cohort Study

There are conflicting data on patient characteristics and outcomes of myocardial infarction (MI) patients presenting with and without the symptom of chest pain. Compare the characteristics and survival of patients stratified by the symptom chest pain. This retrospective cohort study identified patients with an emergency department discharge diagnosis of MI, who arrived by ambulance at a teaching hospital in Perth, Western Australia, between January 2008 to October 2009. The cohort was linked to hospital data and the state-based death register; clinical data were extracted by medical record review. Patient characteristics were compared using logistic regression models and survival analysis using Kaplan-Meier curves and Cox regression models. Of 382 patients, 26% presented without chest pain. The odds of presenting without chest pain were increased if aged 80+ (OR 7.54; 95%CI 2.81-20.3) and aged 70-79 years (OR 4.33; 95% CI 1.50-12.5), and female (OR 1.67; 95%CI 0.99-2.82). The adjusted hazard (median follow-up time 2.2 years) of presenting without chest pain was not significantly associated with survival (HR 1.03; 95%CI 0.71-1.48). Characteristics differed between patients with and without chest pain. However, the symptom of chest pain was not associated with survival.

Epidemiology of Clostridium difficile infection in two tertiary-care hospitals in Perth, Western Australia: a cross-sectional study.

The epidemiology of Clostridium difficile infection (CDI) has changed over time and between countries. It is therefore essential to monitor the characteristics of patients at risk of infection and the circulating strains to recognize local and global trends, and improve patient management. From December 2011 to May 2012 we conducted a prospective, observational epidemiological study of patients with laboratory-confirmed CDI at two tertiary teaching hospitals in Perth, Western Australia to determine CDI incidence and risk factors in an Australian setting. The incidence of CDI varied from 5.2 to 8.1 cases/10 000 occupied bed days (OBDs) at one hospital and from 3.9 to 16.3/10 000 OBDs at the second hospital. In total, 80 patients with laboratory-confirmed CDI met eligibility criteria and consented to be in the study. More than half (53.8%) had hospital-onset disease, 28.8% had community-onset and healthcare facility-associated disease and 7.5% were community-associated infections according to the definitions used. Severe CDI was observed in 40.0% of these cases but the 30-day mortality rate for all cases was only 2.5%. Besides a shorter length of stay among cases of community-onset CDI, no characteristics were identified that were significantly associated with community-onset or severe CDI. From 70 isolates, 34 different ribotypes were identified. The predominant ribotypes were 014 (24.3%), 020 (5.7%), 056 (5.7%) and 070 (5.7%). Whereas this study suggests that the characteristics of CDI cases in Australia are not markedly different from those in other developed countries, the increase in CDI rate observed emphasizes the importance of surveillance.

Symptoms of Myocardial Infarction: Concordance between Paramedic and Hospital Records

Introduction. To further reduce time to definitive therapy for acute myocardial infarction (MI) patients, the focus of research needs to be on better understanding prehospital delay in recognition and response to symptoms. Paramedic clinical records can serve as a convenient source of data for such studies, but their accuracy needs to be established. Objectives. This study aimed to determine the concordance of the symptoms and symptom-onset time recorded in the paramedic patient care record (PCR) with those recorded in the hospital medical record for MI patients. Methods. A retrospective review of paramedic and hospital medical records was undertaken between January 1, 2008 and October 31, 2009 for all patients with an emergency department (ED) discharge diagnosis of MI at a single teaching hospital in Perth, Western Australia. The symptoms of MI and onset times documented in the paramedic PCR were compared with those recorded in the hospital medical record, which was considered the “gold standard.” The study assessed differences in documentation using McNemar's tests, and concordance was described by kappa and adjusted kappa statistics, sensitivity, specificity, and positive and negative predictive value (PPV, NPV). Results. Of 810 patients with an ED discharge diagnosis of MI, 584 (71%) patients arrived by ambulance and 509 patients had a paramedic PCR. After exclusions, 400 patients had both paramedic PCR and hospital medical records available for review. Of 21 documented MI symptoms, the majority (71.4%) had adjusted kappa statistics greater than 0.75, and observed agreement greater than 90%. For the symptom of chest pain, sensitivity, specificity, PPV, and NPV were all over 85%. Where recorded in both records (n = 196, 49%) the symptom-onset time agreed exactly for 118 (60.2%) records, differed by 1–15 minutes for 24 (12.2%) records, and differed by 16–30 minutes for 22 (11.2%) records. Conclusion. Our study demonstrated that documentation of the common symptoms of MI and symptom-onset time was similar between the paramedic and hospital records, justifying the use of paramedic PCRs as a source of data for research in prehospital MI patient delay. Further research is required to investigate why symptom-onset time was not routinely documented for all patients with chest pain.

Changing trends in venous thromboembolism‐related imaging in Western Australian teaching hospitals, 2002–2010

OBJECTIVE To determine trends in referral for venous thromboembolism (VTE) imaging in Western Australian teaching hospitals. DESIGN AND SETTING Retrospective audit of the WA picture archiving and communication system, PathWest Laboratory Medicine records, the hospital morbidity database at the four adult teaching hospitals in Perth, WA, and the WA death registry. PATIENTS All patients referred for VTE-related imaging, and all hospital separations for pulmonary embolism (PE) during 2002-2010. MAIN OUTCOME MEASURES Number of referrals for computed tomography pulmonary angiography (CTPA), ventilation-perfusion lung scintigraphy, leg ultrasound and plasma D-dimer assay; hospital separations for PE and deaths from PE. RESULTS Referrals for VTE-related imaging increased by 34%, while PE-related imaging increased by 65% during the study period, owing entirely to referrals for CTPA, which increased by more than 500%. The number of hospital separations for PE increased by 45% over the same period and the prevalence of PE among referred patients fell from 22.1% in 2002 to 19.5% in 2010. There was no fall in the death rate from PE in WA during the study period (P = 0.19). The number of D-dimer tests performed in the same hospitals increased by 42% over the study period. CONCLUSIONS The increased number of referrals for PE-related imaging resulted in more diagnoses but no reduction in deaths from PE in WA. Widespread D-dimer testing did not reduce referrals for imaging and is likely to have resulted in increased referrals. Increased imaging leads to overdiagnosis of clinically insignificant PE, and alternative strategies are required to reduce PE death rates.

The economic benefits of increased levels of nursing care in the hospital setting

To assess the economic impact of increased nursing hours of care on health outcomes in adult teaching hospitals in Perth, Western Australia. Advancing technology and increased availability of treatment interventions are increasing demand for health care while the downturn in world economies has increased demand for greater efficiency. Nurse managers must balance nurse staffing to optimize care and provide efficiencies. This longitudinal study involved the retrospective analysis of a cohort of multi-day stay patients admitted to adult teaching hospitals. Hospital morbidity and staffing data from September 2000 until June 2004, obtained in 2010 from a previous study, were used to analyse nursing-sensitive outcomes pre- and post-implementation of the Nurse Hours per Patient Day staffing method, which remains in place today. The cost of the intervention comprised increased nursing hours following implementation of the staffing method. The number of nursing-sensitive outcomes was 1357 less than expected post-implementation and included 155 fewer 'failure to rescue' events. The 1202 other nursing-sensitive outcomes prevented were 'surgical wound infection', 'pulmonary failure', 'ulcer, gastritis', 'upper gastrointestinal bleed', and 'cardiac arrest'. One outcome, pneumonia, showed an increase of 493. Analysis of life years gained was based on the failure to rescue events prevented and the total life years gained was 1088. The cost per life year gained was AUD$8907. The implementation of the Nurse Hours per Patient Day staffing method was cost-effective when compared with thresholds of interventions commonly accepted in Australia.

Changing trends in venous thromboembolism‐related imaging in Western Australian teaching hospitals, 2002–2010

To determine trends in referral for venous thromboembolism (VTE) imaging in Western Australian teaching hospitals. Retrospective audit of the WA picture archiving and communication system, PathWest Laboratory Medicine records, the hospital morbidity database at the four adult teaching hospitals in Perth, WA, and the WA death registry. All patients referred for VTE-related imaging, and all hospital separations for pulmonary embolism (PE) during 2002-2010. Number of referrals for computed tomography pulmonary angiography (CTPA), ventilation-perfusion lung scintigraphy, leg ultrasound and plasma D-dimer assay; hospital separations for PE and deaths from PE. Referrals for VTE-related imaging increased by 34%, while PE-related imaging increased by 65% during the study period, owing entirely to referrals for CTPA, which increased by more than 500%. The number of hospital separations for PE increased by 45% over the same period and the prevalence of PE among referred patients fell from 22.1% in 2002 to 19.5% in 2010. There was no fall in the death rate from PE in WA during the study period (P = 0.19). The number of D-dimer tests performed in the same hospitals increased by 42% over the study period. The increased number of referrals for PE-related imaging resulted in more diagnoses but no reduction in deaths from PE in WA. Widespread D-dimer testing did not reduce referrals for imaging and is likely to have resulted in increased referrals. Increased imaging leads to overdiagnosis of clinically insignificant PE, and alternative strategies are required to reduce PE death rates.

Approaching Families for Organ Donation—Intensivists’ Perspectives

In Australia the initial approach to families for organ donation is almost always undertaken by intensivists. There is, however, a paucity of literature on intensivists' views on this approach and how their approach compares with recommendations in published literature on this subject. This study consisted of a survey of the views of intensive care consultants and senior intensive care registrars in the four major teaching hospitals in Perth, Western Australia, on how they approached families for organ donation. The study also includes a review of recently published literature on approaching families for organ donation. The survey results indicate that most intensive care consultants felt adequately trained to approach families for organ donation, but almost half of the group surveyed would prefer a collaborative approach with either a donor co-ordinator or a colleague with additional training on this subject. Despite recommendations in the literature and from the Australian and New Zealand Intensive Care Society to determine the registration status of potential donors on the Australian Organ Donation Registry prior to discussions with families, this was not always undertaken. In addition, the benefits of organ donation were not always discussed with families, nor were the reasons for refusal of consent sensitively explored.

Total Laparoscopic Hysterectomy – New Endoneedle for Ligation of Uterine Vessels and Vault Closure

To show that two challenges in TLH - uterine vessel haemostasis and vault closure - can be overcome by the use of a new laparoscopic endoneedle. This paper uses slides and videos of operations to present the results of the study. Operations were performed in a major private teaching hospital in Perth, Australia. 20 private patients who underwent TLH had their uterine arteries ligated with the endoneedle using 1 vicryl suture before bipolar and division. The vaginal vault was closed with the endoneedle using 1 monocryl suture. 20 private patients with fully informed financial and operative consent. There were no interventions. The study revealed that the uterine suture provided better haemostasis than when only an energy-sealing device was used. The suture on the uterine pedicle provided a clear lateral landmark for ureteric safety. The vaginal vault was closed with single bite or figure of 8 sutures. No vault dehiscence was encountered. The use of the new laparoscopic endoneedle provides the GYN performing TLH with a new tool to tackle the uterine pedicle and vault suturing. Numerous laparoscopic workshops have a suturing component, as this is a challenging task for GYNs. It is hoped that this new tool will lead to more GYNs undertaking TLH, thereby spreading the benefits of MIS.

A qualitative exploration of nurse's perception of Critical Outreach Service: A before and after study

Critical Care Outreach Services (CCOS) have been reported to streamline the transfer of patients from the intensive care unit (ICU) to the wards and provide a follow-up service supporting ward staff to provide optimum care for patients discharged from ICU. The aim of this study was to explore the perceptions of nursing staff before and after the introduction of a CCOS at three adult teaching hospitals in Perth, Western Australia. Exploratory focus groups were conducted with registered nurses (RNs) at each of the participating hospitals prior to and 6 months after the introduction of a CCOS. Framework analysis was used to analyse the transcribed data using a thematic approach with themes developed from the narratives of the participants. Inexperienced RNs in particular voiced positive comments about the CCOS. The role was seen as a senior nurse who was an additional resource for less experienced staff as they educated them on complex procedures that were not common on the general wards. The RNs reported that apprehensions about the role that they had pre-implementation were not borne out in practice and that they believed that the CCOS had positive effects on patient outcomes. The CCOS improved communication processes between members of the multidisciplinary team and units within the hospital, which subsequently enhanced the ward transition process for critically ill patients and ward nursing staff.

Total Laparoscopic Hysterectomy (TLH) – Technique To Demystify the Procedure

Study Objective: 600,000 hysterectomies are performed in the USA each year. Yet only 10% have been performed laparoscopically each year over the last ten years. Here we present a technique combining bipolar energy and dissecting scissors with a unique Australian designed vaginal delineator. This paper uses slides and movies to present our technique of performing TLH. Design: This paper uses slides and movies to present our technique of performing TLH. Setting: Operations were performed in a major private teaching hospital in Perth, Australia. This technique has been used to perform over 2000 TLH cases. Patients: Private patients with informed financial and operative consent. Intervention: No conversion to open hysterectomy was required using this technique and instrumentation in patients chosen for TLH. Measurements and Main Results: All TLH operations were successfully concluded using this technique and instrumentation. Conclusion: The technique demystifies TLH for GYNs contemplating commencing the procedure. The advantages of MIS operations can be extended to benefit patients requiring a hysterectomy.

Student and intern awareness of ionising radiation exposure from common diagnostic imaging procedures

This study aims to evaluate medical student and intern awareness of ionising radiation exposure from common diagnostic imaging procedures and to suggest how education could be improved. Fourth to sixth year medical students enrolled at a Western Australian university and interns from three teaching hospitals in Perth were recruited. Participants were asked to complete a questionnaire consisting of 26 questions on their background, knowledge of ionising radiation doses and learning preferences for future teaching on this subject. A total of 331 completed questionnaires were received (95.9%). Of the 17 questions assessing knowledge of ionising radiation, a mean score of 6.0 was obtained by respondents (95% CI 5.8-6.2). Up to 54.8% of respondents underestimated the radiation dose from commonly requested radiological procedures. Respondents (11.3 and 25.5%) incorrectly believed that ultrasound and MRI emit ionising radiation, respectively. Of the four subgroups of respondents, the intern doctor subgroup performed significantly better (mean score 6.9, P < 0.0001, 95% CI 6.5-7.3) than each of the three medical student subgroups. When asked for the preferred method of teaching for future radiation awareness, a combination of lectures, tutorials and workshops was preferred. This study has clearly shown that awareness of ionising radiation from diagnostic imaging is lacking among senior medical students and interns. The results highlight the need for improved education to minimise unnecessary exposure of patients and the community to radiation. Further studies are required to determine the most effective form of education.

Sixteen Years of Severe Tiger Snake (Notechis) Envenoming in Perth, Western Australia

We aimed to describe the characteristics, clinical course, management and outcome of patients presenting to Perth teaching hospitals after envenoming by Tiger snakes. We undertook a chart review from six Perth teaching hospitals over a 16 year period from 1990 to 2005. Data were collected by a trained investigator using a preformatted data abstraction tool. We included patients bitten in the appropriate geographical area, with defibrination coagulopathy and positive Venom Detection Kit result for Tiger snake or response to specific antivenom. Of 381 charts reviewed, 23 patients were envenomed by a Tiger snake. The mean age was 36 years, 83% were male and all were bitten on a limb. First aid was applied poorly and all patients were symptomatic on presentation. Six patients developed rhabdomyolysis, one renal failure, four clinical bleeding, three neurotoxicity, one non-fatal respiratory arrest and one fatal cardiac arrest. All patients received antivenom, 13 received adrenaline premedication, with two mild allergic reactions developing in non-premedicated patients. The average dose of antivenom was four ampoules. Mean hospital stay was 2.6 days. This is the largest series of Tiger snake envenoming reported in Australia. Only one patient of 23 (4%) died, despite all patients being significantly envenomed. With rapid antivenom treatment and modem emergency and intensive care management, most patients envenomed by Tiger snakes survive.

Trends and Effect of Medication Use on Long-Term Survival Outcome in Heart Failure Patients

Background:Optimal use of provenpharmacotherapies is recommended in the management of heart failure (HF) patients. We examined trends in discharge prescription of medications after incident HF hospitalization and their effect on 5-year survival. Methods: Medical record review of a random sample of 1006 patients admitted to teaching hospitals in Perth between 1996 and 2006 with a principal diagnosis of HF. Cox proportional hazard models adjusted for significant covariates were used to examine the relationship (hazard ratio [HR]) between prescribedmedication and 5-year mortality. Results:Among 944 patients surviving to discharge, the proportions of discharge medications were: loop diuretics (85.5%), ACE-Inhibitors/ARB (74.3%), aspirin (52.3%), beta-blockers (33.7%), digoxin (30.5%), statins (27.1%) and spironolactone (16.3%). In 2005–2006 compared to 1996–1998, the uptake of ACEI/ARBwas unchanged,while those of beta-blockers and statins increased by 4.9-fold and 3.7-fold, respectively. Prescribed discharge medications by ACEI/ARB (HR 0.58, 95% CI 0.48–0.71, p= 0.001), beta-blockers (HR 0.64, 95% CI 0.51–0.81, p= 0.001), and statins (HR 0.74, 95% CI 0.58–0.96, p= 0.021) were all associated with a lower adjusted hazard for 5-year mortality. Although patients with preserved systolic function versus those with LV systolic dysfunction were less likely to be prescribed ACEI/ARB (74.3% vs. 86.7%, p= 0.001) and beta-blockers (35.6% vs. 44.4%, p= 0.04), their use was associated with a significantly better survival in both patient groups. Conclusion: The uptake of evidence-based therapy in HF, with loop diuretics, ACEI/ARB and beta-blockers increased by almost fivefold between 1996 and 2006. Use of ACEI/ARB remained high. Discharge prescription of ACEI/ARB, beta-blockers, and statins was associated with better long-term survival.

Determinants of long-term survival after intensive care*

To identify prognostic determinants of long-term survival for patients treated in intensive care units (ICUs) who survived to hospital discharge. An ICU clinical cohort linked to state-wide hospital records and death registers. Adult patients admitted to a 22-bed ICU at a major teaching hospital in Perth, Western Australia, between 1987 and 2002 who survived to hospital discharge (n = 19,921) were followed-up until December 31, 2003. The main outcome measures are crude and adjusted survival. The risk of death in the first year after hospital discharge was high for patients who survived the ICU compared with the general population (standardized mortality rate [SMR] at 1 yr = 2.90, 95% confidence interval [CI] 2.73-3.08) and remained higher than the general population for every year during 15 yrs of follow up (SMR at 15 yrs = 2.01, 95% CI 1.64-2.46). Factors that were independently associated with survival during the first year were older age (hazard ratio [HR] = 4.09; 95% CI 3.20-5.23), severe comorbidity (HR = 5.23; 95% CI 4.25-6.43), ICU diagnostic group (HR range 2.20 to 8.95), new malignancy (HR = 4.60; 95% CI 3.68-5.76), high acute physiology score on admission (HR = 1.55; 95% CI 1.23-1.96), and peak number of organ failures (HR = 1.51; 95% CI 1.11-2.04). All of these factors were independently associated with subsequent survival for those patients who were alive 1 yr after discharge from the hospital with the addition of male gender (HR = 1.17; 95% CI 1.10-1.25) and prolonged length of stay in ICU (HR = 1.42; 95% CI 1.29-1.55). Patients who survived an admission to the ICU have worse survival than the general population for at least 15 yrs. The factors that determine long-term survival include age, comorbidity, and primary diagnosis. Severity of illness was also associated with long-term survival and this suggests that an episode of critical illness, or its treatment, may shorten life-expectancy.