Teaching Hospital In Sydney Research Articles

Increased Adherence to CPAP With a Group Cognitive Behavioral Treatment Intervention: A Randomized Trial

To improve adherence to continuous positive airway pressure (CPAP) treatment in participants with obstructive sleep apnea (OSA) using a cognitive behavioral therapy (CBT) intervention. A randomized controlled trial. A major teaching hospital in Sydney (2005). One hundred individuals (96 men), ranging in age from 32 to 81 years, diagnosed with OSA. Two 1-hour CBT interventions (including a video of real CPAP users) plus treatment as usual (mask fitting and information) or treatment as usual only. Hours of CPAP usage was assessed at 7 nights and 28 nights. Adherence was defined as usage at least 4 hours per night. Questionnaires measuring self-efficacy, social support, and expectancy (mediators of adherence) were given after intervention or after usual treatment. A higher adherence to CPAP therapy was found in the CBT group (2.9 hours difference) relative to treatment as usual (P < 0.001) at 28 days. Only 4 participants in the CBT group did not initiate treatments after their titration study, compared with 15 in the treatment as usual group (P < 0.02). The CBT group had significantly higher scores for self-efficacy (P < 0.001) and social support P < 0.008) but not for expectancy. The CBT intervention resulted in both increased adherence and "uptake" of CPAP and therefore would be expected to reduce the social, economic, and health-related consequences of untreated OSA.

Predictors of Pneumococcal Vaccination Uptake in Hospitalized Patients Aged 65 Years and Over Shortly Following the Commencement of a Publicly Funded National Pneumococcal Vaccination Program in Australia

In January 2005, Australia became the first country to introduce a publicly funded pneumococcal vaccination program for persons 65 years and older which is free at point of service, although the vaccine cost had previously been partially subsidised. Hospitalisation in this age group is an important indicator of risk of invasive pneumococcal disease but vaccine uptake has been suboptimal. To determine vaccination rates and predictors of vaccination in the elderly hospitalised patients before and after January 2005. We validated vaccination status against general practitioner (GP) records for patients aged ≥65 years admitted to a large teaching hospital in Sydney between 16th of May 2005 and the 20th of February 2006 and examined predictors of vaccinationCommencement of the new program resulted in a significant increase in vaccination uptake from 39% of inpatients prior to the free program to 73% in the same cohort of inpatients post January 2005. We found that patient recall of vaccination status was not reliable. Self-report of pneumococcal vaccination had a sensitivity of 0.53 and a specificity of 0.55, highlighting that validation of vaccination status is required. Age over 80 years and dementia significantly predicted under-vaccination.This highlights the importance of integrating free vaccine supply and delivery in primary care to achieve high vaccination coverage. However, demented patients and the very elderly remain under-vaccinated, despite being admitted to hospital for active management of acute conditions.

How intravenous immunoglobulin is used in clinical practice: audits of two Sydney teaching hospitals

The clinical demand for i.v. immunoglobulin (IVIg) continues to increase in Australia for reasons that are not clear. IVIg is distributed for approved indications according to Australian Health Ministers' Advisory Council 2000 guidelines that are currently under review. IVIg may also be purchased by hospitals for uses not covered by these indications on an individual patient use basis. These audits were developed to examine current hospital practice in IVIg use. Six-month prospective audits of all IVIg use were conducted at two teaching hospitals in Sydney (Concord and Royal Prince Alfred Hospitals). Medical files and dispensing records were examined and compared with current guidelines. One hundred and sixty-five recipients received 24,251 g of IVIg (mean total use 147 g/patient) for 36 distinct diagnoses, with 5.5% mortality. Drug committees supplied 1580 g of IVIg (6.5% of total product issued) to 12 recipients (7.3% of total recipients). The clinical specialties of immunology, haematology and neurology accounted for 92.9% of IVIg use, with 51.8% of overall use for replacement indications. Forty-two patients (25.5%) received IVIg for non-category 1 indications (4718 g, 19.5% of total product). Patients receiving IVIg for category 1 disorders had a 94.4% compliance with the guideline prerequisites where data were sufficient for assessment. Our findings show a greater than expected proportion of non-category 1 IVIg use and substantial contributions from drug committees. Careful case selection within category 1 indications is evident in the high level of compliance with qualifying criteria. Current distribution procedures do not enable capture of outcome data to inform guideline revisions. These audits emphasize the requirement for updated National Clinical Practice Guidelines, improved approval procedures, consensus statements in the specialties of immunology, haematology and neurology and clarification of the role of drug committees.

Outcomes of acutely ill older hospitalized patients following implementation of tailored models of care: A repeated measures (pre- and post-intervention) design

Background There is a lack of research investigating models of nursing care for older hospitalised patients that address the nursing needs of this group. Objectives The objective of this study is to evaluate the efficacy of models of care for acutely older patients tailored to two contexts: an aged care specific ward and a medical ward. Design This is a repeated measures design. Efficacy of the models was evaluated in terms of: patient and nurses’ satisfaction with care provided; increased activities of daily living; reduced unplanned hospital readmissions; and medication knowledge. Settings An aged care specific ward and a medical ward in two Sydney teaching hospitals. Participants There were two groups of patients aged 65 years or older who were admitted to hospital for an acute illness: those admitted prior to model implementation ( n=232) and those admitted during model implementation ( n=116). Patients with moderate or severe dementia were excluded. The two groups of nurses were the pre-model group ( n=90) who were working on the medical and aged care wards for the study prior to model implementation, and the post-model group ( n=22), who were the nurses working on the wards during model implementation. Methods Action research was used to develop the models of care in two wards: one for an aged care specific ward and another for a general medical ward where older patients were admitted. The models developed were based on empirical data gathered in an earlier phase of this study. Results The models were successful in both wards in terms of increasing satisfaction levels in patients and nurses ( p<0.001), increasing functional independence as measured by activities of daily living ( p<0.01), and increasing medication knowledge ( p<0.001). Conclusions Findings indicate that models of care developed by nurses using an evidence-based action research strategy can enhance both satisfaction and health outcomes in older patients.

Advocacy at end-of-life: Research design: An ethnographic study of an ICU

Background Clinicians worldwide are being called upon to reconcile accountability for patient outcomes with the resources they consume. In the case of intensive care, contradictory pressures can arise in decisions about continuing treatment where benefit is diminishing. As concern grows about the cost effectiveness of treatment at end-of-life, nursing expertise and advocacy become significant factors in decision making. Objectives To explore the potential for a nursing advocacy role within a specific regime of nursing practice: end-of-life care; specifically to examine the concept of nursing advocacy from the literature, to consider its application in the workplace and to assess the capacity for nurses to advocate for people who die in institutions such as intensive care units. Design Open-ended interviews with nurse managers and educators (4), palliative care specialists (2), chaplain (1), medical managers (2), intensives (7); focus groups with nurses (4 focus groups and 29 participants); patient case studies (13); observation of family conferences (6 conferences and 15 participants); observation of ward rounds (3 ward rounds and 11 participants). Total number of participants: 84. Setting A large ICU in a principal referral and teaching hospital in Sydney, Australia. Participants Clinical staff within, and clinical and non-clinical caregivers external to the unit. Method Qualitative, ethnographic study. Results Spurious economic imperatives, primacy given to medical intervention, conflict between medical and nursing clinicians about patient management and absence of nursing operational autonomy and organizational authority, impede the opportunity for nurses to define and enact an advocacy role. Conclusions If nurses are to be effective patient advocates at end-of-life, they will need to develop clear criteria within which nursing assessments of patient status can be framed, the specialized skills to manage the non-medical needs of dying people and the organizational and political skills to negotiate changing clinical practice and workplace relations.

Persistence of Coronary Risk Factor Status in Participants 12 to 18 Months After Percutaneous Coronary Intervention

Percutaneous coronary intervention (PCI) is a widely performed revascularization technique for coronary heart disease; however, there is limited research investigating the risk factor status of patients 1 year after the procedure. This cross-sectional study was conducted to investigate the self-reported risk factor status by patients who had undergone a PCI at a major teaching hospital in Sydney, Australia. : Two hundred seventy participants who underwent PCI between April 2003 and March 2004 and who met the inclusion criteria were followed up 1 year after the PCI. After obtaining informed consent, a follow-up self-administered questionnaire was mailed to participants. Information was collected relating to the following coronary risk factors: smoking, and physical activity status, blood pressure and cholesterol levels, body mass index, depression, anxiety, and stress levels. Two hundred two participants (75%) returned a completed questionnaire. Approximately one third of participants had at least two modifiable risk factors. The most common cardiovascular risk factors identified were physical inactivity, increased body mass index, high blood pressure, and high cholesterol. Approximately half the women (46%) and a quarter of the men had at least two modifiable risk factors. Only a minority (11%) of the participants continued to smoke at 1-year follow up. Participating in physical activity for a total time of 150 minutes or more per week was reported by only 42% of the participants. Depression and anxiety were present in 25% and stress in 17% of the participants. A third of the participants (n = 64) erroneously believed that they had no heart problems. The findings reveal inadequate management of modifiable risk factors among post-PCI participants 12 to 18 months after revascularization, which highlights a need for tailored secondary prevention interventions to address factors contributing to cardiovascular risk. The evidence obtained from this study will inform the development of an intervention to address cardiovascular risk factor modification.

Extended Roles for Pharmacists in Warfarin Therapy: Identifying Opportunities for Pharmacist Prescribing

ABSTRACTBackgroundWarfarin has traditionally posed a challenge to clinicians because of its narrow therapeutic index. Extended roles for pharmacists may address some of the problems in warfarin management. International experience has involved anticoagulation clinics in which pharmacists have authority to engage in collaborative prescribing activities with physicians.AimTo identify opportunities for pharmacist prescribing activities in warfarin management within the hospital setting.MethodPharmacists from a Sydney teaching hospital were recruited. The first stage involved an audit of pharmacists' interventions in patients receiving warfarin. Stage two involved a focus group discussion to further explore these issues.Results9 pharmacists saw 41 warfarinised patients over the 5‐day data collection period. Pharmacists saw reason to intervene in the warfarin therapy of 19 (46%) of these patients and a prescribing activity was involved in 16 (84%) of these interventions. Despite these ample opportunities to prescribe, pharmacists felt limited in their ability to use these opportunities. Lack of information about the patient, workloads, medicolegal responsibility, and the need for further training and experience, were cited as the main reasons pharmacists were hesitant to prescribe. It was also suggested that the outpatient setting may be more appropriate to trial a pharmacist prescribing role.ConclusionThere are ample opportunities for pharmacist prescribing in the area of warfarin management. However, practice change is needed before such a role can be taken up in the hospital setting.

Accuracy of Ambulatory Blood Pressure Monitors in Routine Clinical Practice

To determine the extent of discrepancies between ambulatory blood pressure measurement (ABPM) devices and mercury sphygmomanometry in pre-use testing in routine clinical practice and whether such discrepancies are associated with patient characteristics and subsequent 24-h ABPM readings. A retrospective analysis of a database of 683 prospectively collected records was performed. The study population comprised of patients referred for ABP monitoring at a Sydney teaching hospital. Patients had same-arm sequential measurements with a mercury sphygmomanometer and Spacelabs 90207 or 90217 device before 24-h ABPM. The discrepancy between the test devices and the standard mercury sphygmomanometer were then described by two measures, calculated for both systolic and diastolic pressures for each patient: 1) difference of means (DeltaBP average), and 2) the mean of differences between device measurement and the range of mercury sphygmomanometer readings, analogous to the British Hypertension Society protocol (DeltaBP sequential). The main outcome measures were DeltaBP average and DeltaBP sequential and their relationship to patient characteristics. The median DeltaBP average was 1/2 mm Hg (ABPM device underestimation) and the median DeltaBP sequential was 3/2 mm Hg. Age, gender, arm circumference, body mass index, and degree of hypertension influenced the accuracy of ABPM readings on multivariate analysis. Device accuracy was slightly weaker in patients with higher mercury or ABPM-derived systolic BP. These ABPM devices are accurate enough for routine clinical use in a variety of patients. Factors such as age, weight, gender, and severity of hypertension are statistically associated with greater device error but the differences are small enough to be unlikely to affect clinical practice.

Mood state and psychological adjustment to pregnancy

The aim of this study was to investigate whether there is an association between antenatal mood state (depression and anxiety) and psychological adjustment to pregnancy. Participants were first-time, low obstetric risk mothers at a Sydney teaching hospital who completed self-report questionnaires measuring depression, anxiety, thoughts about motherhood and self as mother and relationship with the fetus. Higher symptom levels of antenatal anxiety were related to less optimal maternal-fetal quality of attachment, more negative attitudes towards motherhood and the self as mother. Similar trends were found for symptoms of depression, however depression was not significantly related to psychological adjustment to pregnancy variables. The significance of anxiety in the current study highlights the importance of considering anxiety in the psychological adjustment to pregnancy, as well as the in the context of perinatal mental health more generally. Implications of these findings for intervention are also briefly discussed.

Lack of Supervision and Independent Clinical Decision Making in Postgraduate Pediatric training in Australia

Objective: Evaluation of postgraduate pediatric training is a complex yet critical task. We aimed to review pediatric trainees’ attitudes to clinical decision-making, levels of supervision and end of life issues in a tertiary pediatric teaching hospital in Sydney, Australia.Method: A questionnaire was devised and distributed to all trainees at Sydney Children’s Hospital, Randwick. All responses were anonymous. Results were independently analyzed using SPSS statistical software.Results:Forty percent of trainees spent three hours or less per week face to face with more senior colleagues and 14% spent greater than 10 hours per week with more senior colleagues. Seventy-five percent of trainees spent three hours or less on the phone with more senior colleagues while 10% spent five hours or more on the phone with more senior colleagues. There was no association (or correlation) (p>0.05) between seniority of trainee and the number of times a trainee met face to face or phoned a more senior colleague to discuss a management plan. One in three trainees felt that they made less than 10% of clinical decisions on their own and 54% felt that they made less than half of decisions on their own. There was a statistically significant difference between seniority of training and the percentage of important clinical decisions made (p<0.01). Nearly half the trainees (47.7%) have not had the occasion to inform families of the death or impending death of a child. There was a statistically significant difference between seniority of training and the opportunity of informing families of a death of a child (p<0.01).Greater than two thirds of trainees feel that they have not received formal training in clinical decision-making. At the completion of four years of pediatric training only half the trainees considered themselves to be making the majority of clinical decisions.Conclusion: There is a need for closer supervision of pediatric trainees by senior colleagues, who themselves, may require additional ongoing training to supervise appropriately. There should be a balanced environment where trainees can make safe, independent decisions. The perceived absence of clinical decision making training suggests a deficiency in the training program.

Does home treatment affect delirium? A randomised controlled trial of rehabilitation of elderly and care at home or usual treatment (The REACH-OUT trial)

delirium is a frequent adverse consequence of hospitalisation for older patients, but there has been little research into its prevention. A recent study of Hospital in the Home (admission substitution) noted less delirium in the home-treated group. a tertiary referral teaching hospital in Sydney, Australia. we randomised 104 consecutive patients referred for geriatric rehabilitation to be treated in one of two ways, either in Hospital in the Home (early discharge) or in hospital, in a rehabilitation ward. We compared the occurrence of delirium measured by the confusion assessment method. Secondary outcome measures were length of stay, hospital bed days, cost of acute care and rehabilitation, functional independence measure (FIM), Mini-Mental State Examination (MMSE) and geriatric depression score (GDS) assessed on discharge and at 1- and 6-month follow-up and patient satisfaction. the home group had lower odds of developing delirium during rehabilitation [odds ratio (OR) = 0.17; 95% confidence interval 0.03-0.65], shorter duration of rehabilitation (15.97 versus 23.09 days; P = 0.0164) and used less hospital bed days (20.31 versus 40.09, P < or = 0.0001). The cost was lower for the acute plus rehabilitation phases (7,680 pounds versus 10,598 pounds; P = 0.0109) and the rehabilitation phase alone (2,523 pounds versus 6,100 pounds; P < or = 0.0001). There was no difference in FIM, MMSE or GDS scores. the home group was more satisfied (P = 0.0057). home rehabilitation for frail elderly after acute hospitalisation is a viable option for selected patients and is associated with a lower risk of delirium, greater patient satisfaction, lower cost and more efficient hospital bed use.

The current pattern of hepatitis B virus infection in Australia

There is little recent data of the seroprevalence of hepatitis B in Australia. We have surveyed a large cohort of endoscopy patients attending a teaching hospital in central Sydney, and related the presence of hepatitis B virus (HBV) markers with putative risk factors for exposure using the SAS statistical package. Of the 2115 patients tested: 2.1% (45/2115) were HBV surface antigen positive, 0.75% (14/2115) viraemic, 9.5% (200/2115) anti-HBs and anti-HBc positive, 20.1% (430/2115) vaccinated (anti-HBs only) and the remaining 70% were susceptible. The adjusted OR of HBV infection was significantly increased in patients who had been diagnosed with human immunodeficiency virus (36.3-fold), born in Asia or Pacific islands (12.4-fold), born in North Africa, Middle East & Mediterranean countries (6-fold) or born abroad elsewhere in the world (2.7-fold), had household contact with someone diagnosed with hepatitis between 1980 and 1990 (3.9-fold), injected drugs between 1980 and 1990 (4.4-fold), resided in a military establishment for 3 months (2.3-fold) or in a hospital for 3 months (2.2-fold), never been vaccinated for hepatitis B (2.8-fold), received blood transfusion due to an accident and/or a haemorrhage (1.92-fold) and finally been a male gender (1.59-fold). The prevalence of HBV in this hospital population was higher than predicted on the basis of notifications to the passive surveillance scheme. Most HBV patients had multiple risk factors for infection, but the hierarchy of odds ratios provides a rational basis for targeted programmes to identify asymptomatic HBV carriers who might benefit from treatment.

Histiocytosis and bone: experience from one major Sydney teaching hospital

Langerhans cell histiocytosis (LCH) has diverse presentations which can bring it before all physicians regardless of specialty. A retrospective audit was undertaken at Westmead Hospital, Sydney, Australia, to ascertain the incidence, epidemiology and clinical features of patients with LCH over a 10-year period (1994-2004). A total of 12 patients was identified (six male, six female). Eleven patients had involvement of the skeletal system, three of the patients had pulmonary LCH and only one patient presented with soft tissue involvement (nose and antrum). Three patients had diabetes insipidus. Our results are consistent with that noted in the published literature and confirm the low incidence, diverse nature of presentation and the differing treatment strategies available for this rare and yet interesting condition.

Optimizing the Use of Antithrombotic Therapy for Atrial Fibrillation in Older People: A Pharmacist‐Led Multidisciplinary Intervention

To develop, implement, and evaluate a pharmacist-led multidisciplinary intervention in a hospital setting that would optimize antithrombotic use in elderly atrial fibrillation patients. The hypothesis that there would be an increase in the proportion of patients receiving antithrombotic therapy at discharge was tested. Evidence-based algorithms were developed to define the criteria (stroke risk vs contraindications) by which an elderly patient's requirement for antithrombotic therapy was assessed. A major Sydney teaching hospital. Two hundred eighteen consecutively admitted elderly patients (mean age 85.2) were recruited over a 6-month period. A pharmacist-coordinated multidisciplinary review process was implemented to coordinate risk assessments and subsequently recommend appropriate antithrombotic therapy, as per the algorithms. The proportion of patients receiving antithrombotic therapy was assessed on admission (preintervention), at discharge (postintervention), and postdischarge (follow-up at 3 and 6 months). As a result of the intervention, 78 patients (35.8%) required changes to their existing antithrombotic therapy. Of these changes, 60 (76.9%) were "upgrades" to more-effective treatment options (e.g., from no therapy to any agent or from aspirin to warfarin). The remaining 18 (23.1%) changes were "downgrades" to less-effective, albeit safer, options. Despite a significant increase in anti thrombotic use overall (59.6% vs 81.2%, P<.001), fewer patients received warfarin postintervention, after having been assessed as inappropriate candidates (20.7% vs 17.4%, P=.39). A pharmacist-led multidisciplinary process was successfully developed and implemented within the hospital setting to increase overall antithrombotic use. Having addressed some of the known barriers and limitations to warfarin use, these algorithms may allow allied health workers, patients, and clinicians to work collaboratively to achieve optimal and, importantly, appropriate (i.e., safe and effective) antithrombotic use in at-risk elderly patients.

Investigation of Leukaemia and Lymphoma AR-DRGs at a Sydney Teaching Hospital

Using non-blinded methodology, this study checked the coding of acute leukaemia, non-acute leukaemia and lymphoma episodes assigned to the AR-DRGs R60 A, B, C and R61 A, B during the fiscal year 2000-2001 at a Sydney teaching hospital. The purpose was to investigate whether the assignment of fewer episodes of these diseases to the highest complexity AR-DRGs during that year compared to 1999-2000 was due to miscoding, or due to a true decrease in episodes. A check of all 242 episodes revealed a degree of miscoding (mainly under-coding) of complications and comorbidities that had caused a 15% DRG error rate; nevertheless, there was a true decrease in the highest complexity episodes. The error in DRG assignment may have caused some financial disadvantage to the hospital.

Discrete-choice experiment to measure patient preferences for the surgical management of colorectal cancer

Establishing trust between a patient and his or her surgeon is of paramount importance. The aim of this study was to assess the relative importance of the 'attributes of trust' between surgeon and patient with colorectal cancer. A discrete-choice questionnaire was conducted with 60 men and 43 women who had completed primary treatment for colorectal cancer in two teaching hospitals in Sydney, Australia. Forty-seven of the 103 patients based their choice of surgical management on a single attribute and the remainder were willing to trade between different attributes. In order of importance, patients based their choice of surgical management on specialty training (beta coefficient = 0.83), surgeon's communication (beta = 0.82), type of hospital (beta = 0.72) and who decides treatment (beta = 0.01). Patients who were vigilant in their decision-making style and those who did not have tertiary education were more likely to change their preferences in the repeat interview. Clinicians may have a better chance of meeting a patient's expectations about the process of care if they assess the patient's desire for knowledge and give those who do not have tertiary education more time to assimilate information about their treatment.

MENTAL HEALTH LIAISON NURSING IN THE EMERGENCY DEPARTMENT: ONSITE EXPERTISE AND ENHANCED COORDINATION OF CARE

Objective: To evaluate the Mental Health Liaison Nurse (MHLN) service based in the emergency department (ED) of a large, inner city teaching hospital in Sydney, Australia. Design: Data were gathered over the first two years of the position. Information is presented regarding the length of time that patients waited to be seen by the MHLN. Results from two rounds of surveys conducted with ED nursing and medical staff are tabulated. Results: Data obtained from the Emergency Department Information System (EDIS) demonstrates that the Mental Health Nurse Practitioner (MHNP) is able to see a majority of patients at, or close to, the point of triage. These findings are reinforced by ED staff who rate highly the readily available access to mental health assessment and enhanced coordination of care. The strong clinical focus of the role is acknowledged by the ED staff who perceive that patients are better supported therapeutically and spend less time waiting in the department due to MHLN intervention Conclusions: This evaluation suggests that the MHLN role has significant benefit for patients presenting to the ED by reducing waiting times, streamlining transition through the department and improving follow-up. The MHLN is highly regarded by the staff as an on-site source of clinical expertise. The information obtained supports the established model and will be used to guide the direction of the service.

Introduction of standardised emergency department paediatric asthma clinical guidelines into a general metropolitan hospital

'Aiming for Asthma Improvement in Children' is a South East Sydney Area Health Service (SESAHS) initiative. It is funded by the Commonwealth Government, under the Chronic & Complex Care Programmes, which is linked to New South Wales (NSW) Government Action Plan. One specific objective of the programme is to implement standardised paediatric asthma guidelines across the Emergency Departments of an area tertiary and local area hospitals. This paper will focus on the process of piloting, implementing and evaluating the guidelines into one local area hospital within SESAHS. SESAHS includes Sydney Children's Hospital, Randwick, a major paediatric referral and tertiary teaching hospital in Sydney. The paediatric asthma clinical practice guidelines (CPG) were developed, piloted and disseminated from Sydney Children's Hospital, Randwick, for local implementation and adaptation. The successful introduction of these guidelines at the local hospital promoted evidence-based practice and reduced the admission rate for children with asthma.

Small bowel tumours: a 10 year experience in four Sydney teaching hospitals.

Small bowel tumours are uncommon and can have a long delay prior to diagnosis. The present study aims to compare the use of computed tomography (CT) and contrast small bowel series (SBS) in their diagnosis and to outline the clinical features of small bowel tumours. A retrospective, case note study was conducted between 1990 and 2000 in four Sydney teaching hospitals. The data collected included clinical features, investigations and tumour characteristics. One hundred and sixty-six people with small bowel tumours were identified (91 malignant; 75 benign). Malignant tumours consisted of adenocarcinomas (31%), carcinoid tumours (12%), lymphomas (7%) and leiomyosarcomas (5%). Benign tumours consisted of adenomas (22%), hamartomas (13%), leiomyomas (4%), inflammatory polyps (4%) and hyperplastic polyps (2%) and a benign schwannoma (1%). Adenocarcinomas were mainly located in the duodenum (P < 0.001) and carcinoid tumours in the ileum (P < 0.001). Malignant tumours were associated with a higher proportion of symptoms (P < 0.01), signs (P < 0.001) and episodes of small bowel obstruction (P < 0.01). Abdominal CT scans demonstrated a greater sensitivity (87.7%) than SBS (72.9%) with a slightly improved sensitivity when both investigations were used (89.3%). Abdominal ultrasound had a lower sensitivity than both of the above investigations of 65%. Gastroduodenoscopy had a sensitivity of 90% for diagnosing duodenal tumours. Operative procedures were performed on 92 patients with a preoperative diagnosis made in 77%. Metastatic spread of malignant tumours was evident in 46%. The sites of spread were to lymph nodes (23%), liver (21%) and distant locations (2%) at diagnosis. Malignant small bowel tumours are more likely to produce symptoms and signs than benign tumours, particularly caused by small bowel obstruction. Abdominal CT is the best radiological investigation for small bowel tumours and has a slight complimentary effect with SBS in improving the chances of detection. Gastroduodenoscopy remains the best investigation of duodenal tumours.

Assessing outcomes of cancer care: lessons to be learned from a retrospective review of the management of small cell lung cancer at the Cancer Therapy Centre, Liverpool Hospital, January 1996-July 2000.

The purpose of the present paper was to review the outcomes of care of small cell lung cancer (SCLC) at one Sydney teaching hospital. A retrospective cohort study was carried out of patients with SCLC seen between January 1996 and July 2000. The main outcomes were relapse-free and overall survival. Secondary outcomes of interest were the uniformity of staging investigations, initial treatment, use of prophylactic cranial irradiation (PCI), patterns of relapse and treatment received following relapse. One hundred and three patients with SCLC were treated at the Liverpool Hospital Cancer Therapy Centre during this period. There were 58 men (56%) and 45 women (44%). Forty-two patients (41%) had limited stage disease (LD) and 61 (59%) had extensive stage disease (ED). There was considerable variation in staging investigations. There was little variation in systemic treatment of SCLC. Only 32 of 42 patients with limited stage SCLC were candidates for thoracic radiotherapy and only seven patients received PCI. Median relapse-free survival was 11.2 months (95% confidence interval (CI): 7.7-14.8) for patients with LD and 6 months (95%CI: 4.4-7.5) for ED. Median overall survival was 15.1 months (95%CI: 11-19.1) for patients with LD and 8.9 months (95%CI: 7.5-10.2) for ED. Some health outcomes similar to that reported in clinical trials can be achieved in clinical practice. Measuring health outcomes is an important process of maintaining quality of care.