Internal Medicine Journal最新文献

Background: Statins are widely used to prevent atherosclerotic cardiovascular disease through the reduction of low-density lipoprotein cholesterol. However, in patients with limited life expectancy or significant multimorbidity, the long-term benefits of statins may be reduced while the risks can increase.

Aims: The aim of this study was to evaluate the evidence supporting statin deprescribing and develop a clinical algorithm to guide appropriate discontinuation.

Methods: We conducted a systematic literature search in PubMed (18 November 2024) using the terms 'statins AND (deprescribing OR deprescription)'. Eligible studies reported statin deprescribing interventions and were analysed based on study design, population, outcomes and healthcare professional involvement.

Results: Fifty-six studies met the inclusion criteria. Among these, 65% were real-world studies, 17% narrative reviews, 9% systematic reviews, 11% randomised controlled trials (RCTs), and 2% a single case report. Study sample sizes ranged from 1 to 212 566 patients. Outcome assessment tools varied across studies; 61% employed database analyses to evaluate clinical, administrative and quality-of-life outcomes. Notably, 41% of studies reported favourable outcomes following statin deprescribing, suggesting that discontinuation was not associated with serious adverse events and was often linked to improved quality of life. A multidisciplinary team conducted the deprescribing intervention in 43% of cases.

Conclusion: These findings support statin deprescribing as a safe and effective strategy in selected patients, particularly those with limited life expectancy or multiple comorbidities. Personalised, shared decision-making and multidisciplinary collaboration are essential to guide appropriate deprescribing. Further high-quality research, especially RCTs, is needed to consolidate current evidence and inform future clinical guidelines.

Background: Lung cancer diagnosis requires multiple investigations, with delays causing increased mortality. To reduce diagnostic delays, a general practitioner (GP) referral pathway program was developed in 2016 within a rural Australian health district to assist GPs in referring patients with suspected lung cancer for further management.

Aims: To assess the effectiveness of this GP cancer referral program, and the impact on high-risk patient populations.

Methods: Patients who underwent curative intent radiotherapy for lung cancer at the North NSW Cancer Institute between 2012 and 2022 were included in the study. Patients were stratified based on Eastern Cooperative Oncology Group (ECOG) performance status, stage of malignancy and level of rurality. Comparison was performed between patients diagnosed between 2012-2016, 2017-2019 and 2020-2022. The diagnostic pathway was split into four steps, and the time taken between each point was mapped. Chi-squared analysis was used to assess for demographic differences. Mann Whitney U test was used to assess for differences between the three time periods and between high-risk groups for each step within the diagnostic pathway.

Results: There were 214 patients in the study cohort. There were no demographic differences between the three time periods (P > 0.05). ECOG performance status and level of rurality did not impact any step of the diagnostic timeline (P > 0.05). There was an improvement in diagnostic timelines for stage III patients compared to stage I/II patients from 2017 onwards, through multiple steps of the diagnostic pathway (P < 0.05).

Conclusion: Implementation of a local GP intervention improves diagnostic timelines for patients with advanced stages of disease.

Background: Ciprofol, a novel sedative-hypnotic agent and structural analog of propofol, has emerged as a promising sedative agent in recent years. However, its efficacy in mechanically ventilated intensive care unit (ICU) patients is not well understood.

Aims: To compile and synthesise the existing evidence on the efficacy and safety of ciprofol compared to propofol in mechanically ventilated ICU patients.

Methods: We systematically searched PubMed, Scopus, Web of Science and CNKI databases from inception to June 2025 for randomised controlled trials (RCTs) comparing ciprofol and propofol in ICU settings. Outcomes analysed included sedation success, hypotension, time to extubation, rescue sedation and bradycardia. Meta-analysis was then conducted to quantitatively assess and compare these outcomes between ciprofol and propofol.

Results: Three RCTs, comprising 228 participants, were included. There was no significant difference in sedation success between ciprofol and propofol (risk ratio (RR) = 0.989, 95% confidence interval (CI) = 0.809-1.209; P = 0.913), indicating that ciprofol is as efficient as propofol (the gold standard in this area) in inducing sedation. Ciprofol was associated with a lower risk of hypotension, although this association did not reach statistical significance (RR = 0.668, 95% CI = 0.397-1.124; P = 0.128). Similarly, the mean difference in time to extubation was not significant (MD = -2.98 min, 95% CI = -6.80 to 0.83; P = 0.125). Rescue sedation rates also did not differ significantly (RR = 0.786, 95% CI = 0.163-3.800; P = 0.764), and no significant difference was found in the risk of bradycardia (RR = 0.874, 95% CI = 0.298-2.558; P = 0.805). Across all outcomes, heterogeneity was negligible (I² = 0.0%).

Conclusions: Ciprofol demonstrates comparable efficacy and safety to propofol for ICU sedation in mechanically ventilated adults. Further large-scale RCTs are needed to confirm these findings.

Background: The presence of a general physician assessing patients upon referral in the emergency department (ED) may improve patient outcomes compared with the traditional model of post-take ward rounds.

Aim: This study examines the impact of such an intervention on patient discharge rates and readmissions in a single centre.

Methods: From July 2019 to June 2020, a general physician was rostered to review patients on the day of referral from the ED. Four cohorts were compared: pre-intervention, intervention, concurrent controls (admitted during the intervention period but not reviewed) and post-intervention. Multivariate analyses evaluated the association between same-day consultant review and the likelihood of same-day discharge, as well as other variables including median length of stay (LoS) and readmission rate.

Results: Among 22 620 admissions, median LoS was shorter in the intervention period than in the before or after period (87 h vs. 97 and 93 h (P < 0.001)). Same-day general physician assessment increased the odds of day zero discharge by fivefold compared with before the intervention (adjusted odds ratio (aOR) 5.47, 95% confidence interval (CI): 3.62-8.26, P < 0.001). This effect was not sustained after the intervention ended (aOR 0.47, 95% CI 0.27-0.80, P < 0.006). Lower triage acuity and younger age were associated with discharge on day zero. Notably, longer ED decision time correlated with higher day zero discharge (aOR 1.09, 95% CI: 1.03-1.15), possibly reflecting appropriate consultant involvement in cases with an unclear disposition. Day zero discharge rates varied among individual general physicians (range 4.1%-14.0%). Increased day zero discharges did not lead to higher 7-day readmission rates.

Conclusions: This large trial showed that early general physician review was associated with decreased median LoS and increased rate of day zero discharge, with no increase in readmission rates or mortality. Variability between physicians suggests potential for further optimisation in practice.

The recent NEJM Evidence trial questioned the benefit of enoxaparin for venous thromboembolism (VTE) prevention among older hospitalised medical patients. We conducted a retrospective, observational audit of 142 elderly inpatients at a large Australian tertiary institution; most received enoxaparin unless contraindicated, with excellent adherence to guidelines. Clinical events were rare with two VTE (1.4%) and five minor bleeds (3.5%) recorded and no major bleeding observed. Approximately 10% of patients were ambulant and prescribed thromboprophylaxis outside guideline criteria, yet bleeding rates were low. Our findings suggest high guideline compliance and minimal bleeding associated with enoxaparin prophylaxis in this population. There is a need for simple and practical risk stratification tools with clear ambulation definitions, routine mobility assessments where appropriate and consideration of patient-accepted approaches such as oral thromboprophylaxis options.

Background: Longitudinal data on in-hospital glycaemia from Australian hospitals are limited.

Aims: The aim of this study was to evaluate the efficacy and safety of current inpatient management strategies in New South Wales hospitals and to compare hospital-acquired complication (HAC) rates in patients with and without diabetes. We also evaluated trends in diabetes admissions, glycaemia and HAC between 2017 and 2024.

Methods: This was a retrospective, observational study of adult medical and surgical admissions to three hospitals over an 8-year period.

Results: Diabetes was observed in 21% of admissions (n = 84 864/398 803), with the proportion increasing over time (OR 1.008 per year (95% CI 1.005, 1.011), P < 0.001). Among diabetes admissions, the mean blood glucose (BG) of the hospital admission was 9.17 ± 2.82 mmol/L. The odds of BG <3 mmol/L (OR 0.996 per quarter (CI 0.994, 0.997), P < 0.001) or of BG >15 mmol/L (OR 0.999 per quarter (CI 0.998, 0.999), P = 0.012) during the admission decreased over time. The odds of hospital-acquired infection (HAI) (OR 0.977 per year (95% CI 0.962, 0.992), P < 0.001) and hospital-acquired cardiac complication (OR 0.973 per year (95% CI 0.947, 0.999), P < 0.039) decreased over time. However, the age-standardised HAI rate ratio increased in diabetes compared with non-diabetes admissions (Exp(B) 1.028 per year (95% CI 1.004, 1.032), P = 0.020). The composite HAC rate decreased in non-diabetes admissions (OR 0.982 per year (95% CI 0.975, 0.989), P < 0.001) but increased in diabetes admissions (OR 1.020 (95% CI 1.009, 1.032), P < 0.001).

Conclusion: We demonstrate marginal improvements in glycaemia. While some HACs improved, the gains were of greater magnitude in those without diabetes. These findings highlight both progress and persisting inequities in hospital outcomes for people with diabetes.

Background: Encephalitis is a condition of brain dysfunction and parenchymal inflammation with many aetiologies. Guidelines for Australia and Aotearoa New Zealand on diagnosis and management were published in 2015. There have been no recently published local studies of encephalitis.

Aims: This study assessed guideline adherence for recommended investigations and antimicrobial management of suspected community-acquired encephalitis cases. Secondary aims were to compare clinical diagnoses to the International Encephalitis Consortium (IEC) consensus case definition and to provide descriptive epidemiology of encephalitis in Sydney, Australia.

Methods: A retrospective review of medical records was conducted for all adults with a cerebrospinal fluid (CSF) sample collected between 1 July 2018 and 30 June 2019 to investigate suspected community-onset meningoencephalitis or encephalitis at four Sydney metropolitan hospitals.

Results: Two hundred and nine suspected cases were reviewed including 35 ultimately diagnosed as encephalitis. Adherence to guideline recommendations was variable but overall better in cases subsequently diagnosed as encephalitis, significantly so for some investigations. Viral polymerase chain reaction testing of non-CSF samples, serology for human immunodeficiency virus and syphilis, repeat herpes simplex virus (HSV) PCR when indicated and anti-N-methyl-D-aspartate receptor antibody testing were areas for improvement. Empiric aciclovir was not given in 30% of suspected cases but was at the appropriate dose and frequency when prescribed. Ten of 35 cases with clinical encephalitis diagnoses did not meet the IEC case definition criteria. The most common infectious aetiology was HSV, while the most common mimics were drug-associated presentations.

Conclusions: Guideline application was variable, with areas identified for improvement. Prospective studies are needed to investigate guideline-adherence barriers.

Reflection is essential to physician development, yet too often it is treated as a mandatory exercise in continuing professional education. This article reframes reflection through two fresh lenses. First, drawing on autonomic physiology, it argues that reflection flourishes in parasympathetic 'rest-and-digest' states that promote psychological safety. Second, using optics, it shows how the choice of 'light' and 'mirror' shapes perspectives and the insights gained during reflection. Individual, pairwise and group reflection activities carry different benefits and risks; these all require specific safeguards and boundaries. By reframing reflection, this article offers useful strategies to integrate authentic reflection into clinical training and medical practice.

Introduction: The epidemiology of inflammatory bowel disease (IBD) in New Zealand (NZ) has been explored in regional studies but not at a national level. This study aimed to use administrative data to define the first nationwide IBD population and estimate the incidence, prevalence and mortality of IBD in NZ.

Methods: The Integrated Data Infrastructure (IDI) is a statistical database linking population-level health data. An IBD population was created within the IDI using hospital discharge information by International Classification of Diseases, Tenth Revision code. Incidence and prevalence rates were calculated for 16 years (2006/07-2021/22) by age, sex, ethnicity and urban/rural location. Age-sex-standardised mortality was measured annually from 2012 to 2022.

Results: Between 1 July 2021 and June 30 2022, 19 566 people in the IDI were identified as having IBD, giving a prevalence of 391.4 (95% confidence interval (CI) 386.0-396.9) per 100 000 people. The prevalence of Crohn's disease (CD), 206.9 (95% CI 203.0-211.0), was similar to that of ulcerative colitis (UC), 213.2 (95% CI 209.2-217.2), both per 100 000 people. In the same year, 1407 new cases of IBD were observed, giving an incidence rate of 28.1 (95% CI 26.7-29.7) per 100 000 person-years. The 2012-2022 standardised mortality ratio for IBD was 1.69 (95% CI 1.60-1.79).

Conclusions: A high incidence and prevalence of IBD were seen in NZ, and increased all-cause mortality rates were observed. Despite the limitations of using hospital data, this work established the value of IDI data for IBD epidemiological studies and produced national estimates of IBD burden.

Diabetes is a leading cause of kidney failure, and individuals with both diabetes and chronic kidney disease (CKD) experience significantly higher rates of complications and mortality. The international guideline developer Kidney Disease: Improving Global Outcomes (KDIGO) has produced clinical practice guidelines that reflect recent advances in pharmacotherapy for this population, extending beyond glycaemic control to include cardio-renal benefits. However, these guidelines were developed without specific consideration of the healthcare systems, access issues and population needs in Australia and New Zealand. In response, the Caring for Australians and New Zealanders with Kidney Impairment (CARI) Guidelines Working Group has provided a regional commentary on the KDIGO 2022 guideline. This commentary highlights key recommendations and contextualises their implementation within the Australian and New Zealand healthcare environments. It addresses issues such as medication access, equity for Indigenous populations and the importance of shared decision-making, aiming to support clinicians in delivering evidence-based, locally relevant care for people living with diabetes and CKD.