Internal Medicine Journal最新文献

Heparin-induced thrombocytopenia (HIT) is a serious adverse reaction to heparin. Other HIT-like syndromes are increasingly recognised, mediated by antibodies binding to platelet factor 4, with or without identifiable polyanions. The history of heparin exposure is atypical for classical HIT and standard HIT laboratory tests may be negative. This manuscript describes subtypes of HIT-like syndromes and highlights practical tips for diagnosis and therapy.

Background and aims: Significant burnout and low professional fulfilment are noted among medical oncologists and trainees. The National Oncology Mentorship Programme (NOMP23) was designed to evaluate the impact of a 1-year mentorship program between oncology trainees (mentees) and consultants (mentors) on improving professional fulfilment and burnout.

Methods: NOMP23 was a single-arm, prospective cohort study. One hundred twelve participants (56 mentors and 56 mentees) across Australia were recruited. Mentee/mentor pairs were orientated to the program virtually and met at least three times throughout 2023. The primary outcome was improvement in professional fulfilment as assessed using the Stanford Professional Fulfilment Index at conclusion of NOMP23 compared to baseline.

Results: A total of 112 participants enrolled. Eighty-six (77%) completed the baseline and 63 (56%) completed the end-of-program survey. At baseline, 82% of mentees and 77% of mentors were classified as burnt out, which reduced to 57% and 51% at the conclusion of NOMP23; a reduction of 25% and 26% (P < 0.01). Baseline professional fulfilment was 0% and 5% for mentees and mentors respectively, which improved to 21% and 34% at the end of NOMP23 (P < 0.01). However, significant reduction in feelings of regret towards oncology as a profession was seen for mentees and mentors between baseline and the conclusion of NOMP23 (40% vs 14% and 29% vs 0% respectively, P < 0.01).

Conclusions: NOMP23 demonstrated that a centrally coordinated, low-cost mentorship program could be feasible and was of high value. Mentorship programs, alongside multifactorial institutional, state-based and national interventions to improve well-being, can help ensure a sustainable workforce.

Background: Immunotherapy has emerged as a standard treatment for deficient mismatch repair (dMMR) metastatic colorectal cancer (mCRC). Pembrolizumab became widely available as a first-line (1L) option in Australia following the Pharmaceutical Benefits Scheme (PBS) listing in August 2021. The uptake of new treatment options can be lengthy.

Methods: The Treatment of Recurrent and Advanced Colorectal Cancer mCRC registry data at participating Australian sites was analysed from January 2015 (when MMR testing became routine). 1L treatment of dMMR cancers was compared with pre- and post-PBS funding.

Results: Out of 2819 patients, 2344 (83%) had known MMR status. Of these, 162 (7%) were dMMR, which was associated with older age (median age 69 vs 63 years, P = 0.001), a right-side primary (68% vs 31%, P < 0.001) and a BRAF V600E mutation (49% vs 11%, P < 0.001). Prior to August 2021, 85 out of 117 (73%) patients with dMMR received 1L treatment: 63 out of 85 (74%) chemotherapy and 20 out of 85 (24%) immunotherapy. Following approval, 39 out of 45 (87%) received 1L treatment and 39 out of 39 (100%) pembrolizumab. Of the patients 75 years and older, a significantly higher proportion of patients were treated with any 1L therapy post-PBS listing (89% vs 60%, P = 0.036).

Conclusion: Previously reported associations of dMMR were observed. The higher-than-expected proportion of patients with dMMR is likely driven by the inclusion of older patients in this real-world study. Many patients were able to access immunotherapy prior to PBS listing, potentially through trials or access programs. Early uptake of pembrolizumab following PBS listing has been high, and this effective and well-tolerated option has increased the proportion of elderly patients receiving active therapy.

The environmental impact of large language models (LLMs) in medicine spans carbon emission, water consumption and rare mineral usage. Prior-generation LLMs, such as GPT-3, already have concerning environmental impacts. Next-generation LLMs, such as GPT-4, are more energy intensive and used frequently, posing potentially significant environmental harms. We propose a five-step pathway for clinical researchers to minimise the environmental impact of the natural language algorithms they create.

Lower extremity ulcers contribute a significant burden to patient care. Targeted investigation and management are pertinent to improving patient outcomes. We evaluated the aetiology, risk factors, investigations and management of lower extremity ulcers in general medicine patients. There was evidence of under-ordering of appropriate investigations, and over-treatment for infection. We proposed a quality improvement initiative to optimise lower extremity ulcer care.

To evaluate experience in a tertiary rheumatology service with melanoma differentiation-association-protein-5 (MDA5) disease and testing, patients with positive autoantibody results were reviewed for the presence of clinical disease. Anti-MDA5 positivity was detected in 2% of myositis-specific antibody tests. Of these, 29% did not have features consistent with anti-MDA5 disease. However, when present, MDA5 disease is severe with a high mortality.

There are routine hospital workflows that are not addressed by certain institutional electronic medical records, including the detection of patients requiring haemodialysis who are admitted under non-nephrology services. In this study, the feasibility and performance of a clinician-developed automated haemodialysis patient finder was evaluated. The programme ran with zero downtime for 6 months and had zero false negatives or false positives. This work demonstrates the potential benefits that may be gained when clinicians can meaningfully alter electronic clinical workflows.

Background: Abdominal paracentesis is a frequently performed procedure in hospitalised patients with ascites. Concurrently, most hospitalised adult patients receive pharmacologic anticoagulation, either for therapeutic purposes or prophylactically to prevent venous thromboembolism. Despite this, minimal evidence exists to guide management of anticoagulant therapy pre- and post-paracentesis.

Aims: The authors aimed to investigate the safety of abdominal paracentesis in hospitalised patients receiving therapeutic or prophylactic anticoagulation, including in patients for whom these medications were withheld periprocedurally.

Methods: TriNetX, an electronic health record data set, was queried to identify patients between the ages of 18 and 80 years who received an abdominal paracentesis while hospitalised at the authors' institution between September 2017 and June 2022. Patients receiving prophylactic anticoagulation (137), therapeutic anticoagulation (74) and no anticoagulation because of coagulopathy or thrombocytopenia (15) were compared. Rates of withholding anticoagulation, performing service, pre- and post-paracentesis haemoglobin, bleeding complications, thrombotic complications and need for red blood cell transfusion were analysed.

Results: Procedure-related bleeding complications occurred in two (1.4%) patients in the prophylactic group and 0 (0%) patients in the therapeutic group (P = 0.54). No thrombotic complications occurred. Rates of red blood cell transfusions post-paracentesis were similar between groups. Analysis of secondary end-points identified significant differences in rates of withholding anticoagulation and mean change in haemoglobin between performing services.

Conclusion: Performance of abdominal paracentesis in patients receiving therapeutic or prophylactic anticoagulation appears to be safe regardless of whether anticoagulation was interrupted periprocedurally, with low rates of bleeding complications, thrombotic complications or need for red blood cell transfusions post-paracentesis.

Background: Central line-associated bloodstream infections (CLABSIs) are a potential complication for home parenteral nutrition (HPN) patients.

Aim: We sought to analyse risk factors of developing HPN-related CLABSI and assess CLABSI management in the Australian context.

Methods: A retrospective observational cohort study was conducted on 34 adult patients receiving HPN via a central venous catheter (CVC) at a Queensland tertiary referral centre between 2016 and 2023. Patient charts were reviewed, and Kaplan-Meier analysis was employed to determine associations between characteristics and time to CLABSI in the first CVC using Peto-Peto Prentice test.

Results: A total of 39 CLABSI episodes occurred in 19 patients. Patients with ≥1 CLABSI used regular opioids more than those without CLABSI (P = 0.016). Fourteen (41%, n = 14/34) patients developed a CLABSI in their first CVC. No patient or line characteristics were found to be predictive of CLABSI in their first CVC. The CLABSI rate was 1.02/1000 catheter days. Most CLABSIs were caused by Enterobacterales (22%, n = 12/55) and Candida sp. (22%, n = 12/55). Empiric antimicrobial therapy was adequate in only 25% (n = 7/28), and the median time to effective antibiotic therapy was 22.7 h (interquartile range 4.8-29.8). There were three successful CVC salvages (8%, n = 3/39).

Conclusions: In this cohort of patients, regular opioid use was associated with increased risk of developing CLABSI. Based on our findings, an empiric antimicrobial regime of vancomycin, cefepime and caspofungin will provide adequate coverage for most HPN-related CLABSIs in Australian IF units with a similar antimicrobial distribution and resistance pattern.