Internal Medicine Journal最新文献

Background: Mortality following transjugular intrahepatic portosystemic shunt (TIPS) placement remains a critical concern. Traditional scoring systems, such as the Model for End-Stage Liver Disease (MELD) and MELD-Na, as well as the newer Modified TIPS-Score (MOTS) and Freiburg Index of Post-TIPS Survival (FIPS), have shown potential for refining risk stratification.

Aims: To externally validate prognostic scores for predicting 30- and 90-day mortality following TIPS.

Methods: This retrospective study, conducted at Austin Health, Australia, included 117 patients who underwent TIPS with ≥90 days of follow-up between 2011 and 2024. Prognostic scores were calculated using pre-TIPS clinical and laboratory data. Discrimination and calibration were assessed and prognostic accuracy evaluated at established thresholds for MELD ≥ 18, MELD-Na ≥ 20, MOTS > 1, FIPS ≥ 0.92 and additional scores.

Results: TIPS indications included ascites and/or hepatic hydrothorax (56.4%), variceal haemorrhage (34.2%), Budd-Chiari syndrome (6.0%) and other indications (3.4%). Mortality occurred in 13 (11.1%) and 21 patients (17.9%) by 30 and 90 days respectively. MELD demonstrated the best discrimination for 30-day mortality (area under the curve (AUC) = 0.82), followed by MOTS (0.80), FIPS (0.76) and MELD-Na (0.73), with similar trends at 90 days. MOTS was best calibrated, followed by FIPS and MELD. FIPS ≥ 0.92 had excellent specificities (94% and 95%) and negative predictive values (94% and 88%) for 30- and 90-day mortality, marginally outperforming MELD and MOTS. MELD-Na and other scores performed less well.

Conclusion: MOTS, MELD and FIPS demonstrated robust discriminative performance for early post-TIPS mortality and outperformed other models. Further research is required to establish optimum risk thresholds for these tools and support these findings.

Background: Alcohol-associated hepatitis (AAH) causes significant morbidity, mortality and healthcare expenditure. Increased alcohol consumption during the SARS-CoV-2 (COVID-19) pandemic was observed globally.

Aims: This study aims to assess temporal associations between the COVID-19 pandemic and AAH admission frequency and outcomes.

Methods: Retrospective cohort study of inpatients aged ≥18 years fulfilling National Institute of Alcohol Abuse and Alcoholism diagnostic criteria for AAH from three Australian tertiary referral hospitals. AAH admissions and outcomes between 1 March 2020 and 31 March 2021 ('COVID-19 cohort') were compared with a 'historical cohort' (1 January 2016-29 February 2020). The primary endpoint was the monthly rate of AAH admissions according to the COVID-19 timepoint. Secondary outcomes included change in AAH severity, interventions and healthcare costs.

Results: In the study period, 301 eligible AAH admissions were identified. The COVID-19 cohort (n = 104) had a significantly higher median AAH monthly admission rate (8 (interquartile range (IQR) 6, 9) vs 3 (3, 5), P < 0.0001) and proportion requiring intensive care unit admission (26% (n = 27) vs 12% (n = 24), P = 0.002), despite similar median MELD-Na scores (20 (IQR 15, 25.5) vs 19 (14, 25), P = 0.24) to the historical cohort (n = 197). Higher median monthly healthcare costs were identified in the COVID-19 cohort ($90 912 (IQR 43 853, 243 469) vs $42 983 (IQR 18 231, 71 410), P = 0.03). Ninety-day mortality was 14%. No patients were diagnosed with COVID-19.

Conclusions: In this multicentre analysis, AAH admission frequency, ICU requirement and healthcare costs increased during the COVID-19 pandemic. These observations provide the impetus for future studies to help develop preventive strategies that reduce alcohol-related admissions.

Syphilis has re-emerged as a significant public health concern in Australia, with rising notification rates among both traditional and non-traditional risk groups. Declared a Communicable Disease Incident of National Significance, syphilis continues to pose a diagnostic challenge due to its myriad of different presentations and ability to mimic other diseases. The recent rise in cases of congenital syphilis is particularly concerning and highlights the urgent need for improvement in syphilis testing in antenatal care. This clinical perspective provides a contemporary and relevant summary of the evolving epidemiology, staging of syphilis infections, interpretation of serological tests, as well as management approaches including partner notification and follow-up testing. We also outline advances in syphilis diagnostics-including nucleic acid amplification tests and point-of-care tests-which have made it much easier to detect syphilis infections early. The recent availability of doxycycline as post-exposure prophylaxis is also discussed, which offers a promising tool to prevent infections and re-infections in at-risk populations, namely men who have sex with men and transgender women. Treatment for syphilis continues to rely primarily on long-acting injectable benzathine benzylpenicillin, with alternative regimens being used increasingly amid a continual global shortage of this formulation of penicillin. Encouragingly, there are early signs that suggest notification rates for syphilis are finally decreasing in some jurisdictions, likely in response to the multitude of interventions implemented as part of the national syphilis response. Physicians in all specialties should remain aware and confident in testing and managing syphilis in order to continue cementing this downward trend.

Background: Phase 1 oncology trials (POTs) are challenging to discuss with patients due to safety and efficacy uncertainties. In Australia, there is currently no formal training on POTs for oncology trainees.

Aims: This study aims to assess trainees' experiences and attitudes towards POTs to identify gaps that could inform the development of training and educational resources.

Methods: A 25-item online questionnaire was distributed to recently fellowed or current medical oncology advanced trainees in Australia. Responses regarding experience, perceptions and confidence in POT patient care and communication were analysed descriptively. Wilcoxon rank sum tests were performed to identify factors positively associated with confidence in POT domains.

Results: Twenty trainees completed the questionnaire. Although trainees typically had considerable clinical experience with POTs, half (n = 10) received 'None' or 'Slight' training, and only three (15%) evaluated the quality of their training to be above average. Trainees expressed confidence in assessing POT eligibility (mean score 3.55) and tumour response evaluation (mean score 3.3). Trainees reported lower confidence with discussing efficacy, toxicity and logistics of POTs (combined mean score 2.8). Higher levels of oncology experience (P = 0.011) and training in POTs (P = 0.034) were significantly associated with greater confidence in POT clinical domains.

Conclusion: Australian medical oncology trainees are highly involved in the care of patients on POTs despite receiving minimal training. Trainees report greater confidence in performing trial-specific clinical assessments than in discussing clinical aspects of POTs. This study highlights the need for formalised training and the development of education resources to enhance conduct and information provision regarding POTs.

Background: Risk stratification and management of pulmonary embolism (PE) continues to evolve, particularly for patients in the intermediate- and high-risk category, where treatment decisions are complicated by patient heterogeneity and limited guidance on reperfusion strategies. Catheter-based therapy (CBT) is becoming commonplace internationally; however, there is no published guidance on a standard approach to when to use these therapies in the Australian setting.

Aim: We aimed to develop a consensus-based, evidence-informed algorithm for risk stratification and management of PE at our institution, with a focus on effective utilisation of CBT.

Methods: We conducted a retrospective audit of PE patients treated at our hospital. reviewed current evidence and international guidelines and convened a PE working group comprising respiratory physicians, interventional radiologists, intensive care physicians and anaesthetists. This group developed consensus guidelines and a standardised treatment algorithm.

Results: The resulting treatment algorithm provides a clear, evidence-based approach to risk stratifying and managing PE patients, with a particular focus on the intermediate risk group. It facilitates uniform, multidisciplinary, physician-led decision-making and supports safe and effective integration of CBT. This treatment algorithm is novel in the Australian setting.

Conclusion: As CBT and other advanced therapies become increasingly available, the absence of national consensus guidelines presents a challenge. By integrating emerging clinical evidence expert opinion, we provide a pragmatic model that may support decision-making in similarly resourced centres.

Gout is an increasingly prevalent condition with high global burden of disease due to a myriad of factors, including population ageing, rising affluence, changes in dietary habits and higher rates of obesity and metabolic syndrome. While many cases of gout flares can be managed with standard anti-inflammatory medications (colchicine, non-steroidal anti-inflammatory drugs and/or corticosteroids), increasingly, there are patients who are refractory, intolerant or unsuitable (due to associated cardiometabolic conditions) for such treatments - whom we define as the "difficult-to-treat" cases. In this article, we sought to provide a practical approach to treating such cases of complex and refractory gout flares, through a simple 4A acronym (consider Alternate diagnosis, use of Anakinra and other IL-1 receptor antagonists, ACTH injections and Adjuvant measures).

Background: Novel models of ambulatory care have been used in chronic disease management, but implementation in advanced chronic liver disease remains limited.

Aims: We aimed to explore clinical outcomes of a multidisciplinary clinic for patients with chronic liver disease.

Methods: We performed a retrospective cohort study of patients attending a multidisciplinary liver clinic between February 2019 and May 2024. The clinic comprised co-located hepatologists, a dietitian, a pharmacist and an addiction medicine specialist, coordinated by a hepatology nurse. Patients accessed on-site point-of-care ultrasound, abdominal paracentesis and albumin infusions. The primary outcome was liver-related admission. Secondary outcomes were 12-month admission-free survival and change in liver disease prognostic scores at 3 and 6 months.

Results: A total of 285 patients were included, of whom 61% were men, 56% had alcohol-related liver disease and 95% had cirrhosis. The median baseline model for end-stage liver disease (MELD) score was 14.6 (interquartile range (IQR): 10.6-18.9) and 52% were in Child-Pugh B class at index appointment. The liver-related admission rate was 33% at a median of 546 days (IQR: 149-1095 days) from index appointment, and 12-month admission-free survival was 40.4% (IQR: 34.6-46.1). Median MELD improved at 3 months (12.8 months (IQR: 9.8-15.9 months), P < 0.05) and plateaued by 6 months (11.9 months (IQR: 9.4-16.2 months), P = 0.29). The proportion of patients with ascites decreased at each time point (54% vs 35% vs 27%, P < 0.05).

Conclusions: Two-thirds of patients attending a multidisciplinary liver clinic had no subsequent liver-related admissions, with a median 18-month latency to admission in the remainder. Co-location of clinicians and supportive measures may contribute to these findings.