Internal Medicine Journal最新文献

General physicians as system leaders play a significant role in quality improvement (QI) initiatives within respective health services. However, there are very few formal QI training programmes available for general physicians in Australia. This survey described the experiences of attendees at the 2024 Internal Medicine Society of Australia and New Zealand QI workshop, which delivered topics on understanding variations in healthcare data using QI tools such as run charts and statistical process control (Shewhart) charts.

Less common cancers are underserved with expertise compared to other cancers. This is accentuated in regional areas where patients may need to travel for expert opinion. Development of a virtual multidisciplinary meeting (MDM) can help overcome this disadvantage but can be a challenge to establish. We describe the development of a framework for future less common cancer MDMs.

Background: Return-to-work (RTW) following lung transplant has been associated with increased quality of life, but little is known regarding the rates of and barriers to this in the Australian population.

Aims: We aimed to describe, characterise and determine predictors of return to work and social participation in Australian lung transplant recipients. We also sought to explore the relationship between return to work and quality of life.

Methods: We conducted a cross-sectional questionnaire-based study at the Alfred Hospital, Melbourne between October 2018 and August 2019. The questionnaire evaluated demographics, transplant history, respiratory parameters, employment history and social integration prior to and after lung transplantation.

Results: A total of 172 lung transplant recipients were included for analysis. The population was mostly male (56.5%), median age 61 years (interquartile range (IQR) 49.8-67.0) and median time from transplant 4 years (IQR 2-7). A total of 19.2% of patients were working at time of transplant, with 35.5% working after transplant representing an increase in workforce engagement of 84.8% (P < 0.001). A total of 96% of those who returned to work reported an improvement in quality of life. Median time to RTW after transplant was 180 days (IQR 90-360). Multivariable analysis demonstrated an increased rate of RTW in younger recipients (odds ratio (OR) 0.94, 95% confidence interval (CI) 0.89-0.99, adjusted P = 0.029), at greater length of time after transplant (OR 1.09, 95% CI 0.99-1.19, P = 0.084), among those working at the time of transplant (OR 9.55, 95% CI 2.70-33.75, P < 0.001) and with higher socioeconomic status (OR 1.02, 95% CI 1.01-1.04, P = 0.009). Recipients with cystic fibrosis were more likely to RTW (65.8%) than those with other underlying conditions.

Conclusions: RTW should be encouraged in lung transplant recipients. Targeted supports and resources aimed at younger recipients may result in greater workforce engagement and overall outcomes after transplant.

Background: With improved outcomes in human immunodeficiency virus (HIV) due to the use of anti-retroviral therapy, ensuring adequate preventative healthcare and management of HIV-related comorbidities is essential.

Aims: To evaluate adherence with recommended guidelines for comorbidity and immunisation status screening amongst people living with HIV within a hospital-based setting across two timepoints.

Methods: A single-centre retrospective case series was conducted at a hospital between 2011 and 2021. Inclusion criteria were ≥18 years, confirmed diagnosis of HIV and commencement of care within study period. Medical data were reviewed over two 12-month periods to capture comorbidity screening and vaccination adherence using established guidelines (Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, Alfred Screening tool and Australian Technical Advisory Group recommendations). Descriptive statistics were obtained with IBM spss (version 29.0).

Results: Of 102 patients, 82 (80.4%) were male and 55 (53.9%) born overseas. Nineteen (18.6%) patients entered in 2011, with a median of 36.5 months from service entry to exit. Within 12 months of entry 56 (55.4%) participants had influenza vaccination recorded. Within the last 12 months, 94.8% had recorded COVID-19 vaccination, with improvements in pneumococcal (72.3%) and hepatitis B (82.8%) since service entry. Recording of comorbidity screening was >90% for blood pressure, weight and renal function at both timepoints, however, suboptimal (<10%) for substance misuse, cognitive and osteoporosis screening.

Conclusions: There is a disparity amongst comorbidity screening and documentation of vaccination status. Further measures are required to target improvements in immunisation, bone health, substance misuse and cognitive impairment screening.

Background: Sepsis-associated acute kidney injury (SA-AKI) is common among patients admitted to the intensive care unit (ICU) with sepsis.

Aims: This study aimed to demonstrate an association between an episode of SA-AKI and progression to dialysis dependence, with a view to identifying a cohort who may be suitable for intensive nephrology follow-up.

Methods: Design: Retrospective data-linkage cohort study.

Setting: Alice Springs Hospital ICU, 10-bed regional facility, housed in a 200-bed regional hospital, located in Central Australia.

Participants: All patients admitted with a diagnosis code associated with sepsis between 2015 and 2017.

Main outcome measures: Primary outcome was a composite measure comprising death or initiation of maintenance dialysis within 5 years of the index case of sepsis leading to ICU admission.

Results: The unadjusted risk of the composite outcome was significantly higher in the SA-AKI group (odds ratio (OR) 3.22, 95% confidence interval (CI) 1.81-5.74, P < 0.01). This effect remains after adjustment for age, illness severity and co-morbidities (adjusted OR (aOR) 2.64, 95% CI 1.22-5.68, P = 0.01). Progression to maintenance dialysis was the primary driver of this effect (OR 7.56, 95% CI 2.23-25.65, P = 0.02), although it was modified by the effect of confounders (aOR 7.3, 95% CI 0.7-75.94, P = 0.10).

Conclusions: These results demonstrate an association between an index episode involving SA-AKI and the composite outcome in a defined population. Identification of this group may allow intensive nephrology follow-up and secondary prevention with the goal of mitigating the risk of progression of disease with significant economic and personal benefits.

Background: Type 2 diabetes mellitus (T2DM) poses a significant public health challenge in Australia, particularly among underserved populations such as First Nations people and rural communities. In response, the Together Strong Connected Care (TSCC) programme was developed to address these disparities by offering a culturally appropriate, multidisciplinary approach to diabetes management in a regional hospital setting.

Aims: The aim of the study was to assess the impact of the TSCC programme on glycaemic and metabolic control in people living with diabetes.

Methods: This was a retrospective observational study. Baseline characteristics, including age, gender, ethnicity and clinical measures, were collected. The primary outcome was the change in HbA1c over 12 months. Statistical analysis included descriptive analysis, univariate comparative analysis, paired t-tests for change in outcomes and multivariate linear regression analysis.

Results: The study included 119 patients, divided into those who participated in the TSCC programme (n = 68) and those who declined participation (n = 51). The study participants had a mean age of 55.71 years, with 58.82% identifying as female. The mean baseline HbA1c was 8.25% (SD = 2.60) and mean baseline weight was 97.38 kg (SD = 28.81). People in the TSCC group had significantly greater reductions in HbA1c (-1.65%, P < 0.001) compared to the no-TSCC group (+0.02%, P < 0.001). After adjusting for confounders, TSCC participation remained independently associated with improved glycaemic control (β = -0.78, P < 0.001), particularly in patients with T2DM.

Conclusions: The TSCC programme significantly improved glycaemic control in regional First Nations patients, supporting the effectiveness of culturally appropriate, multidisciplinary care models in managing diabetes in underserved communities. Further research is warranted to evaluate long-term outcomes of similar interventions.

Background: Smoking has been shown to have detrimental effects on KT outcomes and survival. Most units and guidelines advocate for the cessation of smoking prior to a kidney transplant and consider it a general contraindication to listing. Smoking prevalence is higher in disadvantaged groups. Smoking cessation is complex and often takes many years. For those suffering from the burden of chronic kidney disease, a delay in transplantation with a longer dialysis time may result in worse outcomes and accentuate the difficulty of cessation.

Aim: The objective of this study was to describe the cohort of excluded smokers for kidney transplantation (KT) and further examine the current practices regarding smoking and KT waitlisting.

Methods: We undertook a retrospective observational study of dialysis patients in Hunter New England Local Health District 2013-2023 <65 years old and assessed but not listed for KT. We examined the reasons for non-transplant listing and divided them into two categories, smoking versus others (comorbidities, patient preference and cancer). We compared the categories in terms of demography, comorbidities and dialysis modality. We also conducted a survey of KT units across Australia and New Zealand regarding their policies towards smoking.

Results: We reviewed the records of 333 patients (142 female), 89 of whom were smokers. Patients not listed due to smoking were less comorbid than those rejected for another reason (83% vs 40% having ≤1 comorbid condition, P < 0.001). Patients rejected due to smoking were younger than those rejected for other reasons (47.8 vs 52.1, P = 0.007). There was no difference between the two groups in terms of sex or dialysis modality. All the acute KT units were surveyed (response rate 100%); 72% of units do not list current smokers for KT.

Conclusion: Patients not listed for KT due to smoking are generally younger and less comorbid than those not listed for other reasons. Our survey shows variation in practice between units. As smoking is more prevalent in marginalised communities, not listing these patients for KT may be an equity-of-access-to-treatment issue.