Internal Medicine Journal最新文献

Background/aims: To assess the effectiveness of an antimicrobial stewardship (AMS) intervention in haematology patients with febrile neutropenia (FN) on days of therapy (DOT) of empiric broad-spectrum antibiotic therapy (EBAT).

Methods: A single-centre, prospective cohort study of adult haematology patients admitted with FN from 1 May to 30 November 2022, compared with a retrospective cohort of patients admitted from 1 January 2018 to 31 December 2021. AMS intervention involved infectious diseases advice at weekly haematology meetings to encourage cessation of EBAT for patients with FN who were clinically stable with no isolated source. Primary outcome was duration and agent of EBAT DOT for patients without an identifiable source of fever.

Findings: For FN without an identifiable infective source, mean DOT was significantly shorter (7.1 vs 5.0 days (P = 0.04)). There was also a significant increase in the number of patients for whom EBAT was ceased prior to neutrophil recovery in the prospective cohort (40% vs 61%, P = 0.016). For patients without an identified source, duration of piperacillin-tazobactam and meropenem therapy decreased from 2018-2021 to 2022, with a trend towards significance (6.1 vs 4.4, P = 0.07; 12.7 vs 4.4, P = 0.07 respectively). There was no increase in recurrence of fever, antibiotic escalation, intensive care unit admission or death within 30 days in the post-intervention group.

Interpretation: We demonstrate that an AMS intervention decreased EBAT duration for patients without a source of infection.

The role of anti-resorptive agents in patients with bone metastases from neuroendocrine neoplasms is unclear. Our aim was to review bone-specific treatment recommendations by the New Zealand National Neuroendocrine Tumour Multidisciplinary Meeting (MDM). Recommendations for bone-specific treatment were given at 29/365 MDMs (7.9%); 44.8% were confirmed to have received the recommended therapy. Bone-specific treatment recommendations were infrequent; there is a need for more data on the role of anti-resorptive agents in this group.

Epilepsy is a prevalent chronic neurological disorder marked by recurrent seizures, affecting over 70 million people worldwide. This review offers an up-to-date guide for general physicians, general practitioners and general neurology trainees on diagnosing and managing epilepsy, emphasising the importance of early referral to specialist teams. It discusses the epidemiology, significant societal burden and common comorbidities-including cognitive, psychiatric and cardiovascular conditions-which contribute to reduced quality of life and increased mortality, including sudden unexpected death in epilepsy. The article outlines a structured approach to first seizures and their mimics, emphasising the role of electroencephalography and neuroimaging in diagnosis. Medical management centres on seizure control through anti-seizure medications (ASMs), but up to one-third of patients develop drug-resistant epilepsy, necessitating specialist interventions such as epilepsy surgery or neuromodulation. Accurate seizure classification and tailored treatment plans, including consideration of ASM teratogenicity in women of childbearing age, are essential. Case vignettes illustrate complex scenarios requiring specialist multidisciplinary evaluation. This review reinforces that timely specialist input can significantly enhance outcomes in patients with challenging or refractory epilepsy.

Background: With an ageing population, there is an increasing demand for home-based palliative care to improve end-of-life care. Funding models can impact service utilisation and patient outcomes.

Aims: To compare two funding models to assess the effects on service utilisation, hospital admission, home death rates and concordance between preferred and actual place of death.

Methods: A single-centre, prospective cohort study compared the first 12 months of two funding models. Eligible patients accessing a private health insurance-funded palliative care programme were included. Each funding model had different eligibility criteria: the capitation model (May 2020-April 2021) required a ≤3-month prognosis and preference for home death, while the fee-for-service model (December 2022-November 2023) had a ≤6-month prognosis with no preference.

Results: The capitation cohort had fewer hospital admissions (27% vs. 64%) in the last 4 weeks of life, and a higher rate in home or a residential aged care facility (78% vs. 31%). Concordance with preferred place of death was similar across cohorts (91% vs. 76%). Except for assistants in nursing, the fee-for-service cohort accessed more services, with utilisation increasing near death. In the final 4 weeks, the capitation cohort had higher service use (median 14 vs. 7) and more involvement of assistants in nursing (40% vs. 5%) and medical practitioners (60% vs. 35%).

Conclusions: This is one of the first studies to look into funding models and how funding mechanisms influence service utilisation, intensity and timing. While trends emerged, cohort differences led to variability and limited interpretation.

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.

Background: Previous studies have identified distinct subgroups (phenogroups) of patients with heart failure with preserved ejection fraction (HFpEF).

Aims: This study aims to identify distinct phenotypes in older patients with HFpEF hospitalised for acute heart failure (AHF) and investigate the relationship between subgroups and outcomes.

Methods: Retrospective, single-center study, including patients ≥65 years hospitalised for AHF over a 4-year period. We used electronic medical records to collect clinical data, including hospital outcomes. Latent class analysis (LCA) was performed to identify clusters of clinical phenogroups. The primary outcome was all-cause in-hospital mortality.

Results: Overall, 770 patients were included. Based on LCA, three phenogroups were identified. Phenogroup 1 (n = 323) had both the lowest burden of comorbidities and N-terminal pro-brain natriuretic peptides (NT proBNP) values. Phenogroup 2 (n = 224) had the oldest patients (median age 82 years), the highest prevalence of women (62%) and atrial fibrillation and the worst right ventricular function. Phenogroup 3 (n = 223) consisted mainly of men (57%) and had a higher prevalence of diabetes, obesity and established cardiovascular disease and the worst renal function. Phenogroups 2 and 3 showed a significantly higher risk of primary outcome than phenogroup 1. In addition, survival analysis showed that phenogroup 2 had the worst prognosis, with more than double the risk of in-hospital death.

Conclusions: In this real-world cohort of older patients with HFpEF hospitalised for AHF, we identified three subgroups with significantly different features and prognoses. Phenomapping may be an effective tool to identify individuals most likely to experience adverse outcomes, providing a basis for phenotype-specific treatment strategies.

Direct-to-consumer telemedicine services have become increasingly popular, allowing consumers to access virtual consultations and electronic prescriptions. However, the expansion of this innovation raises concerns surrounding safety, privacy and ethics. There is a need for formal evaluation within the Australian healthcare landscape to harness the benefits of DTC platforms while maintaining high-value and high-quality care.