Internal Medicine Journal最新文献

Background: The inaugural Australian National Oncology Mentorship Program 2023 (NOMP23) demonstrated that virtual matching of trainee oncologists (mentees) with senior clinicians (mentors) for a 1-year mentorship programme was associated with significant reductions in burnout and improved professional fulfilment.

Aims: This sub-study sought to determine the bidirectional benefits of the programme for both mentees and mentors and unpack themes discussed at mentorship meetings to provide an insight into the benefit of top-down-led mentorship programmes.

Methods: The NOMP23 programme methodology has been previously reported. Additionally, participants were invited to partake in semi-structured interviews that were transcribed and thematic analyses conducted to assess benefits, themes discussed and future directions to improve NOMP.

Results: Of 112 participants enrolled, 86% completed the baseline questionnaire, 62% completed the mid-programme questionnaire and 54% completed the end-of-programme questionnaire. Nine participants - four mentors and five mentees - were interviewed at NOMPs conclusion. A high level of connection between matched pairs with adequate ability for pairs to meet was identified. The most common topics discussed were career planning, professional fulfilment, research and time management. The benefits of the mentoring relationship fell into five themes: (i) professional guidance; (ii) personal connection; (iii) support and reassurance; (iv) external perspectives; and (v) future perspectives. Benefits of providing mentorship fell into two themes: (i) personal connection and (ii) future-proofing oncology as a profession.

Conclusion: Qualitative analyses of the NOMP23 programme demonstrated a positive effect on trainee and mentor well-being with benefits including personal guidance for trainees, fulfilment for mentors and instilling hope for the future.

Patients with newly diagnosed multiple myeloma and considered transplant ineligible (TIE) because of age, frailty and/or comorbidities now have access to highly effective therapies that can achieve deep and/or durable remission. TIE patients are a highly heterogeneous population whose biological and chronological age can vary substantially. The treatment of these patients can be challenging in clinical practice and requires a frailty-adapted, individualised approach with an emphasis on treatment deliverability and tolerability to optimise patient outcomes. Here, we summarise recommendations for TIE patients, including pre-treatment considerations, induction and maintenance therapies, and supportive care management.

Background: Direct oral anticoagulants (DOACs) have changed the paradigm of atrial fibrillation (AF) management in preventing ischaemic cerebrovascular accidents (CVAs). They are safe and effective in this aim. Their dosing is simpler than the vitamin K antagonist warfarin; however, there are certain nuances in dosing adjustments which clinicians must be aware of before initiating changes.

Aim: We sought to investigate the role of inappropriate DOAC underdosing in contributing to the development of ischaemic CVAs.

Methods: A retrospective cohort study was performed on all ischaemic CVA presentations to an Australian tertiary centre in the 12 months of 2023. We analysed all those already on DOAC therapy and the significance of inappropriate DOAC underdosing. This was compared to all DOAC prescriptions, without associated ischaemic CVA complication, within the centre during the same period and whether underdosing played a significant role.

Results: Seventy-two patients presented to our centre with an ischaemic CVA, already prescribed and taking DOAC therapy. Underdosing of DOAC therapy, away from established guidelines, was the most common attributable factor found. Underdosing of DOACs had an overall odds ratio of 4.31, with a 95% confidence interval (95% CI) of 2.49-7.46, of suffering an ischaemic CVA. The periprocedural period was also found to be high risk for patients undergoing DOAC therapy.

Conclusions: Underdosing of DOAC therapy has a significant impact on whether individuals develop ischaemic CVAs. Clinicians must be stringent in applying dose reductions based on established guidelines and must be aware to review dosing for all their DOAC patients.

Introduction: Giant cell arteritis (GCA) is the most common vasculitis of the elderly. Delayed diagnosis or inadequate treatment can lead to severe and irreversible consequences. There are limited data on diagnosis and management practices of rheumatologists and rheumatology trainees in Australia. This study aimed to determine practices and views of Australian rheumatologists/rheumatology trainees in the diagnosis and management of GCA.

Methods: An online survey was completed by Australian rheumatologists/trainees. The survey gathered data on the respondent demographics and a range of topics related to the diagnosis and management of GCA, including the use of temporal artery biopsy (TAB) and imaging, confidence in ultrasound, use of steroid-sparing medication, and approaches to aortic aneurysm screening and referral back to primary care.

Results: There were 58 respondents (52 rheumatologists, six trainees). On average, respondents used TAB alone (56% of respondents), imaging alone (19%), both (15%) or neither (10%). The majority of respondents (79%) rarely or never made a diagnosis of GCA without TAB. Only 40% expressed confidence in GCA diagnosis by temporal artery ultrasound from their preferred radiology provider. Management approaches following the end of government-funded tocilizumab varied. Only 12% of respondents reported that >50% of their GCA patients were able to cease prednisolone by 12 months.

Conclusions: Australian rheumatologists and trainees have low confidence in ultrasound and rarely make a diagnosis of GCA without a TAB. Variable practice would support the need to develop Australian clinical care standards for GCA.

Objectives: To examine the association between physical multimorbidity and 6-month quit outcomes among treatment-seeking smokers.

Methods: We analysed data from 120 732 adults enrolled in Ontario's largest publicly funded smoking cessation programme. At enrolment, participants self-reported zero, one or two or more chronic physical health conditions. The primary outcome was 7-day point prevalence abstinence at 6 months. We used mixed-effects logistic regression to assess the association between multimorbidity and quit outcomes, adjusting for demographic and tobacco use characteristics.

Results: Of participants, 39.4% reported no conditions, 26.8% reported one and 33.8% reported two or more. Those with multimorbidity were older, had lower socioeconomic status and showed higher tobacco dependence but also greater motivation to quit. Compared to individuals without comorbidities, those with one condition (OR = 0.94, 95% CI: 0.90-0.98) and those with two or more (OR = 0.81, 95% CI: 0.77-0.85) had lower odds of quitting. Mental health conditions further reduced quit success among those with physical multimorbidity.

Discussion: Physical multimorbidity is associated with 19% lower odds of cessation success despite high motivation to quit. Tailored, intensive cessation support may improve outcomes for this high-risk group.

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.

Background: Hip fractures are associated with poor functional outcomes and increased mortality. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) surgical risk calculator is an open access tool that estimates the probability of postoperative outcomes.

Aims: To externally validate the calculator in predicting geriatric outcomes (delirium, functional decline, pressure injury), 30-day inpatient mortality and discharge destination in patients aged 65 and older undergoing surgical fixation of neck of femur fractures.

Methods: A retrospective single-centre cohort study of patients admitted from July 2022 to June 2023 to a large, metropolitan health service in Melbourne, Australia, was conducted. The calculator's performance was analysed using the area under the receiver operating characteristic curve (AUC), the Hosmer-Lemeshow test and the Brier score.

Results: We included 305 patients in the study. Mean age was 82.4 ± 7.8 years and 215 (70.5%) were female. The calculator performed well for predicting delirium (AUC 0.859, 95% CI 0.811-0.902, Brier score 0.150), functional decline (AUC 0.883, 95% CI 0.826-0.935, Brier score 0.120) and mortality (AUC 0.854, 95% CI 0.774-0.917, Brier score 0.065). Results from the Hosmer-Lemeshow test for all of these outcomes demonstrated good calibration. The calculator had reduced performance in predicting discharge destination and pressure-injury risk.

Conclusion: The calculator is a moderately reliable predictor of delirium, functional decline and inpatient mortality in older patients who undergo hip fracture surgery. Further prospective research is required to validate it across other Australian healthcare settings.

Background: The Kidney Failure Risk Equation (KFRE) is a validated tool for assessing the risk of progression to kidney failure requiring renal replacement therapy (RRT). A 2-year KFRE risk threshold of ≥40% may support timely vascular access planning.

Aims: To compare the utility of KFRE with traditional estimated glomerular filtration rate (eGFR) thresholds for guiding vascular access planning in an Australian cohort.

Methods: This single-centre observational cohort study retrospectively reviewed 580 adult patients referred to a Kidney Disease Education Clinic (KDEC) between 2016 and 2021. Among these, 211 patients who underwent dialysis access formation were analysed. Patient trajectories, including eGFR and 2-year KFRE scores at referral, access formation and dialysis initiation, were described alongside rates of emergency access.

Results: Of 211 patients with access created, 204 commenced dialysis. A median 2-year KFRE of 46% predicted dialysis within 12 months, supporting its use for access planning. Compared with eGFR < 15 mL/min/1.73m², KFRE thresholds (≥40% or ≥ 50%) better identified those at risk. A 2-year KFRE ≥ 50% offered the best balance of sensitivity (70%) and specificity (68%) for predicting dialysis within 12 months, whereas ≥40% was more accurate for forecasting dialysis at 24 months and guiding early education. Emergency access was required in 31.5% of haemodialysis patients with lower eGFR at referral (11 vs 15 mL/min/1.73 m²), higher 2-year KFRE (87% vs 62%) and more preceding hospitalisations (95.4% vs 38.5%) than others.

Conclusion: KFRE-based thresholds improve risk-stratified access planning compared with eGFR alone. A KFRE ≥ 40% supports early referral for modality education and vascular access, tailored to patient and institutional needs.

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.