Internal Medicine Journal最新文献

This review of omalizumab use in chronic spontaneous urticaria (CSU) over a 9-year period in a rural setting identified that a ‘complete response’ to 3 months of omalizumab treatment was associated with an elevated IgE level, absence of other autoimmune diseases and older age, compared with a ‘partial response’. Median CSU duration was 36 months prior to omalizumab. There is insufficient evidence to recommend routine IgE testing to predict omalizumab response as it is unlikely to change management.

Cognitive dissonance is a term coined by Festinger in the 1950s that describes an uncomfortable tension experienced whenever one simultaneously holds contradicting beliefs or finds that one's behaviour is inconsistent with inner beliefs. This phenomenon is unfortunately commonplace in medical training and practice, where many lived experiences in its 'hidden curriculum' reflect observations, attitudes and practices that run contrary to what is formally taught or one's personal values/beliefs. As medical professionals training and practising in modern healthcare settings, we herein share our perspectives on the key areas in which cognitive dissonance occurs in real-world clinical environments, and offer practical strategies at both individual and systemic levels to mitigate this issue.

Chronic respiratory diseases, including chronic obstructive pulmonary disease and asthma, pose substantial challenges to healthcare systems worldwide, which are projected to grow in coming years. Variations in care represent a threat to health equity and must be identified and remedied. Robust auditing systems can improve healthcare effectiveness and efficiency by identifying strengths and weaknesses in existing service models. The Australia New Zealand Respiratory Audit Programme (ANZRAP) is a new funded research and quality improvement programme commencing in 2025 aiming to improve quality of care, clinical outcomes and health service provision for people with respiratory illness across Australia and New Zealand. This paper describes the development, plans for implementation and likely outcomes of the ANZRAP.

This update of the Australasian consensus guidelines for the initial empiric management of neutropenic fever occurs in the context of major changes in cancer treatment paradigms, as well as advances in the management of sepsis and new models of care for infections since the last version of these guidelines in 2011. Acknowledging the important role of antimicrobials in the disruption of the gut microbiome and emerging antimicrobial resistance, as well as the changing epidemiology of antimicrobial resistance more broadly, these guidelines address current evidence for optimal empiric neutropenic fever therapy. A writing group - including adult and paediatric representatives across infectious diseases, microbiology, haematology, transplant and oncology, as well as across craft groups, including medicine, nursing and pharmacy - was developed to produce and address key management questions. This was overseen by a steering committee, which included consumer representation. Using an extensive review of the literature, these guidelines provide consensus recommendations with evidence grading for initial empiric management of neutropenic fever in adults and children, including recommended investigations, antimicrobial therapy and approach to patients with beta-lactam allergy or risk factors for multidrug-resistant infection. Management beyond the first 72 h is discussed in separate chapters of this issue: the Subsequent Management (for high-risk neutropenic fever) and Ambulatory Management (for low-risk neutropenic fever) chapters.

Since the publication of the Australian consensus guidelines in 2011, the routine use of prophylactic antibiotics in patients with neutropenia has remained controversial, because of concern that the risks of promoting antimicrobial resistance outweighed the level of evidence that their use reduced mortality. Populations at risk have changed over this period and now include a multitude of new cancer therapies, such as targeted cancer therapies and immunotherapies. Emerging understanding about the importance and role of the microbiome in defining treatment response and patterns of antibiotic resistance has also expanded. In addition, the management of neutropenic fever has improved significantly through the development and routine implementation of sepsis pathways. These updated consensus guidelines review recent evidence for the use of antibacterial prophylaxis in adults and children receiving cancer therapies associated with neutropenia. Recommendations presented in these guidelines were based on evaluating current evidence for the benefits and harms of antibacterial prophylaxis while considering the current Australian and New Zealand healthcare setting. In most circumstances, the potential harm of antibiotic resistance, adverse effects of antibiotics and disruption to the microbiome, outweighed the benefit of reducing the incidence of infection, without a benefit in mortality.

Neutropenic fever is a common complication of haematology and oncology treatments and is associated with a significant risk of morbidity and mortality. Few studies report patients' and carers' understanding of neutropenic fever, including risk reduction, recognition and optimal management. This guideline aims to improve communication around prevention, recognition and management strategies for neutropenic fever in patients receiving cancer treatment. Medical specialists, allied health physicians, other key stakeholders, parents and carers, and patient consumers collaborated to develop guidelines for patients and carers on neutropenic fever. This addition to the 2024 Australasian Consensus Guidelines for the Management of Neutropenic Fever in Patients with Cancer is the first directed at healthcare workers treating paediatric and adult patients at risk of neutropenic fever.

Background: Neutropenic fever (NF) is a common complication of systemic anti-cancer therapy requiring prompt management. A previous 2009 Australian survey of NF clinical practices identified evidence-practice gaps that informed the 2011 Australian Consensus Guidelines for the Management of Neutropenic Fever in Adult Cancer Patients. The emergence of novel cancer therapies and evidence for risk-stratified NF treatment warrant re-evaluation of current approaches to management.

Aims: To describe current clinical practices in Australia and New Zealand in adult NF management, compare results to the 2009 survey, and identify areas for improvement.

Methods: An electronic survey was distributed to haematology, oncology, and infectious diseases clinicians across Australia and New Zealand between June and August 2023. Survey domains included risk stratification, empiric treatment, use of prophylaxis, and management of patients colonised with multidrug-resistant organisms. Descriptive analyses compared responses between specialties and to 2009 data.

Results: A total of 132 clinician responses were received. Improvements were observed in the appropriateness of empiric treatment of NF with a reduction in the use of dual therapy and prescribing of antibacterial prophylaxis. However, knowledge of risk stratification and utilisation of ambulatory care for low-risk NF remained low. Heterogeneity in empiric antibiotic duration and management of patients colonised with multi-drug resistant organisms was observed. Infectious diseases involvement remained widespread but decreased among the medical oncology cohort between 2009 and 2023.

Conclusions: While practices have evolved, critical gaps in risk assessment, appropriateness for early discharge, and antimicrobial stewardship remain. Investments in infrastructure, education and multidisciplinary collaboration are essential to improve the uptake of ambulatory care models for NF. The updated consensus guidelines have addressed ambulatory care, antimicrobial duration and empiric management of those colonised with resistant organisms.

In the context of significant advances in the literature, this chapter of the 2024 Australasian Consensus Guidelines for the Management of Neutropenic Fever in Patients with Cancer addresses the management of patients beyond the first 72 h, focusing on high-risk patients. A writing group - including adult and paediatric representatives across infectious diseases, microbiology, haematology, transplant and oncology across Australia and New Zealand, as well as across craft groups, including medicine, nursing and pharmacy - was developed to produce and address key management questions, overseen by a steering committee that included consumer representation. This chapter follows on from the Initial Empiric Management chapter and it complements the Ambulatory Care chapter, which is dedicated to low-risk patients. Using an extensive review of the literature, these guidelines provide consensus recommendations with evidence grading on topics including investigation of persistent and recurrent fever, common causes of non-infection-related fever and antibiotic rationalisation options, such as cessation, de-escalation and targeted therapy.