Internal Medicine Journal最新文献

Prehabilitation, a multidisciplinary approach to optimise patients pre-surgery, aims to reduce frailty and enhance surgical outcomes. However, limited evidence exists on the effectiveness of improving clinical outcomes in patients with frailty undergoing cancer-related surgery. This systematic review assessed whether prehabilitation enhanced clinically relevant outcomes for patients with frailty undergoing cancer-related surgery. We conducted a systematic review and meta-analysis, reviewing four databases from January 2000 through April 2024 for studies examining the association between prehabilitation before elective cancer surgery and clinical outcomes. The primary outcome was hospital length of stay (LOS). Secondary outcomes included functional status, complication rates and readmission rates. We performed a random-effects meta-analysis, estimating associations for binary outcomes using relative risks (RRs) and continuous outcomes using mean differences (MDs). Risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool for randomised clinical trials and Joanna Briggs Institute for observational cohort studies. We included 15 studies (1955 patients); 67.7% (657 of 970) were frail. The hospital LOS was comparable between the prehabilitation and control groups (MD = -0.29 (95% confidence interval (CI): -0.89 to 0.30); P = 0.34). No significant improvements were noted in post-operative functional status (MD = 29.95 (95% CI: -11.24 to 71.14); P = 0.15), complication rates (RR = 0.76 (95% CI: 0.56-1.04); P = 0.085) or readmission (RR = 1.23 (95% CI: 0.84-1.81); P = 0.29). Prehabilitation approaches and frailty assessments were notably heterogeneous and inconsistently reported. Prehabilitation did not reduce hospital LOS or major postoperative complications in patients with frailty undergoing cancer-related surgery. Heterogeneity in prehabilitation protocols and reporting limited the interpretation of results and highlights a critical gap in research methodologies.

Background: The HINTS (head impulse, nystagmus, and test of skew) examination can surpass early magnetic resonance imaging (MRI) in detecting central causes of acute vestibular syndrome (AVS) when performed by neurologists, but its accuracy in routine hospital practice by non-neurologists is uncertain.

Aims: To evaluate the utilisation, documentation, diagnostic accuracy and clinical influence of HINTS in AVS cases at a tertiary Australian hospital and whether combining HINTS with the ABCD² (age, blood pressure, clinical features, duration, diabetes (clinical risk score)) score improves diagnosis.

Methods: We retrospectively reviewed adult AVS presentations to the Gold Coast University Hospital's emergency department from January 2021 to July 2024. Data included HINTS performance rates, documentation completeness, clinician specialty/seniority and impact on neuroimaging decisions. Diagnostic metrics were compared with MRI, and we assessed whether combining 'central' HINTS with an ABCD² score ≥4 improved test characteristics.

Results: Of 322 patients, fully performed HINTS examinations were completed in 42% of emergency department, 40% of neurology, 18% of general medicine and 93% of physiotherapy encounters. Documentation completeness ranged from 30% (general medicine) to 89% (physiotherapy). Sensitivity for central causes was low (21.4% in emergency, 58.8% in physiotherapy), and inter-rater agreement was poor (κ = 0.10). HINTS rarely altered MRI ordering, except in physiotherapy. Combining a central HINTS with an ABCD² score ≥4 improved specificity but reduced sensitivity.

Conclusions: HINTS was under-utilised and inconsistently interpreted and demonstrated lower accuracy in this study compared with previous studies involving neurology specialists. Improved training and standardisation of documentation are needed to optimise AVS diagnosis and care.

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.

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.

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.

Multiparametric flow cytometry (MFC) enables rapid and sensitive quantification of measurable residual disease (MRD) in patients with acute myeloid leukaemia (AML), providing valuable prognostic information and guiding post-remission therapeutic strategies. Given the clinical utility of MFC AML MRD assessment and its inherent technical and analytical complexity, inter-laboratory standardisation is essential to ensure consistency of practice, diagnostic accuracy and reproducibility of results. However, limited options for external quality assessment exist. Representatives from all diagnostic laboratories in Australia and New Zealand currently performing AML MRD testing were invited to attend an in-person workshop to review site-specific practices and develop harmonisation processes. All six participating laboratories demonstrated a high level of concordance with respect to pre-analytical testing; however, greater variation was observed in post-analytical reporting, and a number of consensus recommendations were formulated for harmonisation. Ongoing meetings have also been established to promote continued sharing of expertise between AML MRD laboratories, align analytical strategies and enhance assay validation in accordance with regulatory requirements. These collaborative efforts provide guidance to existing MRD laboratories and those seeking to establish a new MRD service, facilitating sustainable provision of a high-quality regional MFC AML MRD testing network to meet current and anticipated increases in clinical demand.