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Context: Hyperglycemia in hospital inpatients without pre-existing diabetes is associated with increased mortality. However, the independent contribution of hyperglycemia to health care-associated infection (HAI), acute kidney injury (AKI), and stroke is unclear., Objective: To investigate the relationship between hyperglycemia and adverse clinical outcomes in hospital for patients with and without diabetes., Methods: Diabetes IN-hospital: Glucose and Outcomes (DINGO) was a 26-week (October 2019-March 2020) prospective cohort study. Clinical and glucose data were collected up to the 14th day of admission. Primary stratification was by hyperglycemia, defined as ≥2 random capillary blood glucose (BG) measurements ≥11.1 mmol/L (≥200 mg/dL). Propensity weighting for 9 clinical characteristics was performed to allow interrogation of causality. To maintain the positivity assumption, patients with HbA1c >12.0% were excluded and prehospital treatment not adjusted for. The setting was the Royal Melbourne Hospital, a quaternary referral hospital in Melbourne, Australia. Admissions with at least 2 capillary glucose values and length of stay >24 hours were eligible, with half randomly sampled. Outcome measures were HAI, AKI, stroke, and mortality., Results: Of 2558 included admissions, 1147 (45%) experienced hyperglycemia in hospital. Following propensity-weighting and adjustment, hyperglycemia in hospital was found to, independently of 9 covariables, contribute an increased risk of in-hospital HAI (130 [11.3%] vs 100 [7.1%], adjusted odds ratio [aOR] 1.03, 95% CI 1.01-1.05, P = .003), AKI (120 [10.5%] vs 59 [4.2%], aOR 1.07, 95% CI 1.05-1.09, P < .001), and stroke (10 [0.9%] vs 1 [0.1%], aOR 1.05, 95% CI 1.04-1.06, P < .001)., Conclusion: In hospital inpatients (HbA1c ≤12.0%), irrespective of diabetes status and prehospital glycemia, hyperglycemia increases the risk of in-hospital HAI, AKI, and stroke compared with those not experiencing hyperglycemia., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

ObjectiveThis study aimed to evaluate the feasibility of a workplace-delivered outpatient multidisciplinary service (ReCOV) for staff experiencing post COVID-19 condition ('Long COVID').MethodsA mixed-methods study of staff at a large, tertiary hospital with Long COVID who attended the service was conducted. Participants completed questionnaires to determine baseline symptoms and were offered allied health appointments for up to 12weeks each based on clinical indication. Acceptability, implementation, practicality and limited efficacy were evaluated via one-on-one semi-structured interviews and analysed using inductive thematic analysis. Limited efficacy was evaluated via pre- and post-questionnaires and demand via multidisciplinary utilisation.ResultsTwenty-three (median age 37 [interquartile range 30-45] years, 52% female) participants were included. Participants had appointments with a median of 4 [3-5] different professions; most commonly exercise physiology (n=19, 83%), occupational therapy (n=17, 74%) and neuropsychology (n=15, 65%). Median time spent on the ReCOV service was 15 [9-19] weeks. Thirteen semi-structured interviews were completed and analysed. Participants valued ReCOV for being a COVID-19 specific, convenient, flexible and multidisciplinary service at their workplace. Participants preferred the service to have been available for longer than 12weeks to achieve further benefits as many participants perceived little change in physical health.ConclusionsAttending a multidisciplinary service located at their workplace was feasible for staff to manage post COVID-19 symptoms. Further research is required to confirm the efficacy on patient outcomes.

Objectives: The Hypoglycemia During Hospitalization (HyDHo) score predicts hypoglycemia in a population of Canadian inpatients by assigning various weightings to 5 key clinical criteria known at the time of admission, in particular age, recent presentation to an emergency department, insulin use, use of oral hypoglycemic agents, and chronic kidney disease. Our aim in this study was to externally validate the HyDHo score by applying this risk calculator to an Australian population of inpatients with diabetes., Methods: This study was a retrospective data analysis of a subset of the Diabetes IN-hospital: Glucose & Outcomes (DINGO) cohort. The HyDHo score was applied based on clinical information known at the time of admission to stratify risk of inpatient hypoglycemia., Results: The HyDHo score was applied to 1,015 patients, generating a receiver-operating characteristic c-statistic of 0.607. A threshold of ≥9, as per the original study, generated a sensitivity of 83% and a specificity of 20%. A threshold of ≥10, to better suit this Australian population, generated a sensitivity of 90% and a specificity of 34%. The HyDHo score has been externally valid in a geographically different population; in fact, it outperformed the original study after accounting for local hypoglycemia rates., Conclusions: Our findings support the external validity of the HyDHo score in a geographically different population. Application of this simple and accessible tool can serve as an adjunct to predict an inpatient's risk of hypoglycemia and guide more appropriate glucose monitoring and diabetes management., (Copyright © 2024 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Background: A multidisciplinary approach is required for the management of long COVID. The aim of this study was to determine the feasibility (demand, implementation, practicality, acceptability, and limited efficacy) of an allied-health-led multidisciplinary symptom management service (ReCOV) for long COVID., Methods: A single-group observational cohort feasibility study was conducted to determine demand (referrals), acceptability (survey), implementation (waitlist times, health professions seen), practicality (adverse events), and limited efficacy (admission and discharge scores from the World Health Organization Disability Assessment Scale, Brief Illness Perception Questionnaire (BIPQ), Patient Health Questionnaire, and EuroQol 5D-5L). Data are presented as median [interquartile range] or count (percentage)., Results: During the study, 143 participants (aged 42.00 [32.00-51.00] years, 68% women) participated in ReCOV. Participants were waitlisted for 3.86 [2.14-9.86] weeks and engaged with 5.00 [3.00-6.00] different health professionals. No adverse events occurred. The thematic analysis revealed that ReCOV was helpful but did not fully meet the needs of all participants. Limited efficacy testing indicated that participants had improved understanding and control ( p < 0.001) of symptoms (BIPQ) and a small improvement in EQ VAS score (median difference 5.50 points [0.00-25.00], p = 0.004])., Conclusions: A multidisciplinary service was safe and mostly acceptable to participants for the management of long COVID. Further research should investigate the clinical and cost effectiveness of such a service, including optimal service duration and patient outcomes.

Objectives: Hypophosphatemia occurs frequently. Enteral, rather than IV, phosphate replacement may reduce fluid replacement, cost, and waste., Design: Prospective, randomized, parallel group, noninferiority clinical trial., Setting: Single center, 42-bed state trauma, medical and surgical ICUs, from April 20, 2022, to July 1, 2022., Patients: Patients with serum phosphate concentration between 0.3 and 0.75 mmol/L., Interventions: We randomized patients to either enteral or IV phosphate replacement using electronic medical record-embedded program., Measurement and Main Results: Our primary outcome was serum phosphate at 24 hours with a noninferiority margin of 0.2 mmol/L. Secondary outcomes included cost savings and environmental waste reduction and additional IV fluid administered. The modified intention-to-treat cohort comprised 131 patients. Baseline phosphate concentrations were similar between the two groups. At 24 hours, mean ( sd ) serum phosphate concentration were enteral 0.89 mmol/L (0.24 mmol/L) and IV 0.82 mmol/L (0.28 mmol/L). This difference was noninferior at the margin of 0.2 mmol/L (difference, 0.07 mmol/L; 95% CI, -0.02 to 0.17 mmol/L). When assigned IV replacement, patients received 408 mL (372 mL) of solvent IV fluid. Compared with IV replacement, the mean cost per patient was ten-fold less with enteral replacement ($3.7 [$4.0] vs. IV: $37.7 [$31.4]; difference = $34.0 [95% CI, $26.3-$41.7]) and weight of waste was less (7.7 g [8.3 g] vs. 217 g [169 g]; difference = 209 g [95% CI, 168-250 g]). C O2 emissions were 60-fold less for comparable phosphate replacement (enteral: 2 g producing 14.2 g and 20 mmol of potassium dihydrogen phosphate producing 843 g of C O2 equivalents)., Conclusions: Enteral phosphate replacement in ICU is noninferior to IV replacement at a margin of 0.2 mmol/L but leads to a substantial reduction in cost and waste., Competing Interests: Drs. Nguyen’s, Panganiban’s, and Ali Abdelhamid’s institutions received funding from the Clive and Vera Ramaciotti Foundations. Dr. Nguyen’s institution received funding from the Fox Family Foundation. Dr. Ali Abdelhamid’s institution received funding from the Intensive Care Foundation of Australia and New Zealand and the Victorian Medical Research Acceleration Fund. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background: The proliferation of electric scooters globally has been associated with an increase in related injuries and consequent economic burden. This study aims to assess the injury patterns and the economic impact associated with electric scooter use in Melbourne, Australia., Methods: A retrospective cohort study was conducted using hospital and registry data from January 2022 to January 2023. Data collected included demographic details, alcohol and helmet use, injury type and severity, operative treatment provided, and direct medical costs. The economic impact (in AUD) of the patient's emergency presentation and hospital admission was calculated., Results: During the study period, 256 electric scooter related injuries were recorded, comprising 247 riders and nine pedestrians. The majority of patients were males (69%) with a median age of 29.5 (15-78). Alcohol use was reported by 34% and helmet use by 33%. Injuries most commonly affected the upper limb (53%) and head (50%), with abrasions (75%) and fractures (48%) being the most common type of injury sustained. The total hospital cost was $1 911 062, and the median cost was $1321.66 per patient (IQR: $479.37-$5096.65)., Conclusion: Electric scooter usage, as observed through patient presentations to the Royal Melbourne Hospital, is associated with a considerable number of injuries, primarily among young males, and an ensuing substantial economic burden. The findings underscore the urgent need for improved safety measures to minimize electric scooter-related injuries and their clinical and economic repercussions., (© 2023 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

To establish the feasibility of embedding an RCT into EMR in the ICU, we evaluated the route of phosphate replacement. The EMR screened 207 patients who met the inclusion criteria from 20 April 2022 to 30 June 2022. 162 patients were randomised and 145 patients allocated to treatment. Our study showed that it was feasible to embed screening, randomisation, and treatment allocation for an RCT within an EMR in the ICU.

Objective: The cost of providing care in an intensive care unit (ICU) after brain death to facilitate organ donation is unknown. The objective of this study was to estimate expenditure for the care delivered in the ICU between the diagnosis of brain death and subsequent organ donation. Design: Cohort study of direct and indirect costs using bottom-up and top-down microcosting techniques. Setting: Single adult ICU in Australia. Participants: All patients who met criteria for brain death and proceeded to organ donation during a 13-month period between 1 January 2018 and 31 January 2019. Main outcome measures: A comprehensive cost estimate for care provided in the ICU from determination of brain death to transfer to theatre for organ donation. Results: Forty-five patients with brain death became organ donors during the study period. The mean duration of postdeath care in the ICU was 37.9 hours (standard deviation [SD], 16.5) at a mean total cost of $7520 (SD, $3136) per donor. ICU staff salaries were the greatest contributor to total costs, accounting for a median proportion of 0.72 of total expenditure (interquartile range, 0.68-0.75). Conclusions: Substantial costs are incurred in ICU for the provision of patient care in the interval between brain death and organ donation., Competing Interests: No relevant disclosures., (© 2021 College of Intensive Care Medicine of Australia and New Zealand.)

Objective: Traumatic brain injury (TBI) patients with prolonged intensive care unit (ICU) stay are at risk of secondary intracranial haemorrhage (ICH) and venous thromboembolism (VTE). We aimed to study VTE prophylaxis, secondary ICH, and VTE prevalence and outcomes in this population. Design: Retrospective observational study. Setting: Level 1 trauma centre ICU. Patients: One hundred TBI patients receiving prolonged ICU treatment (≥ 7 days). Interventions: We collected data from medical records, pathology and radiology systems, and hospital and ICU admission databases. We analysed patient characteristics, interventions, episodes and types of secondary ICH and VTE, and timing and dosage of VTE prophylaxis. Results: Data from the 100 patients in our study showed that early use of compression stockings and pneumatic calf compression was common (75% and 91% in the first 3 days, respectively). VTE chemoprophylaxis, however, was only used in 14% of patients by Day 3 and > 50% by Day 10. We observed VTE in 12 patients (10 as pulmonary embolism), essentially all after Day 6. Radiologically confirmed secondary ICH occurred in 43% of patients despite normal coagulation. However, 72% of ICH events (42/58) were radiologically mild, and the median time of onset of ICH was Day 1, when only 3% of patients were on chemical prophylaxis. Moreover, 82% of secondary ICH events (48/58) occurred in the first 3 days, with no severe ICH thereafter. Conclusions: In TBI patients receiving prolonged ICU treatment, early chemical VTE prophylaxis was uncommon. Early secondary ICH was common and mostly radiologically mild, whereas later secondary ICH was essentially absent. In contrast, early VTE was essentially absent, whereas later VTE was relatively common. Earlier chemical VTE prophylaxis and/or ultrasound screening in this population appears logical., Competing Interests: No relevant disclosures., (© 2021 College of Intensive Care Medicine of Australia and New Zealand.)

The cornerstone treatment of hyperphenylalaninemia (HPA) and phenylketonuria (PKU) is a lifelong low-protein diet with phenylalanine (Phe) free L-amino acid supplements. However, the PKU diet has significant shortcomings, and there is a clinically unmet need for new therapeutics to improve patient outcomes. CDX-6114 is a modified phenylalanine ammonia-lyase (PAL) enzyme obtained by a mutation in the Anabaena variabilis PAL sequence. CodeEvolver® protein engineering technology has been applied to improve the degradation resistance of the enzyme. In our first phase I trial, 19 patients were given a single oral dose of CDX-6114 at 7.5 g, 2.5 g, 0.7 g, or placebo in a cross-over design. After an overnight fast, patients received a standardised breakfast of 20 g of protein, thus exceeding the dietary recommendations for a single meal in patients with PKU. Plasma levels of Phe and cinnamic acid (CA) were measured over a 5-h period following CDX-6114 dosing. During the development of CDX-6114, a stability assessment using reverse-phase high-performance liquid chromatography (HPLC) assay revealed two peaks. The second peak was identified as CA. It was not previously known that as part of the mechanism of action, the CA remained associated with the protein following the conversion of Phe. Thus, recalculating the historical PAL enzyme amounts in CDX-6114 bulk substance was necessary. An updated extinction coefficient was achieved by applying a correction factor of 0.771 to previously reported doses. Postprandial plasma levels of Phe increased in all dose cohorts over time between 10% and 30% from baseline, although the actual peak of Phe levels was not achieved within the 5-h observation. When accounting for the interquartile ranges, these concentrations were similar to the placebo. As plasma levels of Phe were no longer a reliable marker for pharmacodynamics, the consistently detectable amount of CA seen in all patients who received CDX-6114 provided proof of the enzymatic activity of CDX-6114 in metabolising gastrointestinal Phe. Peak levels of CA were seen shortly after CDX-6114 intake, with a rapid decline, and remained low compared with the plasma Phe levels. This pattern indicates a short half-life, possibly due to the liquid formulation or the inability to withstand the lower pH in the human stomach compared with animal models in earlier studies. This was the first trial in patients with PKU to establish the safety and tolerability of CDX-6114. A single dose of CDX-6114 was safe and well tolerated, with no serious adverse events or presence of anti-drug antibodies detected. Efficacy will be explored in future trials using an optimised formulation., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Timothy Fazio: Nothing to declare. Tim Heise: declares institutional research grant from Nestlé Health Science. Anita Inwood: Nothing to declare. Catherine Manolikos: Nothing to declare. Yusof Rahman: Nothing to declare. Hans-Juergen Woerle: Employee of Nestlé Healthcare Science. Louise Healy: Nothing to declare. Christian J. Hendriksz: Employee of Nestlé Healthcare Science., (© 2023 Nestlé Health Science, Vevey, Switzerland.)

Background: There is increasing global incidence of acute kidney injury (AKI) and significant short- and long-term impacts on patients., Aims: To determine incidence and outcomes of community-acquired AKI (CA-AKI) and hospital-acquired AKI (HA-AKI) among inpatients in the Australian healthcare setting using modern health information systems., Methods: A retrospective cohort study of adult patients admitted to a quaternary hospital in Melbourne, Australia, between 1 January 2018 and 31 December 2019 utilising an electronic data warehouse. Participants included adult patients admitted for >24 h who had more than one serum creatinine level recorded during admission. Kidney transplant and maintenance dialysis patients were excluded. Main outcomes measured included AKI, as classified by the Kidney Disease Improving Global Outcomes (KDIGO) criteria, hospital length of stay and 30-day mortality., Results: A total of 6477 AKI episodes was identified across 43 791 admissions. Of all AKI episodes, 77% (n = 5011), 15% (n = 947) and 8% (n = 519) were KDIGO stage 1, 2 and 3 respectively. HA-AKI accounted for 55.9% episodes. Patients required intensive care unit admission in 22.7% (n = 1100) of CA-AKI and 19.3% (n = 935) of HA-AKI, compared with 7.5% (n = 2815) of patients with no AKI (P = 0.001). Patients with AKI were older with more co-morbidities, particularly chronic kidney disease (CKD). Length of stay was longer in CA-AKI (8.8 days) and HA-AKI (11.8 days) compared with admissions without AKI (4.9 days; P < 0.001). Thirty-day mortality was increased with CA-AKI (10.2%) and HA-AKI (12.8%) compared with no AKI (3.7%; P < 0.001)., Conclusion: The incidence of AKI detected by the electronic data warehouse was higher than previously reported. Patients who experienced AKI had greater morbidity and mortality. CKD was an important risk factor for AKI in hospitalised patients., (© 2022 Royal Australasian College of Physicians.)

Objective: This article aims to quantify prevalence of patient aggression or threatened/actual violence during critical illness., Design: This is a retrospective cohort study., Setting: This study was conducted in single adult trauma intensive care unit (ICU)., Participants: Patients aged 18 years or over, admitted between January 2015 and December 2020, who triggered a "Code Grey" response due to aggression or threatened/actual violence., Main Outcome Measure: The primary outcome was prevalence of Code Grey events. Secondary outcomes included unadjusted and adjusted (logistic mixed model) effects of patient demographics, diagnoses and severity of illness on Code Grey events., Results: There were 16175 ICU admissions relating to 14085 patients and 807 Code Grey events involving 379 (2.7%) patients. The observed count of events increased progressively from 2015 (n = 77) to 2020 (n = 204). For patients with a Code Grey, the median count of events was 3 (range 1-33). Independent predictors of at least one ICU Code Grey event included male sex (OR 2.5; 95% CI 1.8 to 3.4), young age (most elevated odds ratio in patients 20-30 years), admission from the emergency department (OR 2.8, 95% CI 2.1 to 3.6) and a trauma diagnosis (OR 1.4, 95% CI 1.1 to 1.9). Code Grey patients had longer admissions with a reduced risk of death., Conclusions: The prevalence of Code Grey events in ICU appears to be increasing. Patients may have repeated events. Younger male patients admitted to ICU via the emergency department with a trauma or medical diagnosis are at greatest risk of a Code Grey event., (© 2023 The Authors.)

Objective: Sodium-glucose co-transporter-2 inhibitors (SGLT2-I's) are novel oral hypoglycaemic agents, with proven decreased MACE and re-hospitalisation risk in type 2 diabetic patients with concomitant heart failure. This study aimed to assess the current practice in the use of SGLT2-I's in general medical units at a large metropolitan health service., Methods/results: A retrospective audit was conducted of patients admitted to general medicine over a 12 month period (between April 2018 and 2019). Inclusion criteria included decompensated heart failure of any aetiology and ejection fraction, and type 2 diabetes mellitus with an HbA1c ⩾ 7 within 6 months of the admission period. A total of 150 admissions fulfilled criteria. Baseline demographics and comorbidities identified an older, more comorbid population than reference trials. These included age (75% over 75 years), smoking history (46%), hypertension (83%), chronic kidney disease grade IV or V (26%), previous myocardial infarction (57%), stroke (18%), atrial fibrillation (55%) and known left ventricular ejection fraction < 50% (38%). Co-prescribed medications included ACE-I/ARB (53%), beta-blocker (67%), loop diuretic (87%), thiazide (7%), MRA (31%), insulin (57%), metformin (47%), sulphonylurea (31%), DPP-4 Inhibitor (21%), GLP-1 analogue (6%) and 15% of patients had an HbA1c > 10. There was a significant difference between patients in our study eligible for and prescribed metformin (66/111) compared to SGLT-2 inhibitors (4/25) ( P  = .013). A total of 26 patients had readmissions within 28 days, of which one had been discharged on an SGLT2-I., Conclusion: The results of this study identified significant under prescribing of SGLT2-I's in eligible type 2 diabetic patients with heart failure admitted under general medicine., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted the health-care system both in Australia and internationally, and has rapidly transformed the delivery of health care in hospitals and the community. Implementation of social isolation and distancing measures to stop the spread of the disease and to reduce potential harm to patients has necessitated the use of alternate models of health-care delivery. Changes that would normally take months or years have occurred within days to weeks., Methods: We conducted analysis of outpatient clinic data during the period of the pandemic and compared this to previous telehealth use. We also present the results of clinician and patient telehealth experience surveys., Results: We describe a 2255% increase in the use of telehealth at a tertiary hospital within a period of six weeks, and a significant simultaneous reduction in the outpatient clinic failure-to-attend rate. The vast majority of patients and clinicians agreed that the standard of care provided by telehealth was the same as that provided by on-site appointments., Discussion: Telehealth that previously had only limited utilisation has now become a main method for the delivery of outpatient care. Clinicians and patients agreed that consultations provided by telehealth were of the same standard as those provided on site. Health care in the post-pandemic period should embed the use of telehealth for outpatient care and consider the range of other clinical contexts where this can be utilised.

Background: Hospital acquired infections are common, costly, and potentially preventable adverse events. This study aimed to determine the effect of the COVID-19 pandemic-related escalation in infection prevention and control measures on the incidence of hospital acquired infection in surgical patients in a low COVID-19 environment in Australia., Method: This was a retrospective cohort study in a tertiary institution. All patients undergoing a surgical procedure from 1 April 2020 to 30 June 2020 (COVID-19 pandemic period) were compared to patients pre-pandemic (1 April 2019-30 June 2019). The primary outcome investigated was odds of overall hospital acquired infection. The secondary outcome was patterns of involved microorganisms. Univariable and multivariable logistic regression analysis was performed to assess odds of hospital acquired infection., Results: There were 5945 admission episodes included in this study, 224 (6.6%) episodes had hospital acquired infections in 2019 and 179 (7.1%) in 2020. Univariable logistic regression analysis demonstrated no evidence of change in odds of having a hospital acquired infection between cohorts (OR 1.08, 95% CI 0.88-1.33, P = 0.434). The multivariable regression analysis adjusting for potentially confounding co-variables also demonstrated no evidence of change in odds of hospital acquired infection (OR 0.93, 95% CI 0.74-1.16, P = 0.530)., Conclusion: Increased infection prevention and control measures did not affect the incidence of hospital acquired infection in surgical patients in our institution, suggesting that there may be a plateau effect with these measures in a system with a pre-existing high baseline of practice., (© 2022. The Author(s).)

Background: The COVID-19 pandemic has had a profound effect on the presentation and management of trauma at the Royal Melbourne Hospital, a level 1 adult major trauma service and a designated COVID-19 hospital. This study compares the changes in epidemiology and trauma patient access to emergency imaging and surgery during the pandemic response., Methods: The population of interest was all trauma patients captured in the hospital's trauma registry from 16 March 2016 to 10 September 2020. Regression modelling assessed changes in mechanism and severity of the injury, and mortality during two lockdowns compared with the proceeding 4 years. Cases were matched with hospital administrative databases to assess mean time from admission to emergency computed tomography (CT) scan, operating theatre, length of stay (LOS) and immediate surgery (OPSTAT)., Results: Throughout 2020, the hospital treated 525 COVID-19 patients. Compared with previous years, there was up to 34% reduction in major trauma and a 28% reduction in minor trauma admissions during the pandemic (p < 0.05). Intensive care unit admissions were almost half of predicted. Some of the largest reductions were seen in motor vehicle crashes (49%) and falls (28%) (p < 0.05). Time to CT, surgery and immediate surgery (OPSTAT) showed no change and having a suspected COVID-19 diagnosis did not prolong any of these times except for the LOS. Mortality was similar to previous years., Conclusion: The COVID-19 pandemic has had widespread societal changes, resulting in a substantial decrease in trauma presentations. Despite COVID's immense impact on the hospital's trauma service, the quality of care was not impaired., (© 2021 Royal Australasian College of Surgeons.)

Background: A rise and/or fall in high sensitivity cardiac troponin (hs-Tn) is critical in defining acute myocardial injury and therefore the diagnosis of acute myocardial infarction. A significant rise in hs-Tn is not well defined in current guidelines. Calculation of a z-score for two consecutive hs-Tn measurements is a method-independent measure of dynamic troponin elevation. However, the association of hs-Tn z-score with outcomes for unselected emergency department admissions is unknown. Moreover, the association of non-dynamic troponin elevations, as defined by a normal z-score, with clinical outcomes remains to be assessed., Methods: We retrospectively calculated z-scores for patients presenting to emergency department over 18 months who had serial troponin measurements with at least one result >99th percentile using the Abbott hs-TnI assay. We assessed the association of z-score with discharge diagnosis, cardiac interventions, inpatient mortality, length of stay and readmission rates., Results: There were 2062 presentations for 1830 patients where a z-score was calculated. Z-score was elevated in 1080 presentations. Dynamic troponin elevation (z-score ≥ 2) was associated with acute myocardial infarction (OR = 9.1, P  < 0.01), admission to an inpatient unit (95 vs. 88%, P  < 0.01), increased inpatient length of stay (97 vs. 65 days, P  < 0.01), inpatient coronary intervention (21 vs. 6%, P  < 0.01) and mortality (4.4 vs. 2.4%, P  < 0.05) compared with myocardial injury with a static troponin elevation., Conclusions: Z-score is an assay-independent tool to alert clinicians of significant, dynamic troponin elevation and acute myocardial injury. It is associated with poorer clinical outcomes.

Objectives: The threat of a pandemic, over and above the disease itself, may have significant and broad effects on a healthcare system. We aimed to describe the impact of the SARS-CoV-2 pandemic (during a relatively low transmission period) and associated societal restrictions on presentations, admissions and outpatient visits., Design: We compared hospital activity in 2020 with the preceding 5 years, 2015-2019, using a retrospective cohort study design., Setting: Quaternary hospital in Melbourne, Australia., Participants: Emergency department presentations, hospital admissions and outpatient visits from 1 January 2015 to 30 June 2020, n=896 934 episodes of care., Intervention: In Australia, the initial peak COVID-19 phase was March-April., Primary and Secondary Outcome Measures: Separate linear regression models were fitted to estimate the impact of the pandemic on the number, type and severity of emergency presentations, hospital admissions and outpatient visits., Results: During the peak COVID-19 phase (March and April 2020), there were marked reductions in emergency presentations (10 389 observed vs 14 678 expected; 29% reduction; p<0.05) and hospital admissions (5972 observed vs 8368 expected; 28% reduction; p<0.05). Stroke (114 observed vs 177 expected; 35% reduction; p<0.05) and trauma (1336 observed vs 1764 expected; 24% reduction; p<0.05) presentations decreased; acute myocardial infarctions were unchanged. There was an increase in the proportion of hospital admissions requiring intensive care (7.0% observed vs 6.0% expected; p<0.05) or resulting in death (2.2% observed vs 1.5% expected; p<0.05). Outpatient attendances remained similar (30 267 observed vs 31 980 expected; 5% reduction; not significant) but telephone/telehealth consultations increased from 2.5% to 45% (p<0.05) of total consultations., Conclusions: Although case numbers of COVID-19 were relatively low in Australia during the first 6 months of 2020, the impact on hospital activity was profound., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background & Aims: Chronic viral hepatitis is a leading cause of worldwide liver-related morbidity and mortality, despite the availability of effective treatments that reduce or prevent complications in most patients. Electronic-health (eHealth) technologies have potential to intervene along the whole cascade of care. We aimed to summarize available literature on eHealth interventions with respect to conventional screening, diagnostic and treatment outcomes in chronic hepatitis B (HBV) and hepatitis C (HCV)., Methods: We systematically reviewed MEDLINE, EMBASE, Cochrane Library and international conference abstracts, including studies published from 2009 - 2020. Overall 80 studies were included, covering electronic medical record (EMR) interventions (n=39), telemedicine (n=20), mHealth (n=5), devices (n=4), clinical decision support (n=3), web-based (n=5), social media (n=1) and electronic communication (n=3)., Results: Compared to standard care, EMR alerts increase screening rates in eligible populations including birth cohort screening in HCV, universal HCV screening in Emergency Departments, ethnic groups with high HBV prevalence, and HBV screening prior to immunosuppression. Direct messaging alerts to providers and automated testing may have a greater effect. No significant difference was found in sustained virological response outcomes between telemedicine and face-to-face management for community, rural and prison cohorts in HCV in the direct acting antiviral era of treatment, with higher patient satisfaction in telemedicine groups., Conclusions: EMR alerts significantly increase screening rates in eligible cohorts in both chronic HBV and HCV. Telemedicine is equally efficacious to face-to-face care in HCV treatment. Other eHealth technologies show promise; however rigorous studies are lacking., (Copyright © 2021 AGA Institute. All rights reserved.)

Background: Metabolic acidosis is a major complication of critical illness. However, its current epidemiology and its treatment with sodium bicarbonate given to correct metabolic acidosis in the ICU are poorly understood., Method: This was an international retrospective observational study in 18 ICUs in Australia, Japan, and Taiwan. Adult patients were consecutively screened, and those with early metabolic acidosis (pH < 7.3 and a Base Excess < -4 mEq/L, within 24-h of ICU admission) were included. Screening continued until 10 patients who received and 10 patients who did not receive sodium bicarbonate in the first 24 h (early bicarbonate therapy) were included at each site. The primary outcome was ICU mortality, and the association between sodium bicarbonate and the clinical outcomes were assessed using regression analysis with generalized linear mixed model., Results: We screened 9437 patients. Of these, 1292 had early metabolic acidosis (14.0%). Early sodium bicarbonate was given to 18.0% (233/1292) of these patients. Dosing, physiological, and clinical outcome data were assessed in 360 patients. The median dose of sodium bicarbonate in the first 24 h was 110 mmol, which was not correlated with bodyweight or the severity of metabolic acidosis. Patients who received early sodium bicarbonate had higher APACHE III scores, lower pH, lower base excess, lower PaCO 2 , and a higher lactate and received higher doses of vasopressors. After adjusting for confounders, the early administration of sodium bicarbonate was associated with an adjusted odds ratio (aOR) of 0.85 (95% CI, 0.44 to 1.62) for ICU mortality. In patients with vasopressor dependency, early sodium bicarbonate was associated with higher mean arterial pressure at 6 h and an aOR of 0.52 (95% CI, 0.22 to 1.19) for ICU mortality., Conclusions: Early metabolic acidosis is common in critically ill patients. Early sodium bicarbonate is administered by clinicians to more severely ill patients but without correction for weight or acidosis severity. Bicarbonate therapy in acidotic vasopressor-dependent patients may be beneficial and warrants further investigation.

Background: Phenylketonuria (PKU) is an autosomal recessive inherited disorder characterised by a deficiency in phenylalanine hydroxylase. Untreated, PKU is associated with a wide range of cognitive and psychiatric sequelae. Contemporary management guidelines recommend lifetime dietary control of phenylalanine (Phe) levels, however many individuals who discontinue dietary control subsequently suffer symptoms of anxiety, depression and disturbances to cognition. We undertook a prospective cohort study of patients with early-treated phenylketonuria who had ceased dietary control to test the hypothesis that resumption of dietary control of PKU is associated with improvements in measures of psychiatric morbidity and cognitive functioning., Methods: We re-initiated dietary control for early-treated patients with PKU and monitored cognitive and psychiatric outcomes over a twelve-month period. Assessments included objective cognitive function (measured by cognitive proficiency index (CPI)), anxiety and depression scales. General linear mixed model (GLMM) analyses were performed to assess change in psychometric variables from baseline over twelve months after resumption of dietary control., Results: A total of nine patients were recruited. Mean age was 33 years (SD = 8.75), five were female. Mean time off dietary control was 19.1 years (SD = 11.3), and mean baseline phenylalanine (Phe) levels were 1108 µmol/L (SD = 293). GLMM analysis demonstrated a positive relationship between CPI and time on diet (b = 0.56 [95% CI = 0.17, 0.95]). Age, time off diet, Phe levels and depression scores were not associated with cognitive function. There was a negative relationship between time on diet and anxiety (b = - 0.88 95% CI = [- 1.26, - 0.50]) and depression ratings (b = - 0.61, 95% CI = [- 0.95, - 0.26])., Conclusions: This study demonstrated improvements in cognitive function, anxiety, and depression ratings associated with resumption of dietary control of PKU. Raw Phe levels were not strongly associated with psychiatric or cognitive scores in this cohort. These findings support the importance of lifelong treatment for PKU in improving the cognitive and psychiatric sequelae of the disease.

Objective: To determine the frequency, indications and complications associated with the use of faecal diversion systems (rectal tubes) in critically ill patients., Design: A single centre observational study over 15 months., Setting: Intensive care unit (ICU)., Participants: Patients admitted during this period., Main Outcome Measures: Frequency of rectal tubes utilisation in ICU, as well as associated adverse events, with major events defined as lower gastrointestinal bleeding associated with defined blood transfusion of two or more units of red cells or endoscopy or surgical intervention., Results: Of 3418 admission episodes, there were 111 episodes of rectal tubes inserted in 99 patients. Rectal tubes remained indwelling for a median of 5 days (range, 1-23) for a total of 641 patient-days. The most frequent indication for insertion was excessive bowel motions. A major adverse event was observed in three patients (3%; 0.5 events per 100 device days). Two patients underwent laparotomy and one patient sigmoidoscopy. These patients received between two and 23 units of packed red blood cells. Patients who had a rectal tube inserted had a substantially greater duration of ICU admission (mean, 14 days [SD, 14] v 2.8 days [SD, 3.7]) and hospital mortality (15% v 7.7%; risk ratio, 2.0; 95% CI, 1.2-3.4) as well as an overall higher Australian and New Zealand Risk of Death (ANZROD) score (mean, 27 [SD, 22] v 12.6 [SD, 20])., Conclusion: Rectal tubes appear to be frequently inserted and can lead to major adverse events in critically ill patients.

Royal Melbourne Hospital (RMH) performs over 140 kidney transplant operations annually. Kidney transplant recipients require regular medical review, which results in loss of time and costs from travel, particularly for regional patients, and places high demand on the hospital outpatient service. The RMH renal transplant unit initiated a telehealth service in 2016 to provide cost effective, patient-centred clinical care for regional patients. To date, 263 clinical reviews have been conducted via telehealth, potentially saving 203,202 kilometres in travel distance; 2771 hours in car travel time; an estimated AUD $31,048 in petrol savings and 51 tonnes CO 2 equivalents of greenhouse gas emissions. Lessons learnt have included the importance of using technology that allows patients to access telehealth from their place of choice. The option of a joint consultation with local healthcare providers has facilitated the development of extended care networks for our patients. Incorporation of telehealth into our outpatient system has been achieved with the existing nephrology workforce, making it a sustainable long-term review option. Our renal transplant telehealth outpatient clinic has been a successful change in the way we provide care to regional patients. Formal comparison of clinical outcomes and the patient experience of telehealth versus in person reviews are underway.

Background: Point-of-care ultrasound (POCUS) is emerging as a reliable and valid clinical tool that impacts diagnosis and clinical decision-making as well as timely intervention for optimal patient management. This makes its utility in patients admitted to internal medicine wards attractive. However, there is still an evidence gap in all the medical setting of how its use affects clinical variables such as length of stay, morbidity, and mortality., Methods/design: A prospective randomized controlled trial assessing the effect of a surface POCUS of the heart, lungs, and femoral and popliteal veins performed by an internal medicine physician during the first 24 h of patient admission to the unit with a presumptive cardiopulmonary diagnosis. The University of Melbourne iHeartScan, iLungScan, and two-point venous compression protocols are followed to identify left and right ventricular function, significant valvular heart disease, pericardial and pleural effusion, consolidation, pulmonary edema, pneumothorax, and proximal deep venous thrombosis. Patient management is not commanded by the protocol and is at the discretion of the treating team. A total of 250 patients will be recruited at one tertiary hospital. Participants are randomized to receive POCUS or no POCUS. The primary outcome measured will be hospital length of stay. Secondary outcomes include the change in diagnosis and management, 30-day hospital readmission, and healthcare costs., Discussion: This study will evaluate the clinical impact of multi-organ POCUS in internal medicine patients admitted with cardiopulmonary diagnosis on the hospital length of stay. Recruitment of participants commenced in September 2018 and is estimated to be completed by March 2020., Trial Registration: Australian and New Zealand Clinical Trial Registry, ACTRN12618001442291. Registered on 28 August 2018.

Atrial myxomas are the most common primary neoplasms of the heart. Clinical presentation varies from asymptomatic incidental masses to serious life-threatening cardiovascular complications. We describe the case of a 37-year-old man who presented with both coronary and cerebral embolisation secondary to an atrial myxoma in the context of a recent normal transthoracic echocardiogram., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Prophylactic laxative regimens may prevent constipation but may increase diarrhea and subsequent rectal tube insertion. Our aim was to compare three prophylactic laxative regimens on the rate of rectal tube insertion (primary outcome) and major constipation- or diarrhea-associated complications., Material and Methods: We conducted a cluster-crossover trial. Three pods in a single ICU were each randomized to one of three regimens for four months with rolling cross-over. All mechanically-ventilated and enterally-fed adult patients received either regimen: A) one coloxyl with senna BD from day one; B) two coloxyl with senna +20 ml lactulose BD commencing on day 3; or C) two coloxyl with senna tablets +20 ml lactulose BD commencing on day 6., Results: We enrolled 570 patients (A = 170, B = 205, C = 195) with similar baseline features. Overall, 53 (9.3%) patients received a rectal tube, and insertion rate was not statistically different between the three regimens (A = 12.9%, B = 7.8%, C = 7.7%; p = 0.15). The proportions of patients with other major constipation- or diarrhea-associated complications were similar, as were major patient-centred outcomes., Conclusion: Earlier commencement of a prophylactic coloxyl-based laxative regimen (day 1 or 3) did not affect the rates of complications associated with constipation or diarrhea when compared to delayed introduction (day 6)., (Copyright © 2019. Published by Elsevier Inc.)

Liver abscess due to Klebsiella pneumoniae infection has been widely reported in Asia, but rarely reported in Australia until now. We describe four previously well Asian-born patients who presented across Australia with community-acquired K. pneumoniae liver abscesses. With prompt recognition, appropriate antibiotics and early drainage, outcome is significantly improved, although vigilance for metastatic complications is essential.