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Background: A resuscitation plan is a medically authorised order to use or withhold resuscitation interventions. Absence of appropriate resuscitation orders exposes patients to the risk of invasive medical interventions that may be of questionable benefit depending on individual circumstances. Aims: To describe among junior doctors: (i) self‐reported confidence discussing and completing resuscitation plans; (ii) knowledge of resuscitation policy including whether resuscitation plans are legally enforceable and key triggers for completion; and (iii) the factors associated with higher knowledge of triggers for completing resuscitation plans. Methods: A cross‐sectional survey was conducted at five hospitals. Junior doctors on clinical rotation were approached at scheduled training sessions, before or after ward rounds or at change of rotation orientation days and provided with a pen‐and‐paper survey. Results: A total of 118 junior doctors participated. Most felt confident discussing (79%; n = 92) and documenting (87%; n = 102) resuscitation plans with patients. However, only 45% (n = 52) of doctors correctly identified that resuscitation plans are legally enforceable medical orders. On average, doctors correctly identified 6.8 (standard deviation = 1.8) out of 10 triggers for completing a resuscitation plan. Doctors aged >30 years were four times more likely to have high knowledge of triggers for completing resuscitation plans (odds ratio 4.28 (95% confidence interval 1.54–11.89); P = 0.0053). Conclusion: Most junior doctors feel confident discussing and documenting resuscitation plans. There is a need to improve knowledge about legal obligations to follow completed resuscitation plans, and about when resuscitation plans should be completed to ensure they are completed with patients who are most at risk. [ABSTRACT FROM AUTHOR]

Abstract: Background: Rituximab, an anti‐CD20 B‐cell depleting monoclonal antibody, is increasingly prescribed off‐label for a range of autoimmune diseases. There has not previously been an audit of off‐label rituximab use in the Northern Territory, where the majority of patients are Aboriginal. Aims: To evaluate retrospectively off‐label rituximab use in autoimmune diseases in the Top End of the Northern Territory. Methods: We performed a retrospective audit of 8 years of off‐label rituximab use at the Royal Darwin Hospital, the sole tertiary referral centre for the Darwin, Katherine and East Arnhem regions. Electronic and paper records were reviewed for demographic information, diagnosis/indication for rituximab, doses, previous/concomitant immunosuppression, clinical outcomes and specific adverse events. Results: Rituximab was prescribed off‐label to 66 patients for 24 autoimmune diseases. The majority of patients (62.1%) were Aboriginal and 60.6% female. The most common indications were refractory/relapsing disease despite standard therapies (68.7%) or severe disease with rituximab incorporated into an induction immunosuppressive regimen (19.4%). Systemic lupus erythematosus was the underlying diagnosis in 28.8% of cases. A clinically significant response was demonstrated in 74.2% of cases overall. There were 18 clinically significant infections; however, 13 were in patients receiving concurrent immunosuppressive therapy. There was a total of nine deaths from any cause. Conclusion: Rituximab has been used off‐label for a range of autoimmune diseases in this population with a high proportion of Aboriginal patients successfully and safely in the majority of cases. [ABSTRACT FROM AUTHOR]

Background: Māori in New Zealand (NZ) are disproportionately affected by chronic kidney disease (CKD) and experience lower life expectancy on community dialysis compared with non‐Māori. We previously identified a higher renal replacement therapy (RRT) requirement for Māori in our intensive care unit (ICU), the tertiary referral centre for NZ's Te Manawa Taki region. Aim: To describe mortality outcomes by ethnicity in the population requiring RRT in our ICU. Methods: Retrospective audit of the Australia and NZ Intensive Care Society database for adult admissions to our general ICU from Te Manawa Taki between 2014 and 2018. Patients were stratified by non‐RRT requirement (non‐RRT), RRT‐requiring acute kidney injury (AKI‐RRT) and RRT‐requiring end‐stage renal disease (ESRD). Results: Relative to the population of Te Manawa Taki, Māori were over‐represented across all strata, especially ESRD (61.8%), followed by AKI‐RRT (35.0%) and non‐RRT (32.4%) (P < 0.001). There was no excess mortality by ethnicity in any stratum. Crude in‐ICU mortality was similar by ethnicity among AKI‐RRT (30.8% among Māori, vs 31.5%; P = 1.000) and ESRD (16.4% among Māori, vs 20.6%; P = 0.826). This trend remained at 1 year. Adjusted for clinically selected variables, neither AKI‐RRT nor ESRD mortality was predicted by Māori ethnicity, both in‐ICU and at 1 year. Irrespective of ethnicity, AKI‐RRT patients had highest in‐ICU mortality (31.2%; P < 0.001), while ESRD had highest 1‐year mortality (46.1%; P < 0.001). Conclusion: Increased RRT requirement among Māori in our ICU is due to higher representation among ESRD. We did not demonstrate excess mortality by ethnicity in any stratum. AKI‐RRT had higher in‐ICU mortality than ESRD, but this reversed at 1 year. [ABSTRACT FROM AUTHOR]

The availability of efficacious systemic therapies for metastatic clear cell renal cell carcinoma has heralded improved survival for Australians. The Pharmaceutical Benefits Schedule registry was interrogated to assess nation‐wide prescribing patterns. Sunitinib remained the most commonly prescribed agent. Prescribing rates were significantly lower in Northern Territory than in other states, raising questions of disparities in access to care. [ABSTRACT FROM AUTHOR]

Background: The influence of health insurance systems on the treatment of end‐stage kidney disease (ESKD) patients ispoorly understood. Aim: We investigated how supplemental private health insurance (PHI) coverage impacted ESKD treatment modalitiesand patient outcomes. The influence of health insurance systems on the treatment of end‐stage kidney disease (ESKD) patients is poorly understood. We investigated how supplemental private health insurance (PHI) coverage impacted ESKD treatment modalities and patient outcomes. Methods: All adult patients commencing ESKD treatment in New South Wales, Australia from 2000 to 2010 were identified using the Australia and New Zealand Dialysis and Transplant Registry. Data were linked to the state hospitalisation dataset to obtain insurance status, allowing the comparisons of mortality, ESKD treatment modality and health service utilisation between privately insured and public patients. Results: The cohort of 5737 patients included 38% (n = 2152) with PHI. At 1 year after ESKD treatment initiation, PHI patients had lower mortality (hazard ratio 0.84, 95% confidence interval (CI) 0.74–0.95, P = 0.01), were more likely to be receiving home haemodialysis (HD) (odds ratio (OR) 1.38, 95% CI 1.01–1.89, P = 0.04), to have been transplanted (OR 1.75, 95% CI 1.25–2.46, P = 0.001) and used fewer hospital days (incidence rate ratio 0.85, 95% CI 0.74–0.96, P = 0.01). After adjustment, PHI patients were more likely to initiate ESKD treatment with facility‐based HD (OR 1.22, 95% CI 1.01–1.46, P = 0.03) but were less likely to be started on peritoneal dialysis (OR 0.81, 95% CI 0.67–0.98, P = 0.03). Conclusion: Our findings suggest that supplemental PHI in Australia is associated with lower‐risk ESKD treatment attributes and improved health outcomes. A greater understanding of the treatment pathways that deliver these outcomes may inform treatment for the broader ESKD treatment population. [ABSTRACT FROM AUTHOR]

Background: Recent prospective studies suggest combination therapy with immunomodulators improves efficacy, but long‐term data is limited. Aim: To assess whether anti‐tumour necrosis factor alpha (anti‐TNF) monotherapy was associated with earlier loss of response (LOR) than combination therapy in a real‐world cohort with long‐term follow up. Methods: A retrospective audit was conducted of inflammatory bowel disease patients receiving anti‐TNF therapy in a tertiary centre and specialist private practices. All patients with accurate data for anti‐TNF commencement and adequate correspondence to determine end‐points were included. Outcomes measured included time to first LOR, causes and biochemical parameters. Results: Two hundred and twenty‐four patients were identified; 139 (62.1%) on combination therapy and 85 (37.9%) on monotherapy. Forty‐five percent of patients had LOR during follow up until a maximum of 8.5 years; 59.4% on combination therapy and 40.6% on monotherapy (P = 0.533). The median time to LOR was not different between groups; 1069 days for combination therapy and 1489 days for monotherapy (P = 0.533). There was no difference in time to LOR between patients treated with different combination regimens or different anti‐TNF agents. Conclusion: In this large cohort of patients in a real‐world setting, patients treated with anti‐TNF monotherapy had similar rates of LOR as patients on anti‐TNF combination therapy, at both short‐ and long‐term follow up. [ABSTRACT FROM AUTHOR]

Background Limited studies of patient survival and alcoholic relapse following transplantation for alcoholic liver disease have been described in Australian populations. Aim To describe these outcomes in an Australian population, to determine the association between harmful alcoholic relapse and patient survival, and to examine pre-transplant variables associated with harmful relapse. Methods Single centre, retrospective review of consecutive patients transplanted at the South Australian Liver Transplant Unit. Relapse was identified by an independent investigator using case note review and confidential patient questionnaire. Results A total of 87 patients (median age 52 years, 84% male, median Model for End-Stage Liver Disease ( MELD) score 18) was included in the study with a median follow-up time of 50 months. The 1-, 3- and 5-year survival of patients was 93.1, 87.4 and 82.0% respectively. Two deaths were directly attributable to graft failure due to alcohol. Fourteen (16%) patients fulfilled criteria for harmful relapse and 18 (21%) patients experienced any form of relapse to alcohol. Harmful relapse was associated with increased mortality (hazard ratio ( HR) 3.2, 95% confidence interval ( CI) 1.1-9.7, P = 0.041). Only two factors were independently associated with harmful relapse on multivariate analysis; prior alcohol rehabilitation ( HR 8.4, 95% CI 2.5-28.4, P = 0.001) and single versus married status ( HR 0.09, 95% CI 0.02-1.2, P = 0.019). Conclusion Good patient survival outcomes were seen for this South Australian population. Harmful alcohol relapse occurs in a minority of patients and rarely results in direct graft loss. Modifiable pre-transplant factors that predict harmful relapse were not identified. [ABSTRACT FROM AUTHOR]

Background Clinical features of infection can become more atypical as we age. Spinal infections can be insidious, and timely diagnosis and treatment are essential to prevent adverse outcomes. Aims To explore differences in presentation and outcomes between younger and older patients with bacterial spinal infections. Methods Clinical, microbiological and radiological information was collected for patients with spinal infections (spondylodiscitis, vertebral osteomyelitis, septic discitis, facet joint septic arthritis and spinal epidural abscess) at a single metropolitan hospital between January 2008 and January 2015. Patients were excluded if they were under 18 years of age or if clinical and imaging findings were inconsistent with the diagnosis. Presenting features, investigations and outcomes were compared for patients ≥65 (older) or <65 (younger) years old. Results Of 53 identified patients, 34 (64%) were classified as older, with more males in both older (65%) and younger (79%) groups. Older patients presented later (median symptom duration 13 vs 4 days, P = 0.016). Back pain was nearly ubiquitous. Older patients presented less commonly with fevers (38 vs 63%) and rigors (24 vs 42%) but more commonly with hypotension (18 vs 5%), delirium (24 vs 11%), higher median inflammatory marker levels and variable microbiological findings, although these differences were not statistically significant. They had longer median lengths of stay (24 vs 14 days) and a higher likelihood of death or failure of medical treatment ( HR 9.34, P = 0.031). Radicular pain was associated with poor outcome ( HR 3.29, P = 0.046). Conclusion Older patients with spinal infections present later, with higher inflammatory markers and fewer typical infective symptoms and signs; these may contribute to poorer outcomes. A low threshold for promptly investigating older patients with new or worsening back pain should be set. [ABSTRACT FROM AUTHOR]

The diagnostic rationale for patients with chest pain requires an electrocardiogram (ECG) often limited by low pretest values and widely variable post-test values. We assess the value of ECG ordered and interpreted by internal medicine junior medical officers in our emergency department (ED). Participants enrolled in this study included patients who presented to the ED for chest pain between June and October 2014. Seventeen leads ECG were performed systematically when an ECG was judged required by the medical officer in charge and interpreted by a blinded medical officer and ED attending. Ultrasensitive troponin T (usTrop T) and creatinine were also withdrawn. Junior medical officers ordered ECG more commonly for atypical chest pain (57 vs 43%, P = 0.049). Univariate and multivariate analysis did not demonstrate a statistically discordant diagnosis between the medical officer and the attending throughout the study period and between the different rotations. We demonstrated 97% sensitivity, 95% specificity, 92% positive predictive value, 98% negative predictive value and 96% accuracy. Our junior medical officers demonstrated an overall high proficiency in the clinical and bedside setting. This finding reinforces our ECG education in the undergraduate curriculum, highlights the importance of the intensive recapitulation sessions undergone at the beginning of the training programme and our daily internal medicine staff discussions rarely performed in other EDs as reported with our experience. [ABSTRACT FROM AUTHOR]

For frail older people, admission to hospital is an opportunity to review the indications for specific medications. This research investigates prescribing for 206 older people discharged into residential aged care facilities from 11 acute care hospitals in Australia. Patients had multiple comorbidities (mean 6), high levels of dependency, and were prescribed a mean of 7.2 regular medications at admission to hospital and 8.1 medications on discharge, with hyper-polypharmacy (≥10 drugs) increasing from 24.3% to 32.5%. Many drugs were preventive medications whose time until benefit was likely to exceed the expected lifespan. In summary, frail patients continue to be exposed to extensive polypharmacy and medications with uncertain risk-benefit ratio. [ABSTRACT FROM AUTHOR]