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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]

Background Weight gain and hypoglycaemia are common adverse effects associated with anti-diabetic treatments. Aim Our aim was to evaluate the long-term effects of adjunctive exenatide therapy on weight loss and glycaemic control in patients with type 2 diabetes. Methods A review of medical records in a specialist diabetes clinic over 5 years identified 446 patients who were prescribed exenatide therapy. We examined change in glycosylated haemoglobin ( HbA1c), weight, albumin-creatinine ratio and hypoglycaemic medication during 24 months follow up. Results Subjects were aged 59 ± 10 years (49% women) and received exenatide in combination with oral agents and insulin (47%). During an average of 17 ± 14 months follow up, 51% (more women than men; odds ratio 1.69, 95% confidence interval 1.14-2.49) remained on treatment. Lack of efficacy (33%) and/or gastrointestinal (27%) side-effects were the main reasons for treatment cessation. At 24 months, there was a reduction in HbA1c of 0.7 ± 1.2% and weight loss of 4.3 ± 5.2 kg. Change in HbA1c was similar regardless of concurrent insulin therapy, yet insulin was associated with greater weight reduction (4.8 ± 5.3 vs 3.8 ± 5.1 kg, P = 0.016). Independent predictors of HbA1c response were higher baseline HbA1c, longer duration of diabetes and use of insulin or sulfonylureas at study end. Predictors of weight response were baseline use of insulin or thiazolidinediones, increased age, female sex and sulfonylurea or thiazolidinediones at study end. Longer exenatide treatment duration was favourable for reducing HbA1c and weight. Conclusions Exenatide is effective in reducing HbA1c and weight, regardless of concurrent insulin, and in a specialist diabetes outpatient clinic, is recommended for use in clinical practice. [ABSTRACT FROM AUTHOR]

Background The balance of benefit versus burden of ongoing treatments for comorbid disease in palliative populations as death approaches needs careful consideration given their particular susceptibility to adverse drug effects. Aim To provide descriptive data regarding the medications being prescribed to patients who have a life-limiting illness at the time of referral to a palliative care service in regional Australia, with particular focus on lipid-lowering medications. Methods A prospective case note review of 203 patients reporting the number of medications prescribed and, for lipid-lowering medications, the indication and level of prevention sought (primary, secondary, tertiary). Rates were compared by performance status, disease phase and comorbidity burden. Results Mean number of regular medications prescribed was 7.2, with higher rates observed in those patients with a non-malignant primary diagnosis (rate ratio 1.28, confidence interval ( CI) 1.11-1.50) or poorer performance status (rate ratio 1.37, CI 1.11-1.69) and lower rates for those in the terminal phase of disease (rate ratio 0.48, CI 0.30-0.76). Over one fifth of patients were prescribed a lipid-lowering medication, and two fifths of these prescriptions were for primary prevention of cardiovascular disease. Patients in the highest quartile of Charlson Comorbidity Index score were 4.6 ( CI 2.06-10.09) times more likely to be prescribed a lipid-lowering medication than those in the lowest quartile. Conclusions Polypharmacy is prevalent for this group of patients, placing them at high risk of drug-drug and drug-host interactions. Prescribing may be driven by risk factors and disease guidelines rather than a rational, patient-centred approach. [ABSTRACT FROM AUTHOR]

Background/Aims Results from interim-positron emission tomography ( PET) studies in diffuse large B-cell lymphoma ( DLBCL) patients are varied. We evaluated the prognostic value of interim- PET in our centre. To improve concordance, interim- PET was combined with the International Prognostic Index ( IPI). Methods We retrospectively reviewed 100 new consecutive DLBCL patients treated with immunochemotherapy from 2005 to 2010. Twenty-four patients did not receive interim- PET and were excluded. Interim- PET images were re-examined using a qualitative assessment technique. Progression-free survival ( PFS) and overall survival ( OS) were analysed by the Cox proportional hazards model and prognostic accuracy was assessed using Harrell's C statistics ( C). Results Eleven patients were positive, and 65 were negative at interim- PET. The 2-year OS and PFS were 70.8% and 60.0%, respectively, in the PET-negative group, 36.4% and 36.4% for the PET-positive group (log-rank P-value 0.0008 for PFS, 0.0001 for OS). The IPI and interim- PET were minimally correlated. On Cox regression analysis, both were significant indicators of PFS ( P < 0.001 and P = 0.002 respectively). The prognostic accuracy for PFS of a negative PET result was limited ( C = 0.63), as it was for IPI ( C = 0.75), but with the two indicators combined, the predictive accuracy was improved ( C = 0.81). A nomogram, predictive for relapse-free survival at 2 years, was constructed. Conclusion In DLBCL patients treated with immunochemotherapy, the IPI and interim- PET provide independent prognostic information. In combination, a more powerful predictive model may be created as a nomogram. This can be refined in prospective trials and may help clinical decision making. [ABSTRACT FROM AUTHOR]

Background Acute rheumatic fever ( ARF) and rheumatic heart disease ( RHD) contribute to Aboriginal Australian and Torres Strait Islander health disadvantage. At the time of this study, specialist ARF/ RHD care in the Kimberley region of Western Australia was delivered by a broad range of providers. In contrast, in Far North Queensland ( FNQ), a single-provider model was used as part of a coordinated RHD control programme. Aims To review ARF/ RHD management in the Kimberley and FNQ to ascertain whether differing models of service delivery are associated with different disease burden and patient care. Methods An audit of ARF/ RHD management. Classification and clinical management data were abstracted from health records, specialist letters, echocardiograms and regional registers using a standardised data collection tool. Results Four hundred and seven patients were identified, with 99% being Aboriginal and/or Torres Strait Islanders. ARF without RHD was seen in 0.4% of Aboriginal and/or Torres Strait Islander residents and RHD in 1.1%. The prevalence of RHD was similar in both regions but with more severe disease in the Kimberley. More FNQ RHD patients had specialist review within recommended time frames (67% vs 45%, χ2, P < 0.001). Of patients recommended benzathine penicillin secondary prophylaxis, 17.7% received ≥80% of scheduled doses in the preceding 12 months. Prescription and delivery of secondary prophylaxis was greater in FNQ. Conclusions FNQ's single-provider model of specialist care and centralised RHD control programme were associated with improved patient care and may partly account for the fewer cases of severe disease and reduced surgical procedures and other interventions observed in this region. [ABSTRACT FROM AUTHOR]

Background The silent epidemic of mesothelioma in Australia is steadily increasing, and 30% of cases occur in New South Wales ( NSW). Aim To describe the patterns of care and outcomes of patients with malignant pleural mesothelioma ( MPM) in NSW. Methods MPM patients in NSW applying for compensation at the NSW Dust Diseases Board from 2007 to 2009 were included. Survival from time of diagnosis was determined by the Kaplan- Meier method. The Chi-squared test was used to determine if there was an association between utilisation of treatment and geographical location. Results A total of 138 patients was included: median age was 72.5; 91.3% male; 60.1% epithelial subtype; and 65.2% lived in major cities. All patients had at least one chest X-ray and computed tomography scan, and 21% had a positron emission tomography scan; 93.5% and 4.3% had histological or cytological confirmation respectively. Thoracoscopy (59.4%) was the most commonly used diagnostic procedure. Treatment utilisation: 53.6% chemotherapy; 35.5% radiotherapy; 9.4% extrapleural pneumonectomy ( EPP); and 72.5% had palliative care involvement. There were no major differences in treatment utilisation between patients living in major cities and those in regional NSW (chemotherapy P = 0.42; radiotherapy P = 0.13 and palliative care P = 0.60), except for a higher rate of EPP in regional patients (16.7% vs 5.6%; P = 0.03). Median survival was 9.7 versus 12.3 months for city and regional patients respectively ( P = 0.22). Conclusion Survival and treatment utilisation was not significantly different between MPM patients living in major cities and regional NSW, except for a higher rate of EPP in patients in regional NSW. [ABSTRACT FROM AUTHOR]