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BACKGROUND: Obtaining informed consent is an important responsibility of all doctors and is a major component of their day-to-day practice. However, little is known regarding practising doctors' understanding of consent in relation to medical law. AIMS: To gain insights into current doctors' understanding of the legal requisites that underpin the consent of patients to medical procedures in Australia. METHODS: A cross-sectional survey of Western Australian medical practitioners was conducted. A 15-question online questionnaire (SurveyMonkey, USA) was developed and distributed to Western Australia medical practitioners via social media, hospital-based Junior doctor society pages and through the email accounts of practitioners registered with MDA National - a large medical defence organisation. Doctors were questioned on their understanding of medicolegal responsibilities, informed consent practice and knowledge of a historically significant Australian medicolegal case (Rogers v Whitaker, 1992). RESULTS: A total of 172 responses was received during the survey period. The respondents came from various levels of seniority and from a variety of subspecialist areas. The survey demonstrated that among the respondents, the understanding of their medicolegal responsibilities around the issues of informed consent was deficient. Only 31% of respondents were aware that it is a court of law that defines the reasonable standard of care in relation to obtaining informed consent. Less than half of the respondents (48%) were aware of the High Court of Australia's definition by which the standard of reasonable care is defined. CONCLUSION: The results from our survey suggest that there is a requirement to enhance the education of medical practitioners to meet the medicolegal requirements and optimise consent.

Yang Jian Ong,1– 3 Nisha Sikotra,1,4 Janelle Prunster,1,2 Nicola Bailey,2 Jane Hadfield,2 Rosemary Smith,2 Rohen Skiba,2 Astrid Arellano,5 Eli Gabbay,1– 3,6 Timothy D Clay1,7,8 1Bendat Respiratory Research and Development Group, St John of God Healthcare, Subiaco, Western Australia, Australia; 2Department of Medical Teaching, St John of God Healthcare, Subiaco, Western Australia, Australia; 3The University of Notre Dame, Fremantle, Western Australia, Australia; 4Research Department, St John of God Healthcare, Subiaco, Western Australia, Australia; 5Department of Infectious Diseases, St John of God Healthcare, Subiaco, Western Australia, Australia; 6Department of Respiratory Medicine, St John of God Healthcare, Subiaco, Western Australia, Australia; 7Department of Medical Oncology, St John of God Healthcare, Subiaco, Western Australia, Australia; 8School of Medical and Health Sciences, Edith Cowan University Joondalup, Joondalup, Western Australia, AustraliaCorrespondence: Nisha Sikotra Tel +61 08 9382 9172Email Nisha.sikotra@sjog.org.auBackground: Febrile neutropenia (FN) is a medical emergency that requires prompt empirical antibiotic treatment. Logistical factors can hamper the timely delivery of antibiotics for patients with suspected FN.Aim: To determine our institution’s adherence to timeliness of antibiotic administration after the implementation of strategies following a previous audit.Methods: Two retrospective audits were performed. Patients were identified through hospital coding and data were extracted from medical records. Interventions following the first audit included targeted staff education; development of a “Febrile Neutropenia Box” and the establishment of an acute medical unit (AMU). Adherence to guidelines and the effect of interventions were compared.Results: Audit one: 72 admissions (January 2017–December 2017); audit two: 55 admissions (October 2018–October 2019). Median time to antibiotics and adherence to 60-minute administration target: audit one: 135 minutes (range 15– 5160; 11% adherence); audit two: 80 minutes (range 0– 2130; 45% adherence, P=< 0.001). In audit two, the admission ward was the major factor that reduced time to treatment – AMU: 43 minutes (range 0– 440; 70% adherence); oncology ward: 98 minutes (range 0– 2130; 40% adherence); other wards: 190 minutes (range 0– 750; 27% adherence) (p=0.028 for adherence).Conclusion: A gap in our routine care of FN was identified. We assessed the effects of several interventions. The most important intervention was the introduction of the AMU which allowed sufficient resources to address time critical tasks. Health institutions without an emergency department should consider similar pathways to ensure timely care for patients with FN. Auditing current practice and evaluating interventions are important.Keywords: febrile neutropenia, quality improvement, complications of cancer, clinical practice guidelines, FN

AIM: Febrile neutropenia is a medical emergency, which poses a significant morbidity and mortality risk to cancer patients receiving chemotherapy. National guidelines recommend that patients presenting with suspected febrile neutropenia receive appropriate intravenous antibiotics within 60 min of admission. We aimed to investigate the management of febrile neutropenia in a large private oncology centre. METHOD: A retrospective audit of all patients who presented to St John of God Hospital, Subiaco in the 2017 calendar year, with a known solid organ malignancy and a recorded diagnosis of febrile neutropenia. Patients were identified through the hospitals Patient Administration System and ICD-10 codes. Information was collected from the hospital medical records using a standardised data collection tool. RESULTS: There were 98 admissions relating to 88 patients with febrile neutropenia during the study period. The median age was 64 years (range: 23-85 years) with 57 (65%) females. Antibiotic selections consistent with the Australian guidelines were made in 88 admissions (89%). The mean time to antibiotic administration was 279 min, with a median of 135 min (range: 15-5160 min). Antibiotics were administered within the recommended time frame in only eight (11%) admissions. CONCLUSION: Clinicians prescribed antibiotics in accordance with national guidelines, however there were systemic inefficiencies which resulting in delayed antibiotic initiation. This has resulted in implementation of strategies to minimise delay. This article is protected by copyright. All rights reserved.

We present the case of a 46-year-old woman with a presumed diagnosis of multiple unprovoked pulmonary emboli. Her cardiorespiratory function continued to deteriorate despite optimal medical therapy. At surgical thrombectomy she was identified to have an intimal soft tissue lesion arising from the right pulmonary artery. This lesion was subsequently diagnosed as a pulmonary artery sarcoma, a rare neoplasm that carries a poor prognosis. It typically presents at an advanced stage with pulmonary vascular obstruction. Surgical debulking is the mainstay of therapy to restore ventilation perfusion mismatching and relieve right-sided heart strain. Median survival of these patients is 20 months with adjuvant chemoradiotherapy. At 9 months after surgery, she has undergone 6 cycles of chemotherapy and has stable disease with no metastases.

Wandering spleen is a rare pathology. A 2-year-old child with abdominal pain was diagnosed to have a torted, avascular wandering spleen. On conservative management, she remains well with no radiological evidence of the spleen. Splenic torsion usually warrants surgery. Nonoperative management in selected cases allows the natural process of autosplenectomy.

Objectives Deep sternal wound infection is a devastating complication of cardiac surgery. In the current era of increasing patient comorbidity, newer techniques must be evaluated in attempts to reduce the rates of deep sternal wound infection. Methods A randomized controlled trial comparing sternal closure with traditional sternal wires in figure-8 formation with the Pioneer cabling system® from Medigroup after adult cardiac surgery was performed. Results A total of 273 patients were enrolled with 137 and 135 patients randomized to sternal wires and cables group, respectively. Baseline characteristics between the two groups were well balanced. Deep sternal wound infection occurred in 0.7% of patients in the wires group and 3.7% of patients in the cables group (absolute risk difference = -3.0%, 95% confidence interval: -7.7 to 0.9%; P = 0.12). Patients in the cables group were extubated slightly earlier than those in the sternal wires group postoperatively (9.7 vs 12.8 h; P = 0.03). There was, however, no significant difference in hospital and follow-up pain scores or analgesia requirements. Conclusions The Pioneer sternal cabling system appears to facilitate early extubation after adult cardiac surgery, but it does not reduce the rate of deep sternal infectionAustralian New Zealand Clinical Trials Registry: ANZCTR-ACTRN12615000973516.

A 70-year-old woman with a background of portopulmonary hypertension, managed with sildenafil and oral diuretics, and cirrhosis, presented with acute on chronic haemorrhoidal bleeding, iron deficiency anaemia and worsening right heart failure. She presented in a normal conscious and cognitive state. Management involved intravenous diuresis with frusemide and blood transfusion. She quickly begun to develop fever, severe polyarticular arthropathy and progressive encephalopathy. Analgesia was started and antibiotics administered for potential septic sources. Extensive investigations, including full septic screen and neurological imaging, revealed no explainable aetiology for her precipitous decline. She continued to have febrile episodes, worsening polyarticular arthropathy and progressive encephalopathy eventually becoming unresponsive. Given the severe polyarticular arthropathy knee aspiration was performed. Urate crystals were identified and intravenous hydrocortisone and colchicine were started. Within 2 days she achieved full resolution of her systemic, musculoskeletal and neurological symptoms. We propose this as a rare case of gout-induced encephalopathy.