Sydney South West Area Health Service, abbreviated SSWAHS and known by the corporate name Sydney South West Health, was an area health service charged with the provision of public health services in central and south-western Sydney. It was formed in January 2005 from the amalgamation of the former Central Sydney Area Health Service and the South Western Sydney Area Health Service. It was a statutory body of the New South Wales Government, operating under the NSW Department of Health. The head office of SSWAHS was located in Liverpool. It was disbanded on 1 January 2011 as part of the National Health Reform and creation of Local Hospital Networks, and replaced by the Sydney Local Health District and South Western Sydney Local Health District.
Kikuchi–Fujimoto disease, also called histiocytic necrotizing lymphadenitis, is a rare, usually self-limiting inflammatory condition of unknown aetiology. It classically presents with acute-to-subacute, painful, localized, or limited regional lymphadenopathy, often associated with fever. We present three cases demonstrating the clinical heterogeneity of Kikuchi–Fujimoto disease. A 24-year-old male of Fijian-Indian background presented with three weeks of daily fevers, drenching night sweats, 5 kg weight loss, peripheral joint oligoarthritis, and oral mucosal erosions. Examination revealed mildly tender generalised lymphadenopathy without hepatosplenomegaly. FDG-PET demonstrated generalized, intensely FDG-avid lymphadenopathy, and widespread peripheral small and large joint synovitis. Core biopsy of a left axillary lymph node showed histiocytic necrotising lymphadenitis. A 23-year-old male of Fijian-Indian background presented with six weeks of daily fevers, drenching night sweats, 11 kg weight loss, peripheral joint polyarthritis, rhinitis, abdominal pain, and non-bloody diarrhoea. Examination revealed mildly tender generalised lymphadenopathy without hepatosplenomegaly. Fecal calprotectin was non-elevated, and he had significant hyperferritinaemia. Bone marrow evaluation demonstrated normocellular marrow with increased haemophagocytic activity. FDG-PET demonstrated generalised, intensely FDG-avid lymphadenopathy (Figure 1). Core biopsy of a right axillary lymph node showed histiocytic necrotizing lymphadenitis. Figure 1. Whole-body FDG-PET scan of case 2; representative coronal slices demonstrating intensely FDG-avid cervical, supraclavicular, axillary, intra-abdominal, inguinal, and femoral lymphadenopathy. A 22-year-old female of Chinese background presented with three weeks of daily fevers, painful cervical lymphadenopathy, generalized myalgias, and oral mucositis. Right axillary lymphadenopathy had been present for over three months. Fine-needle aspiration biopsy of a right axillary lymph node showed histiocytic necrotizing lymphadenitis. Symptoms improved with moderate-dose prednisolone tapered over four months; however, fluctuating axillary lymphadenopathy persisted for approximately four years. Repeat axillary lymph node biopsy at two years did not demonstrate evidence of malignancy. The clinical presentation of Kikuchi–Fujimoto disease may be dominated by constitutional, musculoskeletal, mucosal, or gastrointestinal features rather than lymphadenopathy. Appreciating the diverse clinical features may reduce diagnostic delay and misdiagnosis.
Introduction Many patients experience unrelieved neuropathic cancer-related pain. Most current analgesic therapies have psychoactive side effects, lack efficacy data for this indication and have potential medication-related harms. The local anaesthetic lidocaine (lignocaine) has the potential to help manage neuropathic cancer-related pain when administered as an extended, continuous subcutaneous infusion. Data support lidocaine as a promising, safe agent in this setting, warranting further evaluation in robust, randomised controlled trials. This protocol describes the design of a pilot study to evaluate this intervention and explains the pharmacokinetic, efficacy and adverse effects evidence informing the design. Methods and analysis A mixed-methods pilot study will determine the feasibility of an international first, definitive phase III trial to evaluate the efficacy and safety of an extended continuous subcutaneous infusion of lidocaine for neuropathic cancer-related pain. This study will comprise: a phase II double-blind randomised controlled parallel-group pilot of subcutaneous infusion of lidocaine hydrochloride 10% w/v (3000 mg/30 mL) or placebo (sodium chloride 0.9%) over 72 hours for neuropathic cancer-related pain, a pharmacokinetic substudy and a qualitative substudy of patients’ and carers’ experiences. The pilot study will provide important safety data and help inform the methodology of a definitive trial, including testing proposed recruitment strategy, randomisation, outcome measures and patients’ acceptability of the methodology, as well as providing a signal of whether this area should be further investigated. Ethics and dissemination Participant safety is paramount and standardised assessments for adverse effects are built into the trial protocol. Findings will be published in a peer-reviewed journal and presented at conferences. This study will be considered suitable to progress to a phase III study if there is a completion rate where the CI includes 80% and excludes 60%. The protocol and Patient Information and Consent Form have been approved by Sydney Local Health District (Concord) Human Research Ethics Committee 2019/ETH07984 and University of Technology Sydney ETH17-1820. Trial registration number ANZCTR ACTRN12617000747325.
An important approach to protecting infants against pertussis is to provide a booster vaccination to close contacts, however this strategy requires a good understanding of infection sources to be effective. The objective of this study was to identify the most important sources of transmission of pertussis infection to infants, regardless of hospitalisation status. Standardised interviews were conducted during routine follow-up calls with the parent or guardian of laboratory confirmed pertussis cases less than 12 months of age notified to 3 Sydney metropolitan public health units during a pertussis outbreak from January to May 2009. All contacts with a coughing illness or laboratory confirmed pertussis during the 3 weeks prior to onset of illness in the index case, were recorded. A source of infection could not be identified for 29 infants (31%) and a total of 86 known or suspected sources were identified for the other 66 infants. The most frequently identified sources were siblings (36%) and parents (24%), followed by other family members (21%), friends (13%), and settings outside the home such as medical centres (6%). Of 20 siblings aged 3 or 4 years, 16 (80%) were sources of infection, compared with 14 of the 44 (32%) other siblings less than 18 years of age. During this epidemic siblings were more important sources of infant infection than parents. Siblings aged 3 and 4 years of age were particularly important transmitters of pertussis infection to infants. Minimising pertussis infection in 3 and 4 year olds may be an important measure to prevent infant infection.
AIMS AND OBJECTIVESThe focus of this research was to standardise an emergency observation chart, the Adult Emergency Department Flow Chart, which incorporates elements designed to allow clinicians to more readily recognise the trends of patient deterioration.BACKGROUNDPatients present to the Emergency Department with some form of instability. Core skills and principles of Emergency Department care are to rapidly and continually assess the clinical condition of the patient, prioritise their care and treat accordingly. Often, however, deterioration of these patients is missed. The incidence of missed deterioration is set within a background of increasing presentations to Emergency Departments, greater complexity of the patient health status, longer length of stay within the Emergency Department and an ageing population.DESIGNThis quantitative research study comprised a retrospective medical record audit. Only those records containing notes relating to an Emergency Department admission were included.METHODSAn online data collection tool based on the Adult Emergency Department Flow Chart was developed. A total of 181 medical records were reviewed: 80 during the pre-implementation audit and 101 during the post-implementation audit.RESULTSThe Adult Emergency Department Flow Chart enabled clinicians to better identify deteriorating patients, with a higher number of abnormal vital signs being identified at the post-implementation audit. Identification of pain also dramatically increased at the post-implementation audit. Documentation of notification to Medical Officers also increased, as did documentation of the number of patients receiving medication to help treat the abnormal vital sign.CONCLUSIONThe introduction of the Adult Emergency Department Flow Chart facilitated the essential role of nurses in the identification, documentation and monitoring of the unstable or deteriorating patient in the Emergency Department. Further research is required with larger samples to determine the impact of the Adult Emergency Department Flow Chart on the timely management of abnormal vital signs.RELEVANCE TO CLINICAL PRACTICEThe Adult Emergency Flow Chart provides a valuable tool for the early identification and subsequent management of an unstable / deteriorating adult in the emergency department, particularly for clinicians with limited experience.
Aim Malnutrition is common in patients with chronic liver disease and is recognised as a prognostic factor with evidence suggesting that sufficient nutritional support can improve outcomes. However, malnutrition in this patient population continues to be underdiagnosed and managed in clinical practice. This paper outlines a study aimed to determine current practice among dietitians, compares this with best practice guidelines and identifies barriers to achieving best practice. Methods This study aims to involved an anonymous online survey questionnaire targeted at dietitians with at least 12 months of experience working with patients with liver cirrhosis. Results A total of 41 completed surveys were received and analysed. Results showed that the majority (85%) of respondents were using the European Society of Clinical Nutrition and Metabolism guidelines. Over 85% of surveyed dietitians reported that they were currently recommending high-energy and high-protein diets to their patients. Methods used to calculate dietary requirements varied, with some respondents using actual weight and others using dry weight. There was also variation in nutrition assessment tool used among surveyed respondents. Thirty-six per cent of respondents reported that nasogastric feeding always or often commenced when recommended. The most commonly reported barrier to achieving best practice was patient compliance. Conclusions From the study, it appears that most dietitians are consistently recommending high-energy and protein intake. However, there is significant variation in practice for weights used in calculating nutritional requirements, assessing nutritional status and nasogastric tube use for nutrition support.
