Point-of-care ultrasound (POCUS) is increasingly used in general medicine to support focussed bedside diagnosis and management. However, many implementation models depend on individual clinicians scanning their own patients. This limits equity of access, slows accumulation of provider experience and makes rapid departmental scale-up challenging. To describe the development and early implementation of a hybrid general medicine consultative POCUS service designed to improve access and scalability at a quaternary teaching hospital in Australia. In February 2025, the Alfred Health General Medicine Department implemented a consultative POCUS model delivered by credentialled specialists and a POCUS fellow. The model combined clinician-performed scans for patients under credentialled providers with an intradepartmental referral service for other general medicine patients. Scans were performed predominantly during business hours and documented using a structured template. Critical findings were verbally communicated. Key implementation elements included formal departmental credentialling, device access, a departmental logbook and active case-finding during the initial implementation phase. Major challenges included limited credentialled provider availability, variable clinician familiarity with POCUS, image storage limitations and dependence on a dedicated fellow. Over 12 months, 683 scans were performed, representing approximately one out of five admissions to the Alfred General Medicine wards. Most studies involved cardiac, pulmonary or combined cardiopulmonary assessment. Our experience suggests a hybrid consultative model may be a feasible approach to improving access to POCUS and accelerating departmental adoption during early implementation.
BACKGROUND:Timely discharge summaries are critical for optimal care transitions; however, evidence linking timeliness with patient outcomes remains inconsistent. AIM:This study examined the association between summary completion time and 30-day readmission and mortality among general medical patients. METHODS:This retrospective cohort study at a South Australian tertiary teaching hospital included adult general medical admissions between July 2022 and June 2023. Discharge summaries were categorised as completed within 24 h, 24-48 h or beyond 48 h. The primary outcome was a composite of 30-day readmission or death; secondary outcomes were 30-day readmission and mortality assessed separately. Multivariable logistic regression adjusted for age, sex, comorbidities, frailty and measures of healthcare utilisation with results reported as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). RESULTS:Among 4703 admissions, 21.9% had discharge summaries completed more than 48 h after discharge, while 78.1% were completed within 48 h, and 26.8% experienced the composite outcome - these patients were older, with higher comorbidity and frailty (P < 0.05). Discharge summary completion beyond 48 h was independently associated with higher odds of the composite outcome (aOR 1.42, 95% CI 1.13-1.77, P < 0.001) and mortality (aOR 1.95, 95% CI 1.29-2.96, P = 0.002), but not 30-day readmission (aOR 1.14, 95% CI 0.90-1.43, P = 0.622). Among patients who died within 30 days, 51.3% of deaths occurred within a median of 7 days from discharge (interquartile range 3-16). CONCLUSIONS:Discharge summaries completed after 48 h were associated with adverse 30-day outcomes, particularly mortality. The clustering of death within the first week after discharge highlights the vulnerability of the post-discharge period and underscores the importance of timely communication between hospital and primary care providers.
BACKGROUND:Patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) are at heightened risk of acute kidney injury (AKI). Prior studies have suggested that serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) may be linked to AKI development, proposing it as a potential predictive biomarker. AIM:This study aimed to evaluate whether changes in NT-proBNP levels are associated with the risk of AKI in STEMI patients. METHODS:This retrospective analysis included 107 STEMI patients who underwent PCI. Patients were stratified into three groups based on the percentage change in NT-proBNP levels: a reduction > 30%, a reduction ≤ 30%, or an increase. The primary endpoints were post-PCI AKI incidence and 180-day mortality. Logistic regression was used to assess the association between NT-proBNP dynamics and AKI risk. RESULTS:A reduction in NT-proBNP of >30% was independently associated with a reduced risk of postoperative AKI (OR = 0.41, 95% CI 0.17-0.98, p = 0.045). This group also exhibited the favorable survival profile, with the lowest 180-day mortality rate (11/62, 17.7%) compared to the ≤ 30% reduction group (9/27, 33.3%) and the increase group (13/18, 72.2%; p < 0.001 for trend). CONCLUSION:Dynamics of NT-proBNP levels are closely associated with the incidence of AKI following PCI in STEMI patients. Specifically, an NT-proBNP reduction of >30% may serve as a robust biomarker for predicting lower post-PCI AKI risk and improved short-term survival.
People with cystic fibrosis (pwCF) experience a spectrum of glucose disorders. Spontaneous hypoglycaemia is a unique entity affecting pwCF and can be an incidental finding on biochemistry. Our prospective, single-arm pilot study of eight pwCF without confirmed diabetes and incidental biochemical hypoglycaemia found 62.5% demonstrated fasting or reactive hypoglycaemia on continuous glucose monitoring (CGM). The remaining individuals without hypoglycaemia on CGM demonstrated dysglycaemia consistent with pre-diabetes. Symptomatic spontaneous hypoglycaemia captured on CGM was successfully managed with dietary modifications and dipeptidyl peptidase-4 inhibitor in all participants. Whether spontaneous hypoglycaemia precedes progression to pre-diabetes and overt diabetes in pwCF requires further evaluation.
BACKGROUND:The prognostic value of serum total calcium levels in critically ill patients with gastrointestinal bleeding remains unclear. This study aimed to investigate the association between baseline serum total calcium levels and mortality in critically ill patients with gastrointestinal bleeding using the electronic Intensive Care Unit (eICU) database. METHODS:This retrospective cohort study was based on data collected from the eICU Collaborative Research Database in 2014 and 2015. Critically ill patients with gastrointestinal bleeding were included in this study. The exposure variable was the baseline serum calcium level. The primary outcome was hospital mortality, and the secondary outcome was intensive care unit (ICU) mortality. The non-linear relationship between serum calcium levels and mortality was determined using a generalised additive model and smooth curve fitting, and we calculated the inflection point. RESULTS:A total of 10 731 eligible patients were included. The hospital mortality and ICU mortality rates were 10.49% and 6.53% respectively. After adjusting for potential confounding factors, a U-shaped relationship was detected between serum calcium levels and mortality. The first inflection point was 8.5 mg/dL, and the second inflection point was 10.3 mg/dL. On the left side of the first inflection point (serum calcium <8.5 mg/dL), serum calcium levels were negatively associated with both hospital mortality (OR = 0.85, 95% CI 0.76-0.95) and ICU mortality (OR = 0.82, 95% CI 0.72-0.93). Conversely, on the right side of the second inflection point (serum calcium >10.3 mg/dL), serum calcium levels were positively associated with both hospital mortality (OR = 1.57, 95% CI 1.05-2.34) and ICU mortality (OR = 1.56, 95% CI 1.02-2.38). CONCLUSIONS:A U-shaped relationship between serum total calcium levels and mortality was observed in critically ill patients with gastrointestinal bleeding. Serum total calcium levels were associated with mortality in such patients, and this association has potential reference significance for risk assessment.
Australian general medicine perioperative services provide care to surgical patients with complex comorbidities, for a wide range of medical conditions. Heterogeneous models of care exist; however, their cost-consequence has not been evaluated. Cost analysis was conducted using nationally standardised cost weights for length of stay, medical emergency team call costs and labour costs. Proactive models of general medicine perioperative care likely save approximately $7500 per patient compared with reactive models.
Metformin has gained attention as a potential adjunct therapy in pregnant women with type 1 diabetes mellitus (T1DM), although evidence is limited. We present the first reported experience of metformin use in pregnant women living with T1DM who used continuous glucose monitoring to monitor glycaemic outcomes. In our multicentre case series, metformin use was associated with an increased time in range and reduced glycaemic variability, supporting potential use in pregnant women with T1DM.
Complement inhibitor therapy carries a risk of serious infections, including meningococcal disease. Here we provide evidence-based recommendations and expert consensus for immunisation and prophylactic treatment of patients receiving, or planning to receive, complement inhibitors for neurological conditions in the Australian setting. The primary aim of these consensus recommendations is to minimise the risk of vaccine-preventable infections and to outline alternative infection-prevention strategies where vaccination is problematic. We address disease-specific risks and propose timing considerations, including a pragmatic approach to clinical implementation.
BACKGROUND:Dose escalation of biologic therapies is commonly used to manage secondary loss of response in inflammatory bowel disease, although long-term real-world outcomes remain limited. AIMS:To evaluate long-term clinical outcomes and treatment persistence following biologic dose escalation for secondary loss of response in inflammatory bowel disease. METHODS:We conducted a retrospective cohort study of patients with inflammatory bowel disease who underwent dose escalation of infliximab, adalimumab or vedolizumab at a tertiary referral centre between 2018 and 2024. Outcomes included clinical disease activity scores, biochemical markers and treatment persistence, assessed at 3-12 months and annually up to 36 months following escalation. RESULTS:A total of 155 patients were included (median age 31 years; 46% female), of whom 76% had Crohn's disease. A total of 89 patients received infliximab, 48 adalimumab and 18 vedolizumab. Dose escalation was undertaken for secondary loss of response in 68% and low drug concentrations in 42%. Infliximab escalation was associated with improvement in disease activity scores at 3 months, sustained to 36 months, with reductions in C-reactive protein across follow-up. Adalimumab escalation improved Harvey-Bradshaw Index at 3, 12 and 24 months, with reduction in faecal calprotectin at 3 months. Vedolizumab escalation improved Simple Clinical Colitis Activity Index at 3 months only. Treatment persistence at 36 months was 58% for infliximab, 65% for adalimumab and 73% for vedolizumab. Nine patients experienced minor adverse events. CONCLUSIONS:Biologic dose escalation was associated with improvement in disease activity and modest treatment persistence following secondary loss of response in inflammatory bowel disease.
BACKGROUND:Peroral endoscopic myotomy (POEM) is an established treatment for achalasia, achieving >90% short-term clinical success. However, long-term durability remains less clear. This study evaluates POEM outcomes beyond 5 years in a multi-centre cohort. AIMS:This study evaluates POEM outcomes beyond 5 years in a multi-centre cohort. METHODS:Patients with achalasia who underwent POEM across four Australian tertiary centres (January 2014-January 2020) were prospectively enrolled. Eckardt scores were recorded pre-treatment and at multiple intervals up to ≥5 years after POEM. Primary outcome was clinical success at ≥5 years, defined as Eckardt score ≤3 without need for re-intervention. Secondary outcomes included risk factors for failure and management strategies. RESULTS:Of 221 eligible patients, 153 (69.2%) had ≥5-year follow-up data available, with median follow-up of 6.5 years (interquartile range (IQR) 5.6-7.6). Achalasia subtypes included type I (23.5%), type II (62.1%) and type III (14.4%). Among the patients, 52.3% were treatment-naïve; prior therapies included laparoscopic Heller myotomy (14.3%), botulinum toxin (17.0%) and pneumatic balloon dilation (30.7%). Clinical success at ≥5 years was observed in 118 (77.1%) patients. Median Eckardt scores improved from 8.0 (IQR 6.0-10.0) before POEM to 0.0 (IQR 0.0-1.0) at 3-6 months, 1.0 (IQR 0.0-2.0) at 2 years and 2.0 (IQR 0.0-3.0) at 5 years. Sustained success was associated with lower baseline Eckardt scores (P = 0.033). Prior lower oesophageal sphincter (LOS)-directed therapy predicted failure (odds ratio 3.80, P < 0.001). Age, achalasia subtype, myotomy characteristics and post-POEM endoscopy findings were not predictive. CONCLUSION:POEM provides durable symptom relief beyond 5 years for achalasia. Higher pre-POEM symptom burden and prior LOS-directed interventions are associated with reduced long-term success.
BACKGROUND:With major lower limb orthopaedic surgery performed in increasingly older and comorbid patients, accurate risk prediction is essential to guide perioperative management and shared decision-making. AIMS:To compare the Clinical Frailty Scale (CFS), Charlson Comorbidity Index (CCI) and the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS NSQIP Calculator) in predicting complications following major lower limb orthopaedic surgery. METHODS:We conducted an audit assessing the clinical utility of the CFS, CCI and ACS NSQIP Calculator at an Australian tertiary hospital (2023-2024). Scores were calculated retrospectively using admission documentation, and complications were identified prospectively. RESULTS:We recruited 302 patients with a mean age of 75.1 ± 12.7 years. Patients underwent surgery for hip fracture (n = 100), elective total knee (n = 103) and hip (n = 69) arthroplasty and other indications (n = 30). During index hospitalisation, 27.5% (n = 83) experienced a serious complication (Clavien-Dindo Grade ≥ II). All tools demonstrated moderate discrimination for serious in-hospital complications; the CFS, CCI and ACS NSQIP Calculator had area under the receiver operating characteristic curves of 0.77 (95% confidence interval (CI) 0.71-0.83), 0.71 (95% CI 0.64-0.77) and 0.76 (95% CI 0.70-0.82) respectively. The CFS was the fastest tool to administer, and the ACS NSQIP Calculator was the most time-consuming (median time 9.5 s (interquartile range (IQR) 7-13) vs 98.5 s (IQR 73-165), P < 0.001). CONCLUSION:The CFS and ACS NSQIP Calculator demonstrated similar predictive performance in this cohort. Given its faster administration, the CFS may represent a practical tool for routine perioperative risk stratification, though prospective validation is required to confirm performance in real-time clinical workflows.
BACKGROUND:Hospital in the Home (HITH) has been formally recognised in Australia for more than 30 years and continues to expand nationally. Despite this growth, there is limited contemporary information regarding the structure, workforce, governance and models of care provided by Australian HITH services. AIMS:To provide a national description of public HITH services across Australia. METHODS:A national cross-sectional survey of Australian public HITH services was conducted between 1 October and 31 December 2024. A census approach was used to identify and survey all known public HITH services. Data relating to service characteristics, workforce, governance, activity, technologies and models of care were collected and analysed descriptively. RESULTS:Of 164 Australian health services identified as providing HITH, 101 (62%) were represented in the study, corresponding to 84 discrete HITH services. HITH was most commonly delivered as an acute adult service (69/84, 82%), while acute paediatric HITH was less frequently available (23/84, 27%). HITH was delivered in every state and territory of Australia, predominantly in metropolitan areas (51/82, 62%). Workforce findings demonstrate strong alignment with internal medicine, but clinical governance and use of technology remain diverse. CONCLUSIONS:This study provides the first comprehensive national description of public HITH services in Australia. Substantial variation exists in governance arrangements, workforce composition, models of care and technological capability, highlighting opportunities for greater national consistency and informing future policy, service planning and research.
Regional, rural and remote Australians experience poorer health outcomes and substantially higher rates of suicide and self-harm than those in major cities. Artificial intelligence could support earlier identification of distress, safer triage and more timely care alongside telehealth and clinical decision support, but only if it is treated as a health intervention with explicit safety nets and independent evaluation. We propose a minimum viable governance model, including Indigenous partnership, language safety, translational evaluation and post-deployment monitoring, to ensure AI reduces, rather than deepens, rural mental health inequity.
BACKGROUND:Salmonellosis contributes to a significant burden on global healthcare systems. The impact of this foodborne bacterium is more pronounced when the infection is invasive, leading to bacteraemia and sepsis. Studies on invasive salmonellosis are few, and there is an urgent need to understand the spatial distribution of bacteraemia and the different contributing serotypes. AIMS:To describe the spatial and temporal distribution of Salmonella bacteraemia in Queensland from 2010 to 2019 and identify high-risk areas and demographic groups. METHODS:A retrospective population-based spatiotemporal analysis was conducted using laboratory-confirmed Salmonella bacteraemia notifications. Standardised incidence ratios (SIRs) were estimated at the postcode level using indirect standardisation with age and sex as stratification variables. A Besag-York-Mollè (BYM) Poisson model was used to estimate posterior mean relative risks (RRs), assess spatial clustering and identify hotspots. RESULTS:The highest risk was observed in children aged 0-10 years (RR = 2.36, 95% CI: 2.00-2.78), and males had a 24% higher risk than females (RR = 1.24, 95% CI: 1.10-1.40). Across the study period, approximately 39% of postcode areas exceeded RR > 1.5. The three most common Salmonella serotypes also exhibited notable spatial heterogeneity. We found that Tropical North QLD (RR ranges from 1.6 to 5.39) and the outback areas of Central QLD (RR ranges from 1.8 to 6.19) were high-risk areas for bacteraemia. CONCLUSIONS:Salmonella bacteraemia in QLD shows substantial spatial and demographic heterogeneity, with clear hotspots in remote and tropical regions, supporting targeted, serotype-informed surveillance and prevention strategies, particularly for children and males in high-risk areas.
BACKGROUND:Hip fractures are common among residential aged care (RAC) residents and associated with a larger burden of mortality and functional impairment. RAC residents are often prioritised for early discharge back to RAC and are at risk of disjointed care and limited support in their functional recovery. AIM:To compare next-of-kin and RAC staff perspectives on the discharge care transition from hospital following hip fracture surgery, using routinely collected questionnaire data from a geriatrician-led virtual service. A secondary aim was to describe clinical outcomes including mobility, readmission and mortality rates. METHODS:This prospective descriptive study was conducted between 1/5/22 and 30/4/23 in an Australian metropolitan region. Paired responses from next-of-kin and RAC staff were analysed to assess agreement on key aspects of discharge care planning, discharge processes and post-discharge outcomes. RESULTS:We analysed 94 paired responses (next-of-kin and RAC staff) for 47 older persons. Low levels of agreement were observed in goal-setting, timing of discharge, discharge summaries, pain management and mobility. Agreement was highest at conclusion of the virtual care service when 79% pairs felt the older person's care needs were being met at the RAC facility. Limited mobility improvements were observed, with 19% regaining baseline mobility within a median of 18.5 days after surgery. The 30-day readmission rate was 13%, and 12-month mortality was 34%. CONCLUSION:While there was high agreement that care needs were eventually met at the RAC facility, gaps remain in pre-discharge communication and post-discharge mobility and pain management. Clinicians should address communication on discharge to enhance transition of care from the hospital.
BACKGROUND:Football (soccer) referees are crucial to contol of football matches. Exposure to emotional stressors may precipitate coronary events. AIMS:To characterise emotional stressors, including abuse faced by football (soccer) referees, which may lead to burnout and potential cardiac risk. METHODS:The survey was disseminated to referees from eight referee associations ranging from grassroots/amateur to professional competitions in Sydney, Australia. The questionnaire assessed the level and type of emotional stressors that football referees faced in the preceding 12 months and whether they had experienced verbal or physical abuse in the prior 12 months or at any time in their career. RESULTS:One hundred thirty-four participants undertook the survey, mean age 44.0 years, 117 (87.3%) male and 17 (12.7%) female, 83.6% Caucasian with 62.7% refereeing grassroots football, 23.9% semi-professional and 13.4% professional football. Most participants had experienced stress (69.8%), anxiety (58.3%), frustration (57.2%) and/or anger (42.9%) during at least one match in the previous 12 months. Younger referees and those refereeing at higher levels reported higher levels of psychological stressors than their colleagues, with age remaining a multivariable predictor. Most participants (93.6%) during their career had experienced verbal abuse while refereeing, while 15.2% reported physical abuse, with younger age being a positive predictor. One in five (21.5%) referees had considered quitting due to the stress they experienced. CONCLUSIONS:Findings show a significant emotional stress burden exists with Australian football referees. These findings can guide support and education for referees about stress management techniques and highlight the need to reduce stress and abuse that might contribute to referee burnout and cardiac risk.
BACKGROUND:Kidney transplant recipients (KTRs) disproportionately experience severe COVID-19 infections. We previously identified concern regarding vaccine-induced rejection as a barrier to vaccine uptake. AIM:This study assesses COVID-19 vaccine uptake, infection outcomes and allograft rejection in KTRs during the delta and omicron waves (BA.1/BA.2). METHODS:This cohort study included all adult KTRs with a functioning allograft at 22 March 2021 at our centre. KTR and vaccination-related risk factors for the primary outcome of severe COVID-19 infection (requiring hospitalisation) and the secondary outcomes of death and all COVID-19 infections were assessed using Cox proportional hazards models. Rejection risk following infection/vaccination was also assessed. RESULTS:Of the 986 included KTRs, there were 333 (33.8%) COVID-19 infections, 79 (23.7%) severe infections and 13 deaths (n = 13/333, 3.9%). Vaccine number was the most significant modifiable predictor of severe infection (adjusted hazards ratio, per additional dose, 0.5; 95% confidence interval, 0.40-0.65, P < 0.001) and death. While older age also predicted severe infection and death, lower estimated glomerular filtration rate, history of diabetes and previous allograft rejection predicted severe infection. Male gender was the only predictor of all infections. Mycophenolate dose, prednisolone use and vaccine type did not predict infection or severe disease. Infections and vaccinations did not increase the risk of rejection. CONCLUSIONS:KTRs should be encouraged to be optimally vaccinated to prevent severe disease and can be reassured about the low risk of allograft rejection. Risk factors that compound the state of immunocompromise and severe COVID-19 infections should prompt vigilance and targeted interventions to mitigate these risks.
BACKGROUND:Systemic anticancer therapy (SACT) near the end of life can contribute to significant patient morbidity and mortality in an already vulnerable population. There are variable rates of SACT use within 30 days of death in Australia, including immunotherapy (IO). AIMS:To assess the characteristics of medical oncology patients who died within 30 days of SACT and 30 or 90 days of IO and identify factors associated with treatment-related mortality (TRM). METHODS:Retrospective study of 2948 medical oncology patients at a tertiary metropolitan hospital, between 1 January 2019 and 31 December 2023, who received intravenous or subcutaneous SACT within 30 days of death, and a subgroup who received IO within 90 days of death. Demographic, oncological and mortality-related data were collected. Descriptive statistics and univariable logistic regression analyses were used. RESULTS:Overall, 170 (5.8%) patients died within 30 days of receiving SACT. Thirty-seven (22%) deaths were attributed to treatment-related complications. Pre-treatment Eastern Co-operative Group Score 0-1 (odds ratio (OR) = 2.43, P = 0.03, 95% confidence interval (CI) 1.08-5.49) or chemotherapy administration (OR = 20.3, P < 0.001, 95% CI 4.58-89.97) were associated with TRM within 30 days of SACT. A total of 855 patients received IO containing regimens, of which 61 (7.1%) died within 30 days and 139 (16.3%) died within 90 days. CONCLUSION:The proportion of patients who died within 30 days of SACT was comparable to that of previous Australian studies. TRM was associated with good pre-treatment performance status or chemotherapy administration. Prospective research should examine IO use at the end of life and evaluate optimal patient selection for SACT in larger Australian cohorts.
BACKGROUND:Amyloidosis encompasses a group of diseases characterised by extracellular deposition of misfolded protein fibrils, potentially leading to organ dysfunction. Liver involvement occurs via direct amyloid infiltration, common in immunoglobulin light chain (AL) amyloidosis, or congestive hepatopathy, more typical in transthyretin (ATTR) amyloidosis. The utility of liver stiffness measurement (LSM) using FibroScan as a non-invasive alternative to liver biopsy remains uncertain. AIMS:To prospectively evaluate the utility of Fibroscan in diagnosing and monitoring for hpeatic infiltratioin in AL and ATTR amyloidosis. METHODS:This pilot prospective study included 14 patients with newly diagnosed amyloidosis at a single centre. Liver involvement was evaluated via FibroScan, liver function tests, liver ultrasound and cardiac biomarkers at baseline and follow-up over 24 months. LSM trends were then descriptively analysed. RESULTS:Five patients (35.7%) - three ATTR and two AL amyloidosis - had baseline LSM >10 kPa, suggestive of increased liver stiffness. AL amyloidosis patients exhibited higher LSM values (>17.3 kPa) despite normal ALP levels. LSM improved in 60% of treated patients. No observable association was found between ALP levels and LSM trends. In ATTR amyloidosis patients, LSM >10 kPa was associated with advanced Gilmore stage and elevated NT-proBNP. CONCLUSION:This pilot study suggests LSM may provide a useful early non-invasive adjunct in the assessment of hepatic involvement in amyloidosis; however, it should be interpreted as a non-specific marker. Larger studies are required to validate the diagnostic and prognostic role of FibroScan in this population.
