Research activities in general medicine: a scoping survey by the Internal Medicine Society of Australia and New Zealand.

BACKGROUND: In developing an effective framework for a collaborative research network (RN) that supports members involved in research, the Internal Medicine Society of Australia and New Zealand (IMSANZ) required a better understanding of the current level of research activity and engagement by general physicians, and factors influencing such engagement. AIMS: To explore the current research landscape amongst general physicians in Australia and Aotearoa New Zealand. METHODS: A questionnaire exploring research participation, scope, research enablers and barriers was disseminated to IMSANZ members over a 3-month period. Core functions of IMSANZ-RN, research priorities, potential solutions to perceived barriers and required level of support were also evaluated. RESULTS: A total of 82 members, mostly senior medical staff (74.4%), responded to the survey (11.8% response rate). More than 70% were involved in impactful research across multiple disciplines, encompassing a wide range of research themes and topics. However, there is limited support and resources available to conduct research, with most projects being self-instigated and self-funded. There is overwhelming support to increasing the profile of research in general medicine through the establishment of IMSANZ-RN, whose principal purposes, as identified by respondents, are to foster collaboration, promote research, provide research education and training, and share information among general physicians. Quality improvement studies (56.1%) and clinical trials (41.5%) were also identified as priority research types. CONCLUSIONS: This study has profiled the constraints faced by general physicians in conducting high-quality collaborative research and provides insights into what is needed to support greater research engagement, through development of a discipline-specific clinical RN.

Junior medical doctors' decision making when using advance care directives to guide treatment for people with dementia: a cross-sectional vignette study.

BACKGROUND: Junior medical doctors have a key role in discussions and decisions about treatment and end-of-life care for people with dementia in hospital. Little is known about junior doctors' decision-making processes when treating people with dementia who have advance care directives (ACDs), or the factors that influence their decisions. To describe among junior doctors in relation to two hypothetical vignettes involving patients with dementia: (1) their legal compliance and decision-making process related to treatment decisions; (2) the factors influencing their clinical decision-making; and (3) the factors associated with accurate responses to one hypothetical vignette. METHOD: A cross-sectional survey of junior doctors, including trainees, interns, registrars and residents, on clinical rotation in five public hospitals located in one Australian state. The anonymous, investigator-developed survey was conducted between August 2018 and June 2019. Two hypothetical vignettes describing patients with dementia presenting to hospital with an ACD and either: (1) bacterial pneumonia; or (2) suspected stroke were presented in the survey. Participants were asked to indicate whether they would commence treatment, given the ACD instructions described in each vignette. RESULTS: Overall, 116 junior doctors responded (35% consent rate). In Vignette 1, 58% of respondents (n = 67/116) selected the legally compliant option (i.e. not commence treatment). Participants who chose the legally compliant option perceived 'following patient wishes' (n = 32/67; 48%) and 'legal requirements to follow ACDs' (n = 32/67; 48%) as equally important reasons for complying with the ACD. The most common reason for not selecting the legally compliant option in Vignette 1 was the 'ACD is relevant in my decision-making process, but other factors are more relevant' (n = 14/37; 38%). In Vignette 2, 72% of respondents (n = 83/116) indicated they would commence treatment (i.e. not follow the ACD) and 18% (n = 21/116) selected they would not commence treatment. (i.e. follow the ACD). Similar reasons influenced participant decision-making in Vignette 2, a less legally certain scenario. CONCLUSIONS: There are critical gaps in junior doctors' compliance with the law as it relates to the implementation of ACDs. Despite there being differences in relation to the legal answer and its certainty, clinical and ethical factors guided decision-making over and above the law in both vignettes. More education and training to guide junior doctors' clinical decision-making and ensure compliance with the law is required.

Junior Medical Officers' knowledge of advance care directives and substitute decision making for people without decision making capacity: a cross sectional survey.

BACKGROUND: For the benefits of advance care planning to be realised during a hospital admission, the treating team must have accurate knowledge of the law pertaining to implementation of advance care directives (ACDs) and substitute decision making. AIMS: To determine in a sample of Junior Medical Officers (JMOs): (1) knowledge of the correct order to approach people as substitute decision makers if a patient does not have capacity to consent to treatment; (2) knowledge of the legal validity of ACDs when making healthcare decisions for persons without capacity to consent to treatment, including the characteristics associated with higher knowledge; and (3) barriers to enacting ACDs. METHODS: A cross-sectional survey was conducted at five public hospitals in New South Wales, Australia. Interns, residents, registrars, and trainees on clinical rotation during the recruitment period were eligible to participate. Consenting participants completed an anonymous pen-and-paper survey. RESULTS: A total of 118 JMOs completed a survey (36% return rate). Fifty-five percent of participants were female and 56.8% were aged 20-29 years. Seventy-five percent of JMOs correctly identified a Guardian as the first person to approach if a patient did not have decision-making capacity, and 74% correctly identified a person's spouse or partner as the next person to approach. Only 16.5% identified all four persons in the correct order, and 13.5% did not identify any in the correct order. The mean number of correct responses to the questions assessing knowledge of the legal validity of ACDs was 2.6 (SD = 1.1) out of a possible score of 6. Only 28 participants (23.7%) correctly answered four or more knowledge statements correctly. None of the explored variables were significantly associated with higher knowledge of the legal validity of ACDs. Uncertainty about the currency of ACDs and uncertainty about the legal implications of relying on an ACD when a patient's family or substitute decision maker disagree with it were the main barriers to enacting ACDs. CONCLUSION: JMOs knowledge of the legal validity of ACDs for persons without decision making capacity and the substitute decision making hierarchy is limited. There is a clear need for targeted education and training to improve knowledge in this area for this cohort.

Concerns and psychological well-being of healthcare workers during the COVID-19 pandemic in a tertiary care hospital in New South Wales.

BACKGROUND: In early 2020, the impending COVID-19 pandemic placed a once-in-a-generation professional and personal challenge on healthcare workers. Publications on direct physical disease abound. The authors wanted to focus on doctors' psychological well-being. AIMS: To assess the impact of the COVID-19 pandemic on doctors' well-being and evaluate their concerns as the pandemic progressed. METHODS: A mixed-methods, hospital-based survey was sent to doctors at the 650-bed tertiary referral hospital in NSW at two different periods (late-March and early May 2020). A validated mental well-being tool (Short Warwick Edinburgh Mental Well-being Scale (SWEMWBS)) was combined with COVID-19-specific questions. RESULTS: Two hundred and thirty-five responses were obtained from 450 doctors, with a response rate of 32% in the first survey and 20% in the second. The majority (35%) of respondents were doctors-in-training, followed by staff-specialists (23%). The highest response was from frontline workers in both surveys, including the intensive care unit (27%), anaesthesia (21%) and emergency department (13%). 'Extreme concern' regarding personal protective equipment (PPE) shortage dropped from 22.6% to 2.2% and 'extreme concern' of contracting COVID-19 fell from 22.6% to 3.4% in the second survey. The proportion of respondents with a 'low' psychological well-being score improved from 38% to 27% between the two surveys. The resulting mean improvement in the SWEMWBS was 3.49 (95% confidence interval = 3.06-3.91, P < 0.001). CONCLUSION: Both COVID-19 specific concerns and psychological well-being improved greatly in the second survey. Possible explanations are the fall in COVID-19 cases in the district, improvements in PPE supply and supportive measures communicated to doctors during this period.

Antimicrobial anaphylaxis: the changing face of severe antimicrobial allergy.

OBJECTIVES: The epidemiology, clinical characteristics and outcomes of antimicrobial-associated anaphylaxis remain ill-defined. We sought to examine antimicrobial anaphylaxis with regard to: (i) the frequency of implicated antimicrobials; (ii) attributable mortality; and (iii) referral for definitive allergy assessment. METHODS: This was conducted through a national retrospective multicentre cohort study at five Australian tertiary hospitals (January 2010 to December 2015). Cases of antimicrobial anaphylaxis were identified from ICD-10 coding and adverse drug reaction committee databases. RESULTS: There were 293 participants meeting the case definition of antimicrobial anaphylaxis and 310 antimicrobial anaphylaxis episodes. Of 336 implicated antimicrobials, aminopenicillins (62/336, 18.5%) and aminocephalosporins (57/336, 17%) were implicated most frequently. ICU admission occurred in 43/310 (13.9%) episodes; however, attributable mortality was low (3/310, 1%). The rate of anaphylaxis to IV antibiotics was 3.5 (95% CI=2.9-4.3) per 100 000 DDDs and the rate of hospital-acquired anaphylaxis was 1.9 (95% CI=2.1-3.3) per 100 000 occupied bed-days. We observed overall low rates of hospital discharge documentation (222/310, 71.6%) and follow-up by specialist allergy services (73/310, 23.5%), which may compromise medication safety and antimicrobial prescribing in future. CONCLUSIONS: This study demonstrated that a high proportion of severe immediate hypersensitivity reactions presenting or acquired in Australian hospitals are secondary to aminopenicillins and aminocephalosporins. Overall rates of hospital-acquired anaphylaxis, predominantly secondary to cephalosporins, are low, and also associated with low inpatient mortality.

Fannyhessea vaginae causing bacteraemia and vertebral osteomyelitis: first report of invasive disease in a male.

Introduction.Fannyhessea vaginae (formerly Atopobium vaginae) is an anaerobic organism commonly associated with female genital flora, with rare cases of invasive disease reported in females. Case report. We discuss the case of an 81-year-old male who presented with an acute history of back pain and signs of urinary tract infection in the context of intermittent self-urinary catheterisation. Multiple blood cultures grew Fannyhessea vaginae with a later finding of lumbar vertebral osteomyelitis as the cause of back pain. Treatment was commenced with ampicillin, later switched to ceftriaxone, with improvement of acute signs of infection. Conclusion. Gram-positive anaerobic organisms including Fannyhessea vaginae are possibly under-recognised causes of urinary tract particularly in older males. These bacteria may prove challenging to grow in standard protocols for urine culture; anaerobic or extended incubation could be considered particularly in complicated cases of urinary tract infection without an identifiable pathogen.

The effect of context on performance of an acute medical unit: experience from an Australian tertiary hospital.

OBJECTIVE: To ascertain the improvements in length of stay and discharge rates following the opening of an acute medical unit (AMU). METHODS: Retrospective cohort study of all patients admitted under general medicine from June-November 2008. Main outcome measures were length of stay in hospital and in the emergency department (ED). RESULTS: The length of time spent in the emergency department for those admitted to the AMU was significantly shorter than those admitted directly to a medical ward (6.83h v. 9.40h, P<0.0001). A trend towards shorter hospital length of stay continued after the AMU opened compared with the same period in the previous year (5.15 days (2.49, 11.57 CI) v. 5.66 days (2.76, 11.52 CI)). However, the number of ward transfers for a patient and the need to wait for a nursing home bed or public rehabilitation affected length of stay much more than the AMU. CONCLUSION: An AMU was successful in decreasing ED length of stay and contributed to decreasing hospital length of stay. However, we suggest that local context is crucially important in tailoring an AMU to obtain maximal benefit, and that AMUs are not a 'one size fits all' solution.

Treatment of Neisseria meningitidis prosthetic joint infections with short-course antibiotics: three cases and a literature review.

Neisseria meningitidis is a rare cause of prosthetic joint infection (PJI), with only three cases previously reported. Here we report three further cases, all of which were successfully treated with implant retention and short-course antibiotics ( < 6  weeks).

Staphylococcus aureus Myocarditis with Associated Left Ventricular Apical Thrombus.

Staphylococcus aureus myocarditis is a rare diagnosis with a high mortality rate, usually seen in people who are immunocompromised. Here, we report a case of a 44-year-old man on methotrexate for rheumatoid arthritis who presented in septic shock and was diagnosed with staphylococcus aureus myocarditis. The myocarditis was associated with a left ventricular apical thrombus, with normal systolic function. The myocarditis and associated thrombus were characterised on transthoracic echocardiogram and subsequently on cardiac magnetic resonance imaging. Cardiac magnetic resonance (CMR) imaging showed oedema in the endomyocardium, consistent with acute myocarditis, associated with an apical mural thrombus. Repeat CMR 3 weeks following discharge from hospital showed marked improvement in endomyocardial oedema and complete resolution of the apical mural thrombus. He was treated with a 12-week course of antibiotics and anticoagulated with apixaban. The patient was successfully managed with intravenous antibiotics and anticoagulation with complete recovery.

The effect of curing hepatitis C with direct-acting antiviral treatment on endothelial function.

BACKGROUND: Epidemiological data suggest that chronic HCV infection (CHC) is associated with increased cardiovascular risk, but it is unknown if it is associated with endothelial dysfunction. We aimed to assess the effect of antiviral treatment on endothelial function in non-cirrhotic adults with CHC. METHODS: Self-controlled before and after study. All patients had genotype-1 CHC and were treated with 12 weeks of paritaprevir/ritonavir, ombitasvir and dasabuvir (PrOD), with ribavirin added for those with genotype-1a infection. Endothelial function was assessed at three time points before antiviral treatment, at treatment weeks 1, 4, 8 and 12, and 12 weeks after the end of treatment. The main assessment tools were reactive hyperaemia peripheral arterial tonometry (RHPAT) and serum concentrations of angiopoietin-2 (Ang-2) and E-selectin. RESULTS: A total of 16 patients were enrolled. Mean (sd) age was 51.4 (6.9) years and 11 participants (69%) were male. All 16 patients achieved a sustained virological response. The mean (sd) baseline RHPAT index was 2.05 (0.48), and there was no significant change during treatment (mean within-patient change from baseline to end of treatment =-0.23 [0.45]; P= not significant). There was a significant improvement in both mean Ang-2 (baseline 2.44 [0.79] ng/ml, within-patient change -0.60 [0.44]; P<0.001) and E-selectin (baseline 48.7 [21.5] ng/ml, within-patient change -14.4 [13.0]; P<0.001). CONCLUSIONS: Removing HCV viraemia is associated with a significant improvement in endothelial function as measured by serum markers, but not in bedside microvascular reactivity. Chronic HCV viraemia may be associated with endothelial cell dysfunction and therefore long-term cardiovascular risk.

Cross-species characterisation of polymorphic microsatellite loci in the giant otter (Pteronura brasiliensis).

Nineteen microsatellite loci developed for the Eurasian otter (Lutra lutra) and 15 loci developed for the North American river otter (Lontra canadensis) were tested for ease of amplification and degree of polymorphism on a set of 20 giant otter (Pteronura brasiliensis) faecal samples from the Bolivian Amazon basin. Nineteen loci amplified consistently well, with polymorphisms ranging from two to nine alleles and observed heterozygosity ranging from 0.15 to 0.85.

Using epidemiological and molecular methods to investigate an outbreak of gonorrhoea associated with heterosexual contact in Newcastle, NSW, Australia.

BACKGROUND: We report a cluster of gonorrhoea among mainly heterosexual men that occurred in October 2005, which was first identified when routine weekly surveillance review procedures indicated a three-fold increase in reporting rates compared with historical data. METHODS: Each case was followed up with the treating medical officer to review treatment regimes and risk exposures, and to carry out enhanced contact tracing. The phenotype and genotype of the outbreak gonococcal isolates and gonococci prevalent in the months preceding and following the cluster were determined. Links between cases reported from the local Sexual Health Clinic and those reported by general practitioners were established. RESULTS: Laboratory data indicated that a particular gonococcal subtype (ST 225 and NR/Brpyst) was prevalent during the outbreak. CONCLUSIONS: Gonorrhoea rates returned to pre-outbreak levels following a targeted health promotion intervention with no further cases of the outbreak subtype detected.

Mammalian and avian diversity of the Rewa Head, Rupununi, Southern Guyana / Diversidade de mamíferos e aves do Chefe Rewa, Rupununi, Guiana do Sul

We report the results of a short expedition to the remote headwaters of the River Rewa, a tributary of the River Essequibo in the Rupununi, Southern Guyana. We used a combination of camera trapping, mist netting and spot count surveys to document the mammalian and avian diversity found in the region. We recorded a total of 33 mammal species including all 8 of Guyana's monkey species as well as threatened species such as lowland tapir (Tapirus terrestris), giant otter (Pteronura brasiliensis) and bush dog (Speothos venaticus). We recorded a minimum population size of 35 giant otters in five packs along the 95 km of river surveyed. In total we observed 193 bird species from 47 families. With the inclusion of Smithsonian Institution data from 2006, the bird species list for the Rewa Head rises to 250 from 54 families. These include 10 Guiana Shield endemics and two species recorded as rare throughout their ranges: the harpy eagle (Harpia harpyja) and crested eagle (Morphnus guianensis).

Reportamos os resultados de uma curta expedição às remotas cabeceiras do Rio Rewa, tributário do Rio Essequibo no interior da Guiana. Utilizamos uma combinação de armadilhas fotográficas, redes de neblina e avistamento para documentar a diversidade de mamíferos e aves encontrados na região. Nós registramos um total de 33 espécies de mamíferos, incluindo todas as oito espécies de primatas que ocorrem na Guyana, além de espécies ameaçadas como anta (Tapirus terrestris), ariranha (Pteronura brasiliensis) e cachorro-do-mato (Speothos venaticus). Nós registramos uma população mínima de 35 ariranhas em cinco grupos no 95 km do rio. Registramos também um total de 187 espécies de aves que pertencem a 47 diferentes famílias. Incluindo os dados gerados pelo Smithsonian Institution em 2006, a lista de espécies para a cabeceira do Rio Rewa aumenta para 252, com 48 famílias, incluindo 10 espécies endêmicas do escudo das Guianas e duas espécies consideradas raras: a harpia (Harpia harpyja) e o gavião-real-falso (Morphnus guianensis).