Changing Demographics of Stroke Mimics in Present Day Stroke Code Era: Need of a Streamlined Clinical Assessment for Emergency Physicians.

Background There is an apparently high incidence of stroke mimics in the present-day stroke code era. The reason being is the intense pressure to run with time to achieve the "time is brain"-based goals. Methods The present study was a retrospective analysis of the data collected over a duration of 6 months from April 2019 to September 2019. We observed the incidence of stroke mimics among the patients for whom rapid response stroke code was activated during the study period. We also performed a logistic regression analysis to identify the clinical features which can act as strong predictors of stroke and mimics. Results A total of 314 stroke codes were activated of which 256 (81.5%) were stroke and 58 (18.5%) were the mimics. Functional disorders and epilepsy were the most common mimics (24.1% each). Female gender ( p = 0.04; odds ratio [OR] 2.9[1.0-8.8]), isolated impairment of consciousness ( p < 0.01; OR 4.3[1.5-12.6]), and isolated dysarthria ( p < 0.001) were the strong independent predictors for a stroke mimic. Hemiparesis was the strong independent predictor for a stroke ( p < 0.001; OR 0.0[0.0-0.1]). Conclusion In the present epoch of rapid response stroke management, a streamlined assessment by the emergency physicians based on the above clinical predictors may help in avoiding the misdiagnosis of a mimic as stroke.

Measured energy expenditure in mildly hypothermic critically ill patients with traumatic brain injury: A sub-study of a randomized controlled trial.

BACKGROUND & AIMS: Prophylactic hypothermia, often used in critically ill patients with traumatic brain injury, reduces energy expenditure and may affect energy delivered by nutrition therapy. The primary objective of this study was to measure energy expenditure in hypothermic patients over the first 3 days after traumatic brain injury (TBI). Secondary objectives included comparison of measured energy expenditure and nutrition delivery to day 7. METHODS: A prospective sub-study of a randomized controlled trial conducted in patients with severe TBI, investigating prophylactic hypothermia (33-35 °C) as a neuroprotective therapy. In two centers, indirect calorimetry was initiated within 24 h of randomization and repeated up to twice daily to day 7. Data are presented as n (%), mean (standard deviation (SD)), median [interquartile range (IQR)], and mean difference (95% confidence interval (CI)). RESULTS: Forty patients were included (20 in each group), with 17 patients in the hypothermic and 16 in the normothermic group having an indirect calorimetry measurement in the first 3 days. Over the first 3 days, the mean temperature in the hypothermic and normothermic groups was 33.5 (0.6) ºC (n = 17) and 37 (0.5) ºC (n = 16), p < 0.0001, and the mean measured energy expenditure, was 21 (5) and 27 (4) kcal/kg, p = 0.002, representing a mean difference of 5 (95% CI: 2-8) kcal/kg. Energy expenditure was 20% (95% CI: 9.5-29%) less in hypothermia patients compared to normothermia patients. Hypothermia patients also had higher gastric residual volumes across the 7 day study period (438 (237) mls vs 184 (103) mls, p < 0.0001) and higher use of metoclopramide and erythromycin as prokinetics. Despite enteral nutrition intolerance, hypothermia patients received 93% of measured energy expenditure over 7 days. CONCLUSION: In TBI patients, energy expenditure was 20% less when receiving prophylactic hypothermia compared to normothermia. Greater gastric residual volumes, use of prokinetics and energy delivery that approximated measured energy expenditure was also observed in hypothermia patients. TRIAL REGISTRY NUMBER: POLAR-RCT: clinicaltrials.gov Identifier: NCT00987688; Anzctr.org.au Identifier: ACTRN12609000764235. This sub-study was not registered separately.

Stratification of Pre-procedure Risk Factors Associated with Difficult-to-remove Inferior Vena Cava (IVC) Filters: A 6-year Retrospective Analysis at a Tertiary Center.

PURPOSE: Currently, data surrounding predicting difficulty of IVC filter retrievals are heterogenous and conflicting. We aimed to identify which of many variables associated with IVC filters is a risk for procedural difficulty. MATERIALS AND METHODS: This study retrospectively reviewed 6 years of IVC filter retrievals at a tertiary center identifying 356 consecutive retrievals. A difficult retrieval was defined as any case where the fluoroscopy time exceeded 7 min, an advanced technique was required, the retrieval attempt failed and required an additional attempt or was left permanent, or there was major complication such as IVC filter fracture/migration/vessel injury. RESULTS: There were 105 filter retrievals defined as difficult (29.5%). Univariate analysis showed significantly increased risk for retrievals with an embedded top. Multivariate analysis assessed the association between dwell time, tilt, age, non-hooked filters, leg penetration and difficult retrieval. This showed a significant increase in the difficulty of retrieval for filters tilted between 5° and 15° (odds ratio 2.38, p < 0.001), for filters tilted more than 15° (odds ratio 7.91, p < 0.001), and dwell time greater than 6 months (odds ratio 2.06, p = 0.033). No significant increase in difficulty was seen with filters with a dwell time of less than 6 months, leg penetration, non-hooked filters, or with increasing patient age. CONCLUSIONS: Identifying these risks in patients in advance of the procedure allows appropriate planning and improved workflow efficiency.

Predictive energy equations are inaccurate for determining energy expenditure in adult burn injury: a retrospective observational study.

BACKGROUND: Severe burn injuries are associated with hypermetabolism. This study aimed to compare the measured energy expenditure (mEE) with predicted energy requirements (pERs), and to correlate energy expenditure (EE) with clinical parameters in adults with severe burn injury. METHODS: Data were retrospectively analysed on 29 burn patients (median (interquartile range) age: 46 (28-61) years, % total body surface area burn: 37% (18-46%)) admitted to an intensive care unit. Indirect calorimetry was performed on 1-4 occasions per patient to measure EE. mEE was compared with pER calculated using four prediction equations. Bland-Altman and correlation analyses were performed. RESULTS: Mean ± SD mEE was 9752 ± 2089 kJ/day (143 ± 32% of predicted basal metabolic rate). Bland-Altman analysis demonstrated clinically important overestimation for three of the four prediction equations and wide 95% limits of agreement for all equations. Overestimation of EE was more marked early post-burn. mEE correlated with day post-burn (r = 0.42, P = 0.004) and number of operations prior to first EE measurement (r = 0.34, P = 0.016), but not with % total body surface area (r = 0.02, P = 0.9). CONCLUSIONS: Patients with severe burn injury exhibit hypermetabolism. The observed poor agreement between pER and mEE at an individual level indicates the value of indirect calorimetry in determining EE in burn injury.

Effect of cultural background and healthcare environment on postoperative opioid requirement.

PURPOSE: The objective of this prospective observational study was to investigate the interactions between cultural background, healthcare environment, and postoperative pain experience. METHODS: We enrolled 128 Chinese patients living in rural mainland China and 134 patients in Hong Kong with a higher level of Western cultural influences (defined by educational attainment, place of residence, and ability to understand English). All patients had major abdominal surgery and received patient-controlled analgesia with intravenous morphine for postoperative pain relief. The primary endpoint was total opioid requirement up to 48 hr after surgery. Other measures included pain intensity, opioid-related side effects, and genetic markers for opioid responsiveness. RESULTS: The mean (95% confidence interval) cumulative opioid requirement, expressed as morphine equivalent, during the first 48 hr after surgery was significantly less in patients from mainland China (18.8 [15.7 to 22] mg) compared with patients from Hong Kong (42.0 [38.3 to 45.6] mg, P < 0.0001). In a multivariable analysis, opioid requirement was influenced by ethnicity, duration of surgery, and severity of pain upon admission to the postanesthetic care unit. CONCLUSIONS: These results suggest that postoperative pain behaviours and opioid requirement may be influenced by cultural background and healthcare environment in two populations of Chinese descent. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ACTRN12614000601639); registered 6 May, 2014.

RéSUMé: OBJECTIF: L'objectif de cette étude observationnelle prospective était d'étudier les interactions entre le contexte culturel, l'environnement de soins de santé et l'expérience de la douleur postopératoire. MéTHODES: Nous avons recruté 128 patients chinois vivant en zones rurales en Chine continentale et 134 patients vivant à Hong-Kong avec un haut niveau d'influences culturelles occidentales (définies par le niveau d'éducation atteint, le lieu de résidence et la capacité à comprendre l'anglais). Tous les patients avaient subi une chirurgie abdominale majeure et reçu une analgésie contrôlée par le patient par morphine intraveineuse pour le soulagement de la douleur postopératoire. Le critère d'évaluation principal était la demande totale en opioïdes pendant les 48 premières heures suivant la chirurgie. D'autres mesures ont inclus l'intensité de la douleur, les effets indésirables liés aux opioïdes et des marqueurs génétiques de sensibilité aux opioïdes. RéSULTATS: Le besoin cumulé moyen (intervalle de confiance à 95 %) cumulé en opioïdes, exprimé sous forme d'équivalent-morphine, au cours des 48 premières heures suivant la chirurgie était significativement inférieur pour les patients de Chine continentale (18,8 [15,7 à 22] mg) comparativement aux patients de Hong-Kong (42,0 [38,3 à 45,6] mg, P < 0,0001). Une analyse multifactorielle a montré que la demande en opioïdes était influencée par l'origine ethnique, la durée de l'intervention chirurgicale et l'intensité de la douleur au moment de l'arrivée dans l'unité de soins postanesthésiques. CONCLUSIONS: Ces résultats suggèrent que les comportements postopératoires envers la douleur et le besoin d'opioïdes peuvent être influencés par l'arrière-plan culturel et l'environnement des soins de santé dans deux populations différentes d'origine chinoise. ENREGISTREMENT DE L'ESSAI CLINIQUE: Registre des essais cliniques d'Australie et de Nouvelle-Zélande (ACTRN12614000601639); enregistré le 6 mai 2014.

Interdisciplinary model of care (RADICALS) for early detection and management of chronic obstructive pulmonary disease (COPD) in Australian primary care: study protocol for a cluster randomised controlled trial.

INTRODUCTION: Up to half of all smokers develop clinically significant chronic obstructive pulmonary disease (COPD). Gaps exist in the implementation and uptake of evidence-based guidelines for managing COPD in primary care. We describe the methodology of a cluster randomised controlled trial (cRCT) evaluating the efficacy and cost-effectiveness of an interdisciplinary model of care aimed at reducing the burden of smoking and COPD in Australian primary care settings. METHODS AND ANALYSIS: A cRCT is being undertaken to evaluate an interdisciplinary model of care (RADICALS - Review of Airway Dysfunction and Interdisciplinary Community-based care of Adult Long-term Smokers). General practice clinics across Melbourne, Australia, are identified and randomised to the intervention group (RADICALS) or usual care. Patients who are current or ex-smokers, of at least 10 pack years, including those with an existing diagnosis of COPD, are being recruited to identify 280 participants with a spirometry-confirmed diagnosis of COPD. Handheld lung function devices are being used to facilitate case-finding. RADICALS includes individualised smoking cessation support, home-based pulmonary rehabilitation and home medicines review. Patients at control group sites receive usual care and Quitline referral, as appropriate. Follow-ups occur at 6 and 12 months from baseline to assess changes in quality of life, abstinence rates, health resource utilisation, symptom severity and lung function. The primary outcome is change in St George's Respiratory Questionnaire score of patients with COPD at 6 months from baseline. ETHICS AND DISSEMINATION: This project has been approved by the Monash University Human Research Ethics Committee and La Trobe University Human Ethics Committee (CF14/1018 - 2014000433). Results of the study will be disseminated in peer-reviewed journals and research conferences. If the intervention is successful, the RADICALS programme could potentially be integrated into general practices across Australia and sustained over time. TRIAL REGISTRATION NUMBER: ACTRN12614001155684; Pre-results.

Identification and assessment of potentially high-mortality intensive care units using the ANZICS Centre for Outcome and Resource Evaluation clinical registry.

PURPOSE: A hospital's highest-risk patients are managed in the intensive care unit. Outcomes are determined by patients' severity of illness, existing comorbidities and by processes of care delivered. The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation (CORE) manages a binational clinical registry to benchmark performance, and report and assess ICUs which appear to have worse outcomes than others. METHODS: A descriptive retrospective cohort study was undertaken to detail processes, outcomes, limitations and practical lessons learnt from monitoring ICU performance throughout Australia and New Zealand. All ICUs contributing to the ANZICS Adult Patient Database between 2009 and 2014 were included. A potential outlier ICU was defined as one with a statistically significantly higher standardised mortality ratio (SMR) than its peer group. RESULTS: There were 757 188 admissions to 168 ICUs. Of these, 27 ICUs (16%) were identified as potential outlier ICUs at least once. Data quality problems led to inaccurate or artificially elevated SMRs at 16/27 ICUs. Variation in diagnostic casemix partly or completely explained the elevated SMR at 15/27 ICUs. At nine ICUs where data quality and casemix differences did not explain the elevated SMR, process-of-care problems were identified. CONCLUSIONS: A combination of routine monitoring techniques, statistical analysis and contextual interpretation of findings is required to ensure potential outlier ICUs are appropriately identified. This ensures engagement and understanding from clinicians and jurisdictional health departments, while contributing to the improvement of ICU practices throughout Australia and New Zealand.

The ANZROD model: better benchmarking of ICU outcomes and detection of outliers.

OBJECTIVE: To compare the impact of the 2013 Australian and New Zealand Risk of Death (ANZROD) model and the 2002 Acute Physiology and Chronic Health Evaluation (APACHE) III-j model as risk-adjustment tools for benchmarking performance and detecting outliers in Australian and New Zealand intensive care units. METHODS: Data were extracted from the Australian and New Zealand Intensive Care Society Adult Patient Database for all ICUs that contributed data between 1 January 2010 and 31 December 2013. Annual standardised mortality ratios (SMRs) were calculated for ICUs using the ANZROD and APACHE III-j models. They were plotted on funnel plots separately for each hospital type, with ICUs above the upper 99.8% control limit considered as potential outliers with worse performance than their peer group. Overdispersion parameters were estimated for both models. Overall fit was assessed using the Akaike information criterion (AIC) and Bayesian information criterion (BIC). Outlier association with mortality was assessed using a logistic regression model. RESULTS: The ANZROD model identified more outliers than the APACHE III-j model during the study period. The numbers of outliers in rural, metropolitan, tertiary and private hospitals identified by the ANZROD model were 3, 2, 6 and 6, respectively; and those identified by the APACHE III-j model were 2, 0, 1 and 1, respectively. The degree of overdispersion was less for the ANZROD model compared with the APACHE III-j model in each year. The ANZROD model showed better overall fit to the data, with smaller AIC and BIC values than the APACHE III-j model. Outlier ICUs identified using the ANZROD model were more strongly associated with increased mortality. CONCLUSION: The ANZROD model reduces variability in SMRs due to casemix, as measured by overdispersion, and facilitates more consistent identification of true outlier ICUs, compared with the APACHE III-j model.

Audit of demand for after-hours CT scanning services in RANZCR-accredited training departments.

INTRODUCTION: The aims of this study were to measure: (i) the growth in after-hours emergency department--referred CT (ED-CT) performed in accredited training departments between 2011 and 2013; (ii) the growth in ED CT relative to growth in ED presentations at the same hospitals; and (iii) trainee workload resulting from after-hours ED CT. METHODS: Ethics approval was obtained for all participating sites. Accredited training facilities in Australia and New Zealand with three or more trainees and serving one or more EDs were invited to participate (N = 32). Four nights were surveyed between August and December 2013. For data collection, the number of ED patients having one or more CT scans; ED CT scan total images; non-contrast head CTs; and ED patients (total and categories 1 and 2) attending the ED in the preceding 24 h and first half of calendar year were collected for 2013 and corresponding days in 2012 and 2011. Trainee staffing levels were measured. RESULTS: Eleven of 32 sites provided data for all four nights and 14 of 32 for one or more nights. A 15.7% increase in number of ED CTs between 1700 and 2200 h and 16.8% increase between 2201 and 0730 h occurred in the 2 years between 2011 and 2013 compared with a 6.9% increase in overall ED and 26% increase in categories 1 and 2 presentations over the same period. The number of CT images, however, increased 23%. CONCLUSION: Growth in demand by EDs for after-hours CT services has implications for service provision and trainee workloads in Royal Australian and New Zealand College of Radiologists-accredited training departments.

Risk prediction of hospital mortality for adult patients admitted to Australian and New Zealand intensive care units: development and validation of the Australian and New Zealand Risk of Death model.

PURPOSE: The purpose of this study is to develop and validate a new mortality prediction model (Australian and New Zealand Risk of Death [ANZROD]) for Australian and New Zealand intensive care units (ICUs) and compare its performance with the existing Acute Physiology and Chronic Health Evaluation (APACHE) III-j. MATERIALS AND METHODS: All ICU admissions from 2004 to 2009 were extracted from the Australian and New Zealand Intensive Care Society Adult Patient Database. Hospital mortality was modeled using logistic regression with training (two third) and validation (one third) data sets. Predictor variables included APACHE III score components, source of admission to ICU and hospital, lead time, elective surgery, treatment limitation, ventilation status, and APACHE III diagnoses. Model performance was assessed by standardized mortality ratio, Hosmer-Lemeshow C and H statistics, Brier score, Cox calibration regression, area under the receiver operating characteristic curve, and calibration curves. RESULTS: There were 456605 patients available for model development and validation. Observed mortality was 11.3%. Performance measures (standardized mortality ratio, Hosmer-Lemeshow C and H statistics, and receiver operating characteristic curve) for the ANZROD and APACHE III-j model in the validation data set were 1.01, 104.9 and 111.4, and 0.902; 0.84, 1596.6 and 2087.3, and 0.885, respectively. CONCLUSIONS: The ANZROD has better calibration; discrimination compared with the APACHE III-j. Further research is required to validate performance over time and in specific subgroups of ICU population.

Educational intervention for older people with asthma: a randomised controlled trial.

OBJECTIVES: To improve the asthma control and adherence to asthma preventer medication of older people using the Patient Asthma Concerns Tool (PACT) to identify and address unmet needs and patient concerns. METHODS: Community dwelling adults over 55 years, living in Victoria or New South Wales were recruited into a single-blind, parallel design, randomised-controlled trial comparing person-centred education including device technique, versus written information-only education. Fifty-eight participants randomised to the intervention group and 56 to the control completed participation. OUTCOME MEASURES: asthma control, adherence to preventer medication, asthma related quality of life, asthma exacerbations and written action plan ownership were assessed at baseline, and 3 and 12 months post intervention. RESULTS: Intervention participants experienced improvements in asthma control, adherence to asthma preventer medication, reduced exacerbations, improved quality of life and an increase in asthma action plan ownership at 3 and 12 months. CONCLUSION: Asthma outcomes in older people can be significantly improved by delivering tailored education that identifies specific patient concerns and unmet needs. PRACTICAL IMPLICATIONS: Use of the PACT to identify patient concerns and unmet needs will assist health professionals to improve the health literacy of patients by addressing gaps in their knowledge and perceptions of asthma control.

Development of a validated clinical case definition of generalized tonic-clonic seizures for use by community-based health care providers.

PURPOSE: To develop and test a clinical case definition for identification of generalized tonic-clonic seizures (GTCSs) by community-based health care providers. METHODS: To identify symptoms that can help identify GTCSs, patients with history of a jerky movements or rigidity in any part of the body ever in life were recruited from three sites: the community, secondary care hospital, and tertiary care hospital. These patients were administered a 14-item structured interview schedule focusing on the circumstances surrounding the seizure. Subsequently, a neurologist examined each patient and, based on available investigations, classified them as GTCS or non-GTCS cases. A logistic regression analysis was performed to select symptoms that were to be used for case definition of GTCSs. Validity parameters for the case definition at different cutoff points were calculated in another set of subjects. RESULTS: In total, 339 patients were enrolled in the first phase of the study. The tertiary care hospital contributed the maximal number of GTCS cases, whereas cases of non-GTCS were mainly from the community. At the end of phase I, the questionnaire was shortened from 14 to eight questions based on statistical association and clinical judgment. After phase II, which was conducted among 170 subjects, three variables were found to be significantly related to the presence of GTCSs by logistic regression: absence of stress (13.1; 4.1-41.3), presence of frothing (13.7; 4.0-47.3), and occurrence in sleep (8.3; 2.0-34.9). As a case definition using only three variables did not provide sufficient specificity, three more variables were added based on univariate analysis of the data (incontinence during the episode and unconsciousness) and review of literature (injury during episode). A case definition consisting of giving one point to an affirmative answer for each of the six questions was tested. At a cutoff point of four, sensitivity was 56.9 (47.4-66.0) and specificity, 96.3 (86.2-99.4). Among the 197 GTCS and 26 new non-GTCS patients recruited from hospitals from select SEAR Member Countries, in phase III, the sensitivity of this clinical case definition was 72% and specificity, 100%. A stratified analysis by gender in all the three phases did not show any differences between the sexes. CONCLUSIONS: Based on these criteria, we recommend that all patients with a history of two or more episodes of jerking or rigidity of limbs, having a score of > or =4 in the case definition, be identified as having GTCSs and started on antiepileptic medications. This clinical case definition can be very useful for community-based health care providers to identify and manage cases of GTCSs in the community. This should play a major role in the reduction of treatment gap for epilepsy in developing countries.