A nurse-led Asthma Care Team transitioning patients from hospital to home improves asthma control: A pilot study exploring an alternative model of care.

INTRODUCTION: Recurrent asthma admissions are frequent in our patients at a tertiary Australian hospital and are commonly related to poor health literacy and medication adherence. A need exists to improve these asthma self-management skills within our current model of care, especially during the vulnerable postdischarge period. AIM: To examine if the addition of a nurse-led Asthma Care Transition Team (ACTT) compared with usual care alone (UC) (1) improves asthma control at 12 weeks posthospital discharge; the number of patients using a Written Action Plan (WAP), compliance with inhaler therapy at 12 weeks, and readmission rates at 6 months. METHODS: Adults admitted with asthma were randomised to either: UC: involving review of asthma medication and self-management skills by the ward team prior to discharge; a standard 6-week post discharge clinic visit and a 12-week study visit where an independent assessor assessed outcomes; or ACTT: In addition to UC, involved ACTT nurse-led review at 1 week and 6 weeks. Key aspects included a pre defined, structured review reinforcing education and self-management skills, and telephone support during working hours. RESULT: Sixty participants (UC and ACTT) had similar baseline characteristics: Mean age: 41 vs 38 years, asthma duration: 20 vs 18 years, baseline Asthma Control Questionnaire 3.1 vs 3.4. At 12 weeks Asthma Control Questionnaire (ACQ) improved significantly in both groups but more so with ACTT; ACTT group had a higher uptake of WAP and a trend to reduced readmissions. CONCLUSION AND PRACTICE IMPLICATION: A nurse-led ACTT improves asthma control and self-management skills following discharge and may lead to fewer readmissions.

Massive haemoptysis in a woman with left lower lobe pulmonary artery interruption-A rare clinical presentation.

Proximal interruption of the pulmonary artery (PA) is a rare congenital vascular anomaly with varying presentation. These patients can be asymptomatic or symptomatic with breathlessness, haemoptysis, recurrent chest infections and pulmonary hypertension. Here, we present a patient who presented with massive haemoptysis secondary to interruption of the left lower lobe PA. To the best of our knowledge, massive haemoptysis due to isolated interruption of the left lower lobe PA has been rarely reported in the English medical literature.

Nocturnal Wakefulness and Suicide Risk in the Australian Population.

Objective: Temporal patterns for suicide over a 24-hour period have shown mixed results among prior studies. However, analyses of 24-hour temporal patterns for wakeful actions including suicidal behavior should adjust for expected sleep requirements that inherently skew such activities to conventional wakeful times. This study analyzed the time-of-day for suicide cases from the Australian population for the year 2017, adjusting for expected sleep patterns. Identification of time-of-day trends using this methodology may reveal risk factors for suicide and potentially modifiable contributors.Methods: The Australian National Coronial Information System database was accessed, and data for completed suicide were extracted for the most recent completed year (2017). Time of suicide was allocated to one of four 6-hourly time bins across 24 hours, determined from time last seen alive and time found subsequently. Prevalence of suicide for each time bin was adjusted for the likelihood of being awake for each bin according to sleep-wake norms published from a large Australian community survey. Observed prevalence of suicide was compared to expected values predicted from likelihood of being awake across each time bin calculated as a standardized incidence ratio (SIR).Results: For the year 2017, there were 2,808 suicides, of which 1,417 were able to be allocated into one of four 6-hourly time bins. When compared to expected values, suicides were significantly more likely to occur in the overnight bin (2301-0500; SIR = 3.93, P < .001).Conclusions: Higher-than-expected rates of suicide overnight associated with nocturnal wakefulness may represent a modifiable risk factor for triggering suicide events.

2004 chronic obstructive pulmonary disease with and without bronchiectasis in Aboriginal Australians: a comparative study.

BACKGROUND: Chronic respiratory disorders are highly prevalent in Aboriginal Australian population, including chronic obstructive pulmonary disease (COPD) and bronchiectasis. However, there is paucity of information in the literature among Aboriginal patients with underlying COPD with and without bronchiectasis. AIMS: In this retrospective study we evaluated the demographic and clinical characteristics of adult Aboriginal Australian patients with a clinical diagnosis of COPD with and without bronchiectasis from the remote communities of the Northern Territory of Australia. METHODS: Clinical records were reviewed to extract information on demographics, respiratory and medical comorbid conditions, COPD directed treatment, hospital admission frequency and exacerbations. Chest radiology were reviewed to evaluate the presence or absence of bronchiectasis. Spirometry results, sputum culture and cardiac investigations were also recorded. RESULTS: Of the 767 patients assessed in the remote community respiratory outreach clinics 380 (49%) patients had a clinical diagnosis of COPD. Chest X-ray and computed tomography scan were available to evaluate the presence of bronchiectasis in 258 patients. Of the 258/380 patients, 176/258 (68.2%) were diagnosed to have COPD alone and 82/258 (31.8%) had bronchiectasis along with COPD. The mean age was 56 and 59 years among patients with and without bronchiectasis, respectively, and 57% were males with bronchiectasis. Patients with bronchiectasis had lower body mass index (22 vs 24 kg/m2 ), frequent hospital admissions (2.0 vs 1.5/year) and productive cough (32.1% vs 28.9%). Spirometry showed 77% had forced expiratory volume in 1 s (FEV1 )/forced vital capacity ratio <0.7. In 81% and 75% of patients with and without bronchiectasis the FEV1 /forced vital capacity ratio was <0.7 and the mean FEV1 was 39% and 43% respectively. CONCLUSIONS: About 32% of Aboriginal Australians had co-existent bronchiectasis with COPD. Lower body mass index, productive cough, frequent hospital admission and marginally more severe reduction in lung function were noted among patients with COPD and bronchiectasis compared to those with COPD in isolation.

Chronic Obstructive Pulmonary Disease In Aboriginal Patients Of The Northern Territory Of Australia: A Landscape Perspective.

Background: The Aboriginal population of Australia has a higher burden of chronic health conditions than non-Aboriginal Australians. However, there is a paucity of data on clinical and demographic characteristics of chronic obstructive pulmonary disease (COPD) in this population. Method: In this retrospective study we evaluated the clinical, demographic and environmental influences in adult Aboriginal patients with COPD living in the regional and remote communities of the Northern Territory of Australia. Results: There were 380 patients (49%) with a diagnosis of COPD of the 767 patients referred to specialist respiratory outreach clinics. The mean age was 57 years (56% were female) and mean±SD BMI was 24.30±7.01 kg/m2. Smoking history was noted in 93% of the study cohort. The most common respiratory symptom was shortness of breath in 62%, and inhaled medications (salbutamol, tiotropium, salmeterol/fluticasone) were used by 79%, 44% and 58% of patients, respectively. Spirometry showed obstructive impairment (FEV1/FVC <0.7) in 79% (0.56±0.17), with mean FEV1 42% of predicted, and a bronchodilator response was present in 28.6%. Comorbid bronchiectasis was diagnosed in 49.8% along with COPD. The relationship between COPD and community demography showed a higher proportion of smokers and those with underlying bronchiectasis to have lower FEV1/FVC ratios. Communities with a higher proportion of asthma were younger and had higher smoking rates. Mortality increased with increasing number of exacerbations and hospital admissions. Conclusion: The Aboriginal population with COPD has a higher prevalence of smoking, moderate to severe airflow obstruction on spirometry and frequently co-diagnosed bronchiectasis with increased severity of ventilatory impairment.

Chronic Pulmonary Melioidosis Masquerading as lung malignancy diagnosed by EBUS guided sheath technique.

Diagnosis of pulmonary mass lesions can be challenging with several possible differentials. A 41-year-old Caucasian woman presented with intermittent non-specific chest pain on a background of 30 pack years of smoking history. A CT scan of the chest confirmed an opacity in the right lower lobe suspicious for primary pulmonary malignancy and PET scan showed moderate FDG avidity of the lesion. Conventional flexible bronchoscopy did not demonstrate an endobronchial lesion, Using Endobrochial Ultrasound (EBUS) Guide sheath technique, the lesion was localized in the posterior segment of the right lower lobe. Brushings, biopsies and washings were taken through the guide sheath, along with transbronchial cryobiopsy. Culture of bronchial brushings from the lesion on Ashdown's agar medium showed Burkholderia pseudomallei, confirming melioidosis. Treatment was with intravenous ceftazidime for 4 weeks, followed by oral sulphamethoxazole/trimethoprim for 3 months. During the follow up visits, the patient demonstrated significant improvement both clinically and radiologically.

Spontaneous cerebrospinal fluid rhinorrhoea and aspiration pneumonitis following initiation of continuous positive airway pressure treatment for obstructive sleep apnoea.

Continuous positive airway pressure (CPAP) therapy is very often the treatment of choice for obstructive sleep apnoea (OSA). The association between intracranial hypertension and spontaneous cerebrospinal fluid (CSF) rhinorrhoea is being increasingly recognized among patients with OSA. However, spontaneous CSF rhinorrhoea following initiation of CPAP therapy for OSA is very rarely documented in the literature. In this report, we describe a 53-year-old woman with severe OSA who, while being evaluated for possible intracranial hypertension, developed spontaneous CSF rhinorrhoea and CSF aspiration pneumonitis as a complication of CPAP therapy. Magnetic resonance imaging confirmed fluid tracks at the skull base, and a nasal swab demonstrated positive ß2-transferrin. Computer tomography (CT) chest showed findings consistent with CSF aspiration pneumonitis. Resolution of both CSF leak and pneumonitis were noted following treatment with azetozolamide and curative endoscopic trans-nasal surgery along with ventriculoperitoneal shunt.

Prevalence and nature of lung function abnormalities among Indigenous Australians referred to specialist respiratory outreach clinics in the Northern Territory.

BACKGROUND: Poor lung function is a predictor of future all-cause mortality. In Australia, respiratory diseases are particularly prevalent among the indigenous population, especially in remote communities. However, there are little published pulmonary function tests' (PFT) data of remote-based adult indigenous patients. AIM: To evaluate the severity of airflow obstruction and other PFT abnormalities of adults referred to specialist respiratory clinics in remote indigenous communities. METHODS: Retrospective analysis of PFT (pre- and post-bronchodilator spirometry, total lung capacity (TLC) and diffusing capacity to carbon monoxide (DLCO)) of indigenous patients collected during specialist respiratory clinics in remote Northern Territory (NT) indigenous communities (Australia) between 2013 and 2015. The National Health and Nutrition Examination Survey (NHANES) III without ethnic correction was used as the reference. RESULTS: Of the 357 patients, 150 had acceptable spirometry, and 71 had acceptable DLCO and TLC studies. Despite the relatively young age (mean = 49 years, SD = 12.9), their lung function was generally low; mean % predicted values were FEV1 = 55% (SD = 20.5%), FVC = 61% (SD = 15.6%), DLCO = 64.0% (SD = 19.7%) and TLC = 70.1% (SD = 18.2%). Mean FEV1 /FVC ratio was preserved (0.71, SD = 0.16). Post-bronchodilator airflow obstruction (FEV1 /FVC < 0.7) was observed in 37% of patients, where a large proportion (67%) demonstrated at least a severe airflow obstruction, with a mean FEV1 of 41% predicted. CONCLUSION: In this first study of PFT findings of indigenous adults from a remote-based clinical service, we found a high rate of at least moderate airflow limitation and low FVC along with preserved FEV1/FVC ratio. Increased awareness and screening for reduced lung function needs to be considered in this population.