A multi-centre retrospective study of long-term outcomes of spinal re-irradiation with SABR.

INTRODUCTION: Stereotactic ablative body radiotherapy (SABR) is a highly conformal technique utilising a high dose per fraction commonly employed in the re-treatment of spinal metastases. This study sought to determine the safety and efficacy of re-irradiation with SABR to previously treated spinal metastases. METHODS: This was a retrospective analysis of patients at three Australian centres who have undergone spinal SABR after previous spinal radiotherapy to the same or immediately adjacent vertebral level. Efficacy was determined in terms of rates of local control, while safety was characterised by rates of serious complications. RESULTS: Thirty-three spinal segments were evaluated from 32 patients. Median follow-up for all patients was 2.6 years, and median overall survival was 4.3 years. Eleven of 33 (33.3%) treated spinal segments had local progression, with a local control rate at 12 months of 71.4% (95% C.I. 55.2%-92.4%). Four patients (16.7%) went on to develop cauda equina or spinal cord compression. Thirteen out of 32 patients (40.6%) experienced acute toxicity, of which 12 were grade 2 or less. Five out of 30 spinal (16.7%) segments with follow-up imaging had a radiation-induced vertebral compression fracture. There was one case of radiation myelitis which occurred in a patient who had mediastinal radiotherapy with a treatment field which overlapped their prior spinal radiation. CONCLUSION: The patients in this study experienced long median survival, durable tumour control and high rates of freedom from long-term sequelae of treatment. These results support the use of SABR in patients who progress in the spine despite previous radiotherapy.

A double-blinded randomised controlled study of fluid restriction versus liberal fluid during induction of labour: A pilot study.

BACKGROUND: Excess intravenous fluid for women requiring an induction of labour may adversely affect the duration of labour and maternal/neonatal outcomes. AIMS: This study aimed to determine the difference in duration of labour and outcomes with a low background infusion rate, compared to liberal background intravenous fluid management. MATERIALS AND METHODS: A double blind randomised controlled pilot study was performed on 200 women who underwent induction of labour at a single institution. Women were randomised to an intravenous rate of 40 mL/h versus 250 mL/h of Hartmann's solution. Fluid boluses were strictly controlled to limit bias. This trial was registered with the Australian clinical trial registry: ACTRN12621001298808. RESULTS: Analysis of the total amount of fluid received showed good separation with Group 1 (40 mL/h) receiving 1,736 mL less than Group 2 (250 mL/h), median (interquartile range) 841 mL (458, 1691) versus 2,577 mL (1620, 4326) (P < 0.001). Median duration of labour was shorter in Group 1 by 24 min (P = ns). Subset analysis of nulliparous women showed that duration of labour was shorter in Group 1 by 83.5 min (P = ns). CONCLUSION: As this was a pilot study, a significant difference in duration of labour or secondary outcomes was not seen. Given the increasing numbers of nulliparous women having an induction of labour, potential for adverse maternal and neonatal outcomes and the associated higher rate of operative birth, this study guides power calculations and supports proof of concept for future research into optimum fluid management during induction of labour for these women.

Addressing disparities in health outcomes for patients with advanced pancreatic cancer and limited English proficiency.

INTRODUCTION: There are significant challenges and a lack of data related to culturally and linguistically diverse (CALD) cancer patients. We compared patient characteristics, treatment patterns, and outcomes of patients with advanced pancreatic cancer that required an interpreter. METHODS: Registry data was extracted for advanced pancreatic cancer patients from a single health institution with a comprehensive Transcultural and Language Service (TALS). Demographic and clinicopathologic characteristics were compared. Kaplan-Meier survival estimates with log-rank testing, and univariate and multivariable regression analysis were performed to compare the group with limited English proficiency (LEP) to the English proficient (EP) group. RESULTS: Of 155 patients, 32.9% (n = 51) required the TALS. The LEP group had a higher mean age (71.2 vs. 76.8 years; p = 0.005) and received less chemotherapy (42.3% vs. 31.4%, p = 0.220). Univariate analysis revealed a shorter median overall survival (OS) in the LEP group (3.6 vs. 5.0 months), with a hazard ratio [HR] of 1.51 (95% confidence interval [CI]: 1.03-2.21, p = 0.033). Upon multivariable analysis, adjusting for Eastern Cooperative Oncology Group (ECOG) performance scale, the number of sites of metastatic disease and chemotherapy use, the strength of association between LEP and OS reduced marginally (HR 1.42, 95% CI: 0.93-2.16), and was no longer statistically significant (p = 0.103). CONCLUSIONS: In patients with advanced pancreatic cancer utilizing a comprehensive TALS, there was a trend to poorer survival with limited English proficiency, although this association was not statistically significant. An ongoing research commitment to the CALD experience is necessary to build a granular understanding of this population and ensure equitable outcomes.

Temporal changes in toe-brachial index results in haemodialysis patients.

INTRODUCTION: Toe brachial index (TBI), the ratio of toe pressure to systolic blood pressure (SBP), helps predict peripheral arterial disease. In patients with kidney failure this may be performed during haemodialysis for convenience. Until recently there has been little evaluation of the impact of haemodialysis in limb and systemic perfusion on these values. We aimed to determine if the values of TBI would change during and after dialysis compared to pre-dialysis assessments. METHODS: Using a repeated measures study, TBIs and toe pressures were measured using the Hadeco Smartop Vascular Ultrasound Doppler in 31 patients undergoing haemodialysis. TBI assessments were completed pre-dialysis and compared to values obtained at 1 hour, 2 hours, 3 hours, and post-dialysis to monitor change in TBI results. Comparison of values for each patient were tested for differences using paired t-tests. Linear mixed-effects models were used to test for the effect of patient and clinical factors on change in outcome measures. RESULTS: Mean TBI decreased from pre-dialysis at 1 hour (0.72 to 0.63, p = 0.01) and remained lower at 2 hours and 3 hours, before returning to pre-dialysis levels at post-dialysis. Mean systolic blood pressure also declined during dialysis. Mean TBI results were lower in those with a history of lower limb ulceration and in females. Sixteen patients (51.6%) had a normal TBI at baseline, 14 (45.2%) had a mildly low TBI, and one (3.2%) had a severely low TBI. Between baseline and 1 h, five patient's results moved from normal to mildly abnormal and one from mildly abnormal to severely abnormal. As haemodialysis concluded (post-dialysis) there were 17 (56.7%) 'normal' TBIs, with no severely abnormal TBIs (p = 0.73). 0.30). CONCLUSION: TBI and toe pressures are impacted significantly by dialysis. TBI and toe pressure assessments should be conducted before haemodialysis begins, or between dialysis sessions to avoid variability.

Impact of Visitor Restrictions on the Pain and Psychological Wellbeing of Palliative Care Patients: A Cohort Study.

Aim: Palliative care patients with advanced or life-threatening illnesses in hospital during the COVID-19 pandemic are likely to be affected by visitor restrictions (VR). We aimed to explore the impact of VR on patients' levels of physical pain and psychological distress. Design: Retrospective cohort study comparing two cohorts of patients admitted to a palliative care unit in a major metropolitan hospital in Australia; the first cohort from 1 April to 30 June 2019 (pre-pandemic; n = 96), and the second from 1 April to 30 June 2020 (during pandemic; n = 95). Methods: Patient-rated pain scores (using the Symptom Assessment Scale; SAS) and clinician-rated pain and psychological/spiritual severity scores (using the Palliative Care Problem Severity Score; PCPSS) on admission and on discharge or death were compared between pre-pandemic and pandemic cohorts. Discharge pain scores and change in scores from admission to discharge were also assessed via multivariable analyses. Results: Case-mix of patients in both cohorts were similar. After adjusting for demographics and functional status, pain scores in the pandemic cohort were higher for patients deceased on discharge, compared to the pre-pandemic cohort (SAS: coefficient = 0.86, 95%CI: 0.09 to 1.64, P = 0.029; PCPSS: coefficient = 0.24, 95%CI: -0.07 to 0.86, P = 0.131, respectively). Differences in SAS and PCPSS pain and psychological/spiritual scores for those discharged alive were not statistically significant. Conclusion: Among palliative care inpatients affected by VR, we observed higher pain scores for patients discharged deceased; suggesting that VR may have impacted the physical wellbeing (pain) of these patients.

P2/N95 fit testing and the risk of COVID-19 in Healthcare Workers.

BACKGROUND: Guidelines recommend healthcare workers (HCWs) undertake fit testing of P2/N95 respirators to mitigate the risk of infectious aerosols, however few studies have assessed whether fit testing reduces COVID-19 infection. METHODS: A retrospective cohort study was conducted amongst HCWs across two tertiary health services in Melbourne, Australia during a period of low community transmission. Institution-wide quantitative fit testing and detailed questionnaires assessing COVID-19 acquisition risk factors were undertaken from September 2020. HCWs diagnosed with COVID-19 in the period prior to the fit testing program (February 1st - August 31st 2020) were matched on a 1:3 ratio to HCWs who had not been diagnosed with COVID-19. Risk factors for COVID-19 acquisition, including fit testing outcome, were compared between groups. RESULTS: A total of 1571 HCWs took part in fit testing programs. Seventy-two (4.6%) were diagnosed with COVID-19 within the study period. Younger age, nursing staff, close contact with a COVID-19 case, and working longer periods in wards with COVID-19 patients, were associated with COVID-19 infection. After matching for intensity of occupational exposure to infectious aerosols, close contact was the only independent variable associated with COVID-19 infection (OR 3.50, 95% CI:1.65-7.44, p = 0.001). Adequate fit test for the respirator predominately worn before the fit testing period was not associated with COVID-19 (OR 1.08, 95% CI:0.59-1.98, p = 0.815). CONCLUSION: After controlling for intensity of occupational exposure to infectious aerosols, P2/N95 respirator fit testing was not associated with reduced risk of COVID-19 infection. The utility of widespread fit testing to reduce HCW COVID-19 infections should be reconsidered.

Multivariable risk model for postpartum re-presentation with hypertension: development phase.

OBJECTIVES: Postpartum hypertension is one of the leading causes of re-presentation to hospital postpartum and is associated with adverse long-term cardiovascular risk. Postpartum blood pressure monitoring and management interventions have been shown to reduce hospital re-presentation, complications and long-term blood pressure control. Identifying patients at risk can be difficult as 40%-50% present with de novo postpartum hypertension. We aim to develop a risk model for postpartum re-presentation with hypertension using data readily available at the point of discharge. DESIGN: A case-control study comparing all patients who re-presented to hospital with hypertension within 28 days post partum to a random sample of all deliveries who did not re-present with hypertension. Multivariable analysis identified risk factors and bootstrapping selected variables for inclusion in the model. The area under the receiver operator characteristic curve or C-statistic was used to test the model's discriminative ability. SETTING: A retrospective review of all deliveries at a tertiary metropolitan hospital in Melbourne, Australia from 1 January 2016 to 30 December 2020. RESULTS: There were 17 746 deliveries, 72 hypertension re-presentations of which 51.4% presented with de novo postpartum hypertension. 15 variables were considered for the multivariable model. We estimated a maximum of seven factors could be included to avoid overfitting. Bootstrapping selected six factors including pre-eclampsia, gestational hypertension, peak systolic blood pressure in the delivery admission, aspirin prescription and elective caesarean delivery with a C-statistic of 0.90 in a training cohort. CONCLUSION: The development phase of this risk model builds on the three previously published models and uses factors readily available at the point of delivery admission discharge. Once tested in a validation cohort, this model could be used to identify at risk women for interventions to help prevent hypertension re-presentation and the short-term and long-term complications of postpartum hypertension.

Ivabradine in the Prevention, and Reduction in Size, of Perioperative Myocardial Injury in Patients Undergoing Orthopedic Surgery for Acute Fracture.

BACKGROUND: Perioperative myocardial injury is common after major noncardiac surgery and is associated with adverse outcomes. This study investigated the use of ivabradine in patients undergoing urgent surgery for fracture. METHODS AND RESULTS: This was a prospective, double-blind, placebo-controlled, randomized clinical trial. Participants were enrolled 1:1 into ivabradine or placebo arm, and study drug was commenced before operation and continued for 7 days or until discharge. High-sensitivity troponin I was measured daily using Abbott Alinity analyzer and assay, and heart rate data were obtained using continuous Holter monitoring. A total of 199 patients underwent acute orthopedic surgery, 98 in the ivabradine group and 101 in the placebo group. The mean age was 78.7 years (range, 77.5-79.9 years), with 68% women. The average heart rate was 5 to 11 beats per minute lower in the ivabradine group compared with the placebo group at all time points (P<0.001 for all). There was no statistically significant difference between the ivabradine and placebo groups in the number of patients who had perioperative myocardial injury: 28.6% versus 31.6% (P=0.71). In patients with perioperative myocardial injury, average peak troponin was 168.8 ng/L (±431.2 ng/L) in the ivabradine group and 2094.5 ng/L (±7201.9 ng/L) in the placebo group (P=0.16). There was no statistically significant difference between groups in 30-day mortality, blood pressure, stroke, or major adverse cardiovascular event. CONCLUSIONS: Starting ivabradine preoperatively in elderly patients requiring acute surgery for fracture did not result in a statistically significant difference in the incidence of perioperative myocardial injury. There was no statistically significant difference in morbidity, mortality, or adverse events between treatment groups. REGISTRATION: URL: https://www.anzctr.org.au/; Unique identifier: ACTRN12616001634460p.

Frequent hospital presenters' use of health information during COVID-19: results of a cross-sectional survey.

BACKGROUND: High-frequency hospital users often present with chronic and complex health conditions and are at increased risk of serious morbidity and mortality if they contract COVID-19. Understanding where high-frequency hospital users are sourcing their information, whether they understand what they find, and how they apply the information to prevent the spread of COVID-19 is essential for health authorities to be able to target communication approaches. METHODS: Cross-sectional survey of 200 frequent hospital users (115 with limited English proficiency) informed by the WHO's "Rapid, simple, flexible behavioral insights on COVID-19". Outcome measures were source of, and trust in information, and knowledge of symptoms, preventive strategies, restrictions, and identification of misinformation. RESULTS: The most frequently cited source of information was television (n = 144, 72%) followed by the internet (n = 84, 42%). One in four television users sought their information from overseas news outlets from their country of origin, while for those using the internet, 56% relied on Facebook and other forms of social media including YouTube and WeChat. Overall, 41.2% of those surveyed had inadequate knowledge about symptoms, 35.8% had inadequate knowledge about preventative strategies, 30.2% had inadequate knowledge about government-imposed restrictions, and 69% believed in misinformation. Half of the respondents (50%) trusted all information, and only one in five (20%) were uncertain or untrusting. English-speaking participants were almost three times more likely to have adequate knowledge about symptoms (OR 2.69, 95%CI 1.47;4.91) and imposed restrictions (OR 2.10 95%CI 1.06; 4.19), and 11 times more likely to recognize misinformation (OR 11.52 95%CI 5.39; 24.60) than those with limited English. CONCLUSION: Within this population of high-frequency hospital users with complex and chronic conditions, many were sourcing their information from less trustworthy or locally relevant sources, including social media and overseas news outlets. Despite this, at least half were trusting all the information that they found. Speaking a language other than English was a much greater risk factor for having inadequate knowledge about COVID-19 and believing in misinformation. Health authorities must look for methods to engage diverse communities, and tailor health messaging and education in order to reduce disparities in health outcomes.

Association between COVID-19 vaccination and 28-day all-cause mortality in SARS-CoV-2-infected older people living in residential aged care facilities.

This retrospective cross-sectional study reviewed the association between COVID-19 vaccination and the 28-day all-cause mortality amongst SARS-CoV-2-infected older people living in residential aged care facilities. A lower mortality rate was observed in fully vaccinated residents compared with not fully vaccinated residents. Further research is required to investigate the optimal timing of vaccination boosters and vaccine efficacy as variants evolve.

Global coagulation assays in patients with chronic kidney disease and their role in predicting thrombotic risk.

BACKGROUND: Despite cardiovascular diseases and thrombosis being major causes of death in patients with chronic kidney disease (CKD), there remains no effective biomarker to predict thrombotic risk in this population. OBJECTIVE: To evaluate global coagulation assays in patients with CKD and correlate the biomarkers to clinical outcomes. MATERIAL AND METHODS: Patients with eGFR<30 mL/min/1.73m2 were recruited (n = 90) in this prospective observational study. Blood samples were collected for global coagulation assays, including thromboelastography, calibrated automated thrombogram (CAT), overall hemostatic potential (OHP) and tissue factor pathway inhibitor (TFPI). RESULTS: Following adjustment for age and gender, CKD subjects (mean age 66 years, 36 % female) had increased maximum amplitude on thromboelastography (70.1 vs 60.2 mm, p < 0.001), higher peak thrombin (233.2 vs 219.7 mm, p = 0.030) and increased OHP (16.1 vs 6.4 units, p < 0.001) compared to healthy controls (n = 153). TFPI was also increased in CKD patients (36.4 vs 14.5 ng/mL, p < 0.001). Compared to hemodialysis patients (n = 43), peritoneal-dialysis patients (n = 25) had more hypercoagulable parameters. Thirty-five CKD patients reported thrombotic complications - key predictors included dialysis, higher fibrinogen, reduced endogenous thrombin potential, elevated D-dimer and increased TFPI. Using the dialysis cohort, the predictive risk model based on the key predictors performed better than Framingham heart score and number of cardiovascular risk factors (Harrell's C-stat 0.862 vs 0.585 vs 0.565). CONCLUSION: CKD appears to confer a hypercoagulable state compared to healthy controls. Interestingly, reduced thrombin generation and raised TFPI was paradoxically associated with increased thrombotic risks, highlighting possible complex compensatory mechanisms within the coagulation system, which may be important in predicting clinical outcomes.

Pre-medical emergency team activations - Patient characteristics, outcomes and predictors of deterioration.

BACKGROUND: Pre-medical emergency team (MET) calls are an increasingly common tier of Rapid Response Systems, but the epidemiology of patients who trigger a Pre-MET is not well understoof. OBJECTIVES: This study aims to examine the epidemiology and outcomes of patients who trigger a pre-MET activation and identify risk factors for further deterioration. METHODS: This is a retrospective cohort study of pre-MET activations in a university-affiliated metropolitan hospital in Australia, between 13 April 2021 and 4 October 2021. A multivariable regression model was used to identify variables associated with further deterioration, defined as a MET call or Code Blue within 24 h of pre-MET activation. RESULTS: From a total of 39 664 admissions, there were 7823 pre-MET activations (197.2 per 1000 admissions). Compared to inpatients that did not trigger a pre-MET, the patients were older (68.8 vs 53.8 years, p < 0.001), were more likely to be male (51.0 vs 47.6%, p < 0.001), had an emergency admission (70.1% vs 53.3%, p < 0.001), and were under a medical specialty (63.7 vs 54.9%, p < 0.001). They had a longer hospital length of stay (5.6 vs 0.4 d, p < 0.001) and higher in-hospital mortality (3.4% vs 1.0%, p < 0.001). A pre-MET was more likely to progress to a MET call or Code Blue if it was activated for fever, cardiovascular, neurological, renal, or respiratory criteria (p < 0.001), if the patient was under a paediatric team (p = 0.018), or if there had been a MET call or Code Blue prior to the pre-MET activation (p < 0.001). CONCLUSION: Pre-MET activations affect almost 20% of hospital admissions and are associated with a higher risk of mortality. Certain characteristics may predict further deterioration to a MET call or Code Blue, suggesting the potential for early intervention via clinical decision support systems.

Early outcomes following the implementation of a specialised pleural disease service.

BACKGROUND: Pleural effusion is a common cause of hospitalisation and a poor prognostic marker that is associated with morbidity and mortality. The evaluation and management of pleural effusion may be performed more effectively by a specialised pleural disease service (SPDS). AIMS: To evaluate the impact of a SPDS established in 2017 at a 400-bed metropolitan hospital in Victoria, Australia. METHODS: A retrospective observational study was undertaken comparing outcomes of individuals with pleural effusions. People with pleural effusion were identified using administrative data. Two 12-month time periods were compared, 2016 (Period 1, before SPDS) and 2018 (Period 2, after SPDS). RESULTS: Period 1 had n = 76 and Period 2 had n = 96 individuals with pleural effusion receiving intervention. Age (69.8 ± 17.6 vs 71.8 ± 15.8), gender and Charlson Comorbidity Index (4.9 ± 2.8 vs 5.4 ± 3.0) were similar across both periods. Utilisation of point-of-care ultrasound for pleural procedures increased from Period 1 to 2, 57.3-85.7% (P < 0.001). There was a reduction in median days from admission to intervention (3.8-2.1 days, P = 0.048) and pleural-related re-intervention rate (32% vs 19%, P = 0.032). Pleural fluid testing was more consistent with recommendations (16.8% vs 43.2%, P < 0.001). Overall, there was no difference in the median length of stay (7.9 vs 6.4 days, P = 0.23), pleural-related readmissions (11% vs 16%, P = 0.69) or mortality (17.1% vs 15.6%, P = 0.79). Procedural complications were similar between the two periods. CONCLUSIONS: The introduction of a SPDS was associated with increased point-of-care ultrasound utilisation for pleural procedures, shorter delays to intervention and improved standardisation of tests on pleural fluid.

Current state of radiomic research in pancreatic cancer: focusing on study design and reproducibility of findings.

OBJECTIVES: To critically appraise methodology and reproducibility of published studies on CT radiomics of pancreatic ductal adenocarcinoma (PDAC). METHODS: PRISMA literature search of MEDLINE, PubMed, and Scopus databases was conducted from June to August 2022 relating to CT radiomics human research articles pertaining to PDAC diagnosis, treatment, and/ or prognosis, utilising Image Biomarker Standardisation Initiative-compliant (IBSI) radiomic software. Keyword search included [pancreas OR pancreatic] AND [radiomic OR [quantitative AND imaging] OR [texture AND analysis]]. Analysis included cohort size, CT protocol used, radiomic feature (RF) extraction, segmentation, and selection, software used, outcome correlation, and statistical methodology, with focus on reproducibility. RESULTS: Initial search yielded 1112 articles; however, only 12 articles met all inclusion/exclusion criteria. Cohort sizes ranged from 37 to 352 (median = 106, mean = 155.8). CT slice thickness varied among studies (4 using ≤ 1 mm, 5 using > 1 to 3 mm, 2 using > 3 to 5 mm, 1 not specifying). CT protocol varied (5 using a single portal-venous (pv)-phase, 5 using a pancreas protocol, 1 study using a non-contrast protocol). RF extraction and segmentation were heterogeneous (RF extraction: 5 using pv-phase, 2 using late arterial, 4 using multi-phase, 1 using non-contrast phase; RF selection: 3 pre-selected, 9 software-selected). 2D/3D RF segmentation was diverse (2D in 6, 3D in 4, 2D and 3D in 2 studies). Six different radiomics software were used. Research questions and cohort characteristics varied, ultimately leading to non-comparable outcome results. CONCLUSION: The current twelve published IBSI-compliant PDAC radiomic studies show high variability and often incomplete methodology resulting in low robustness and reproducibility. CLINICAL RELEVANCE STATEMENT: Radiomics research requires IBSI compliance, data harmonisation, and reproducible feature extraction methods for non-invasive imaging biomarker discoveries to be valid. This will ensure a successful clinical implementation and ultimately an improvement of patient outcomes as part of precision and personalised medicine. KEY POINTS: • Current state of radiomics research in pancreatic cancer shows low software compliance to the Image Biomarker Standardisation Initiative (IBSI). • IBSI-compliant radiomics studies in pancreatic cancer are heterogeneous and not comparable, and the majority of study designs showed low reproducibility. • Improved methodology and standardisation of practice in the emerging field of radiomics has the potential of this non-invasive imaging biomarker in the management of pancreatic cancer.

Haemoglobin drift in patients following Whipple's procedure.

BACKGROUNDS: This study aims to identify the objective findings of haemoglobin (Hb) drift in patients that had a Whipple's procedure in the last 10 years, their transfusion status intraoperatively and post-operatively, the potential factors affecting Hb drift, and the outcomes following Hb drift. METHODS: A retrospective study was conducted at Northern Health, Melbourne. All adult patients who were admitted for a Whipple's procedure from 2010 to 2020 were included and information collected retrospectively for demographics, pre-operative, operative and post-operative details. RESULTS: A total of 103 patients were identified. The median Hb drift calculated from a Hb level at the end of operation was 27.0 g/L (IQR 18.0-34.0), and 21.4% of patients received a packed red blood cell (PRBC) transfusion during the post-operative period. Patients received a large amount of intraoperative fluid with a median of 4500 mL (IQR 3400-5600). Hb drift was statistically associated with intraoperative and post-operative fluid infusion leading to concurrent issues with electrolyte imbalance and diuresis. CONCLUSION: Hb drift is a phenomenon that does happen in major operations such as a Whipple's procedure, likely secondary to fluid over-resuscitation. Considering the risk of fluid overload and blood transfusion, Hb drift in the setting of fluid over-resuscitation needs to be kept in mind prior to blood transfusion to avoid unnecessary complications and wasting of other precious resources.

An integrated interpreting service normalizes access to care for culturally and linguistically diverse (CALD) patients with colorectal cancer.

AIM: To compare access to the initial management and overall survival with colorectal cancer for limited English proficient (LEP) patients compared with patients from an English background. METHODS: All newly diagnosed patients from 2017 with colorectal cancer from a single health service with a highly multicultural catchment area and a well-developed and integrated translation and language support (TALS) department were recruited. Time from referral to: biopsy, date seen by a surgeon, oncologist, discussion at a multidisciplinary meeting (MDM), and day of commencement of the first treatment modality, and overall survival were analyzed. RESULTS: One hundred sixty-two patients were analyzed, including 57 LEP patients from 22 countries of birth. Interpreters were present at 687/782 appointments with LEP patients. There were no differences in demographics or cancer staging. There were no differences between English background and LEP patients with regard to times from referral to biopsy (1 vs. 0 days), specialist review (surgical: 4 vs. 6 days, oncological: 45 vs. 57 days), MDM discussion (23 vs. 15 days), or commencement of treatment (32 vs. 28.5 days). There were no differences in treatment for colorectal cancer, although a higher rate of stomas was noted in LEP patients. There was no difference in overall survival between groups. CONCLUSION: Time to critical initial checkpoints and overall survival were similar in LEP and English background patients with colorectal cancer. An integrated TALS department may abrogate the language and cultural barriers that are known to disadvantage LEP patients and may contribute to normalizing care for the culturally and linguistically diverse community.

Health professionals' attitudes towards acupuncture/acupressure for post-operative nausea and vomiting: a survey and implications for implementation.

PURPOSE: Level 1 evidence supports the use of acupuncture/acupressure (A/A) to manage post-operative nausea and vomiting (PONV). This study aimed to survey healthcare professionals' attitudes towards A/A, influencing factors and barriers to implementing this effective non-drug intervention into peri-operative care. METHODS: A validated, anonymous survey with 43 questions was emailed or distributed as a hard copy at meetings to anaesthetists, midwives, nurses, obstetricians, gynaecologists and surgeons at a public hospital in Australia. Descriptive data were presented. Influencing factors were explored using chi-square analysis. Multinomial logistical regression was used to identify the influences of confounding factors. RESULTS: A total of 155 completed surveys were returned, reflecting a response rate of 32%. The majority of participants were female (69%), nurses/midwives (61%) and aged between 20 and 50 years old (76%). Eighty-three percent of respondents considered A/A 'clearly alternative' medicine or 'neither mainstream nor alternative'. Eighty-one percent would encourage patients to use acupressure for PONV if it was offered at the hospital. Previous personal use of A/A was the key factor influencing attitudes and openness to clinical use. The key barriers to implementation were perceived lack of evidence and lack of qualified providers and time. CONCLUSION: Hospital-based healthcare professionals strongly supported the evidence-based use of A/A for PONV despite considering the therapy to be non-mainstream and having limited A/A education or history of personal use, providing a positive context for an acupressure implementation study. Significant gaps in training and a desire to learn were identified.

A Predictive Tool for Choledocholithiasis in Patients Undergoing Emergency Cholecystectomy.

Background: Management of acute cholecystitis with emergency laparoscopic cholecystectomy has been established; however, detection and management of concurrent choledocholithiasis are debated. The aim of this study is to develop a more accurate choledocholithiasis predictive model. Materials and Methods: A 9-year audit of emergency cholecystectomies and evaluation of preoperative factors in predictive models. Receiver Operating Curve (ROC) analysis/Youdon Index was used to identify thresholds maximizing these associations for continuous variables. Results: 1601/1828 patients were analyzed. Patients who were diagnosed with choledocholithiasis were more likely to be febrile on admission, have a higher C-reactive Protein, and higher median bilirubin (25.0 µmol/L versus 11.0 µmol/L, P < .001). When excluding bilirubin, multivariate analysis detected several significant variables, including fever, biliary tree dilatation, or a common bile duct stone seen on ultrasound. When bilirubin was included into the model, bilirubin of 20-39 µmol/L (odds ratio [OR] 2.44, 95% confidence interval [CI]: 1.74-3.44) and ≥40 µmol/L (OR 4.84, 95% CI: 3.40-6.91) were shown to have increased likelihood of choledocholithiasis detection on intraoperative cholangiogram, with the ROC model having a significant C-statistic of 0.796 (P < .001). Discussion: A perfect predictive model for concurrent choledocholithiasis in acute cholecystitis does not exist; however, the results from this study are encouraging that high and low predictive groups can be established.

Plasma Angiotensin Converting Enzyme 2 (ACE2) Activity in Healthy Controls and Patients with Cardiovascular Risk Factors and/or Disease.

Angiotensin converting enzyme 2 (ACE2) is an endogenous negative regulator of the renin-angiotensin system, a key factor in the development of cardiovascular disease (CVD). ACE2 is also used by SARS-CoV-2 for host cell entry. Given that COVID-19 is associated with hypercoagulability, it is timely to explore the potential relationship between plasma ACE2 activity and the coagulation profile. In this cross-sectional study, ACE2 activity and global coagulation assays (GCA) including thromboelastography, thrombin, and fibrin generation were measured in adult healthy controls (n = 123; mean age 41 ± 17 years; 35% male) and in patients with cardiovascular risk factors and/or disease (n = 258; mean age 65 ± 14 years; 55% male). ACE2 activity was significantly lower in controls compared to patients with cardiovascular risk factors and/or disease (median 0.10 (0.02, 3.33) vs. 5.99 (1.95, 10.37) pmol/mL/min, p < 0.001). Of the healthy controls, 48% had undetectable ACE2 activity. Controls with detectable ACE2 had lower maximum amplitude (p < 0.001). In patients with cardiovascular risk factors and/or disease, those in the 3rd tertile were older and male (p = 0.002), with a higher Framingham grade and increased number of cardiovascular risk factors (p < 0.001). In conclusion, plasma ACE2 activity is undetectable to very low in young healthy controls with minimal clinically relevant associations to GCA. Patients with cardiovascular risk factors and/or disease have increased plasma ACE2 activity, suggesting that it may be an important biomarker of endothelial dysfunction and atherosclerosis.

Doctors' and Nurses' Attitudes of Acupuncture and Acupressure use in Perioperative Care: An Australian National Survey.

BACKGROUND: Acupuncture and acupressure are not being systematically used in the management of postoperative nausea and vomiting and pain, despite being included in the guidelines. AIM: To examine the beliefs, attitudes, and knowledge of Australian nurses/midwives and doctors toward the perioperative use of AA for the management of postoperative nausea and vomiting and pain; to explore the barriers and enablers influencing acupuncture and acupressure integration into hospital setting. METHODS: A mixed-mode approach was undertaken for data collection. An online approach was used to recruit respondents from Australian College of Perioperative Nurses. Three hospitals from three different Australian states were selected via convenience sampling. RESULTS: A total of 421 usable surveys were included in data analysis. The respondents comprised 14.3% doctors and 72.9% nurses/midwives. Overall, 69.4% were female, 85% were trained in Australia with 35% and 51.4% having knowledge or personal exposure to AA in general respectively. Over 60% of the respondents agreed AA should be routinely integrated into perioperative care, and over 80% would recommend AA to their patients if it was provided at their hospital, and, 75% would be willing to receive further education. The three main reported barriers included: perceived lack of scientific evidence (80.9%), unavailability of credentialed provider (77.2%) and lack of reimbursement (60.4%). CONCLUSIONS: Positive attitudes are reported by Australian doctors and nurses toward AA. This is despite of low levels of knowledge or personal exposure to AA. Further studies are required to explore the implementation of barriers and address respondent calls for further education.