The epidemiology of acute pancreatitis in tasmania over a 12-year period: Is this a disease of disadvantage?

BACKGROUND: The global incidence of acute pancreatitis (AP) is increasing, but little information exists about trends in Australia. This study aimed to describe incidence trends, along with clinical and socio-demographic associations, in the state of Tasmania over a recent 12-year period. METHODS: The study cohort was obtained by linking clinical and administrative datasets encompassing the whole Tasmanian population between 2007 and 2018, inclusive. Pancreatitis case definition was based on relevant ICD-10 hospitalization codes, or elevated serum lipase or amylase in pathology data. Age-standardised incidence rates were estimated, overall and stratified by sex, aetiology, and Index of Relative Socio-economic Disadvantage (IRSD). RESULTS: In the study period, 4905 public hospital AP episodes were identified in 3503 people. The age-standardised person-based incidence rate across the entire period was 54 per 100,000 per year. Incidence was inversely related to IRSD score; 71 per 100,000 per year in the most disadvantaged quartile compared to 32 in the least disadvantaged. Biliary AP incidence was higher than that of alcohol-related AP, although the greatest incidence was in "unspecified" cases. There was an increase in incidence for the whole cohort (average annual percent change 3.23 %), largely driven by the two most disadvantaged IRSD quartiles; the least disadvantaged quartile saw a slight overall decrease. CONCLUSION: This is the first Australian study providing robust evidence that AP incidence is increasing and is at the upper limit of population-based studies worldwide. This increased incidence is greatest in socio-economically disadvantaged areas, meriting further research to develop targeted, holistic management strategies.

Telehealth experiences of vulnerable clients living in Tasmania.

OBJECTIVE: To understand the experiences of vulnerable clients who used telehealth during the Coronavirus pandemic. DESIGN: The study employed a qualitative enquiry, utilising semi-structured interviews lasting 30-60 minutes with a thematic analysis approach to explore factors influencing client experience with telehealth. SETTING: A wide range of locations across Tasmania, Australia. PARTICIPANTS: Twelve participants who were considered to be vulnerable on a number of domains, including: health and human wellbeing factors, social risk factors, functional limitations, and individual behavioural factors. INTERVENTIONS: The provision of telehealth consultations to vulnerable clients. MAIN OUTCOME MEASURES: Four global themes were discovered: i) Telehealth saves time, money and energy; ii) User friendly technology facilitates care; iii) Rapport and confidentiality helps clients to feel safe; and iv) Fit for purpose telehealth provides a quality service. RESULTS: The discovered themes entailed the major finding that most participants were satisfied with the overall quality of the telehealth service they received and the convenience of this service. Concerns were raised regarding the limitations around social interaction, physical examination, and access to fit-for-purpose telehealth devices. CONCLUSION: This research with vulnerable clients, from Tasmania, supports the evidence that the utilisation of telehealth allows more convenient access to care. To optimise the service, however, concerns regarding the desire for social interaction, appropriate physical examination, and access to fit-for-purpose telehealth devices will need to be addressed.

Systemic predictors of adverse events in a national surgical mortality audit: analysis of peer-review data from Australia and New Zealand Audit of Surgical Mortality.

BACKGROUND: Peer review of surgical deaths can identify deficits in individual and systemic delivery of healthcare, ultimately informing quality improvement. METHODS: From 2008 to 2016, cases reported to the Australia and New Zealand Audit of Surgical Mortality were analysed. Variables associated with peer-judged adverse events were sought. RESULTS: Of 21 045 cases evaluated, 24.8% incurred at least one adverse event judgement. The proportion of cases with reported adverse event significantly decreased over time. Following adjustment for demographic and clinical characteristics, significant negative patient-related associations were advanced age, greater American Society of Anesthesiologists grade, and neurological and malignant comorbidities. Significant associations were also found with systemic or organizational factors, including state/territory, surgical specialty and hospital regionality. CONCLUSION: Examination of this peer-reviewed database revealed systemic or organizational predictors of adverse events that may have implications for quality improvement at an institutional or jurisdictional level. The extent to which these associations are due to the peer-review process itself should be the focus of further research.

Endoscopic duodenal perforation: surgical strategies in a regional centre.

BACKGROUND: Duodenal perforation is an uncommon complication of endoscopic retrograde cholangio-pancreatography (ERCP) and a rare complication of upper gastrointestinal endoscopy. Most are minor perforations that settle with conservative management. A few perforations however result in life-threatening retroperitoneal necrosis and require surgical intervention. There is a relative paucity of references specifically describing the surgical interventions required for this eventuality. METHODS: Five cases of iatrogenic duodenal perforation were ascertained between 2002 and 2007 at Cairns Base Hospital. Clinical features were analyzed and compared, with reference to a review of ERCP at that institution for the years 2005/2006. RESULTS: One patient recovered with conservative management. Of the other four, one died after initial laparotomy. The other three survived, undergoing multiple procedures and long inpatient stays. CONCLUSIONS: Iatrogenic duodenal perforation with retroperitoneal necrosis is an uncommon complication of endoscopy, but when it does occur it is potentially life-threatening. Early recognition may lead to a better outcome through earlier intervention, although a protracted course with multiple procedures should be anticipated. A number of surgical techniques may need to be employed according to the individual circumstances of the case.

Clinical predictors of severe acute pancreatitis: value-adding the view from the end of the bed.

BACKGROUND: Research into clinical determinants of severe acute pancreatitis remains important for therapeutic and preventive purposes. To contribute to prognostication, this study aimed to define clinical risk factors for the development of severe acute pancreatitis. METHODS: Study design was a prospective cohort study, using multiple logistic regression. From March 2004 to July 2007, 153 cases of acute pancreatitis were recruited in a regional Australian hospital. Data were collected regarding demographic and clinical characteristics. The outcome measure was severe acute pancreatitis, as defined by composite consensus criteria. RESULTS: After adjustment for potential confounders, there was a significant positive association with waist circumference and a negative association with current smoking status. CONCLUSION: The study confirms other work suggesting central adiposity as a risk factor for severe acute pancreatitis. The finding of a possible protective effect for smoking may be physiologically plausible but merits further confirmatory research.

What is the 'real' admission rate of acute pancreatitis in a regional Australian population?

OBJECTIVE: Capture-recapture analysis was used to more accurately quantify the admission rate for acute pancreatitis in a regional hospital setting, in comparison to the usual method of case ascertainment. Reasons for differences in capture for the various methods were also sought. METHODS: Admissions for acute pancreatitis were enumerated over a 40-month period using three data sources: hospital classification of admission diagnoses, prospective case identification, and receipt of diagnosis-specific pathology specimens. Capture-recapture analysis was applied with log-linear modelling to account for likely dependency between data sources. Covariates were noted to explain capture probability by the various data sources and for eventual stratification in the analysis process. RESULTS: For the census period, there were 304 admissions after merging of data sources, giving a crude admission rate of 7.6 per month. Crude ascertainment rates for discharge records and prospective identification were 44% and 52% respectively. Following log-linear modelling, total admissions more than doubled to 644 (adjusted admission rate 16.1 per month). Of the covariates considered, admissions of less than three days' duration and those occurring in December and January were significantly associated with increased capture by the hospital discharge records data source. CONCLUSIONS: In this clinical setting, admissions for acute pancreatitis are grossly underestimated by the standard case ascertainment method. The reasons for this are not clear. Hospital discharge records are nevertheless more effective than prospective case ascertainment for certain cases, such as brief admissions and those in holiday periods. WHAT IS KNOWN ABOUT THE TOPIC? Capture-recapture analysis was originally developed in animal ecology, but has since been used to estimate both prevalent and incident cases of human disease. WHAT DOES THIS PAPER ADD? This study exposes possible deficiencies in the single-source case ascertainment methods used by most hospitals to enumerate incident cases. It is the first time that capture-recapture techniques have been used to estimate acute pancreatitis admissions. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? To obtain accurate admissions estimates for diseases such as acute pancreatitis, capture-recapture analysis with multiple data sources is advisable. One possible solution may be to conduct intermittent prospective censuses to complement existing retrospective ascertainment methods. On a more general level, clinical staff should be better trained to provide more accurate and detailed information in case records.

Intake patterns of food nutrients and other substances associated with chronic pancreatitis.

BACKGROUND/OBJECTIVES: While alcohol is considered the most common aetiological factor for chronic pancreatitis, the intake of various nutrient and other substances is thought to act as cofactors in the pathogenesis of the disease due to modulation of oxidative stress. This study examined incident cases of acute pancreatitis to determine the dietary and other intakes that characterize those harbouring underlying chronic pancreatitis. METHODS: Cases of acute pancreatitis presenting to a single institution were prospectively recruited (n = 153). The presence of chronic pancreatitis was defined by a composite of clinical, biochemical and radiological criteria. Information was obtained on the intake of dietary macro- and micronutrients, coffee, tobacco and alcohol in the period just prior to the acute exacerbation. Univariate and multivariate analyses of association were undertaken. Principal components analysis (PCA) was employed to elicit patterns of intake. RESULTS: After adjustment for key demographic variables, no individual nutrient or other substance showed a significant association with chronic pancreatitis. However, following PCA there emerged a significant positive association with a so-called "stimulant" intake pattern and a negative association with a so-called "nutritive" pattern. CONCLUSIONS: Preceding an acute exacerbation, patients with underlying chronic pancreatitis are more likely to substitute food-based intake for combinations of other substances, such as tobacco and coffee. This finding may have application in the clinical setting as part of a chronic disease management protocol.

The medical and retrieval costs of road crashes in rural and remote northern Queensland, 2004-2007: findings from the Rural and Remote Road Safety Study.

OBJECTIVE: To estimate costs of retrieval, transport and acute medical services associated with road crashes in northern Queensland from March 2004 to June 2007. DESIGN, SETTING AND PARTICIPANTS: Case study of 696 people aged 16 years or older who had been involved in a road crash in the study area (all areas north and west of Bowen, excluding the urban areas of Townsville and Cairns) and had been admitted to hospital for a minimum of 24 hours after the crash. Data on mode of retrieval, acute care provided and total costs were obtained for each patient. MAIN OUTCOME MEASURES: Method of retrieval or transport; length of stay in intensive care unit (ICU) and/or hospital for each patient; costs of retrieval, transport and inhospital care. RESULTS: Retrieval data were collected for 614 of the 696 study participants (88%). Most primary retrievals (446; 73%) occurred by road. More than half of interhospital transfers were undertaken by fixed or rotary wing services. Casualties in the study occupied a total of 6360 bed-days, of which 734 were ICU bed-days. The total retrieval, transport and acute hospital care costs of road crash victims in northern Queensland over the study period were calculated to be approximately $10.4 million. CONCLUSION: The costs associated with rural and remote road crashes in northern Queensland represent a considerable economic burden.