Internal medicine in the bush: a clinical audit of a rural and remote outreach programme.

BACKGROUND: Provision of internal medicine services in rural Australia is always problematic. AIM: The aim was to undertake an audit of an outreach service operating in Northern New South Wales since 2006. METHODS: The service is conducted eight times a year, involving a consultant and an advanced trainee who travel by car to the towns of Moree and Mungindi and conduct clinics in a general practice setting, an Aboriginal medical service and a local health district clinic. Since 2008, a cardiology service and a diabetes service have been added on a fly-in fly-out basis. Case records of all patients enrolled in the service between February 2006 and July 2013 were reviewed in determining the demographics, clinical presentations and level of service coverage. The experience of the authors in establishing the service provided insights into the challenges and the success factors involved. RESULTS: Five hundred and eighty-three patients were seen on a total of 1070 occasions relating to a wide variety of clinical presentations. Of these, 31.3% were indigenous compared with 20% in the local statistical area, and both indigenous and non-indigenous patients were seen in all settings. Patients fell into 15 different diagnostic categories with indigenous patients more likely to present for diabetes (P < 0.001) and hepatitis B (P < 0.01), but less likely to present for treatment of hepatitis C (P < 0.01). CONCLUSIONS: In providing an outreach service to a mixed community, flexibility in both setting and personnel are essential. Diabetes and liver disease are highly prevalent in indigenous patients, but the low numbers presenting for hepatitis C requires further study.

Marijuana 'bong' smoking and tuberculosis.

The incidence of tuberculosis in the non-indigenous Australian population is low. However, in this paper we report on three cases of cavitating disease, which seem to be associated with a common illicit drug habit namely smoking marijuana using a makeshift pipe or bong. There was a total of 34 positive contacts of these cases and among the contacts sharing a bong with an index case was associated with a sixfold risk of transmission (odds ratio 6.5, confidence interval 1.4-30.4, P = 0.016). When cavitating tuberculosis is detected in a young non-indigenous native born Australian, marijuana use should be considered as a possible risk factor.

Successful surgical treatment of protein-losing enteropathy complicating rheumatic tricuspid regurgitation.

Protein-losing enteropathy may uncommonly complicate cardiac disease. While well described as a complication for patients having undergone previous Fontan surgery for congenital heart disease, pericardial and valvular aetiologies are much less frequent. We report a 35-year-old female presenting with marked hypoalbuminaemia and peripheral oedema on a background of known rheumatic valvular heart disease. After extensive investigation for gastrointestinal, hepatic and renal causes of protein loss, echocardiography demonstrated severe tricuspid valve incompetence. Subsequent invasive testing confirmed severe tricuspid valve regurgitation in the absence of pericardial constriction. The patient proceeded to tricuspid valve repair with resolution of the protein-losing state and correction of hypoalbuminaemia. While cardiac causes of gastrointestinal protein loss are uncommon, they should be considered when initial diagnostic work up is negative. The importance of correction of haemodynamic precipitants of protein-losing enteropathy is also discussed.

Circuit breakers for addiction.

The phenomenon of addiction is complex, although its expression clinically is relatively straightforward. There is a series of neurophysiological changes that mediate changes in the mesolimbic and mesocortical systems which in turn lead to disturbances in reward mechanisms. These then act to perpetuate the cycle of intoxication and reinforcement, withdrawal, craving and compulsive use. As our understanding of the pathophysiology of this process has improved, new pharmacological agents have been developed with the potential to moderate or even reverse it. This article briefly reviews the treatment of addiction with particular reference to emerging pharmaceutical agents.

Eating behaviours are different in youth with obesity and severe obesity.

The study purposes were to: (i) Investigate eating behaviours among patients in a paediatric weight management clinical practice and (ii) Compare eating behaviour phenotypes between children with severe obesity and obesity. This was a retrospective cross-sectional study using data collected during clinical encounters. Participants were included if they were 2-12 years old, had a body mass index ≥95th percentile and if a parent or guardian completed the Child Eating Behaviour Questionnaire (CEBQ). Participants (n = 149) were children with severe obesity (n = 108) and obesity (n = 41). The mean Satiety Responsiveness score was significantly lower for children with severe obesity than for children with obesity. Girls with severe obesity had significantly higher Enjoyment of Food and significantly lower Satiety Responsiveness and Slowness in Eating than girls with obesity. The findings demonstrate the potential clinical utility of the CEBQ for informing tailored treatment strategies through identifying eating behaviour phenotypes.

Benzodiazepine use as a cause of cognitive impairment in elderly hospital inpatients.

BACKGROUND: Benzodiazepine drugs are used very frequently by the elderly and have been associated with a number of untoward events in them. In an earlier publication, we showed that there was an association between benzodiazepine use and episodes of confusion in hospital. The purpose of this study was to examine that association in more detail by studying only patients with intact cognitive function on admission and by taking into consideration a range of demographic, drug use, and clinical confounders. METHODS: A prospective cohort study was carried out of inpatients who had normal cognitive function on admission to hospital. The subjects were 418 hospital inpatients who had a normal result of a Mini-Mental State Examination (MMSE) performed within 24 hours of admission. They were aged 59-88 years. A clinical history and detailed drug use history were taken on admission and then the patients were followed prospectively for 10 days or until discharge, whichever was sooner. The MMSE was repeated every 2 days and all significant clinical events and episodes of delirium noted. RESULTS: 10.8% (95% Confidence Interval [CI]: 7.8-13.8%) of patients developed cognitive impairment (as indicated by a decrease in the MMSE). Factors that were statistically significantly related to the development of cognitive impairment included admission diagnoses of cancer or central nervous system (CNS) disease, alcohol consumption > 40 gms/day, hypoxia, and presence of benzodiazepines in the urine on admission. After adjusting for age, alcohol consumption, and admission diagnoses, those who reported taking benzodiazepines in daily doses equivalent to 5 mg or more of diazepam were at significantly higher risk of cognitive impairment than those who had not taken benzodiazepines (adjusted odds ratio = 3.5; 95% CI: 1.4-8.8). Twenty-one (5.0%, 95% CI: 2.9-7.1%) patients developed delirium as defined by the DSM-IIIR criteria. Age and hypoxia were statistically significantly related to the development of delirium. Due to the small number of cases of delirium, the power of the study to detect significant associations was low. CONCLUSIONS: Elderly hospital inpatients who have intact cognitive function on admission to hospital have a low risk of developing cognitive impairment and delirium during their hospital stay. In this population, however, benzodiazepine use accounted for 29% of cases of cognitive impairment which did occur. The data also suggest that dehydration, urinary retention, and an admission diagnosis of CNS disease may be important risk factors for delirium.

The course of alcohol withdrawal in a general hospital.

We conducted an observational study of 539 episodes of alcohol withdrawal in a general hospital, to determine the natural history, the incidences of seizures, hallucinations and delirium, and the risk factors for these events. The reaction began soon after arrival, at a median time of 5 h, and resolved at a median time of 22 h. Patients with a blood alcohol level of zero were in withdrawal on arrival, and only four patients had reactions lasting 120 h or longer. Complications were observed in 113 patients (21%) during the admission. Seizures occurred on arrival, hallucinations usually in the first 24 h and delirium in the first 48 h. No mortality was associated with alcohol withdrawal itself, but complications did extend length of stay by a median of 4 days, with delirium contributing most to the increase. Patients over 70 years of age or admitted with seizures had an increased risk of complication, but the greatest risk was associated with a delay in assessment of > 24 h. We conclude that in general hospitals, the alcohol withdrawal reaction becomes established very early, and detection and monitoring of patients within the first 24 h is the most important element in management.

Non-specific immunological function in acute myeloblastic leukaemia.

Immunological function was investigated in patients with acute myeloblastic leukaemia, both in the untreated stage of the disease and in remission. IgM concentrations were found to be raised in 7 out of 29 patients during the untreated stage. There were only minimal changes in 1gG, 1gA and C' concentrations, and in the incidence of auto-antibodies to normal tissue components. Reactions to standard skin tests were considerably impaired--only 2 out of 10 leukaemic patients in remission responded to 2 or more of these tests. Furthermore the response in leukaemic patients was much weaker than in the corresponding controls. PHA stimulation of lymphocytes from patients in remission showed considerable variation from near normal to gross impairment but a response below 40% of normal was associated with a short remission period, suggesting that PHA stimulation may be a useful indication of the likelihood of relapse.

Drug withdrawal: a selective review.

This review will concentrate on the contributions medical science, in particular pharmacology and electrophysiology, have made to the understanding of withdrawal states and so will look mostly at the first element in withdrawal. Behavioural and emotional issues will be dealt with in the section on management.

Detoxification: the basis of current practice.

With chronic use of a psychoactive drug the central nervous system undergoes a series of changes. These changes vary both in nature and in extent with each drug, but in general, they alter the responsiveness of the nervous system to the drug so as to reduce the perceived clinical effect, and also alter the innate responsiveness of the affected neurons to various stimuli. With cessation of drug use the nervous system undergoes a natural healing which consists of a restoration of normal responsiveness, but this process takes some time during which the patient's responses are abnormal and they are vulnerable to a variety of stressors. Detoxification is the safe negotiation of this period.

The incidence of alcohol-related problems and the risk of alcohol withdrawal in a general hospital population.

A survey was carried out using the Canterbury Alcohol Screening Test (CAST) and clinical criteria for risk of alcohol withdrawal of 2000 randomly selected hospital in-patients in order to determine the prevalence of alcohol-related problems, the work-load for a specialist alcohol withdrawal service and the target group for early intervention. Patients at risk of alcohol withdrawal were followed prospectively.The major findings were: 14.3% of patients had a positive CAST and 8% were at risk of alcohol withdrawal; the prevalence of positive clinical criteria was greatest in men under the age of 30 years (OR 3.6) and very low (OR 0.34) in women over 60 years. In addition, patients who were too sick or refused to complete the questionnaire had high rates of being at risk for alcohol withdrawal. The prevalence of CAST positivity was greatest in men under the age of 40 years (OR 3.7) and lowest in women over 70 years (OR 0.2). It is concluded that 15-20% of in-patients have alcohol problems and 8% are at risk of withdrawal; questionnaires will produce underestimates of the order of 25%; and female in-patients over the age of 60 years are extremely unlikely to have problems with alcohol.

An open trial of naltrexone for opiate dependence.

The objective of this study was to conduct a pilot study of naltrexone in opiate-dependent patients in order to determine the sample size for a double-blind controlled trial, to identify possible confounders and to obtain experience with the drug's side effects and acceptability to patients. Opiate-dependent patients presenting to a public hospital for treatment for their dependence were invited to participate. Patients with major organic illness, another Axis I diagnosis, or who were pregnant were excluded. Naltrexone was prescribed at a dose of 50 mg daily for 6 months. Data were collected on drug use, social stability, physical and mental health before during and after the treatment programme. Patients were seen weekly for 6 months then monthly for a further 6 months. Forty-four patients were enrolled, but three stopped naltrexone early because of possible side effects. Of the remainder, 32 were followed for at least 12 months. Eight (25%) ceased opiate use from the start, and another two were no longer using at the end of 12 months giving an abstinence rate of 31% at 12 months. Retention in treatment was 34%. Of the abstinent patients however, only two took naltrexone for the whole 6 months. Naltrexone was well tolerated and associated with a significant abstinence rate, but most patients do not feel they need to take the drug for 6 months. A double-blind controlled trial would be justified.

Barbiturate withdrawal--a nomogram for supplementary dosing after the phenobarbitone loading technique.

A case of a woman who presented with a multiple drug overdose and then subsequently had a withdrawal syndrome complicated by seizures and delirium highlights the seriousness of the barbiturate withdrawal syndrome. The patient had a short elimination half-life for phenobarbitone and required supplementary phenobarbitone doses to prevent and treat these complications. We have devised a nomogram which in conjunction with serum levels allows a rapid determination of whether and how much supplementary doses are required during barbiturate withdrawal.

Clinical use of a shortened alcohol withdrawal scale in a general hospital.

BACKGROUND: Multi-item scales for monitoring alcohol withdrawal reactions have been used since the 1970s, and since 1985 we have used a modified version of the Clinical Institute Withdrawal Assessment (CIWA) in our general hospitals. This study was conducted to determine whether a shorter version of the scale would prove easier to use without loss of accuracy. METHODS: A simultaneous 'crossover' clinical audit using two hospitals. The shortened scale was developed from the existing one, and had 10 items as opposed to the previous 18. The patients were followed throughout their course and the incidences of complication, the frequency of sedation, the delay in initiating monitoring and the ease of use were recorded. RESULTS: There were 106 patients managed with the old scale and 96 with the new. The rate of complication was not different, being 16% in patients managed using the old scale and 14.5% using the new scale; the rates of sedation were 49 and 48%, respectively. Patients managed with the new scale had a shorter course with a median duration of 27.6 h compared with 40 h. The time from admission to first recording of a score was 5.4 h for the new scale and 4.8 h for the old, which is not a significant difference. Both scores were used according to instructions, but staff reported that the shortened scale was easier to use. CONCLUSIONS: We conclude that a shortened form of the CIWA alcohol withdrawal scale works as well as the original and is simple to use.

Cigarette smoking in pregnancy.

PIP: It is likely that the most important example of passive smoking is that which is imposed on the fetus. An article in the April 18, 1988, issue of the "Medical Journal of Australia" makes it clear (Condon and Hilton) that great difficulties will be faced in dealing with the effects of smoking during pregnancy. Gritz (1980) examined the evidence for fetal toxicity from tobacco smoke and the risk ratios for the various hazards. The risk of spontaneous abortion is increased by a factor of 1.8, low birth weight by a factor of 2.0, and perinatal mortality by a factor of 1.35. These increases come as no surprise given what is known regarding the pathophysiology of tobacco's effect on the fetus and the placenta. Condon and Hilton report on the observation that pregnant women find it much easier to stop drinking alcohol than to quit smoking cigarettes. Women who reported positive feelings about their pregnancy also indicated that their concern about, and attachment to, their unborn child provided insufficient motivation to stop using nicotine. It is assumed that the women described in this article were aware of the risks to the fetus from smoking in that such information is available almost as a routine part of antenatal care, and all but 1 of the smokers did try to reduce or to stop their use of nicotine. Yet, 14 of the 35 smokers failed in their efforts to reduce their smoking; another 7 smokers could manage only a small reduction. The 23,000 tobacco-associated deaths/year support the importance of developing a strategy to deal with nicotine dependence, particularly in situations of high risk such as pregnancy. The most reasonable and potentially effective approach would be to expend energy on preventing or dissuading young women from smoking in the 1st place. Over the past decade there have been numerous efforts at mass-media and educational campaigns to dissuade women from smoking, but these efforts have been overwhelmed totally by the determined drive on the part of tobacco companies to recruit female smokers.^ieng