Outcomes of patients with Barrett's oesophagus with low-grade dysplasia undergoing endoscopic surveillance in a tertiary centre: a retrospective cohort study.

BACKGROUND AND AIM: Barrett's oesophagus predisposes individuals to oesophageal adenocarcinoma (OAC), with the risk of progression to malignancy increasing with the degree of dysplasia, categorized as either low-grade dysplasia (LGD) or high-grade dysplasia (HGD). The reported incidence of progression to OAC in LGD ranges from 0.02% to 11.43% per annum. In patients with LGD, Australian guidelines recommend 6-monthly endoscopic surveillance. We aimed to describe the surveillance practices within a tertiary centre, and to determine the predictive value of surveillance as well as other risk factors for progression. METHODS: Endoscopy and pathology databases were searched over a 10-year period to collate all cases of Barrett's oesophagus with LGD. Medical records were reviewed to document patient factors and endoscopic and histologic details. Because follow-up times varied greatly, survival analysis techniques were employed. RESULTS: Fifty-nine patients were found to have LGD. Thirteen patients (22.0%) progressed to either HGD or OAC (10 (16.9%) and three (5.1%) respectively); the annual incidence rates of progression to HGD/OAC and OAC were 5.5% and 1.1% respectively. All patients who developed OAC had non-guideline-adherent surveillance. A Cox model found only two predictors of progression: (i) guideline-adherent surveillance, performed in 16 (27.1%), detected progression to HGD/OAC four times earlier than non-guideline-adherent surveillance (95% confidence interval (CI) = 1.3-12.3; P = 0.016). (ii) The detection of visible lesions at exit endoscopy independently predicted progression (hazard ratio = 6.5; 95% CI = 1.9-22.8; P = 0.003). CONCLUSION: Barrett's oesophagus with LGD poses a significant risk of progression to HGD/OAC. Guideline-recommended surveillance is effective, but is difficult to adhere to. Clinical predictors for those who are more likely to progress are yet to be defined.

Concerns and psychological well-being of healthcare workers during the COVID-19 pandemic in a tertiary care hospital in New South Wales.

BACKGROUND: In early 2020, the impending COVID-19 pandemic placed a once-in-a-generation professional and personal challenge on healthcare workers. Publications on direct physical disease abound. The authors wanted to focus on doctors' psychological well-being. AIMS: To assess the impact of the COVID-19 pandemic on doctors' well-being and evaluate their concerns as the pandemic progressed. METHODS: A mixed-methods, hospital-based survey was sent to doctors at the 650-bed tertiary referral hospital in NSW at two different periods (late-March and early May 2020). A validated mental well-being tool (Short Warwick Edinburgh Mental Well-being Scale (SWEMWBS)) was combined with COVID-19-specific questions. RESULTS: Two hundred and thirty-five responses were obtained from 450 doctors, with a response rate of 32% in the first survey and 20% in the second. The majority (35%) of respondents were doctors-in-training, followed by staff-specialists (23%). The highest response was from frontline workers in both surveys, including the intensive care unit (27%), anaesthesia (21%) and emergency department (13%). 'Extreme concern' regarding personal protective equipment (PPE) shortage dropped from 22.6% to 2.2% and 'extreme concern' of contracting COVID-19 fell from 22.6% to 3.4% in the second survey. The proportion of respondents with a 'low' psychological well-being score improved from 38% to 27% between the two surveys. The resulting mean improvement in the SWEMWBS was 3.49 (95% confidence interval = 3.06-3.91, P < 0.001). CONCLUSION: Both COVID-19 specific concerns and psychological well-being improved greatly in the second survey. Possible explanations are the fall in COVID-19 cases in the district, improvements in PPE supply and supportive measures communicated to doctors during this period.

Open Debridement is Superior to Arthroscopic Debridement for the Infected Total Knee Arthroplasty.

BACKGROUND: Acutely infected total knee arthroplasty (TKA) is commonly treated with debridement, antibiotics, and implant retention (DAIR). There are no direct comparative studies to determine whether debridement should be performed open or arthroscopically for infected TKA. The aim of this study is to compare the outcomes of open vs arthroscopic debridement of infected TKAs. METHODS: All patients at a university teaching hospital with an infected TKA treated with DAIR between 2002 and 2017 were analyzed. The primary outcome was successful treatment defined using international consensus criteria. Secondary outcomes included antibiotic suppression, prosthesis retention, mortality, postoperative range of motion, and length of stay. Clinical, laboratory, surgical, and antibiotic treatment data were collected. Propensity score matching was performed to control for selection bias. RESULTS: DAIR was used in 141 patients. The initial DAIR procedure was open for 96 patients and arthroscopic for 45 patients. The success rate was 29% greater for open DAIR (45% open vs 16% arthroscopic; P < .001). After propensity score matching, this benefit was estimated to be 36% (95% confidence interval, 22%-50%; P < .0001). When those on antibiotic suppression were also considered successfully treated, open DAIR was still superior by 34% (95% confidence interval, 18%-51%; P < .0001). CONCLUSION: For infected TKA, open DAIR is a more successful index procedure compared with arthroscopic DAIR. Open DAIR remained more successful even when antibiotic suppression is considered successful treatment.

Unlocking the DOOR-how to design, apply, analyse, and interpret desirability of outcome ranking endpoints in infectious diseases clinical trials.

BACKGROUND: Desirability of outcome ranking (DOOR) outcomes, with or without response adjusted for antibiotic risk (RADAR), are increasingly used in infectious diseases randomized clinical trials (RCTs), with the advantage of being able to combine multiple clinical outcomes and antibiotic duration in a single metric. However, it remains poorly understood, and there is considerable heterogeneity in its use. OBJECTIVES: In this scoping review, we explain how to design, use and analyse a DOOR endpoint, and highlight several pitfalls and potential improvements that can be made to DOOR/RADAR. SOURCES: The Ovid MEDLINE database was searched for terms related to DOOR in English-language articles published up to 31 December 2022. Articles discussing DOOR methodology and/or reporting clinical trial analyses (as either primary, secondary, or post-hoc analysis) using a DOOR outcome were included. CONTENT: Seventeen articles were included in the final review, of which nine reported DOOR analyses of 12 RCTs. Eight articles discussed DOOR methodology. We synthesised information from these articles and discuss (a) how to develop a DOOR scale, (b) how to conduct a DOOR/RADAR analysis, (c) use in clinical trials, (d) use of alternative tiebreakers apart from RADAR, (e) partial credit analyses, and (f) criticisms and pitfalls of DOOR/RADAR. IMPLICATIONS: DOOR is an important innovation for RCTs in infectious diseases. We highlight potential areas of methodological improvement for future research. There remains considerable heterogeneity in its implementation, and further collaborative efforts, with a more diverse range of perspectives, should be made to develop consensus scales for use in prospective studies.

Safety of prolonged outpatient courses of intravenous antibiotics: a prospective cohort study.

OBJECTIVES: The perceived need for prolonged intravenous antibiotic courses has become a major driver behind the growth of outpatient parenteral antimicrobial therapy (OPAT) services. Several recent randomized controlled trials demonstrate noninferiority of an early switch to oral therapy and highlight the need to accurately quantify harms associated with OPAT. METHODS: We conducted a 10-year prospective cohort study in a tertiary hospital OPAT service. Adults admitted to the service between 1 June 2009 and 30 June 2019 who received an intravenous antimicrobial agent were included. Adverse events (AEs) attributable to intravenous antibiotics or intravenous access were recorded in a prospectively maintained database and analyzed. RESULTS: There were 4160 admissions (median length of stay: 20 days) and a total of 88 432 patient-days of observation; 135 patients (3.3% of admissions) experienced at least one major AE (1.54 per 1000 patient-days; 95% CI, 1.29-1.82). The risk of a major AE peaked in the second week of OPAT admission, with acute kidney injury (43 of 136; 32%) and severe cytopenia (42 of 136; 31%) being the most common. At least one minor AE occurred in 38.3% of admissions (1592 of 4160; 26.4 per 1000 patient-days; 95% CI, 25.4-27.5), with central venous catheter-related complications accounting for 71% of AEs (1658 of 2338). DISCUSSION: The incidence of major AEs during long courses of intravenous antibiotics is low, peaking in week 2 and tailing off thereafter. These results should inform decisions concerning the choice of intravenous versus oral antimicrobials.

A desirability of outcome ranking (DOOR) for periprosthetic joint infection - a Delphi analysis.

Background: Treatment outcomes in studies on prosthetic joint infection are generally assessed using a dichotomous outcome relating to treatment success or failure. These outcome measures neither include patient-centred outcome measures including joint function and quality of life, nor do they account for adverse effects of treatment. A desirability of outcome ranking (DOOR) measure can include these factors and has previously been proposed and validated for other serious infections. We aimed to develop a novel DOOR for prosthetic joint infections (PJIs). Methods: The Delphi method was used to develop a DOOR for PJI research. An international working group of 18 clinicians (orthopaedic surgeons and infectious disease specialists) completed the Delphi process. The final DOOR comprised the dimensions established to be most important by consensus with > 75  % of participant agreement. Results: The consensus DOOR comprised four main dimensions. The primary dimension was patient-reported joint function. The secondary dimensions were infection cure and mortality. The final dimension of quality of life was selected as a tie-breaker. Discussion: A desirability of outcome ranking for periprosthetic joint infection has been proposed. It focuses on patient-centric outcome measures of joint function, cure and quality of life. This DOOR provides a multidimensional assessment to comprehensively rank outcomes when comparing treatments for prosthetic joint infection.

Predictors of Treatment Success After Periprosthetic Joint Infection: 24-Month Follow up From a Multicenter Prospective Observational Cohort Study of 653 Patients.

BACKGROUND: Periprosthetic joint infection (PJI) is a devastating condition and there is a lack of evidence to guide its management. We hypothesized that treatment success is independently associated with modifiable variables in surgical and antibiotic management. METHODS: The is a prospective, observational study at 27 hospitals across Australia and New Zealand. Newly diagnosed large joint PJIs were eligible. Data were collected at baseline and at 3, 12, and 24 months. The main outcome measures at 24 months were clinical cure (defined as all of the following: alive, absence of clinical or microbiological evidence of infection, and not requiring ongoing antibiotic therapy) and treatment success (clinical cure plus index prosthesis still in place). RESULTS: Twenty-four-month outcome data were available for 653 patients. Overall, 449 patients (69%) experienced clinical cure and 350 (54%) had treatment success. The most common treatment strategy was debridement and implant retention (DAIR), with success rates highest in early postimplant infections (119 of 160, 74%) and lower in late acute (132 of 267, 49%) and chronic (63 of 142, 44%) infections. Selected comorbidities, knee joint, and Staphylococcus aureus infections were independently associated with treatment failure, but antibiotic choice and duration (including rifampicin use) and extent of debridement were not. CONCLUSIONS: Treatment success in PJI is associated with (1) selecting the appropriate treatment strategy and (2) nonmodifiable patient and infection factors. Interdisciplinary decision making that matches an individual patient to an appropriate management strategy is a critical step for PJI management. Randomized controlled trials are needed to determine the role of rifampicin in patients managed with DAIR and the optimal surgical strategy for late-acute PJI.

Outcomes of paediatric septic arthritis of the hip and knee at 1-20 years in an Australian urban centre.

BACKGROUND: Septic arthritis in children is a joint threatening condition with potentially severe consequences; however, long-term outcome data is lacking. This study aims to determine 1-20-year outcomes following septic arthritis of hip and knee joints in children in an Australian population. METHODS: All paediatric patients with septic arthritis of the hip or knee from 1995 to 2015 treated at our Australian institution were retrospectively assessed. Clinical features, treatment and investigation results were recorded. Long-term functional and radiological outcomes, infection recurrence and reoperation rate at final follow-up (mean 8.5 years, range 1.0-20.3; hip versus mean 7.7 years, range 1.1-20.3; knee) were recorded. RESULTS: Sixty-four patients (37 hip, 27 knee) met inclusion criteria. Fifty-two patients (81.3%) attended follow-up. No mortalities or late infection recurrence occurred. Three patients (1; hip versus 2; knee) had a later operation. Median Oxford scores were excellent (48; hip versus 48; knee); however, a significant proportion had a degree of impaired function (31.3%; hip versus 42.1%; knee). Radiological outcomes were excellent in knees more commonly than hips (81.3%; hip versus 100%; knee). CONCLUSIONS: Outcomes at 1-20 years for the majority of patients following septic arthritis of the hip and knee are excellent with early joint irrigation and intravenous antibiotics. Our results demonstrate a significant proportion of patients following septic hip arthritis have mild to moderately poor functional and radiological outcomes. Those with septic knee arthritis demonstrated universally excellent radiological outcomes and mild functional impairment in approximately one-third of cases.

Use of peripherally inserted central catheters in the management of recalcitrant maxillofacial infection.

PURPOSE: The most common short-term method for the delivery of parenteral antimicrobial therapy in an acute hospitalized patient has traditionally been via a short peripherally inserted intravenous cannula. This approach, however, has significant limitations, particularly in patients who require prolonged, uninterrupted intravenous access. In this article, we report on our experience with an alternative method used to establish and maintain medium- to long-term intravenous access utilizing a peripherally inserted central catheter (PICC) to treat patients presenting with aggressive or recalcitrant maxillofacial head and neck infections. MATERIALS AND METHODS: We undertook a retrospective review of the medical records of 100 consecutive patients admitted to a tertiary referral teaching hospital, during the period February 2006 to February 2007, with a primary diagnosis of infection in the oral and maxillofacial region. We identified 6 patients in whom a PICC was used in the treatment of the condition. We also analyzed data obtained from an audit conducted by our infectious diseases unit. This audit recorded the outcome of 849 nurse-placed PICCs in the department's ambulatory intravenous therapy service. Using this data, we also performed a PICC line survival analysis and in so doing, calculated the complication rates. RESULTS: In our series, the delivery of PICC-based therapy accounted for 6% of the treatment provided for all cases of maxillofacial sepsis. This included 3 cases of actinomycosis, 2 cases of odontogenic osteomyelitis, and 1 case of a zoonotic facial abscess/cellulitis. In this series of patients, catheters remained in situ for an average of 33 days (range 12-42 days). The audit data demonstrated that more than 75% of nurse-placed PICCs are functional without complication at 60 days. The most common complication was phlebitis (1 per 1,000 catheter days). Infection was rare (0.2 per 1,000 catheter days). CONCLUSIONS: PICC is a safe and most reliable means of administering medium- to long-term intravenous antibiotics. We feel PICC-based therapy should be considered in the management of select patients with aggressive or recalcitrant maxillofacial head and neck sepsis.

Open Compared with Arthroscopic Treatment of Acute Septic Arthritis of the Native Knee.

BACKGROUND: Acute native knee septic arthritis is a joint-threatening emergency. Operative treatments by open or arthroscopic methods are available to surgeons. To our knowledge, the literature to date has primarily consisted of case series and no large study has yet compared these methods. The aim of this study was to compare open and arthroscopic treatment for acute native knee septic arthritis. METHODS: All adult patients with acute native knee septic arthritis treated at our institution with either open or arthroscopic irrigation from 2000 to 2015 were retrospectively evaluated. The clinical findings, laboratory evidence, arthrocentesis and microbiology results, knee radiographs, and outcomes were compared. RESULTS: There were 161 patients (166 knees) with acute native knee septic arthritis treated between 2000 and 2015. Initially, 123 knees were treated by arthroscopic irrigation and 43 knees were treated by open irrigation; however, 71% in the open treatment group required repeat irrigation compared with 50% in the arthroscopic treatment group. The superiority of an arthroscopic procedure persisted after adjustment for potential confounders by multivariable analysis, with an odds ratio of 2.56 (95% confidence interval, 1.1 to 5.9; p = 0.027). After 3 irrigation procedures, the cumulative success rate was 97% in the arthroscopic treatment group and 83% in the open treatment group (p = 0.011). The total number of irrigation procedures required was fewer in the arthroscopic treatment group (p = 0.010). In the arthroscopic treatment group, the mean postoperative range of motion was greater (p = 0.016) and there was a trend toward a shorter median length of stay (p = 0.088). CONCLUSIONS: Arthroscopic treatment for acute native knee septic arthritis was a more successful index procedure and required fewer total irrigation procedures compared with open treatment. Long-term postoperative range of motion was significantly greater following arthroscopic treatment. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

An outbreak of scrub typhus in military personnel despite protocols for antibiotic prophylaxis: doxycycline resistance excluded by a quantitative PCR-based susceptibility assay.

Scrub typhus is caused by the obligate intracellular bacterium Orientia tsutsugamushi and is endemic to many countries in the Asia-Pacific region, including tropical Australia. We describe a recent large outbreak amongst military personnel in north Queensland. A total of 45 clinical cases were identified (36% of all potentially exposed individuals). This occurred despite existing military protocols stipulating the provision of doxycycline prophylaxis. Doxycycline resistance in O. tsutsugamushi has been described in South-East Asia, but not Australia. In one case, O. tsutsugamushi was cultured from eschar tissue and blood. Using quantitative real-time PCR to determine susceptibility to doxycycline for the outbreak strain, a minimum inhibitory concentration (MIC) of ≤0.04 µg/mL was found, indicating susceptibility to this agent. It seems most probable that failure to adhere to adequate prophylaxis over the duration of the military exercise accounted for the large number of cases encountered rather than doxycycline resistance.