A sequence symmetry analysis of the interrelationships between statins, diabetes and skin infections.

AIMS: To determine statins' impact on skin infection risk in view of conflicting literature: that statins may reduce infection risk, but are also associated with diabetes mellitus, a risk factor for skin and soft tissue infections (SSTIs). METHODS: Sequence symmetry analysis was performed on prescription claims (2001-2011) from the Australian Department of Veterans' Affairs to determine the interrelationships between: (i) statins and SSTIs; (ii) statins and diabetes; and (iii) diabetes and SSTIs; as well as whether statins increased the risk of SSTIs, independent of diabetes status. Chi-square tests were performed to detect differences in Index of Relative Socio-economic Advantage and Disadvantage scores of patients within each interrelationship. Prescriptions for statins, antidiabetic medication, and antistaphylococcal antibiotics were evaluated using nonidentifiable client numbers, prescription dates filled, residential electorates, and pharmaceutical codes. Adjusted sequence ratio and confidence interval were calculated at intervals of 91, 182 and 365 days for sequence symmetry analysis studies. RESULTS: Statins were associated with: (i) significant SSTI risk (adjusted sequence ratio > 1; confidence interval >1), (ii) significant diabetes risk, and (iii) diabetic patients had increased risk of SSTIs. Diabetic and nondiabetic statin users had significantly increased risks of SSTIs, while the influence from socioeconomic status was not significant for each of the 3 relationships. CONCLUSIONS: Statins are associated with increased risk of SSTIs via direct and indirect mechanisms, probably independent of diabetes or socioeconomic statuses. We believe that clinicians should be aware of the association between statins and SSTIs, and, where appropriate, monitor blood glucose levels of statin users.

Healthcare services use by patients with heart failure in Australia: Findings from the SHAPE study.

BACKGROUND AND OBJECTIVES: General practitioners (GPs) play a central role in healthcare, serving as the first point of contact, making appropriate referrals and coordinating care for chronic conditions such as heart failure (HF). We sought to determine healthcare use by people with HF in primary care. METHOD: In this Study of Heart failure in the Australian Primary carE setting (SHAPE), we analysed records of 1.93 million adult patients who attended a total of 43 practices between 1 July 2013 and 30 June 2018. We identified and examined the data of 20,219 patients with HF to describe the frequency of visits and use of Medicare Benefits Schedule items. RESULTS: Patients with HF saw GPs 14.4 times per annum on average; 59.5% had a General Practice Management Plan (GPMP), 2.9% of GPMPs were reviewed annually or more frequently, and 46.8% of patients had been referred to a cardiologist. A total of 3761 had coexisting anxiety or depression, and of these 37.1% had a mental health plan. DISCUSSION: Patients with HF visit their GP frequently, with many not reaching guideline therapy nor referred to cardiologists. Low use of care planning and reviews presents an opportunity for GPs to improve care.

Epidemiology of heart failure: Study of Heart failure in the Australian Primary carE setting (SHAPE).

AIMS: At present, there is no robust information on the prevalence and incidence of heart failure (HF) in the general Australian community. The present study of primary care data sought to estimate the prevalence and incidence of HF in the community and to describe the demographic and clinical profile of Australians with HF. METHODS AND RESULTS: We undertook a retrospective cohort study based on analysis of anonymized medical records of adult patients cared for at 43 Australian general practices between 1 July 2013 and 30 June 2018. Data were extracted from coded and uncoded fields in electronic medical records. The prevalence and annual incidence of HF were calculated, along with 95% confidence intervals, using the 'active' population of people who were regular attenders at the practices. Age-standardized estimates were also derived using the 2017 Australian population as reference. The mean age of the population with HF was 69.8 years, 50.6% were female, and mean body mass index was 31.2 kg/m2 . The age-standardized prevalence was 2.199% [95% confidence interval (CI): 2.168-2.23%], and the age-standardized annual incidence was 0.348% (95% CI: 0.342-0.354%). These estimates accord with almost 420 000 people living with HF in Australia in 2017, and >66 000 new cases of HF occurring that year. Only 18.9% of patients with definite HF had this formally captured as a 'diagnosis' in their medical record. HF was more frequent among those of lower socio-economic status. CONCLUSIONS: HF is common in Australia. The majority of HF patients do not have this diagnosis optimally noted in their primary care medical records.

Disposition and clinical outcome after intraperitoneal meperidine and ropivacaine administration during laparoscopic surgery.

BACKGROUND: Limited evidence supports the efficacy of intraperitoneal (IP) meperidine or local anesthetic for postoperative analgesia. Our study aims were to investigate analgesic efficacy and to quantify the plasma concentrations of meperidine and ropivacaine after IP administration. The null hypothesis was that there was no significant difference among groups for dynamic pain in the first 24 h after major abdominal laparoscopic surgery. METHODS: This double-blind, five parallel group, placebo-controlled, two-center trial randomized 250 women having laparoscopic surgery to receive IP meperidine 50 or 100 mg (groups M50 and M100), ropivacaine 150 mg (group R150), meperidine 50 mg and ropivacaine 150 mg (group M50R150), all with intramuscular saline, or IP saline, with intramuscular meperidine 50 mg (group C). The primary outcome was pain during recovery. A pharmacokinetic profile of the drugs was obtained. RESULTS: There were no significant differences among groups for mean (sd) dynamic pain scores in the postoperative care unit (2.2 [2.8], 2.5 [3.3], 1.6 [2.5], 2.6 [3.2], 2.7 [3.2] for groups C, M50, M100, R150, and M50R150, P = 0.50) or thereafter. There were no significant differences among groups for pain scores at rest, IV morphine use, recovery characteristics and patient satisfaction. After IP administration of meperidine 50 mg the plasma concentration (median average 55-60 microg/L) was approximately half that of an equivalent intramuscular dose (median average 113 mug/L). CONCLUSIONS: Compared with systemic opioid, IP meperidine and ropivacaine, alone or in combination, did not produce better pain relief or opioid dose-sparing after laparoscopic surgery.

A model for assessment and referral of clients with bowel symptoms in community pharmacies.

BACKGROUND: To expedite diagnosis of serious bowel disease, efforts are required to signpost patients with high-risk symptoms to appropriate care. Community pharmacies are a recognized source of health advice regarding bowel symptoms. This study aimed to examine the effectiveness of a validated self-administered questionnaire, Jodi Lee Test (JLT), for detection, triage, and referral of bowel symptoms suggestive of carcinoma, in pharmacies. METHOD: 'Usual Practice' was monitored for 12 weeks in 21 pharmacies in Western Australia, documenting outcomes for 84 clients presenting with bowel symptoms. Outcome measures were: acceptance of verbal advice from the pharmacist; general practitioner consultation; and diagnosis. Trial of the JLT involved staff training in the research protocol and monitoring of outcomes for 80 recruited clients over 20 weeks. Utility of the JLT was assessed by post-trial survey of pharmacy staff. RESULTS: Significantly more referrals were made by staff using the JLT than during Usual Practice: 30 (38%) vs 17 (20%). Clients' acceptance of referrals was also higher for the intervention group (40% vs 6%). Two-thirds of pharmacy staff agreed that the JLT could be incorporated into pharmacy practice, and 70% indicated they would use the JLT in the future. CONCLUSION: A pre-post design was considered more appropriate than a randomized control trial due to an inability to match pharmacies. Limitations of this study were: lack of control over adherence to the study protocol by pharmacy staff; no direct measure of client feedback on the JLT; and loss to follow-up. The JLT was effective in prompting decision-making by pharmacy staff and inter-professional care between pharmacies and general practice, in triage of clients at risk of bowel cancer.

A questionnaire study of injections prescribed and dispensed for patients diagnosed with mild/moderate community-acquired pneumonia in Mongolia.

Purpose. The study aimed to determine the extent of and factors influencing the prescribing of injections for the treatment of mild/moderate community acquired pneumonia (CAP) in Mongolia. Methods. Questionnaires were developed and administered to medication providers (34 Pharmacists, 27 pharmacy technicians) and prescribers (22 general doctors and 49 medical specialists) working in Mongolia. Results. Cefalosporins were prescribed for patients with mild pneumonia and doctors tended to prescribe injectable cefalosporins (cefazolin) rather than oral dosage forms. This was supported by the questionnaire study with pharmacists and pharmacy technicians. Additionally, 23 pharmacists and pharmacy technicians indicated that OTC injectable cefalosporins (37.7%) and injectable aminopenicillins (33,9%) were frequently sold by pharmacies for the treatment of mild/moderate CAP. Doctors and particularly pharmacists in the questionnaire studies indicated choosing an injection was to avoid non-compliance problems. Conclusion. High levels of injectable prescribing of antibiotics were found in non-hospitalized patients with CAP in Mongolia. This prevalence level indicated that inappropriate injection prescribing is a public health hazard for Mongolia and requires consideration by the appropriate authorities.

An evaluation of patients' adherence with hypoglycemic medications among Papua New Guineans with type 2 diabetes: influencing factors.

PURPOSE: The aims of this study were to evaluate the extent of adherence to hypoglycemic medications, assess the relationship between adherence and glycemic control, and evaluate factors affecting adherence. RESEARCH DESIGN AND METHODS: This was a cross-sectional study of patients with established type 2 diabetes attending the Port Moresby General Hospital Diabetes Clinic. Face-to-face interviews were conducted using a questionnaire designed for the study and data were collected concerning the 3 months prior to interview. The questionnaire covered demographic details, lifestyle, biochemical and physical measurements, and medication management. Glycemic control was investigated among patients adhering to their medications (not missing doses) to different degrees (100%, 95%, 90%, and 80%). RESULTS: Of a total of 356 participants who were prescribed hypoglycemic medications, 59.6% omitted some of their doses. Age appeared to have a significant impact on adherence at some levels of adherence, with those aged >60 years being more likely to be adherent (logistic regression). Those who were 95%-99% and those who were <80% adherent had a statistically significant risk of a high glycated hemoglobin of >10% (85.5 mmol/mol). Multiple factors were identified as contributors to nonadherence, with patient-based issues (86.0%) and the health care system (21.7%) being the most common. CONCLUSION: This study showed a significant level of nonadherence among patients with type 2 diabetes in Papua New Guinea. Nonadherence to medication appeared to be associated with poor glycemic control and was due to a variety of reasons. Future interventions aimed at improving adherence will need to take these into account.

Effectiveness of a topical local anaesthetic spray as analgesia for dressing changes: a double-blinded randomised pilot trial comparing an emulsion with an aqueous lidocaine formulation.

BACKGROUND: Partial thickness skin graft wounds are painful. Topically applied lidocaine has been used for analgesia in several clinical trials. This study compared the effectiveness of two different formulations of topical local anaesthetic for dressing changes of partial thickness skin graft donor sites. METHODS: A double-blind randomised controlled, pilot trial was conducted in 29 patients undergoing split thickness skin graft surgery. Subjects were randomised to either a 3% lidocaine emulsion formulation "Treatment E" (NOPAYNE™) or a 4% aqueous solution "Treatment A" (Xylocaine™). Subjects received one spray per 3 cm(2) of donor site area followed by up to two further spays as required. Endpoints included pain intensity measured by the numerical rating scale (NRS) up to 1h after dressing change commencement, sting sensation, overall satisfaction and lidocaine plasma concentration. RESULTS: The 60 min pain scores for E and A were 1.3 ± 0.3 (mean ± SEM) and 1.8 ± 0.4 (p=0.98) respectively. Nearly 90% of patients were very satisfied with their treatment. The mean plasma concentrations of lidocaine for A and E were 0.132 mg/l and 0.040 mg/l respectively (p=0.069). CONCLUSION: The topical local anaesthetic formulations achieved low pain scores during dressing changes. The safety profile was potentially improved with the emulsion formulation of lidocaine.

How do Australian ICU survivors fare functionally 6 months after admission?

OBJECTIVES: To determine the extent to which physical function is restored 6 months after intensive care unit admission, and whether this is associated with short or long ICU length of stay (LOS). DESIGN, SETTING AND PARTICIPANTS: We conducted a prospective observational study between April and June 2010. All patients admitted for more than 48 hours to the general ICU at Sir Charles Gairdner Hospital, Perth, Western Australia, were eligible for inclusion. "Short" and "long" ICU LOS were defined as < 8 days and ≥ 8 days, respectively. Six months after ICU admission, an investigator (blinded to baseline data) contacted participants by telephone to administer a follow-up questionnaire based on the Functional Independence Measure (FIM). OUTCOME MEASURES: The primary measure was FIM score; secondary measures were rehabilitation requirement, readmission rate, and whether or not patients had returned to work and driving. RESULTS: 77 patients consented to take part in the study, and 71 were followed up. Median total FIM score (124) and motor (89) and cognitive (35) subscores suggested high-level functional independence at follow-up. Fifty per cent of patients who were workers at baseline had returned to work, and 76% of drivers had returned to driving at follow-up. Paired t tests of the changes in total FIM and its subscales showed that only the motor subscore showed a significant deterioration (mean change, -3.7; P=0.04). Changes for the total FIM did not appear to be correlated with any demographic or baseline data. Furthermore, there appeared to be no difference in FIM between patients with short or long ICU LOS. CONCLUSIONS: Our study showed that patients who survive treatment for life-threatening illness in an Australian ICU for more than 48 hours and are subsequently able to communicate are likely to return to their premorbid functional level (as defined by FIM score) within 6 months.

Population based randomised controlled trial on impact of screening on mortality from abdominal aortic aneurysm.

OBJECTIVE: To assess whether screening for abdominal aortic aneurysms in men reduces mortality. DESIGN: Population based randomised controlled trial of ultrasound screening, with intention to treat analysis of age standardised mortality. SETTING: Community based screening programme in Western Australia. PARTICIPANTS: 41,000 men aged 65-83 years randomised to intervention and control groups. INTERVENTION: Invitation to ultrasound screening. MAIN OUTCOME MEASURE: Deaths from abdominal aortic aneurysm in the five years after the start of screening. RESULTS: The corrected response to invitation to screening was 70%. The crude prevalence was 7.2% for aortic diameter > or = 30 mm and 0.5% for diameter > or = 55 mm. Twice as many men in the intervention group than in the control group underwent elective surgery for abdominal aortic aneurysm (107 v 54, P = 0.002, chi2 test). Between scheduled screening and the end of follow up 18 men in the intervention group and 25 in the control group died from abdominal aortic aneurysm, yielding a mortality ratio of 0.61 (95% confidence interval 0.33 to 1.11). Any benefit was almost entirely in men aged between 65 and 75 years, where the ratio was reduced to 0.19 (0.04 to 0.89). CONCLUSIONS: At a whole population level screening for abdominal aortic aneurysms was not effective in men aged 65-83 years and did not reduce overall death rates. The success of screening depends on choice of target age group and the exclusion of ineligible men. It is also important to assess the current rate of elective surgery for abdominal aortic aneurysm as in some communities this may already approach a level that reduces the potential benefit of population based screening.

Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial.

BACKGROUND: Epidural block is widely used to manage major abdominal surgery and postoperative analgesia, but its risks and benefits are uncertain. We compared adverse outcomes in high-risk patients managed for major surgery with epidural block or alternative analgesic regimens with general anaesthesia in a multicentre randomised trial. METHODS: 915 patients undergoing major abdominal surgery with one of nine defined comorbid states to identify high-risk status were randomly assigned intraoperative epidural anaesthesia and postoperative epidural analgesia for 72 h with general anaesthesia (site of epidural selected to provide optimum block) or control. The primary endpoint was death at 30 days or major postsurgical morbidity. Analysis by intention to treat involved 447 patients assigned epidural and 441 control. FINDINGS: 255 patients (57.1%) in the epidural group and 268 (60.7%) in the control group had at least one morbidity endpoint or died (p=0.29). Mortality at 30 days was low in both groups (epidural 23 [5.1%], control 19 [4.3%], p=0.67). Only one of eight categories of morbid endpoints in individual systems (respiratory failure) occurred less frequently in patients managed with epidural techniques (23% vs 30%, p=0.02). Postoperative epidural analgesia was associated with lower pain scores during the first 3 postoperative days. There were no major adverse consequences of epidural-catheter insertion. INTERPRETATION: Most adverse morbid outcomes in high-risk patients undergoing major abdominal surgery are not reduced by use of combined epidural and general anaesthesia and postoperative epidural analgesia. However, the improvement in analgesia, reduction in respiratory failure, and the low risk of serious adverse consequences suggest that many high-risk patients undergoing major intra-abdominal surgery will receive substantial benefit from combined general and epidural anaesthesia intraoperatively with continuing postoperative epidural analgesia.