Introduction (COVID-19) disease can present with respiratory tract infection and influenza-like symptoms. Although increased symptoms during physical exertion and impairments in lung function have been recently reported as some of the negative effects of COVID-19, no study has defined the recovery trajectories during and following the acute phase of the disease from a symptomatic, physical or psychological perspective. The proposed study will aim primarily to provide a multidimensional analysis of the 12-month recovery of symptoms, physical function, health-related quality of life (HRQoL), and psychological function in adults following a diagnosis of COVID-19.
Methods This report describes the method for a prospective, longitudinal, single-area multi-centre cohort study. Possible international extension is envisaged. Eligibility criteria are patients > 18 years old with a confirmed diagnosis of COVID-19, who provide informed consent. Exclusion criteria include those with pre-existing neuromuscular disorders likely to affect the measures of physical function, diagnosed pre-existing mental illness and significant cognitive impairment likely to affect responses to self-report measures. The study assessment protocol is in two parts. Part A will be undertaken by inpatients, who will undergo added clinical and symptom assessments every 48 hours during the admission. At discharge, participants will be eligible for Part B, incorporating assessments at four time points: on discharge and 3, 6, and 12 months from hospital admission. Assessments will include: symptoms (fatigue and shortness of breath), physical function (functional capacity and peripheral muscle force), HRQoL and psychological (feelings of anxiety and depression, and posttraumatic stress) function. Associations of patient and clinical characteristics predictors with longitudinal in-hospital clinical and symptomatic outcomes will be examined using generalised linear mixed models (GLMM) with random subject effects. Corresponding associations of patient characteristic, clinical pathway and rehabilitation pathway predictors with recovery trajectories will also be examined.
Objectives Diffuse idiopathic skeletal hyperostosis (DISH) is a common spinal disorder for which there is no specific drug treatment. The aim of this data audit was to determine the outcome of therapy with tumour necrosis factor inhibition (TNFi) in painful DISH.
Methods We performed a retrospective audit of patients with DISH followed from 2006 to 2020. Twelve patients with painful DISH who had a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) of 6 or higher at outset, who had been treated empirically with a TNFi after failed treatment with exercise, NSAID/Coxibs and/or non-opiate analgesics were compared with 7 patients with DISH (BASDAI < 6 at onset) observed whilst receiving standard of care, but not TNFi.
Results One TNFi-treated patient was intolerant of TNFi. Eight patients had a 2-point or greater reduction in disease activity in the BASDAI measure. This is similar to the clinical response observed in patients with TNFi-treated ankylosing spondylitis in clinical trials. Based on intention to treat, the response rate was 67%. In contrast, only 1 of the 7 untreated DISH patients had a 2-point improvement in BASDAI (14%).
Conclusions These results support the efficacy of TNF inhibition in painful DISH. Based on these uncontrolled results we conclude that a formal prospective trial of the safety and efficacy of TNFi in DISH is justified.
Tasman Medical Journal 2021: 3 (1); 11-16.
Introduction: Real-world survival in acute myeloid leukaemia (AML) is poor, and there has been little change to the intensive induction and consolidative chemotherapy regimens over 30 years. Despite this, there have been developments in therapeutic agents for patients unfit for intensive therapy, supportive care, risk stratification and allogenic stem cell transplant. We report outcomes of these patients with AML treated using contemporary care standards in Western Australia (WA) and compare this with a historical cohort.
Methods: AML diagnosed between 2009-2018 in WA were identified by discharge diagnosis at 3 tertiary public hospitals in Perth and the database of the state reference cytogenetic laboratory at Pathwest. Medical and laboratory records were reviewed retrospectively for characteristics and outcomes. Comparison was made with a historical cohort diagnosed 1991-2015 and analysed with t-test and Kaplan-Meier methods.
Results: 734 patients were identified in the contemporary period. Median age was 64.4 years and 70% were primary/de novo AML. 61% were managed with intensive chemotherapy and 16.9% of these under the age of 60 proceeded to allogeneic stem cell transplant in first remission. There were no significant differences in the rates of intensive therapy or allogenic transplantation compared with the historical cohort. 98.8% of patients had successful cytogenetic studies performed. Of those with a normal karyotype, molecular studies were performed in 57%. Median overall survival in patients treated intensively was 56.6 months for age 60 or less, and 10 months in patients age over 60. Cytogenetic risk group predicted survival (p<0.0001). Survival was significantly improved in both groups treated intensively and non-intensively compared with the historical cohort; 18.7 vs 13.2 months (HR 1.348, 95% CI 1.157-1.571) and 3.1 vs 1.6 months (HR 1.431, 95% CI 1.1223-1.674) respectively.
Conclusion: Survival has improved in all patients with AML in WA over time despite no significant change to intensive chemotherapy regimens. This may be explained by improved risk stratification, supportive care, non-intensive therapy options, and allogeneic donor selection and transplantation techniques.
Tasman Medical Journal 2020; 3(1): 17-22.
Background: The aim of the present study was to measure perceived Allied Health research capacity and culture within the South Metropolitan Health Service (SMHS) and describe strengths, barriers and motivators to undertaking research.
Method: Cross-sectional survey. Allied Health professionals within SMHS were invited to complete the Research Capacity and Culture (RCC) tool. The tool consists of 52 questions examining self-reported success or skill in a range of areas related to research capacity or culture across three domains: (i) the organisation; (ii) the team (i.e. professional group); and (iii) the individual. Each question uses a 10-point numeric rating scale where 10 is the highest possible level of skill or success. Scores for items were categorised as “low” (median <4), “moderate” (median ≥4 and ≤6.9) and “high” (median ≥7) level of skill or success. Data were collected electronically via Survey Monkey for five weeks in February and March 2020.
Results: 320 Allied Health professionals (37% of the SMHS workforce) responded to the survey. Overall, respondents considered their organisation and professional group to be moderately successful in supporting and valuing research. On an individual level, common strengths were in finding relevant literature, critically reviewing the literature and integrating research findings into practice. Areas of weakness included securing research funding, writing ethics application and manuscripts. Motivators for engaging in research were to develop skills, address gaps in clinical practice, increase job satisfaction and provide opportunities for career advancement. Enablers included having dedicated time for research, access to research mentors and encouragement from managers. The most commonly reported barriers to engaging in research included a lack of time, funding and suitable backfill, other work roles taking priority, and a lack of research skills.
Conclusions: In order to increase research culture and capacity of the Allied Health professionals at SMHS, ongoing support and investment of resources is paramount. Initiatives should focus on strengthening existing motivators and mitigating key barriers to research engagement.
Tasman Medical Journal 2021; 3(1): 17-23
Background Allogeneic haemopoietic progenitor cell transplantation (alloHPCT, previously known as ‘stem cell transplantation’) is the only curative procedure for many haematological malignancies (for example, acute leukaemia), and non-malignant conditions such as bone marrow failure and myelodysplasia. Fiona Stanley Hospital (FSH), a new tertiary metropolitan hospital in Perth Western Australia opened in 2015. A Blood and Marrow Transplant Programme (BMTP) was established and replaced the previous State service at Royal Perth Hospital. We describe here the patient demographics and outcomes of alloHPCT at FSH BMTP since its establishment in 2015.
Methods One hundred and ninety-three consecutive adult patients who had alloHPCT were identified retrospectively from 1 February 2015 to 31 December 2019. Pre-transplant, transplant and clinical outcome characteristics were analysed.
Results Acute myeloid leukaemia (AML) was the most common indication for transplant (n = 82, 42.5%) followed by myelodysplasia (16.1%). The median time from diagnosis to alloHPCT in patients with AML in first complete remission was 5.7 m (range, 2.4 – 28.4). The cumulative incidence of grade III-IV aGVHD at 6 months was 10.4% (95% CI 6.5 – 15.4%) and the cumulative incidence of severe cGVHD at 2 years was 10.2% (95% CI 5.7 – 16.3%). The median follow-up was 24.3 m (range, 5.9 – 62.1). Overall survival at 1and 2 years was 73.7% (95% CI 70.1 – 77.3%) and 65.0% (95% CI 61.2 – 68.8%) respectively. Progression-free survival at 2-years was 62.9% (95% CI 59.6 – 66.2%). The cumulative risk of transplant-related mortality at 2-years was 17.8% (95% CI 12.6 – 23.7%), and disease relapse at 2-years was 19.3% (95% CI 13.8 – 25.6%).
Conclusions Clinical outcomes of allogeneic transplantation at the FSH BMTP appear acceptable and are comparable to those reported elsewhere within Australia and overseas. This information is valuable for transplant physicians, referrers and patients in Western Australia and will inform future practice improvement activities in this high risk and complex medical procedure.
Tasman Medical Journal 2020; 3(1): 37-43.
Background: The ‘Can’t Intubate Can’t Oxygenate’ (CICO) crisis is a rare but life-threatening airway emergency. Multiple factors have been implicated in poor outcomes for CICO management. A key modifiable factor is the availability, accessibility and strategic layout of CICO equipment. The ergonomic implications of selective equipment packaging and CICO kit design on clinical practice are yet to be studied. This pilot study aims to investigate the clinical implications of CICO kit ergonomic design on the timed responses of participants within simulated CICO crises at Fiona Stanley Hospital (FSH).
Methods: Paired participants were allocated randomly to either an ergonomically designed kit (Princess Alexandra Hospital modified kit; PAH-M) or to institutionally packaged equipment (FSH kit) within simulated CICO crises, with a crossover design. The primary aim was to compare timed events between CICO kit groups including time to completion of infraglottic rescue technique, oxygenation, ventilation and timing between predetermined participant actions. A secondary objective was to examine whether a difference in heart rate and physiological stress parameters existed between the CICO kit groups.
Results: The PAH-M kit demonstrated a time advantage across the majority of primary timed events. A learning model that factored in carry over effects due to the crossover design demonstrated a time benefit for the PAH-M kit in terms of time to retrieval of equipment (6.5 seconds), infraglottic rescue performance (9.0 seconds) and oxygenation (20.4seconds). An order of effects model also demonstrated the PAH-M kit to have a faster time to oxygenation compared to our institutionally packaged FSH kit (p=0.049). Heart rate variability did not differ between CICO kit groups.
Conclusion: This study highlights CICO kit design and its ergonomic utility as being important factors that may influence time-critical outcomes in simulated CICO crises.
Background Current literature related to the impact of hearing impairment on quality of life (QOL) is focused on patients with mild to moderate hearing loss. Little is known about the quantitative effect of severe hearing losses. The aim of this study was to measure the impact that single sided deafness and bilateral profound deafness has on the QOL of an individual.
Methods QOL was measured by the Hearing Handicap Inventory for Adults (HHIA) in ninety-six subjects with either single sided complete deafness or bilateral profound hearing loss treated with a cochlear implant, with HHIA performed for assessment of cochlear implant candidacy.
Results Seventy one percent of the study cohort indicated that hearing loss had a significant impact on QOL, but the impact was less in the group with unilateral deafness. The difference was identified for both social and emotional domains of the HHIA (t = 4.64, p < 0.005) and (t = 4.08, p < 0.005), respectively.
Conclusions The findings confirms that severe hearing loss has significant effects on QOL. The lesser impact in unilateral deafness is likely to be attributable to the remaining function in the contralateral ear.
Objectives: To examine the safety of early re-introduction of biologic DMARD (bDMARD) therapy for rheumatoid arthritis (RA) during antibiotic treatment for prosthetic joint infections (PJI).
Methods: Medical records of three RA patients with PJI were reviewed. During antibiotic treatment, all patients were recommenced on bDMARD therapy due to worsening disease activity. Details recorded include causative organism, timing of bDMARD re-introduction and infection risk factors.
Results: Case 1: A 67-year-old female with RA developed a Staphylococcus Schleiferi PJI three weeks after an elbow replacement. Etanercept was re-commenced three months later with long term prophylactic antibiotics. After five years, no recurrence of infection had occurred.
Case 2: A 67-year-old male with RA developed a Staphylococcus aureus PJI 15 months after total knee replacement (TKR). Etanercept was recommenced at two months and switched to abatacept at five months. Antibiotics were ceased at seven months, however recurrence of MSSA PJI was confirmed two months later. Abatacept was ceased. Synthetic DMARDs were reintroduced with no further PJI identified over the following four years despite addition of Baricitinib in early 2020.
Case 3: A 74-year-old male with RA experienced a Finegoldia magna PJI eight weeks after TKR. Etanercept was restarted one-month later. No further joint infections occurred during the next 10 years.
Conclusions: One of three RA patients experienced re-activation of PJI with an organism of high virulence. Two with low virulence organisms remain PJI free at five- and 10 years post infection. Treatment considerations should include organism virulence, risk factors for infection, RA disease activity off bDMARDs and patient preference.
Introduction Inclusion body myositis (IBM) is the most common acquired skeletal muscle disease associated with aging, and includes both muscle degeneration and autoimmune attack. Several studies have shown a relationship between exercise and improved outcomes in IBM, and one study not involving exercise has shown a modest benefit of the testosterone analogue oxandrolone compared to placebo. No placebo-controlled studies have explored the effect of testosterone added to exercise in IBM.
Methods and Analysis We describe the design and methods of a double-blinded, two-arm crossover randomised controlled pilot study to test whether testosterone on a background of exercise training will improve measures of muscle strength and physical activity and improve quality of life in men affected by IBM, over and above exercise alone. We hypothesised that a combination of exercise training and testosterone treatment would improve muscle strength and physical activity in males affected by IBM, more than exercise alone. Within this paper we present a summary of the study protocol, and of study design lessons learnt.
Ethical approval and trial registration This study has been approved through the Human Research Ethics Committee at Murdoch University with the approval number 2017/262. This study has been registered with the Australian and New Zealand Clinical Trials registry (ANZCTR) under registration number ACTRN12618000755235.
Tasman Medical Journal 2021; 3(1): 69-75.
Introduction: Epidemiological data linkage studies use International Classification of Diseases (ICD) hospital discharge coding to identify patients with gout. The accuracy of the coding is critical to the validity of the results. This study has assessed the accuracy of ICD discharge coding of gout against both the clinical diagnosis and the 2015 ACR/EULAR Gout Classification Criteria (ACR/EULAR GCC)
Methods: The case records of inpatients with an ICD diagnosis of gout on discharge from two tertiary teaching hospitals were reviewed. The case file was examined for documented evidence of the diagnosis. Second, the ACR/EULAR 2015 Gout Classification Criteria score was calculated. Finally, 100 cases from one hospital were also examined to determine the likelihood of the diagnosis of gout being correct, based on the reviewing doctor’s opinion. Descriptive statistics were used to summarise the demographic and clinical characteristics of patients.
Results: One hundred and ninety nine patients with an ICD code of gout were reviewed. Six appeared to be incorrectly coded. Based on the ACR/EULAR GCC, 25% of patients met the “sufficient” criterion for diagnosis, 26% met the “classification criteria” and 49% did not meet the “classification criteria” or were unable to be scored. Of 100 case records independently reviewed, 55% had definite gout, 18% possible gout, 18% were unlikely to have gout, and 14% had insufficient information to make an assessment.
Conclusion: The ICD coding of gout recorded for patients discharged was relatively accurate when using the case record documentation as the gold standard. However, case note review was unable to substantiate the diagnosis in over half the cases according to the ACR/EULAR GCC, and in almost a third of cases independent review was unable to confirm the diagnosis.
Tasman Medical Journal 2021; 3(1): 76-80.
Objective: The modified Rodnan skin score (mRSS), considered the gold standard to measure skin thickeness in scleroderma, has limitations. We compared skin thickness measured by ultrasound (US) to the mRSS, evaluated the intra- and inter-rater reliability US, and the ability of US to detect skin disease progression in scleroderma.
Methods: Thirteen female and 3 male participants with scleroderma (SSc) attending our hospital from 2010-2017 had skin thickness assessments with mRSS and US (Esaote Mylab 70 XVG, 18MHz linear probe and stand-off pad) at 17 body sites, at baseline and 2 years. Clinical characteristics and medications were also collected.
Results: Ten patients had limited cutaneous scleroderma (lSSc) and 6 had diffuse cutaneous scleroderma (dSSc). The median age was 65 years and median disease duration was 7 years. Individual site skin thickness measured by US had a weak correlation with the site component of the mRSS, but a composite 17 site US skin score did not correlate with the mRSS. US had good intra- and inter-rater reliability at 6/17 sites with intraclass coefficients greater than 0.50. Improvement in skin thickness over 2 years was demonstrated in 2 (33%) patients (at 12/17 sites, p<0.039; and 16/17 sites, p<0.001 respectively).
Conclusion: Whilst US has apparent validity in measuring skin thickness, a 17 site skin thickness US score did not correlate with mRSS. US had good intra- and inter-rater reliability at 6 sites, and detected regression in skin thickness in two dSSc patients.
Tasman Medical Journal 2021; 3(1): 81-86
Objectives: Artificial intelligence (AI) research is undergoing a renaissance, brought about by advances in both machine learning (ML) and deep learning (DL). There is currently no data on Australia’s contribution to AI research in medicine. We performed a bibliometric analysis to assess the quantity and quality of scientific publications concerning AI in medicine over the last ten years, and compare results from Australia to nine other countries publishing in this domain.
Methods: The SCOPUS database was searched for all journal articles or conference papers containing the words “artificial intelligence”, “machine learning” or “deep learning” published in subject areas related to medicine from 1 January 2008 to 31 December 2017.
Results: Australia was the source of 470 papers from 2008 to 2017 and accounted for 3.45% of world’s AI, ML, and DL in medicine publications over this period. Worldwide, publications increased significantly, especially in the last 2 years of the period studied. The increase in output was notable from China (254%), India (179%), Australia (149%), and the United States (142%). When 2016 publication output is adjusted by population Australia ranks third (behind Canada and the United Kingdom), but the trend is not statistically significant. We found no significant variation in the average number of citations received per paper in any of the top publishing countries.
Conclusion: The publication rate for AI, ML, and DL related to medicine has increased over the last 10 years. Australia’s contribution to AI research in this area, measured as both average citation rate or adjusted by country population is comparable in quantity and quality to other leading countries.
Tasman Medical Journal 2021; 3(2): 87-93
Introduction: Adult-onset Stills Disease (AOSD) is a rare immuno-inflammatory disease with an unpredictable course. Contemporary treatment with biological agents is commonplace but the efficacy of treatment and effects on long-term outcomes are poorly defined. We investigated prognostic markers and evaluated outcomes in an Australian cohort of hospitalized patients with AOSD diagnosed and treated over 10 years.
Methods: Patients greater than 18 years of age with a discharge ICD-10 code for AOSD were selected from medical records at 3 tertiary hospitals in Perth, Western Australia from 2009-2019. Demographic data, and clinical and serological outcomes after 12 months of follow-up were collected. Relationships between plasma ferritin and clinical remission, flare rate, need for conventional treatment with or without conventional or biological disease-modifying agents (csDMARD and bDMARD) and Physician Global Assessment score (PGA) were evaluated, as were the effect of treatments on serologic markers of remission and PGA. Fishers exact tests for a categorical comparisons and Mann-Whitney U-tests for comparison of continuous outcomes were performed. P < 0.05 was considered statistically significant.
Results: All patients received corticosteroid therapy and 18 of 24 also received csDMARDs. Of these, 8 progressed to bDMARDs. Lower baseline ferritin concentrations were observed in those who achieved complete remission, required csDMARDs +/- bDMARDs, or had more flares per 100 patient-years and lower PGA scores, but the results were not statistically significant. Serological markers of remission decreased markedly with all treatments, but no significant differences between treatments or in patients achieving remission was observed.
Conclusions: Long term follow-up was limited but remission rates appeared low. No unequivocal predictors of treatment response or outcome were identified. A trend towards greater use of csDMARDs and bDMARDs, and low PGA scores (poor outcome at 12 months), implying worse outcomes was observed with hyperferritinemia. Accordingly, marked hyperferritinemia may be a biomarker for more sustained or severe AOSD manifestations and predispose to more relapses. Further research is required to examine this possibility in more detail.
Tasman Medical Journal 2021; 3(2): 94-101
Background: To describe opioid prescribing practices in adults presenting to the Emergency Department (ED) with upper limb fractures.
Methods: A retrospective descriptive study was conducted in ambulatory adult patients who presented to two EDs in Southeast Queensland and were diagnosed and discharged with upper limb fractures between 1 January and 28 February 2019. Electronic Medical Records of eligible patients were independently extracted by two reviewers. Patient demographics, clinical variables and prescribing practices are described.
Results: Of the 137 individual patients analysed, opioids were prescribed in over half of patients (54.7%) in the ED, with an additional 6.6% of patients receiving opioids prior to presentation. Around one-third of patients (32.1%) received opioid prescriptions on discharge with 90% of these patients being prescribed 20 tablets or more. Severity of injury was associated with higher rate of opioid prescription. Discharge opioid prescriptions were more common in women and older patients. In over half of patients (54%), recommendation to use simple over-the-counter analgesia was not documented as part of discharge pain management.
Conclusion: These findings provide insights in current practice and provide a reference rate of both ED and discharge opioid prescription for discharged ED patients with upper limb fractures. Implementation of guidelines, particularly surrounding the appropriate quantity of opioids supplied on discharge and explicit inclusion of simple analgesia as part of pain management may optimise care. However, opioid prescription is only one aspect of pain management and other pain management strategies, patient factors and patient education should be considered in future studies.
Tasman Medical Journal 2021: 3(3): 102-109
We describe a case of psoriasis complicated by periodontitis and discuss the relationship between the two conditions.
Tasman Medical Journal 2021; 3(3): 110-111
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