Chrianna Bharat

Development of a clinical prediction rule to improve peripheral intravenous cannulae first attempt success in the emergency department and reduce post insertion failure rates: the Vascular Access Decisions in the Emergency Room (VADER) study protocol.

Introduction Peripheral intravenous cannula (PIVC) insertion is one of the most common clinical interventions performed in emergency care worldwide. However, factors associated with successful PIVC placement and maintenance are not well understood. This study seeks to determine the predictors of first time PIVC insertion success in emergency department (ED) and identify the rationale for removal of the ED inserted PIVC in patients admitted to the hospital ward. Reducing failed insertion attempts and improving peripheral intravenous cannulation practice could lead to better staff and patient experiences, as well as improving hospital efficiency. Methods and analysis We propose an observational cohort study of PIVC insertions in a patient population presenting to ED, with follow-up observation of the PIVC in subsequent admissions to the hospital ward. We will collect specific PIVC observational data such as; clinician factors, patient factors, device information and clinical practice variables. Trained researchers will gather ED PIVC insertion data to identify predictors of insertion success. In those admitted from the ED, we will determine the dwell time of the ED-inserted PIVC. Multivariate regression analyses will be used to identify factors associated with insertions success and PIVC failure and standard statistical validation techniques will be used to create and assess the effectiveness of a clinical predication rule. Ethics and dissemination The findings of our study will provide new evidence to improve insertion success rates in the ED setting and identify strategies to reduce premature device failure for patients admitted to hospital wards. Results will unravel a complexity of factors that contribute to unsuccessful PIVC attempts such as patient and clinician factors along with the products, technologies and infusates used. Trial registration number ACTRN12615000588594; Pre-results.

First Australian experience of treating localised prostate cancer patients with CyberKnife stereotactic radiotherapy: early PSA response, acute toxicity and quality of life

This study is to evaluate biochemical response, acute toxicity and health‐related quality‐of‐life (QOL) outcomes among prostate cancer patients following stereotactic body radiation therapy (SBRT) in the first Australian CyberKnife facility.

RESPECT-ED: Rates of pulmonary emboli (PE) and sub-segmental PE with modern computed tomographic pulmonary angiograms in emergency departments: A multi-center observational study finds significant yield variation, uncorrelated with use or small PE rates

Introduction Overuse of CT Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE), particularly in Emergency Departments (ED), is considered problematic. Marked variations in positive CTPA rates are reported, with American 4–10% yields driving most concerns. Higher resolution CTPA may increase sub-segmental PE (SSPE) diagnoses, which may be up to 40% false positive. Excessive use and false positives could increase harm vs. benefit. These issues have not been systematically examined outside America. Aims To describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation. Methods A retrospective multi-centre review of consecutive ED-ordered CTPA using standard radiology reports. ED CTPA report data were inputted onto preformatted data-sheets. The primary outcome was site level yield, analysed both intra-site and against a nominated 15.3% yield. Factors potentially associated with yield were assessed for correlation. Results Fourteen radiology departments (15 ED) provided 7077 CTPA data (94% ≥64-slice CT); PE were reported in 1028 (yield 14.6% (95%CI 13.8–15.4%; range 9.3–25.3%; site variation p <0.0001) with four sites significantly below and one above the 15.3% target. Admissions, CTPA usage, PE diagnosis rates and size of PE were uncorrelated with yield. Large PE (≥lobar) were 55% (CI: 52.1–58.2%) and SSPE 8.8% (CI: 7.1–10.5%) of positive scans. CTPA usage (0.2–1.5% adult attendances) was correlated (p<0.006) with PE diagnosis but not SSPE: large PE proportions. Discussion/ Conclusions We found significant intra-site CTPA yield variation within Australasia. Yield was not clearly correlated with CTPA usage or increased small PE rates. Both SSPE and large PE rates were similar to higher yield historical cohorts. CTPA use was considerably below USA 2.5–3% rates. Higher CTPA utilisation was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE.

Isokinetic shoulder strength correlates with level of sports participation and functional activity after reverse total shoulder arthroplasty

BACKGROUND Reverse total shoulder arthroplasty (RTSA) is increasingly being performed. Many patients may wish to return to high levels of sporting activity. This study aimed to evaluate the correlation of isokinetic shoulder strength with level of participation in sport and recreation after RTSA. METHODS We surveyed 51 patients at a mean of 29.5 months (range, 12-60 months) after surgery. Mean age was 74.1 years. Patient-reported sporting activity was classified as low, medium, or high demand. All patients completed the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire and the Oxford Shoulder Score and underwent Biodex dynamometer testing of the RTSA evaluating isokinetic shoulder strength in flexion and extension, abduction and adduction, and internal and external rotation. RESULTS Reported sporting activity was high demand in 35% and moderate demand in 43%. There was a large variation in shoulder isokinetic strength parameters especially for internal and external rotation. With the exception of abduction, a significant correlation was noted between strength and the level of sports participation that patients reported (P < .03). A significant correlation was also noted between strength and patient-reported outcome measures for internal rotation and arm flexion and abduction (P < .05). CONCLUSION Most patients reported returning to moderate- or high-level sporting activity in the short term after RTSA. Isokinetic shoulder strength, especially in internal rotation and arm flexion, positively correlates with both patient-reported level of participation in sports and recreation and daily function.

p16 immunoreactivity in endometrial stromal cells: stromal p16 expression characterises but is not specific for endometrial polyps

Summary It has been proposed recently that stromal cell p16 immunoreactivity may be useful in the diagnosis of endometrial polyps (EPs). However, the specificity of p16 staining is uncertain and it is also unclear whether sporadic and tamoxifen-related polyps show similar findings. We performed p16 immunostaining on 35 normal endometrial specimens and 32 EPs, six of which were associated with tamoxifen therapy. Normal cyclical endometrium showed patchy glandular staining and there was also focal stromal p16 expression in the functional layer of most proliferative and secretory endometria. Atrophic and lower uterine segment endometrial stromal cells were negative except for localised immunoreactivity in one atrophic case. The EPs demonstrated glandular p16 expression, particularly in epithelium showing ciliated metaplasia. Stromal p16 staining was also seen in all EPs, although the proportion of positive cells varied considerably (20–90%). There was no significant difference in staining between sporadic and tamoxifen-associated cases. In conclusion, stromal p16 immunoreactivity is characteristic of EPs and this may reflect the pathogenesis of polyp formation. Immunohistochemistry can help to distinguish polypoid and non-polypoid mucosa, particularly in small or disrupted biopsy specimens. However, stromal p16 expression is not completely specific since focal staining may be present in normal endometrium.

Clinicopathological and immunohistological features of polypoid endometriosis.

To compare clinicopathological and immunohistochemical features of polypoid endometriosis (PE) and non‐polypoid endometriosis (NPE).

Cox proportional hazards modelling of blockage risk in vitrified clay wastewater pipes

Abstract Older wastewater systems often contain vitrified clay pipes and these pipes are responsible for a significant proportion of blockages. From previous research and site experience, it is known that age, installation period, pipe length, diameter, depth and joint type affect the risk of blockage. Using statistical analysis we extend this list of variables to include soil type, road/rail proximity and road type. The analysis is based on blockage data for 43,976 vitrified clay pipes over a 7 year period. A Cox proportional hazards modelling (PHM) approach using established and new explanatory variables finds that pipe depth, pipe length, pipe gradient, pipe diameter, submergence in water, joint type, pipe installation decade, soil type, road proximity to the pipe, pipe purpose, land use code and road type are associated with risk of blockage. Pipes with the highest risk of failure due to blockage are identified and their locations and risk level are visually represented on a colour coded map. This analysis approach can be used by asset managers working in cost-constrained environments to appropriately target inspection, plan maintenance and replacement programs.

Arm morbidity of axillary dissection with sentinel node biopsy versus delayed axillary dissection

Staging of axillary lymph nodes in breast cancer is important for prognostication and planning of adjuvant therapy. The traditional practice of proceeding to axillary lymph node dissection (ALND) if sentinel lymph node biopsy (SLNB) is positive is being challenged and clinical trials are underway. For many centres, this will mean a move away from intra‐operative SLNB assessment and utilization of a second procedure to perform ALND. It is sometimes perceived that a delayed ALND results in increased tissue damage and thus increased morbidity. We compared morbidity in those undergoing SLNB only, or ALND as a one‐ or two‐stage procedure.

Reliability of the English version of the painDETECT questionnaire

Abstract Background: The painDETECT questionnaire (PD-Q) has been used widely for the identification of neuropathic pain (NeP); however, the reliability of the English version of the PD-Q has never been investigated. Objective: This study aimed to determine the reliability of the PD-Q pre- (T0) and immediately post- (T1) clinical consultation and at one-week follow-up (T2). Methods: We recruited 157 patients attending a Neurosurgery Spinal Clinic and Pain Management Department. Minor changes to PD-Q instructions were made to facilitate patient understanding; however, no changes to individual items or scoring were made. Intraclass correlation coefficients (ICCs) were used to assess the reliability of PD-Q total scores between T0–T1 and T0–T2; weighted kappa (κ) was used to assess the agreement of PD-Q classifications (unlikely NeP, ambiguous, likely NeP) between all time-points. To ensure stability of clinical pain, patients scoring ≤2 or ≥6 on the Patient Global Impression Scale (PGIC) at T2 were excluded from the T0–T2 analysis. Results: Accounting for missing data and exclusions (change in PGIC score), data for 136 individuals (mean [SD] age: 56.8 [15.2]; 54% male) was available, of whom n = 129 were included in the T0–T1 and n = 69 in the T0–T2 comparisons. There was almost perfect agreement between the PD-Q total scores at T0–T1 time-points (ICC 0.911; 95% CI: 0.882–0.941) and substantial agreement at T0–T2 (ICC 0.792; 95% CI: 0.703–0.880). PD-Q classifications demonstrated substantial agreement for T0–T1 (weighted κ: 0.771; 95% CI: 0.683–0.858) and for T0–T2 (weighted κ: 0.691; 95% CI: 0.553–0.830). Missing data was accounted in 13% of our cohort and over 42% of our patients drew multiple pain areas on the PD-Q body chart. Conclusion: The English version of the PD-Q is reliable as a screening tool for NeP. The validity of the questionnaire is still in question and has to be investigated in future studies.

Prevalence of obesity and the effect on length of mechanical ventilation and length of stay in intensive care patients: A single site observational study

OBJECTIVES To provide a snapshot of the prevalence of abnormal body mass index (BMI) in a sample of intensive care unit (ICU) patients; to identify if any medical specialty was associated with abnormal BMI and to explore associations between BMI and ICU-related outcomes. BACKGROUND Obesity is an escalating public health issue across developed nations but there is little data pertaining to critically ill patients who require care that is expensive. METHODS Retrospective observational audit of 735 adult patients (median age 58 years) admitted to the Sir Charles Gairdner Hospital 23 bed tertiary ICU between November 2012 and June 2014. Primary outcome measure was patient BMI: underweight (<18.5kg/m2), normal weight (18.5-24.99kg/m2), overweight (25-29.99kg/m2), obese (30-39.99kg/m2) or extreme obese (40kg/m2 or above). Other measures included gender, acute physiology and chronic health evaluation II score, admission specialty, length of mechanical ventilation (MV), length of stay (LOS) and mortality. RESULTS Compared to the general population there was a higher proportion of obese patients within the cohort with the majority of patients overweight (33.9%) or obese (36.5%) and median BMI of 27.9 (IQR 7.9). There were no significant differences between specialties for BMI (p=0.103) and abnormal BMI was not found to impact negatively on mortality (ICU, p=0.373; hospital, p=0.330). Normal BMI patients had shorter length of MV than other BMI categories and the impact of BMI on ICU LOS was dependent on length of MV. Overweight patients ventilated for five days or more had a shorter LOS, and extremely obese non-ventilated patients had a longer LOS, compared to normal weight patients. CONCLUSIONS Although the obesity-disease relationship is increasingly complex and data presented reflects categorical BMI for patients admitted to a single ICU site it may be important to consider the cost implications of caring for this cohort especially with regard to MV and LOS.