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Selected AbstractsAudit of community-based anticoagulant monitoring in patients with thromboembolic disease: is frequent testing necessary?INTERNAL MEDICINE JOURNAL, Issue 11 2004L. Young Abstract Oral anticoagulant monitoring is managed by general practitioners in Auckland. An audit of this service in 452 patients demonstrated that anticoagulant control was in line with recommended international guidelines, with 58.3% of international normalized ratio (INR) measurements in the therapeutic range. However, the frequency of testing was high, with the majority of patients (68%), including those on long-term treatment, having INR measurements at weekly intervals. We question the need for such frequent INR testing. (Intern Med J 2004; 34: 639,641) [source] Would general practitioners support a population-based colorectal cancer screening programme of faecal-occult blood testing?INTERNAL MEDICINE JOURNAL, Issue 9-10 2004S. Tong Abstract Background:, The success of a population-based screening for colorectal cancer (CRC) is determined to a large extent by general practitioner (GP) attitudes, beliefs and support. The extent to which GPs support population-based CRC screening remains unclear. Aims:, To assess the knowledge, attitudes and practices of GPs in relation to CRC screening, and to identify the determinants of GP support for population-based faecal-occult blood testing (FOBT). Methods:, A cross-sectional postal survey was conducted with a random sample of 692 GPs in Queensland, Australia. We assessed GP knowledge, attitudes and practices concerning CRC screening in relation to their stance on population-based FOBT screening. Results:, Although the response rate was low (41%), participants were representative of Queensland GPs in general. Of 284 participating GPs, 143 (50.5%) indicated that they would support a population-based FOBT screening programme, 42 (14.8%) would not and 98 (34.6%) were unsure. Belief in FOBT test efficacy (P < 0.001), possession of CRC guidelines (P < 0.05) and belief in earlier stage detection (P < 0.05) were major determinants of support for population-based FOBT screening. No significant association was observed for doctor's sex, location of practice, age, year completed medical training, membership of a Division of General Practice, number of weekly consultations, number of patients investigated for CRC per month, size of practice, own family history of CRC, interest in further information on CRC screening or treatment, and current use of FOBT with asymptomatic patients aged ,40 years. Conclusions:, GP support for FOBT population-based screening appears to have increased over recent years. The knowledge and attitudes/beliefs of GPs are key determinants of their support. (Intern Med J 2004; 34: 532,538) [source] Scorpion stings in Australia: five definite stings and a reviewINTERNAL MEDICINE JOURNAL, Issue 7 2004G. K. Isbister Abstract Despite scorpions being locally abundant in many parts of Australia, scorpion sting is a poorly defined clinical condition in Australia. Many health-care workers are unaware of the effects of their stings and scorpions are often feared based on their international reputation. Five scorpion stings that occurred in different parts of Australia where the scorpion was caught at the time of the sting and identified by a professional arachnologist are reported in the present paper. The spectrum of clinical effects of scorpion stings in Australia and the potential for significant effects are discussed. These cases and recent prospective case series demonstrate that in Australia scorpion stings cause only minor effects. The main effect is localized pain lasting for several hours, associated less commonly with systemic effects, local numbness and paraesthesia. Most stings are from smaller scorpions from the family Buthidae and often occur indoors at night. The stings from Australian buthid scorpions cause more severe effects than from the larger species in the families Urodacidae (genus Urodacus) and Liochelidae (genus Liocheles). (Intern Med J 2004; 34: 427,430) [source] Ethics as process and practiceINTERNAL MEDICINE JOURNAL, Issue 6 2004A. W. Frank Abstract The noun form of ethics suggests something substantive; this substance is located in both offices of institutionalized experts and a body of canonical solutions to recognizable troubles. The present article recommends thinking of ethics not as substance but as a process of lives and decisions affecting each other over time. No single decision stands alone and no single patient can be considered as a stand-alone entity. Examples include how people struggle with choices they should not have to make, how decisions at one time are affected by earlier decisions that are not considered within the purview of ethics, and how to deal with conflicts of legitimate interests. When institutional ethics becomes a prescribed activity, the goal of being ethical is easily forgotten. (Intern Med J 2004; 34: 355,357) [source] Management of brain metastasesINTERNAL MEDICINE JOURNAL, Issue 5 2004L. C. Lim Abstract Solid tumour brain metastases are a frequent clinical dilemma for oncologists and general physicians. The sound management of brain metastases requires a multidisciplinary approach. In this review we discuss the diagnosis and management of brain metastases including the role of surgery, radiotherapy, and chemotherapy. The standard approaches of surgical excision and primary radiotherapy have evolved from randomised studies. However, controversies remain regarding post-surgery irradiation in the setting of a solitary metastasis and the role of palliative chemotherapy. (Intern Med J 2004; 34: 270,278) [source] Kennedy's disease: pathogenesis and clinical approachesINTERNAL MEDICINE JOURNAL, Issue 5 2004K. J. Greenland Abstract Kennedy's disease, also known as spinal and bulbar muscular atrophy, is a progressive degenerative condition affecting lower motor neurons. It is one of nine neurodegenerative disorders caused by a polyglutamine repeat expansion. Affecting only men, Kennedy's disease is the only one of these conditions that follows an X-linked mode of inheritance. The causative protein in Kennedy's disease, with a polyglutamine expansion residing in the first N-terminal domain, is the androgen receptor. Research in this field has made significant advances in recent years, and with the increased understanding of pathogenic mechanisms, feasible approaches to treatments are being investigated. In Kennedy's disease research, the most significant issue to emerge recently is the role of androgens in exacerbating the disease process. On the basis of animal experiments, a viable hypothesis is that higher circulating levels of androgens in men could trigger the degeneration of motor neurons causing this disease, and that lower levels in heterozygous and homozygous women are protective. This is a major issue, as treatment of individuals affected by Kennedy's disease with testosterone has been considered a reasonable therapy by some neurologists. The rationale behind this approach relates to the fact that Kennedy's disease is accompanied by mild androgen insensitivity. It was therefore believed that treatment with high doses of testosterone might compensate for this loss of androgen action, with the added benefit of preventing muscle wasting. The current review provides an overview of recent advances in the field of Kennedy's disease research, including approaches to treatment. (Intern Med J 2004; 34: 279,286) [source] Nonalcoholic fatty liver disease: is all the fat bad?INTERNAL MEDICINE JOURNAL, Issue 4 2004A. D. Clouston Abstract Nonalcoholic fatty liver disease is now a major cause of liver disease in developed countries, largely as a result of an epidemic of obesity, diabetes and sedentary lifestyles. This has resulted in raised clinical awareness and diagnostic refinement. The entity encompasses several histologic patterns from benign steatosis to nonalcoholic steatohepatitis, the latter having a significant risk of progressive fibrosis and the development of cirrhosis. Laboratory tests and imaging are not able to distinguish steatosis from steatohepatitis, which requires liver biopsy. However following an assessment of several risk factors, patients can be stratified for the potential risk of fibrosis, allowing the rational use of liver biopsy. This review will describe the various patterns of nonalcoholic fatty liver disease and relate this to disease pathogenesis and progression. Strategies for management, including experimental interventions, will be discussed. (Intern Med J 2004; 34: 187,191) [source] Suspected white-tail spider bite and necrotic ulcersINTERNAL MEDICINE JOURNAL, Issue 1-2 2004G. K. Isbister Abstract Aim: To describe the clinical features, investigation, diagnosis and treatment of ulcers attributed to white-tail (WT) spider bites or necrotic arachnidism. Methods: The study was a prospective case series of patients referred to the Hunter Area Toxicology Service (a tertiary referral toxicology unit servicing a population of 500 000) with an ulcer or skin lesion that had been attributed to either a suspected WT spider bite or necrotic arachnidism. Eleven patients with skin lesions or necrotic ulcers were referred between January 2000 and June 2002. Results: In two patients that were inpatients in other hospitals, investigation and follow up was not possible. In both cases there was no history of spider bite and Staphylococcus aureus was cultured. In nine patients, a diagnosis other than spider bite was made following appropriate investigation and follow up, including: (i) two cases of dermatophytoses, (ii) three staphylococcal infections, (iii) one case of pyoderma gangrenosum, (iv) one case of cutaneous polyarteritis nodosa, (v) one case of Nocardia braziliensis and (vi) one infected diabetic ulcer. There was only one case where the person recalled seeing a spider bite them, but the patient did not collect the spider for identification. The median time to diagnosis was 3 weeks (interquartile range: 3,9 weeks) and 3.5 years in one case. Appropriate treatment was initiated once the correct diagnosis was made and all cases resolved. Conclusions:, In this series, all cases initially referred as WT spider bites or necrotic arachnidism were found to have alternative diagnoses with appropriate investigations. This demonstrates that spider bites are an unlikely cause of necrotic ulcers and that all ulcers should be properly investigated with bacterial, fungal and mycobacterial cultures and skin biopsy for histopathology. (Intern Med J 2004; 34: 38,44) [source] Advance directives and emergency department patients: ownership rates and perceptions of useINTERNAL MEDICINE JOURNAL, Issue 12 2003D. McD. Abstract Background: Advance directives (ADs) are rarely available in Australia to guide management but may become more important as our population ages. Aims: The present study aimed to determine patient knowledge, perception and ownership rates of ADs and the factors that impact upon these variables. Methods: A cross-sectional survey of emergency department patients was undertaken. The main outcome measures were: (i) prior discussion about the extent of medical treatment and ADs, (ii) knowledge and perceptions of ADs, (iii) present AD ownership rates and (iv) likelihood of future AD ownership. Generalized linear models were used for analysis. Results: Four hundred and three patients were enrolled. The mean age of patients was 73 years and 239 (59.3%) were male. Two hundred and forty patients (59.6%) had discussed the extent of treatment. Only 81 patients (20.1%) had discussed the use of an AD. One hundred and thirty-seven patients (34.0%) knew of one type of AD and 333 patients (82.6%) thought some ADs were a good idea. Only 32 patients (7.9%) owned an AD, although 276 (68.5%) would consider owning one. The main reason for never obtaining an AD was ,always wanting full treatment' (93 patients, 23.1%). Level of education was the only characteristic that impacted significantly upon an outcome measure. Patients with a higher level of education were more likely to have known and spoken about ADs, to own an AD and to consider owning one. Conclusions: AD knowledge and ownership rates were low. However, most patients perceive them favourably and many would consider owning one. Intervention strategies to improve AD awareness are indicated. This may empower patients to more effectively participate in their own advance care planning. (Intern Med J 2003; 33: 586,592) [source] The medical emergency team: does it really make a difference?INTERNAL MEDICINE JOURNAL, Issue 11 2003M. Cretikos Abstract Hospital systems are failing the critically ill. This has been well documented in many countries around the world, with detailed reports of suboptimal care prior to intensive care and high rates of serious adverse events, including death. These events are potentially preventable, but insufficient attention has been directed towards developing solutions to these important problems to date. The medical emergency team (MET) is a system approach that promotes early and appropriate intervention in the care of critically ill hospital patients. The benefits of the MET in terms of absolute in-patient mortality and cardiac arrest rates are not yet well-defined, although preliminary studies are promising. The MET does provide a potentially beneficial impact on many other aspects of patient care. These benefits include: (i) facilitating an integrated and coordinated approach to patient care across the hospital, (ii) increasing awareness of at-risk patients, (iii) encouraging early referral of seriously ill patients to clinicians with expertise in critical care and (iv) providing a foundation for quality initiatives for hospital-wide care of the seriously ill. The MET also empowers nursing staff and junior medical staff to call for immediate assistance in cases where they are seriously concerned about a patient, but may not have the experience, knowledge, confidence or skills necessary to manage them appropriately. (Intern Med J 2003; 33: 511,514) [source] Migraine: diagnosis and managementINTERNAL MEDICINE JOURNAL, Issue 9-10 2003P. J. Goadsby Abstract Migraine is the most common form of disabling primary headache and affects approximately 12% of studied Caucasian populations. Non-pharmacological management of migraine largely consists of lifestyle advice to help sufferers avoid situations in which attacks will be triggered. Preventive treatments for migraine should usually be considered on the basis of attack frequency, particularly its trend to change with time, and tractability to acute care. Acute care treatments for migraine can be divided into non-specific treatments (general analgesics, such as aspirin or non-steroidal anti-inflammatory drugs) and treatments relatively specific to migraine (ergotamine and the triptans). The triptans , sumatriptan, naratriptan, rizatriptan, zolmitriptan, almotriptan, eletriptan and frovatriptan , are potent serotonin, 5-HT1B/1D, receptor agonists which represent a major advance in the treatment of acute migraine. Chronic daily headache in association with analgesic overuse is probably the major avoidable cause of headache disability in the developed world. (Intern Med J 2003; 33: 436,442) [source] Progress towards achieving new vaccine and vaccination goalsINTERNAL MEDICINE JOURNAL, Issue 7 2003G. Ada Abstract Viral and bacterial vaccines, especially for childhood use, are one of the most successful public health measures of the last two centuries and have a good safety record. However, there are still many diseases that are caused by infectious agents for which vaccines are not available. Our increasing ability to manipulate the immune system offers hope that, in the future, at least some of these infections may be prevented by vaccination. A surprising recent development is the use of vaccine technology to test whether a range of other generally non-communicable diseases can be prevented (or at least controlled) in this way. Investigation of these diseases is still mainly at the experimental level, however the list includes different types of cancers, allergies, drug addiction and neurodegenerative diseases. (Intern Med J 2003; 33: 297,304) [source] Microscopic colitis: an underdiagnosed cause of chronic diarrhoea , the clue is in the biopsiesINTERNAL MEDICINE JOURNAL, Issue 7 2003C. S. Pokorny Abstract Microscopic forms of colitis (collagenous colitis and lymphocytic colitis) are uncommon but important causes of chronic diarrhoea that are often overlooked. The clinical features of these disorders are similar, and they are more common in middle-aged females, although the female predominance is greater in collagenous colitis. Although their cause is unclear, both are associated with a variety of autoimmune diseases. Colonoscopy and barium enema are typically normal, so that the diagnosis depends on the demonstration of characteristic changes on histopathological examination of colorectal biopsies. These should be taken in all patients undergoing colonoscopy for the investigation of chronic diarrhoea. There are no large controlled trials of therapy available. Treatment is empirical, generally using the same agents as for inflammatory bowel disease. Assessment of therapy is also difficult as spontaneous remissions occur often. (Intern Med J 2003; 33: 305,309) [source] Biological weapons preparedness: the role of physiciansINTERNAL MEDICINE JOURNAL, Issue 5-6 2003C. L. Cherry Abstract The real risk posed by biological weapons was demonstrated with the distribution of anthrax spores via the USA postal service in 2001. This review outlines the central roles of physicians in optimizing biopreparedness in Australia, including maintaining awareness of the risk, promptly recognizing an event, notifying appropriate authorities upon suspicion of an event, and instituting appropriate management. Management aspects covered include appropriate diagnostic tests, infection control procedures, and empirical therapy of agents considered possible biological weapons. The critical role of physicians as public health advocates working to prevent the use of biological weapons is also outlined. (Intern Med J 2003; 33: 242,253) [source] Adherence to antiretroviral therapy: are we doing enough?INTERNAL MEDICINE JOURNAL, Issue 5-6 2003T. Read Abstract Adherence to antiretroviral therapy is a powerful predictor of response to therapy. For optimal antiretroviral therapy response, individuals need to take more than 95% of their prescribed medication. The most widely used method for measuring adherence is self-report of the number of missed doses and this should be done at every clinic visit. There are several well-recognized predictors of poor adherence, such as illicit drug use, depression, limited knowledge or ambivalence about starting treatment. Adherence can be improved by addressing these issues or through other means such as pill boxes or electronic reminders. (Intern Med J 2003; 33: 254,256) [source] Management of atrial fibrillation in the emergency departmentINTERNAL MEDICINE JOURNAL, Issue 4 2003I. Crozier Abstract Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is a frequent cause for presentation to the emergency department. With an understanding of the pathophysiology and types of AF, efficient and effective management strategies for AF can be formulated. Patients with paroxysmal AF will often revert spontaneously and can initially be managed on an outpatient basis, unless an antiarrhythmic is commenced. In patients with AF and severe underlying heart disease, the management is primarily directed at the underlying heart disease, supplemented with rate-controlling measures, and prevention of thromboembolic complications. In patients with persistent AF good rate control, early cardioversion and initiation of an antiarrhythmic are likely to reduce the risk of recurrence. (Intern Med J 2003; 33: 182,185) [source] Misconduct in medical research: whose responsibility?INTERNAL MEDICINE JOURNAL, Issue 4 2003K. J. Breen Abstract Examples of many types of misconduct in medical research continue to be reported. The true incidence is unknown because there is strong evidence of under-reporting as well as suggestions of increased detection. Risks to research participants may also be increasing, with contributing factors such as increased pressure on researchers to publish and to produce commercialization of their research. Institutions are perceived to typically respond slowly and inadequately to allegations of research misconduct. More could be done to try to prevent such misconduct, such as: (i) educating researchers about research ethics, (ii) assisting and protecting whistleblowers and (iii) instituting processes to adequately and promptly investigate and deal with allegations. In addition, a debate needs to take place as to whether research misconduct allegations should be dealt with at the institutional level or at a national level and whether medical boards should be routinely involved in the more serious breaches of ethical standards by medical practitioners engaged in research. (Intern Med J 2003; 33: 186,191) [source] Outcomes research: what is it and why does it matter?INTERNAL MEDICINE JOURNAL, Issue 3 2003M. Jefford Abstract Outcomes research is a broad umbrella term without a consistent definition. However it tends to describe research that is concerned with the effectiveness of public-health interventions and health services; that is, the outcomes of these services. Attention is frequently focused on the affected individual , with measures such as quality of life and preferences , but outcomes research may also refer to effectiveness of health-care delivery, with measures such as cost-effectiveness, health status and disease burden. The present review details the historical background of outcomes research to reveal the origins of its diversity. The value and relevance of outcomes research, commonly employed research techniques and examples of recent publications in the area are also discussed. (Intern Med J 2003; 33: 110,118) [source] Adjuvant chemotherapy in colon cancer: what is the evidence?INTERNAL MEDICINE JOURNAL, Issue 3 2003A. Haydon Abstract Over the last 12 years, numerous randomized trials have addressed the role of adjuvant chemotherapy in resected colon cancer. Together, these studies give conclusive evidence of the benefit of adjuvant 5-fluorouracil combined with folinic acid in stage III (node positive) disease and this is now considered the standard of care. The chemotherapy appears to be equally effective whether it is given daily for 5 days per month or on a weekly schedule. The overall effect is a relative reduction in tumour recurrence of 25% or an absolute improvement in survival of 10%. However, doubt remains as to the role of adjuvant chemotherapy in stage II colon cancer. To date, most of the randomized trials have demonstrated a relative reduction in tumour recurrence but have not shown any significant impact on survival. It seems likely that this inability to demonstrate a survival benefit from adjuvant chemotherapy in stage II disease relates to the fact that the trials have been underpowered to do so. Nevertheless, the absolute survival advantage is only about 2% and clinicians need to weigh this against the costs and toxicities of the treatment when managing these patients. (Intern Med J 2003; 33: 119,124) [source] Vitamin D deficiency is common and unrecognized among recently arrived adult immigrants from The Horn of AfricaINTERNAL MEDICINE JOURNAL, Issue 1-2 2003S. A. Skull Abstract The prevalence of and risk factors for vitamin D deficiency were examined for recent adult immigrants from East Africa living in Melbourne. Demographic data were collected via a face-to-face questionnaire and risk factors predicting deficiency were examined. Suboptimal levels <25 nmol/L were found in 61 patients (53%; 74% of women; 20% of men). Lower levels were more likely in: (i) patients with a longer duration of residence in Australia, (ii) patients who were mostly covered when outdoors and (iii) women. Routine assessment for vitamin D deficiency should be considered for male and female immigrants from East Africa. (Intern Med J 2003; 33: 47,51) [source] Clinical and experimental uses of umbilical cord bloodINTERNAL MEDICINE JOURNAL, Issue 12 2002I. D. Lewis Abstract Umbilical cord blood (UCB) has been used successfully as an alternative source of haemopoietic stem cells (HSC) in allogeneic stem-cell transplantation for the treatment of acquired and genetic diseases. Advantages of using UCB include: (i) no risk to the donor, (ii) no donor attrition, (iii) minimal risk of viral transmission and (iv) immediate availability. Early results have highlighted differences in engraftment rates and toxicity between UCB and other sources of HSC. These differences relate to the low cell dose in UCB and also to the intrinsic properties of UCB. In this article, the clinical outcome of UCB transplantation (UCBT) will be reviewed with a discussion of the biological characteristics of UCB that may account for some of the clinical outcomes. To overcome the limitations of low cell dose, novel approaches such as ex vivo expansion of HSC are being actively explored, and this will be summarized in the present study. Finally, the success of UCBT has led to the establishment of dedicated UCB banks worldwide and the regulatory issues surrounding this will be briefly discussed. (Intern Med J 2002; 32: 601,609) [source] Dementia: an update to refresh your memoryINTERNAL MEDICINE JOURNAL, Issue 11 2002D. Logiudice Abstract The number of people with dementia and cognitive impairment is predicted to rise exponentially in the future. The increasing awareness of dementia in the community has led to a better understanding of the impact of this condition on individuals, their families and their carers. There is burgeoning research in the pathogenesis of dementia, and advances have been made in pharmacological treatments for the management of symptoms, including behavioural and psychological disturbances. However, the mainstay of management rests in comprehensive clinical assessment, education, counselling and provision of support for those affected and their families. The present paper provides a clinical update on recent advances in diagnosis and management of the most common forms of dementia. (Intern Med J 2002; 32: 535,540) [source] Parasitic worms of the central nervous system: an Australian perspectiveINTERNAL MEDICINE JOURNAL, Issue 11 2002A. J. Hughes Abstract The diagnosis and management of parasitic diseases of the central nervous system (CNS) is difficult, even for infectious diseases physicians and neurologists. Furthermore, few overviews of the spectrum of causative helminths and clinical syndromes have been published. In the present study, we review the seven most common parasitic diseases of the CNS: (i) cysticercosis, (ii) neuroschistosomiasis, (iii) paragonimiasis, (iv) angio-strongyliasis, (v) hydatid disease, (vi) sparganosis and (vii) gnathostomiasis. Major syndromes of parasitic disease of the CNS and their differential causes are discussed, including: (i) cystic lesions, (ii) enhancing granulomas (with and without creeping subcutaneous eruptions), (iii) eosinophilic meningoencephalitis and (iv) spinal cord disease. Specific risk factors that predispose to these infections are also discussed and particular attention is drawn to the situation in Australia. (Intern Med J 2002; 32: 541,553) [source] Obesity: the science behind the managementINTERNAL MEDICINE JOURNAL, Issue 5-6 2002K. Steinbeck Abstract The prevalence of obesity is increasing in Western and Westernizing countries. The changing environment plays a major role in this increase, particularly the reduction in physical activity. There is also a strong genetic contribution to the development of obesity, although single-gene defect obesity is rare. Neither the environment nor genes is simple to modify. Obesity is an energy-balance disorder, and the human body has evolved to resist any loss of body fat. This biological drive to maintain weight is coordinated through central pathways, with the involvement of many neuropeptides. Thus, dietary restriction will induce changes designed to counter weight loss, including a fall in resting metabolic rate. The management of obesity demands reasonable goals, which focus on metabolic, rather than cosmetic, improvement. As obesity is a complex condition, multiple therapeutic strategies are required. Dietary modification, an increase in physical activity, a reduction in sedentary activity and behaviour modification all form the basis of obesity therapy. Drug therapy options at present are limited and may have a stronger role in weight maintenance. Currently, surgical management of obesity has the best long-term outcomes. Long-term maintenance of weight loss is achieved by few individuals. Those individuals who are successful are able to maintain long-term restrictive eating habits and high levels of physical activity. (Intern Med J 2002; 32: 237,241) [source] An audit of the use of granulocyte colony-stimulating factor in septic shockINTERNAL MEDICINE JOURNAL, Issue 4 2002D. P. Stephens Abstract Background:,Granulocyte colony-stimulating factor (G-CSF) stimulates the production of neutrophils and modulates the function and activity of developing and mature neutrophils. In septic shock, the immune system can be considered one of the failing organ systems.G-CSF improves immune function and may be a useful adjunctive therapy in patients with septic shock. Aim:,To evaluate the introduction of G-CSF as an adjunct to our standard treatment for community-acquired septic shock. Methods:,We performed a prospective data collection and analysis to determine whether the addition of G-CSF to our standard treatment for community-acquired septic shock was associated with improved hospital outcome, compared with an historical cohort ofsimilar patients. We included all patients admitted to the Intensive Care Unit (ICU) with community-acquired septic shock between December 1998 and March 2000. Patients received 300 µg G-CSF intravenously daily for 10 days in addition to ourstandard treatment for community-acquired septic shock. G-CSF was discontinued early if the patient was discharged from ICU before10 days or if the absolute neutrophil count exceeded 75 × 106/mL. Results:,A total of 36 patients with community-acquired septic shock, an average Apache 2 score of 26.7, and a predictedmortality of 0.79, were treated with G-CSF from December 1998 to March 2000. Hospital mortality was 31% compared with an historical cohort of 11 similar patients with a hospital mortality of 73% (P = 0.018). In the subgroup of patients with melioidosis septic shock, the hospital survival improved from 5% to 100% (P < 0.0001). No significant adverse events occurred as a result of the administration of G-CSF. Conclusion:,G-CSF is a safe adjunctive therapy in community-acquired septic shock and may be associated with improved outcome. The use of G-CSF in septic shock should undergo further investigation to define subgroups of patients who may benefit from G-CSF. The use of G-CSF in patients with septic shock due to Burkholderia pseudomallei is recommended. (Intern Med J 2002; 32: 143,148) [source] Prevalence of snoring and sleep-disordered breathing in a group of commercial bus drivers in Hong KongINTERNAL MEDICINE JOURNAL, Issue 4 2002D. S. C. Hui Abstract Objectives:,To assess the prevalence of sleep-disordered breathing (SDB) and its associated symptoms in a group of commercial bus drivers in Hong Kong. Methods:,Two hundred and sixteen of 410 bus drivers from three different shifts were interviewed with the Sleep & Health Questionnaire (SHQ) and the Epworth sleepiness scale (ESS) at a Hong Kong bus depot. Seventeen subjects from each shift were then randomly selected for at-home sleep study using the Mesam IV device (Madaus Medizin,Elektronik, Freiburg, Germany). Results:,There were 207 men and nine women (mean age 42.4 ± 7.5 years; body mass index (BMI) 25.4 ± 4.5 kg/m2; ESS 5.3 ± 4.2). From the SHQ it was discovered that: (i) daytime sleepiness was reported by 87 subjects (40%), (ii) snoring , 3 times per week was reported by 80 subjects (37%), (iii) witnessed apnoea was reported by 17 subjects (7.9%) and (iv) 29 subjects (13.4%) reported having fallen asleep during driving. Among the 51 subjects who underwent the at-home sleep study: (i) 31 subjects (61%) had respiratory disturbance index (RDI) , 5 per hour of sleep, (ii) 21 subjects (41%) had RDI , 10 per hour of sleep, (iii) 12 subjects (24%) had RDI , 15 per hour of sleep and (iv) 35 subjects (68.6%) snored objectively , 10% of the night. Ten subjects (20%) had RDI , 5 and sleepiness at work, while five subjects (9.8%) had RDI , 5 and ESS > 10. No significant differences were noted in the SHQ responses, ESS, objective snoring or RDI among the three groups. Multiple regression analysis showed that BMI and witnessed apnoea were the only positive independent predictors of RDI. Conclusions:,This study showed a high prevalence of objective snoring and SDB in a group of commercial bus drivers. Neither self-reported sleepiness nor the ESS could identify subjects with SDB. (Intern Med J 2002; 32: 149,157) [source] Myocardial perfusion imaging in evaluation of undiagnosed acute chest painINTERNAL MEDICINE JOURNAL, Issue 9 2001J. C. Knott Abstract Myocardial perfusion imaging is a relatively new technique in the emergency department management of acute chest pain. With improved sensitivity and specificity compared to traditional methods of risk stratification, an abnormal scan rapidly identifies individuals with acute perfusion abnormalities and allows the appropriate utilization of limited resources. Conversely, a normal scan allows prompt hospital discharge and is associated with excellent outcomes both in the short and medium terms. Acute chest pain myocardial perfusion imaging has been demonstrated to alter patient management and disposition and its routine use results in decreased costs in the intermediate risk population. (Intern Med J 2001; 31: 544,546) [source] Sentinel lymph node biopsy in patients with melanoma and breast cancerINTERNAL MEDICINE JOURNAL, Issue 9 2001R. F. Uren Abstract Sentinel lymph node biopsy (SNLB) is a new method for staging regional node fields in patients with cancers that have a propensity to metastasise to lymph nodes. The majority of early experience has been obtained in patients with melanoma and breast cancer. The technique requires the close cooperation of nuclear medicine physicians, surgical oncologists and histopathologists to achieve the desired accuracy. It involves: (i) identification of all lymph nodes that directly drain a primary tumour site (the sentinel nodes) by the use of pre-operative lymphoscintigraphy, (ii) selective excision of these nodes by the surgeon, guided by pre-operative blue dye injection and a gamma detecting probe intra-operatively and (iii) careful histological examination of the sentinel nodes by the histopathologist using serial sections and immunohistochemical stains. If the nodes are normal it can be inferred with a high degree of accuracy that all nodes in the node field are normal. This means that radical dissections of draining node fields can be avoided in patients with normal lymph nodes. A further advantage of lyamphatic mapping is that drainage to sentinel nodes in unusual locations is identified, leading to more accurate nodal staging than could be achieved with routine dissection of the closest node field. (Intern Med J 2001; 31: 547,553) [source] Pharmaceutical industry-sponsored meetings: good value or just a free meal?INTERNAL MEDICINE JOURNAL, Issue 8 2001S. L. Carney Abstract Although the role of the pharmaceutical industry in continuing medical education (CME) has been debated for many years, industry CME funding continues to increase. Because of concern about the educational quality of industry CME, the Hunter Postgraduate Medical Institute (HPMI), an independent Newcastle and Hunter Valley CME provider, evaluated the use and quality of industry CME as reported by rural and urban general practitioners, physicians and psychiatrists. Furthermore, clinicians were asked if they supported increased industry-funded independent CME. Sixty-two per cent of general practitioners and 71% of psychiatrists attended at least three industry-organized meetings each year, compared with 24% of physicians. Twenty-five per cent of general practitioners attended five or more such meetings. Industry meetings were judged to be of good to excellent quality by 81% of generalists, 79% of physicians and 87% of psychiatrists. All clinical groups ranked the topic and then speaker as the most important reason for attending, with CME points, venue and the sponsor ranked lowest. Eighty to 90% of doctors supported a greater role of industry-funded independent CME. Despite the absence of current data on the use and perceived benefits of industry CME, these preliminary results suggest that industry CME is playing an increasingly important role in clinician education. However, many clinicians and industry representatives support a greater role by independent postgraduate organizations in industry-sponsored CME. (Intern Med J 2001; 31: 488,491) [source] Human immunodeficiency virus,hepatitis C coinfection: swapping new problems for newer onesINTERNAL MEDICINE JOURNAL, Issue 7 2001J. Sasadeusz Abstract Recent successes in HIV therapy have uncovered other health problems for HIV-infected individuals. Hepatitis C has become an especially significant problem, partly due to its faster progression in an immunocompromised setting. In addition, the higher viral loads in coinfected patients likely result in more efficient perinatal and perhaps even sexual transmission. Therapy has largely been neglected, despite data suggesting its efficacy in HIV,HCV coinfected patients. Studies of combination interferon and ribavirin studies are lacking, although underway. A major concern is the potential inactivation of certain thymidine analogues by ribavirin. Some antiretroviral therapies, such as ritonavir, indinavir and nevirapine, may enhance liver toxicity in coinfected patients and should be avoided if possible. The role of chronic low-grade liver function abnormalities remains uncertain and requires further investigation. (Intern Med J 2001; 31: 418,421) [source] | ||||||||||