478 research outputs found
Effects of care pathways on stroke care practices at regional hospitals
No full textBackground: Our previous work identified deficiencies in stroke care practices at regional hospitals in comparison to standards suggested by published stroke care guidelines. These deficiencies might be improved by the implementation of clinical pathways. The aim of this study was to assess changes in acute stroke care practices following the implementation of stroke care pathways at four regional Queensland hospitals. Methods: The medical records of two cohorts of 120 patients with a discharge diagnosis of stroke or transient ischaemic attack were retrospectively audited before and after implementation of stroke care pathways to identify differences in the use of acute interventions, investigations and secondary prevention strategies. Results: Following pathway implementation there were clinically important, but not statistically significant, increases in the rates of swallow assessment, allied health assessment (significant for occupational therapy, P = 0.04) and use of deep vein thrombosis prevention strategies (also significant, P = 0.006). Fewer patients were discharged on no anti-thrombotic therapy (statistically significant in the subgroup of patients with atrial fibrillation, P = 0.02). Only 37% of the patients audited were actually enrolled on the pathway. Among this subgroup there were significant increases in the rates of swallow assessment (first 24 h, P = 0.01; any time during admission, P = 0.0001), allied health assessments (all P < 0.05), estimation of blood glucose level (P = 0.0015) and the use of deep vein thrombosis prevention strategies (P = 0.0003). Conclusion: Stroke care pathways appear to improve the process of care. Whether this influences outcomes such as mortality, functional and neurological recovery, the incidence of complications, length of stay or the cost of care was beyond the scope of this study and will require further examination
The road not taken: Lessons to be learnt from the Queen v Gillett
No full textFollowing the decision in the Gillet Case it may no longer be safe to rely on the Austroads guidelines when considering fitness to drive. This paper examines the case and its implications. Although the Guidelines claimed ‘… the identification and application of world best-practice… ’, they were disregarded by the court in Gillet. Both expert witnesses testified that on disclosure of epilepsy the accused would have been endorsed as fit for a licence application to the Roads & Traffic Authority, on the basis of 10 years of only nocturnal seizures, in accordance with the guidelines. The Court rejected this evidence and interpreted failure to disclose epilepsy as recognition of perceived risk and the previously undiagnosed sleep apnoea as the basis for that risk, despite being diagnosed after the accident. There needs to be greater certainty in the application of the guidelines, with legislative intervention and licenses should display a bold statement advising drivers of their responsibility to notify authorities of illnesses that could potentially affect driving
Respiratory infectious disease: complacency with empiricism in the age of molecular science. We can do better!
No full textHeparin-induced thrombocytopenia: recent experience in a large teaching hospital
No full textBackground: Heparin-induced thrombocytopenia (HIT) is a potentially serious adverse reaction caused by platelet-activating antibodies. Aim: To describe experience with HIT. Methods: Twenty-two patients identified by laboratory records of heparin-associated antibodies with a 50% or greater decrease in platelet count were reviewed in our 600-bed metropolitan teaching hospital from 1999 to April 2005. Results: There was an increase in the frequency of HIT diagnosed during the review period, which was associated with a rise in the number of requests for HIT antibodies. Thrombotic complications were identified in 14 of 22 patients with HIT. Mean age was 65 years, and 11 patients were men. Seven patients died and HIT was considered contributory in four. One patient required mid-forearm amputation. Unfractionated heparin was used in all cases and five patients also received enoxaparin. Mean time to HIT screen, reflecting when the diagnosis was first suspected, was 14 days. Platelet nadir ranged from 6 x 10(9)/L to 88 x 10(9)/L, with a percentage drop in platelet count of 67-96%. Alternative anticoagulation (danaparoid) was not used in three patients, two of whom died. Conclusions: HIT is a potentially life-threatening complication of heparin therapy, associated with a fall in platelet count and a high incidence of thromboembolic complications. It is most frequently seen using unfractionated heparin therapy. The increase in frequency of HIT diagnosed in our hospital appears to be associated with a greater awareness of the entity, although detection is often delayed. Platelet count should be monitored in patients on heparin and the presence of antiplatelet antibodies determined if HIT is suspected. Treatment involves both discontinuation of heparin and the use of an alternative anticoagulant such as danaparoid because of the persisting risk of thrombosis
Postural orthostatic tachycardia syndrome: an underrecognized disorder
No full textBACKGROUND: Postural orthostatic tachycardia syndrome (POTS), a clinical syndrome of orthostatic intolerance characterized by excessive tachycardia and symptoms of cerebral hypoperfusion on standing, is not well recognized in Australia. The aim was to study the clinical symptomatology, results of autonomic testing and outcome in patients with POTS. METHODS: Sixteen subjects from a tertiary referral centre who met the criteria for POTS were studied between January 2003 and January 2006. Ten of these patients consented to be interviewed using a validated autonomic symptom questionnaire. Heart rate responses to deep breathing and the Valsalva manoeuvre were measured using Colin BP-508 machine (WR Medical Electronic Co., Stillwater, MN, USA). Tilt studies were carried out for 10 min to 80 degrees of head-up tilting. Patient outcome was assessed as functionally normal, able to stand 30 min without symptoms, able to work and carry out recreational activities or worse on follow up. RESULTS: The mean age of 10 subjects was 24.9 +/- 6.8 years, six being women. The mean duration of symptoms was 70.7 months (range 3-228 months). The common presenting orthostatic symptoms were light-headedness (100%), palpitations (90%), pallor (90%), weakness (80%) and clammy skin (80%). The mean heart rate increment during the tilt study was 51.7 +/- 14.3 b.p.m. The mean duration of follow up was 8.9 months (range 1-16 months). Only five patients were functioning normally at the follow-up visit. CONCLUSION: POTS is an underrecognized but persistent autonomic disorder in young patients with a variety of symptoms and variable outcome
How we mobilize haemopoietic stem cells
No full textMobilization and collection of haemopoietic stem and progenitor cells (HSPC) is the cornerstone of autologous and allogeneic stem cell transplantation for a wide variety of haematological and some non-haematological malignancies. Centres providing this service face the challenge of optimizing the likelihood of successful collection of transplantable doses of cells, while maximizing the efficiency of the apheresis unit and minimizing the risk of toxicity as well as mobilization failure. Recent developments in the understanding of the molecular mechanisms of mobilization have led to the emergence of novel strategies for HSPC mobilization, which may assist in meeting these imperatives. The task for clinicians is how to incorporate the use of these strategies into practice, in the light of emerging evidence for efficacy and safety of these agents. Herein, the literature is reviewed, and a proposed algorithm for HSPC mobilization is presented.K. E. Herbert, J.-P. Levesque, A. K. Mills, D. J. Gottlieb, J. Cooney, J. Szer, J. Rasko and L. B. T
'Free' surfactant in gastric aspirates and bronchoalveolar lavage in children with and without reflux oesophagitis
No full textAim: Dipalmitoylphosphatidycholine (DPPC) is the characteristic and main constituent of surfactant. Adsorption of surfactant to epithelial surfaces may be important in the masking of receptors. The aims of the study were to (i) compare the quantity of free DPPC in the airways and gastric aspirates of children with gastroesophageal reflux disease (GORD) to those without and (ii) describe the association between free DPPC levels with airway cellular profile and capsaicin cough sensitivity. Methods: Children aged < 14 years were defined as 'coughers' if a history of cough in association with their GORD symptoms was elicited before gastric aspirates and nonbronchoscopic bronchoalveolar lavage (BAL) were obtained during elective flexible upper gastrointestinal endoscopy. GORD was defined as histological presence of reflux oesophagitis. Spirometry and capsaicin cough-sensitivity test was carried out in children aged > 6 years before the endoscopy. Results: Median age of the 68 children was 9 years (interquartile range (IQR) 7.2). Median DPPC level in BAL of children with cough (72.7 mu g/mL) was similar to noncoughers (88.5). There was also no significant difference in DPPC levels in both BAL and gastric aspirates of children classified according to presence of GORD. There was no correlation between DPPC levels and cellular counts or capsaicin cough-sensitivity outcome measures. Conclusion: We conclude that free DPPC levels in the airways and gastric aspirate is not influenced by presence of cough or GORD defined by histological presence of reflux oesophagitis. Whether quantification of adsorbed surfactant differs in these groups remain unknown. Free DPPC is unlikely to have a role in masking of airway receptors
Toenails and agranulocytosis
No full textThe objective of this article was the study of 12 cases of granulocytopenia associated with terbinafine use in Australia, the most recent, with agranulocytosis, which is described in detail. The mean age of the participants was 64 years (range 35-79 years). Sex was reported in 11 patients and all but one was a woman. Time to onset of neutropenia/agranulocytosis was 4-5 weeks in most cases. Neutropenia was typically severe with neutrophil count
Polymorphism in human cytomegalovirus UL40 impacts on recognition of human leukocyte antigen-E (HLA-E) by natural killer cells
No full textNatural killer (NK) cell recognition of the nonclassical human leukocyte antigen (HLA) molecule HLA-E is dependent on the presentation of a nonamer peptide derived from the leader sequence of other HLA molecules to CD94-NKG2 receptors. However, human cytomegalovirus can manipulate this central innate interaction through the provision of a "mimic" of the HLA-encoded peptide derived from the immunomodulatory glycoprotein UL40. Here, we analyzed UL40 sequences isolated from 32 hematopoietic stem cell transplantation recipients experiencing cytomegalovirus reactivation. The UL40 protein showed a "polymorphic hot spot" within the region that encodes the HLA leader sequence mimic. Although all sequences that were identical to those encoded within HLA-I genes permitted the interaction between HLA-E and CD94-NKG2 receptors, other UL40 polymorphisms reduced the affinity of the interaction between HLA-E and CD94-NKG2 receptors. Furthermore, functional studies using NK cell clones expressing either the inhibitory receptor CD94-NKG2A or the activating receptor CD94-NKG2C identified UL40-encoded peptides that were capable of inhibiting target cell lysis via interaction with CD94-NKG2A, yet had little capacity to activate NK cells through CD94-NKG2C. The data suggest that UL40 polymorphisms may aid evasion of NK cell immunosurveillance by modulating the affinity of the interaction with CD94-NKG2 receptors.Susan L. Heatley, Gabriella Pietra, Jie Lin, Jacqueline M. L. Widjaja, Christopher M. Harpur, Sue Lester, Jamie Rossjohn, Jeff Szer, Anthony Schwarer, Kenneth Bradstock, Peter G. Bardy, Maria Cristina Mingari, Lorenzo Moretta, Lucy C. Sullivan and Andrew G. Brook
Transition care forum: "Can we really make bed blocking go away? How much would it cost?"
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