Restriction of oxycodone in the emergency department (ROXY-ED): A randomised controlled trial.

Background: The prescription of opioids in emergency care has been associated with harm, including overdose and dependence. The aim of this trial was to assess restriction of access to oxycodone (ROXY), in combination with education and guideline modifications, versus education and guideline modifications alone (standard care) to reduce oxycodone administration in the Emergency Department (ED). Methods: An unblinded, active control, randomised controlled trial was conducted in an adult tertiary ED. Participants were patients aged 18-75 years who had analgesics administered in the ED. The primary intervention was ROXY, through removal of all oxycodone immediate release tablets from the ED imprest, with availability of a small supply after senior clinician approval. The intervention did not restrict prescription of discharge medications. The primary outcome measure was oxycodone administration rates. Secondary outcomes were administration rates of other analgesic medications, time to initial analgesics and oxycodone prescription on discharge. Results: There were 2258 patients eligible for analysis. Oxycodone was administered to 80 (6.1%) patients in the ROXY group and 221 (23.3%) patients in the standard care group (relative risk (RR) 0.26; 95% CI: 0.21 to 0.33; p < .001). Tapentadol was prescribed more frequently in the ROXY group (RR 2.17; 95% CI: 1.71-2.74), while there were no differences in prescription of other analgesic medications. On discharge, significantly fewer patients were prescribed oxycodone (RR 0.51; 95% CI: 0.39-0.66) and no differences were observed in prescription rates of other analgesic medications. There was no difference in time to first analgesic (HR 0.94; 95% CI: 0.86-1.02). Conclusions: Restricted access to oxycodone was superior to education and guideline modifications alone for reducing oxycodone use in the ED and reducing discharge prescriptions of oxycodone from the ED. The addition of simple restrictive interventions is recommended to enable rapid changes to clinician behaviour to reduce the potential harm associated with the prescribing of oxycodone in the ED.

How Clinicians Decide? Exploring Complexity of Antibiotic Prescribing in Emergency Departments Using Video-Reflexive Ethnography.

Antibiotic overprescribing is a global issue that significantly contributes to increased antimicrobial resistance. Strengthening antimicrobial prescribing practices should be considered a priority. The emergency department (ED) represents a setting where antibiotics are frequently prescribed, but the determinants that influence prescribing choices are complex and multifaceted. We conducted an exploratory qualitative study to investigate the contextual factors that influence antibiotic prescribing choices among clinicians in the ED. The study employed video-reflexive ethnography (VRE) to capture prospective clinical decision-making in situated practice. Data collection involved fieldwork observations, video observations, and delivery of facilitated group reflexive sessions, where clinicians viewed a selection of recorded video snippets relating to antibiotic prescribing. Study was conducted across two EDs within the same health service in Australia. A total of 29 clinical conversations focusing on antibiotic prescribing were recorded. Additionally, 34 clinicians participated in group reflexive sessions. Thematic analysis from the transcribed data yielded four themes: 'importance of clinical judgment', 'usability of prescribing guidelines', 'managing patient expectations', and 'context-dependent disruptions'. Our findings provide insights into the challenges faced by clinicians in navigating complex ED environment, utilising electronic decision-support tools and engaging in discussions about patient treatments with senior clinicians. The findings also indicate that VRE is useful in visualising full complexity of the ED setting, and in initiating meaningful discussions among clinical teams. Integrating the use of VRE in everyday clinical settings can potentially facilitate the implementation of pragmatic solutions for delivering effective antibiotic stewardship practices.

A unique case report of relapsing eosinophilic myocarditis causing atrial myopathy and persistent sinus arrest.

BACKGROUND: Eosinophilic myocarditis (EM) is a rare and devastating condition. The underlying cause of EM is unknown, and the natural history is not well understood. CASE SUMMARY: A 20-year-old male presented in cardiogenic shock with preceding 24-h history of pleuritic chest pain associated with nausea and vomiting. Electrocardiogram showed sinus tachycardia with widespread ST elevation, significantly raised high-sensitivity troponin T, and raised white cell count with eosinophilia. Transthoracic echocardiogram demonstrated severe left ventricular (LV) impairment and a moderate-sized pericardial effusion. Right ventricular (RV) endomyocardial biopsy and bone marrow biopsy were performed, with both demonstrating prominent eosinophilia. He was initiated on pulse methylprednisolone leading to rapid clinical improvement with normalization of LV function. Day 9 after discharge, he was readmitted to hospital with presyncope and right heart failure. Electrocardiogram revealed junctional escape rhythm, and cardiac magnetic resonance imaging showed scarring confined to the atria. The patient was treated with mepolizumab and underwent an electrophysiology study with electroanatomical mapping, demonstrating sinus arrest and the absence of electrical activity throughout the right atrium. After much deliberation, an implantable cardioverter-defibrillator was implanted with a deep septal RV pacing lead and an apical RV defibrillator lead. DISCUSSION: We present a unique case of EM with two distinct phases: the first marked by severe LV impairment resolving with immunosuppression; the second characterized by atrial cardiomyopathy leading to persistent symptomatic sinus arrest necessitating permanent pacing. Close follow-up of EM after initial remission is essential to monitor for further complications including heart failure and arrhythmias.

Haemoptysis: just another case of endocarditis? A case report.

BACKGROUND: Pulmonary arteriovenous malformations (PAVM) are rare, and most cases are congenital. They require prompt recognition and management particularly in patients presenting with hypoxia and haemoptysis. We describe a unique case of recurrent endocarditis causing pulmonary artery aneurysms (PAAs) and formation of PAVM. CASE SUMMARY: A 60-year-old woman presented with dyspnoea, haemoptysis, and severe hypoxia. Her background was significant for previous pacemaker lead infection, refractory heart failure secondary to severe tricuspid valve distortion by her pacemaker lead, tricuspid and mitral valve replacements complicated by recurrent endocarditis over several years. Two years prior to her current presentation computed tomography (CT) scanning revealed new small PAAs thought possibly to be mycotic in origin. After her current presentation, prompt high-resolution CT scanning of her chest with contrast revealed significant pulmonary haemorrhage and new clusters of PAVM. Urgent pulmonary angiography confirmed PAVM and was successfully treated with coil embolization. Her dyspnoea, pulmonary haemorrhage, and hypoxia resolved. DISCUSSION: Acquired causes account for a very small percentage of PAVM and the mechanism of their development is unknown. As she had recurrent right-sided endocarditis and her PAAs developed following this, with new PAVM developing 2 years later; we hypothesize that they were causally related. We believe this is the first case of recurrent left- and right-sided endocarditis leading to formation of PAAs and development of PAVM presenting with significant hypoxia and haemoptysis requiring prompt intervention.

A case report of recurrent transient ischaemic attacks on dabigatran for atrial fibrillation: real-world insight into treatment failure.

BACKGROUND: Non-valvular atrial fibrillation (AF) is an important risk factor for acute ischaemic stroke. There has been an increase in the use of direct-acting oral anticoagulants (DOAC therapy) in stroke prophylaxis due to their convenience and rapid action of onset. However, there is a lack of information in the literature regarding management options and possible mechanisms with the apparent failure of DOAC therapy. CASE SUMMARY: We present a clinical case of a 51-year-old man presenting with transient ischaemic attacks on a background of AF on therapeutic doses of dabigatran. His medication box suggested 100% compliance and his admission coagulation studies showed a marginally prolonged activated partial thromboplastin time and thrombin time (TT). While in hospital, our patient had supervised doses of dabigatran (150 mg b.i.d.). Despite this, his peak dabigatran level was undetectable (<40 ng/mL). With the apparent failure of therapy, he was switched to apixaban 5 mg b.i.d., which showed subsequent peak levels in the target range. DISCUSSION: There are a number of isolated case reports of DOAC failure in stroke prophylaxis and management has simply involved switching to another DOAC or warfarin. This case is unique as we have discovered undetectable levels of dabigatran providing a mechanism for failure.

Outcomes of anemic patients presenting with acute coronary syndrome: An analysis of the Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events.

BACKGROUND: Anemia commonly accompanies acute coronary syndromes (ACS) and is associated with poorer outcomes. This study examines the associations between anemia, management and outcomes in an Australian ACS population. METHODS: This analysis of the CONCORDANCE database included 8665 ACS patients presenting to 41 Australian hospitals. Baseline characteristics, management, and outcomes were compared between patients with anemia (Hb ≤ 130 for males, Hb ≤ 120 g/L for females) and non-anemia. RESULTS: A total of 1880 (21.7%) patients presenting with ACS were anemic. These patients were older (72 years vs 63 years, P < .0001), with higher prevalence of comorbidities. STEMI patients with anemia were less likely to be emergently reperfused with either thrombolytic therapy (22% vs 33%, P < .0001) or primary percutaneous coronary intervention (PCI) (45% vs 51% P = 0.033). For all ACS, anemic patients less frequently received: coronary angiography (63% vs 86%, P < .0001); drug eluting stents if undergoing PCI (50% vs 58%, P < .0001); dual antiplatelet therapy (80% vs 89%, P < .0001) ;and parenteral anticoagulants (82% vs 88%, P < .0001). In hospital complications of heart failure (20% vs 9%, P < .0001), renal failure (13% vs 4%, P < .0001), and re-infarction (4% vs 2%, P = .0006) were more common among anemic patients. There was a near-linear inverse relationship between admission hemoglobin and in hospital mortality. CONCLUSIONS: Anemic patients with ACS are a high risk group less likely to undergo invasive and antithrombotic therapy. Further investigation is required to determine if more active treatment of anemic patients presenting with ACS will improve their outcomes.

Accuracy of Screening Tools for Pap Smears in General Practice.

BACKGROUND: Data extraction tools (DETs) are increasingly being used for research and audit of general practice, despite their limitations.Objective This study explores the accuracy of Pap smear rates obtained with a DET compared to that of the Pap smear rate obtained with a manual file audit. METHOD: A widely available DET was used to establish the rate of Pap smears in a large multi-general practice (multi-GP) in regional New South Wales followed by a manual audit of patient files. The main outcome measure was identification of possible discrepancies between the rates established. RESULTS: The DET used significantly underestimated the level of cervical screening compared to the manual audit. In some instances, the patient file contained phone/specialist record of Pap smear conducted elsewhere, which accounted for the failure of the DET to detect some smears. Those patients who had Pap smears whose pathology codes differed between time intervals, i.e. from different pathology providers or from within the same provider but using a different code, were less likely to have had their most recent Pap smear detected by the DET (p < 0.001). CONCLUSION: Data obtained from DETs should be used with caution as they may not accurately reflect the rate of Pap smears from electronic medical records.How this fits in DETs are increasingly being used for research and audit of general practice. This study explores the accuracy of Pap smear rates obtained with a DET compared to that of the Pap smear rate obtained with a manual file audit The DET tested significantly underestimated the level of cervical screening compared to manual screening. Data obtained from DETs should be used with caution as they may not accurately reflect the rate of Pap smears from electronic medical records.