Is post-pneumonia chest X-ray for lung malignancy useful? Results of an audit of current practice.

BACKGROUND/AIM: Patients with community-acquired pneumonia (CAP) are often screened with repeat chest X-ray within 6-12 weeks following an admission. This practice is aimed to detect underlying lung malignancy, which can be difficult to identify initially when an acute infiltrate is present on X-ray. We conducted a study on the use of follow-up chest X-rays after an admission with CAP to determine the yield of suspected or diagnosed cancer. METHODS: During the 2-year period, January 2010-January 2012, we evaluated all patients over the age of 50 who had no previous history of lung cancer and were admitted to Hutt Hospital with CAP. RESULTS: A total of 302 patients was included. Of these, 53% received a follow-up chest X-ray within 6-12 weeks after admission. A total of six patients (2.0%) was diagnosed with lung cancer based on a chest X-ray within 6-12 weeks after admission. After a median period of follow up of 19.5 months, a further five patients who had normal chest X-ray were diagnosed with lung malignancy. CONCLUSION: The majority of patients were screened with follow-up X-rays. The yield from a 6- to 12-week chest X-ray following CAP is low, which is consistent with previous studies. The development of clear guidelines to ensure identification of patient groups at significantly high risk of lung cancer is important to increase the sensitivity of screening. High yielding strategies, such as low-dose computed tomography, should be considered as an alternative.

Adherence and outcomes of patients prescribed dabigatran (Pradaxa) in routine clinical practice.

AIM: To explore and detail clinical experiences of dabigatran, a novel anticoagulant, after it became available in New Zealand in July 2011. METHODS: A cohort of patients was recruited from Hutt Hospital and the two largest primary care practices in the Hutt Valley region. They were included if they took at least one dose of dabigatran between July 2011 and April 2012. Participants undertook a questionnaire 3-12 months after starting dabigatran assessing adherence, perceived side-effects and complications. Those presenting due to an adverse event were analysed separately. RESULTS: Of 102 patients identified, 92 were recruited to this study. At a median of 8 months, 70% of participants were still taking dabigatran, significantly lower than in the RE-LY trial at 12 months (P = 0.0002). The commonest reason given for discontinuation was gastrointestinal (GI) side-effects. Rates of serious adverse outcomes on dabigatran therapy were relatively low. Patients expressed polarised comments, both positive and negative, regarding their experiences of dabigatran. CONCLUSIONS: A high rate of discontinuation of dabigatran, mainly due to GI symptoms, was observed. There does not appear to be any specific predictor of dabigatran tolerance. When prescribed according to guidelines, rates of serious adverse events associated with dabigatran appear to be low.

Stroke thrombolysis in patients taking dabigatran.

Stroke thrombolysis is becoming a common practice in Australian and New Zealand hospitals. There are no established guidelines for thrombolysis of patients who are taking dabigatran, and accurate medication reconciliation may not be possible. Patients with normal activated partial thromboplastin time are unlikely to have clinically significant dabigatran concentration in the blood. For safest outcomes, we suggest incorporating thrombin time assay for acute stroke patients suspected to be taking dabigatran.

Quality of drug prescribing in older patients: is there a problem and can we improve it?

Older patients are at high risk of suboptimal prescribing (overuse, underuse and misuse of drugs), which can lead to serious adverse drug reactions (ADR). About one in four patients admitted to hospital are prescribed at least one inappropriate medication and up to 20% of all inpatient deaths are attributed to potentially preventable ADR. Lists of drugs to avoid (unnecessary or where risks outweigh benefits) and drugs not to be omitted (strong indications if there are no contraindications) can assist in identifying suboptimal prescribing although, to date, no trials have established the ability of such screening, by itself, to improve prescribing quality. Remedial strategies proven to be effective in randomized trials include detailed appraisal of medication lists by multidisciplinary teams, which involve geriatricians and close liaison with specialist clinical pharmacists. A multifaceted quality improvement strategy is proposed that includes an aspirational target of no more than five different drugs be regularly prescribed to vulnerable older patients. Achieving this target involves prioritizing drug selection on the basis of strength of indication which may run counter to current disease-specific clinical guideline recommendations based on trials that have excluded most older patients. Such a strategy is worthy of further evaluation in a multicentre randomized trial.

Delirium among elderly general medical patients in a New Zealand hospital.

BACKGROUND: Overseas studies suggest that delirium is a common and serious health problem of hospitalized elderly. There is very little information in New Zealand. AIMS: To study prospectively the frequency and effect of delirium on a cohort of elderly general medical patients. METHODS: Over 2 months, 317 patients were admitted to general medical wards; 70% were aged 65 years and above. These patients were screened for delirium. Comparisons were made between the delirious and non-delirious patients. RESULTS: Fifty-six of the 216 patients screened had delirium. The prevalence and incidence of delirium were 23.4 and 5.7%, respectively. Thirty-one per cent of delirious patients had a previous history of dementia; 48% of delirious patients had multiple precipitants, most commonly infections. Delirium was associated with higher complication rates--94 versus 39% in the non-delirious patients--and a doubling in the length of hospital stay. Over 50% of delirious patients required increased supports on discharge with a general trend towards higher frequency of institutionalization. The presence of delirium was associated with increased use of neuroleptic medications, special nursing care, cot sides and restraints. A non-significant trend towards increased mortality was seen in the delirious group. CONCLUSIONS: Delirium is a common health problem in elderly patients, associated with multiple adverse outcomes. This study highlighted the prognostic importance of diagnosing delirium. Recommendations included improved health professional education, development of guidelines including rational use of neuroleptic medication and measures to improve follow up for these patients.

Improving quality and safety of hospital care: a reappraisal and an agenda for clinically relevant reform.

Improving quality and safety of hospital care is now firmly on the health-care agenda. Various agencies within different levels of government are pursuing initiatives targeting hospitals and health professionals that aim to identify, quantify and lessen medical error and suboptimal care. Although not denying the value of such 'top-down' initiatives, more attention may be needed towards 'bottom-up' reform led by practising physicians. This article discusses factors integral to delivery of safe, high-quality care grouped under six themes: clinical workforce, teamwork, patient participation in care decisions, indications for health-care interventions, clinical governance and information systems. Following this discussion, a 20-point action plan is proposed as an agenda for future reform capable of being led by physicians, together with some cautionary notes about relying too heavily on information technology, use of non-clinical quality personnel and quantitative evaluative approaches as primary strategies in improving quality.

Epidemic gonococcal conjunctivitis in central Australia.

OBJECTIVES: To describe an epidemic of gonococcal conjunctivitis in central Australian Aboriginal children, the responsible phenotypes of Neisseria gonorrhoeae, factors facilitating spread and treatment efficacy. DESIGN: Prospective study of patients with laboratory confirmed or clinical gonococcal conjunctivitis diagnosed from January to July 1991. SETTING: The Alice Springs and Barkly Tablelands Health Districts of the Northern Territory, the Anangu Pitjantjatjara Lands of South Australia and the Ngaanyatjarra Homelands of Western Australia. METHODS: Cases were identified from surveillance data and laboratory notifications, and by active case finding. A community survey explored risk factors. MAIN OUTCOME MEASURES: Age-specific attack rates, auxotype/serovar characterisation of isolates, and clinical response to single dose treatment. RESULTS: We identified 432 cases. The highest attack rate was in the 0-4 year age group (86 per 1000), and the risk of conjunctivitis decreased with age. The odds ratio of secondary infection in household compared with community contacts was 14.5 (P < 0.002; 95% CI, 1.8-120.0). Disease was less common in children with clean faces and hands. The outbreak occurred after unseasonable rains and large community gatherings. Isolates were predominantly IA serovars, less common among central Australian serovars. CONCLUSIONS: The trigger for nonsexually transmitted gonococcal conjunctivitis epidemics remains obscure. Age is a significant risk factor and social and ecological factors may also contribute. Active case finding within affected households and treatment with a suitable penicillin is effective in stopping transmission.

Epidemic meningococcal meningitis in central Australia, 1987-1991.

OBJECTIVE: To describe an outbreak of meningococcal meningitis and the impact of rifampicin chemoprophylaxis on secondary attack rates among Aboriginal people in central Australia. DESIGN: Prospective study of patients admitted to hospital between September 1987 and May 1991. SETTING: The Alice Springs Health Region of the Northern Territory and the Anangu Pitjantjatjara Lands of South Australia, covering a population of 13,228 Aboriginal people. SUBJECTS: Patients admitted to the Alice Springs Hospital with clinical signs or autopsy findings of meningococcal disease. Rifampicin chemoprophylaxis was given to close contacts of all cases. Mencevax AC vaccine was offered to children aged 1 to 15 years in the Region. MAIN OUTCOME MEASURES: Blood or cerebrospinal fluid (CSF) with Neisseria meningitidis, or a positive result of latex agglutination testing on CSF. Positive isolates were serogrouped. RESULTS: Seventy-seven cases of meningococcal disease were diagnosed in Aboriginal people over four years compared with one to two cases per year previously; of these, 60 were definite, 7 probable and 10 suspected cases. Seventy-six subjects had meningitis, of whom one also had the clinical features of meningococcal septicaemia; one other subject had positive blood cultures with a mild febrile illness without features of meningitis. The annual attack rate of meningococcal disease in the Aboriginal population was 1.6/1000. The relative risk for secondary cases was estimated to be between 0.3 (95% confidence interval [CI], 0.09-0.92) and 0.5 (95% CI, 0.15-1.53). The annual attack rate in the non-Aboriginal population was 0.04/1000. CONCLUSIONS: The epidemic closely resembled those in sub-Saharan Africa, and in socioeconomically marginalised groups in developed countries. The relative risk for secondary cases was lower than generally reported, and was attributed to chemoprophylaxis for close contacts and the mass vaccination program for children. Until there are major improvements in living conditions, infectious diseases such as those transmitted by airborne droplets will continue to occur in Aboriginal communities.

Effect of beta-blocker therapy on serum lipoprotein profiles in patients on renal dialysis and in diabetic nephropathy.

We determined whether the serum lipoprotein levels in insulin-dependent diabetic patients (IDDM) with nephropathy and in patients on haemodialysis or continuous ambulatory peritoneal dialysis were affected by beta-blocker therapy. A case control study was performed in 18 IDDM patients with diabetic nephropathy, in 18 patients receiving chronic haemodialysis (HD) and 16 patients undergoing continuous ambulatory peritoneal dialysis (CAPD). In IDDM patients with diabetic nephropathy very low density lipoprotein-cholesterol (VLDL-CHOL) (0.680 +/- 0.17 vs 0.197 +/- 0.04 mmol/l, p = 0.004), total triglycerides (1.71 +/- 0.23 vs 0.808 +/- 0.14 mmol/l, p = 0.004) and very low density lipoprotein triglyceride (VLD-TG) were higher in the beta-blocker therapy group. In haemodialysis patients, beta-blocker therapy caused no significant changes in the serum lipoprotein profiles compared to the control group. In patients receiving continuous ambulatory peritoneal dialysis VLDL-CHOL was significantly higher (1.47 +/- 0.24 vs 1.08 +/- 0.21 mmol/l, p = 0.042) and cholesterol-high density lipoprotein (HDL-CHOL) was lower in the beta-blocker therapy group. The elevated VLDL-CHOL level (0.96 +/- 0.12 vs 1.24 +/- 0.14 mmol/l, p = 0.021) was correlated with the duration of CAPD in patients receiving beta-blocker therapy. Antihypertensive therapy with beta-blockers in IDDM patients with persistent proteinuria and in patients on continuous ambulatory peritoneal dialysis appears to adversely effect serum lipoproteins which may add to their cardiovascular risk.