The e-patient revolution increasingly enables patients to self diagnose and self educate, influencing decisions affecting their health. This poses a challenge for both patients and health care professionals due to the highly variable and often poor quality information available on the internet.
This study aims to measure the current internet usage in patients attending outpatient clinics, in both a public and private setting. All patients were recruited whilst consulting orthopaedic surgeons.
We developed a 29 question survey which asked questions related to patient demographics, general internet usage and internet usage related to the patient’s orthopaedic condition. Patients were recruited for the public cohort during Western Health outpatient clinics and for the private cohort during private surgical consults in the waiting rooms of eight surgeons’ clinics.
A total of 400 surveys were completed; 200 in both the private and public cohorts of the study. Of all surveyed participants, 79% (n = 316) had access to the internet. Of people who had access to the internet 65.2% (n = 206) used the internet to investigate their orthopaedic condition. 29.6% (n = 61) of participants asked their surgeon questions related to information they had read on the internet. Of patients that had access to the internet 36.1% (n = 114) used the internet to research their surgeon.
Patients are commonly using the internet as an information resource, in spite of the highly variable quality of this information. This highlights the need for patient information websites which reflect the current standards of clinical practice.
Online medical information; Internet use; Patient’s awareness; orthopaedics
Gyrate atrophy is a rare metabolic disease with autosomal recessive inheritance pattern characterised by hyperornithinemia and typical ocular findings. This report presents a 17-year-old intellectually challenged girl consulting for a progressive fall of visual acuity with night blindness. Fundus examination showed patches of chorioretinal atrophy with typical scalloped borders and peri vascular pigmentation in the equatorial region. Fundus fluroscein angiography revealed characteristic staining pattern. Other ocular associations included myopia and posterior sub capsular cataract. Progressive systemic proximal myopathy was one of the associated features. Dietary supplementation of vitamin B6 was advised.
Chorioretinal gyrate atrophy; myopia; posterior sub capsular cataract; myopathy
In Australia, many people ageing in their own homes are becoming increasingly frail and unwell, approaching the end of life. A palliative approach, which adheres to palliative care principles, is often appropriate. These principles provide a framework for proactive and holistic care in which quality of life and of dying is prioritised, as is support for families. A palliative approach can be delivered by the general practitioner working with the community aged care team, in collaboration with family carers. Support from specialist palliative care services is available if necessary.
The Guidelines for a Palliative Approach for Aged Care in the Community Setting were published by the Australian Government Department of Health and Ageing to inform practice in this area. There are three resource documents. The main document provides practical evidence based guidelines, good practice points, tools, and links to resources. This document is written for general practitioners, nurses, social workers, therapists, pastoral care workers, and other health professionals and responded to needs identified during national consultation. Evidence based guidelines were underpinned by systematic reviews of the research literature. Good practice points were developed from literature reviews and expert opinion. Two ‘plain English’ booklets were developed in a process involving consumer consultation; one is for older people and their families, the other for care workers.
The resources are intended to facilitate home care that acknowledges and plans for the client’s deteriorating functional trajectory and inevitable death. At a time when hospitals and residential aged care facilities are under enormous pressure as the population ages, such a planned approach makes sense for the health system as a whole. The approach also makes sense for older people who wish to die in their own homes. Family needs are recognised and addressed. Unnecessary hospitalisations or residential placements and clinically futile interventions are also minimised.
Evidence-based health care; guidelines; palliative care; aged care; community care
There is gap in the literature regarding the current practice of diabetes management of the elderly in Australia and its compliance with available Australian diabetes practice guidelines.
The aims of this study were to describe the pharmacological management of elderly residents with diabetes living in aged care facilities and to identify areas for improvement in the current management as recommended by the current diabetes management guidelines in Australia.
Residents with diabetes from three rural aged care facilities were identified by nursing staff. A cross-sectional medical record audit was carried out to obtain data of residents diagnosed with diabetes.
Thirty-four medical records were audited from three aged care facilities.Data including demographics, medical histories and medications were collected and analysed.
This study had two key findings; Firstly, it showed that about a third of residents with type 2 diabetes are managed with diet only. Secondly, of the residents who are managed with medications, less than half of those audited (41%) were managed according to the current diabetes guidelines in terms of pharmacological treatment which included anti- hypertensive, lipid lowering and anti- platelet therapies. Of those patients with a history of CVD, all were receiving an antihypertensive medication, 71% were not managed for their lipids and 20% were not on any prophylactic anti- platelet therapy.
Management of patients with diabetes living in rural aged care facilities is inconsistent with the current management guidelines. Educational interventions targeting health professionals and patients might be beneficial to increase compliance with the current diabetes guidelines.
Type 2 diabetes; Pharmacological management; diabetes guidelines; elderly; aged care facilities
We describe a 32-year-old lady who was admitted with a urinary tract infection following vacuum-assisted delivery. She was diagnosed with Enterococcus faecium related emphysematous cystitis, bladder gangrene and rupture necessitating emergency laparotomy and partial cystectomy. She had a repeat laparotomy nine days later due to continuing bladder necrosis on cystoscopy. The patient stayed in hospital for over two months due to complications including hospital acquired Klebsiella pneumonia, adult respiratory distress syndrome and malnutrition. Discharge occurred one week after an ileal conduit and ileostomy were performed.
Emphysematous cystitis; bladder rupture; gangrenous cystitis
Globally, it is estimated that 170 million people are living with hepatitis C and between three and four million are newly infected annually. In Australia, around 1% of people are living with chronic hepatitis C, with two-thirds of these being men.
This research aimed to determine the impact of hepatitis C treatment on partners of patients using in-depth exploratory techniques.
Four infected men and their partners (n= 8 participants) and three service providers were recruited and interviewed separately to identify the needs of female partners supporting patients with Hepatitis C. Discussion was based on the experiences of female partners during the treatment phase of male hepatitis C patients.
All participants recognised a need for greater assistance for partners of hepatitis C treatment patients. It was also recognised that strong social support improved treatment outcomes and helped to maintain the survival of family relationships during the intensive treatment phase.
Although this research was limited by size, it provides valuable insights into ways to enhance hepatitis C management outcomes beyond traditional medical treatment regimes, for example through formal partner support.
Caregivers/caring; coping and adaptation; partners; hepatitis C.
Chondrosarcomas of the hand are very rare, constituting less than 0.5% of all chondrosarcomas. Metacarpal involvement and juxtacortical location are still rarer. We report a case of periosteal chondrosarcoma of metacarpal bone in a 38-year-old man, who presented with swelling of the left hand. He underwent extended ray amputation with removal of the entire left third metacarpal bone. Histopathological and radiological features of the tumour are described. Recognition of periosteal chondrosarcoma and its differentiation from other surface bone tumours is very important because the prognosis is excellent after adequate local surgery.
Periosteal chondrosarcoma; juxtacortical; metacarpal
Understanding the viewer impact of the prime time television cooking show, MasterChef Australia , may help us to communicate more positively received messages about food and eating.
Media; health communication; food; pleasure
Routine and continuous electronic monitoring of foetal heart rate (FHR) in labour has become an established obstetric practice in high-risk pregnancies in industrialised countries. However, the same may not be possible in non-industrialised countries where antenatal care is inadequate with a large number of high-risk pregnancies being delivered in crowded settings and inadequate health care provider to patient ratios.
The objective of this study was to evaluate the predictive value of the admission cardiotocogram (CTG) in detecting foetal hypoxia at the time of admission in labour and to correlate the results of the admission CTG with the perinatal outcome in high-risk obstetric cases.
This was a prospective observational study conducted in the labour and maternity ward of a hospital in Gangtok, India, during the period 2008 to 2010. The study included high-risk pregnant women, admitted via the emergency or outpatient department with a period of gestation ≥36 weeks, in first stage of labour with foetus in the cephalic presentation. All women were subjected to an admission CTG, which included a 20 minute recording of FHR and uterine contractions.
One hundred and sixty patients were recruited. The majority of women were primigravida in the 21-30 years age group. About 42% patients were postdated pregnancy followed by pregnancy-induced hypertension (PIH) (15.6%) and premature rupture of membranes (PROM) (11.3%) as the major risk factors. The admission CTG were ‘reactive’ in 77%, ‘equivocal’ in 14.4% and ‘ominous’ in 8.7% women. Incidence of foetal distress, moderate-thick meconium stained liquor and neonatal intensive care unit (NICU) admission was significantly more frequent among patients with ominous test results compared with equivocal or reactive test results on admission. Incidence of vaginal delivery was more common when the test was reactive.
The admission CTG appears to be a simple non-invasive test that can serve as a screening tool in ‘triaging’ foetuses of high-risk obstetric patients in non-industrialised countries with a heavy workload and limited resources.
Cardiotocography; admission test; foetal distress; foetal hypoxia; perinatal outcome.
Carotid artery stenosis is a disabling disease in all age groups. Elderly people are more prone to recurrent strokes due to advancing age and multiple co-morbidities. Treatment options for symptomatic carotid stenosis in the very elderly are the same as in younger patients although with a higher operative risk. We describe a successful case of carotid artery stenting in a nonagenarian with symptomatic carotid artery stenosis, a subgroup for whom treatment options are rarely discussed in guidelines.
Carotid artery stenosis; nonagenarian; carotid artery stenting
Achromobacter xylosoxidans is an uncommon pathogen of low virulence known to cause serious nosocomial infection in the immunocompromised. Its inherent multi-drug resistance makes treatment difficult. Community-acquired infections are rare despite its ubiquitous existence. We present a 50-year-old immunocompetent woman who presented with one-month history of coughing with expectoration who was subsequently diagnosed with bilateral upper lobe pneumonia and acute adrenal insufficiency. Achromobacter xylosoxidans was isolated from sputum and bronchoalveolar lavage culture. The acute adrenal insufficiency recovered after appropriate antibiotic therapy. Amongst the myriad of presentations, we highlight the rarity of acute adrenal insufficiency triggered by the infection.
Achromobacter xylosoxidans; pneumonia; adrenal insufficiency
Surgical site infections are the most common nosocomial infection among surgical patients. Patients who experience surgical site infections are associated with prolonged hospital stay, rehospitalisation, increased morbidity and mortality, and costs. Consequently, surgical antimicrobial prophylaxis (SAP), which is a very brief course of antibiotic given just before the surgery, has been introduced to prevent the occurrence of surgical site infections. The efficacy of SAP depends on several factors, including selection of appropriate antibiotic, timing of administration, dosage, duration of prophylaxis and route of administration. In many institutions around the globe, evidence-based guidelines have been developed to advance the proper use of SAP. This paper aims to review the studies on surgeons' adherence to SAP guidelines and factors influencing their adherence. A wide variation of overall compliance towards SAP guidelines was noted, ranging from 0% to 71.9%. The misuses of prophylactic antibiotics are commonly seen, particularly inappropriate choice and prolonged duration of administration. Lack of awareness of the available SAP guidelines, influence of initial training, personal preference and influence from colleagues were among the factors which hindered the surgeons' adherence to SAP guidelines. Immediate actions are needed to improve the adherence rate as inappropriate use of SAP can lead to the emergence of a strain of resistant bacteria resulting in a number of costs to the healthcare system. Corrective measures to improve SAP adherence include development of guidelines, education and effective dissemination of guidelines to targeted surgeons and routine audit of antibiotic utilisation by a dedicated infection control team.
Surgeon; adherence; compliance; surgical antimicrobial prophylaxis; antibiotic
A 41-year-old Asian-Indian male presented with recurrent episodes of jaundice over the past six months. Physical examination was normal, barring mild icterus. Laboratory parameters revealed indirect hyperbilirubinemia. Further evaluation yielded a diagnosis of severe nutritional vitamin B12 deficiency. Indirect hyperbilirubinemia was ascribed to ineffective erythropoiesis. Underlying Gilbert's syndrome was ruled out by provocative testing with lipid-restricted diet. Presentation of severe vitamin B12 deficiency with isolated hyperbilirubinemia without concomitant major haematologic or neurologic dysfunction is unusual and potentially underdiagnosed. Awareness of this possibility can permit early diagnosis of vitamin B12 deficiency and forestall development of severe haematologic and neurologic sequelae.
Recurrent jaundice; indirect hyperbilirubinemia; vitamin B12 deficiency; ineffective erythropoiesis
The demand for elective joint replacement (EJR) surgery for degenerative joint disease continues to rise in Australia, and relative to earlier practices, patients are discharged back to the care of their general practitioner (GP) and other community-based providers after a shorter hospital stay and potentially greater post-operative acuity. In order to coordinate safe and effective post-operative care, GPs rely on accurate, timely and clinically-informative information from hospitals when their patients are discharged. The aim of this project was to undertake an audit with GPs regarding their preferences about the components of information provided in discharge summaries for patients undergoing EJR surgery for the hip or knee.
GPs in a defined catchment area were invited to respond to an online audit instrument, developed by an interdisciplinary group of clinicians with knowledge of orthopaedic surgery practices. The 15-item instrument required respondents to rank the importance of components of discharge information developed by the clinician working group, using a three-point rating scale.
Fifty-three GPs and nine GP registrars responded to the audit invitation (11.0% response rate). All discharge information options were ranked as ‘essential’ by a proportion of respondents, ranging from 14.8–88.5%. Essential information requested by the respondents included early post-operative actions required by the GP, medications prescribed, post-operative complications encountered and noting of any allergies. Non-essential information related to the prosthesis used. The provision of clinical guidelines was largely rated as ‘useful’ information (47.5–56.7%).
GPs require a range of clinical information to safely and effectively care for their patients after discharge from hospital for EJR surgery. Implementation of changes to processes used to create discharge summaries will require engagement and collaboration between clinical staff, hospital administrators and information technology staff, supported in parallel by education provided to junior medical staff.
General practitioner; joint replacement surgery; discharge; hospital; communication
The Chronic Dental Disease Scheme (CDSS) is the first public dental policy in Australia to attract Medicare benefits for dental services.
This study examines the utilisation of a new federal method of funding dental care in Australia and provides an insight into the implications of government dental programs. The program titled; Chronic Dental Disease Scheme, provided government-subsidised dental care for people suffering from a chronic medical condition.
A retrospective analysis of activity data using the relevant item numbers were extracted from the open source Medicare Benefits Schedule database (MBS) for years 2007-2009.
During the study period, a total of approximately five million dental services were provided. There was a disproportionate use of services between jurisdictions. The highest proportion (66%) of services was provided in the state of New South Wales (NSW) with Victoria second (22%). The adjusted value of care provided as a proportion of comprehensive examinations ranged from $1937 in the northern territory (NT) to $2900 in NSW. The value of care per dentist ranged from nearly $80 000 down to less than $1000 and the value of care per adult of the population ranged between $53 and $1 across Australia. The highest was always in NSW and the lowest always being the NT. Fixed prosthodontics (reconstruction) accounted for the significant costs associated with the program.
The scheme has been utilised above its budget estimate with prosthodontics accounting for the majority of expenses. Treatment plans differed between jurisdictions. The increase in utilisation of the scheme was coincident with periods of increased in subsidy and remuneration and has been postulated to be a main driver for its utilisation rather than the improvement in chronic health.
Dental Public Health; Computational Mathematics; Monte Carlo
As part of our research team's knowledge transfer and exchange (KTE) initiatives, we developed a six-minute video-clip to enable productive deliberations among technology developers, clinicians and patient representatives. This video-clip summarises in plain language the valuable goals and features that are embedded in health technology and raises questions regarding the direction that should be taken by health care innovations. The use of such video-clips creates unique opportunities for face-to-face deliberations by enabling participants to interact and debate policy issues that are pivotal to the sustainability of health care systems. In our experience, we found that audiovisual-elicitation-based KTE initiatives can fill an important communication gap among key stakeholders: pondering, from a health care system perspective, why and how certain kinds of medical technologies bring a more valuable response to health care needs when compared to others.
Health Technology; Values; Health Care Systems; Audiovisual-elicitation-based Methodology; Knowledge Transfer and Exchange.
For eye diseases, such as glaucoma and age-related macular degeneration (ARMD), involved in long-term degeneration procedure, longitudinal comparison of retinal images is a common step for reliable diagnosis of these kinds of diseases.
To provide a retinal image registration approach for longitudinal retinal image alignment and comparison.
Two image registration solutions were proposed for facing different image qualities of retinal images to make the registration methods more robust and feasible in a clinical application system.
Thirty pairs of longitudinal retinal images were used for the registration test. The experiments showed both solutions provided good performance for the accurate image registrations with efficiency.
We proposed a set of retinal image registration solutions for longitudinal retinal image observation and comparison targeting a clinical application environment.
Retinal image registration; Glaucoma; ARMD; clinical decision support
Evidence Based Medicine (EBM) practice requires practitioners to extract evidence from published medical research when answering clinical queries. Due to the time- consuming nature of this practice, there is a strong motivation for systems that can automatically summarise medical documents and help practitioners find relevant information.
The aim of this work is to propose an automatic query- focused, extractive summarisation approach that selects informative sentences from medical documents.
We use a corpus that is specifically designed for summarisation in the EBM domain. We use approximately half the corpus for deriving important statistics associated with the best possible extractive summaries. We take into account factors such as sentence position, length, sentence content, and the type of the query posed. Using the statistics from the first set, we evaluate our approach on a separate set. Evaluation of the qualities of the generated summaries is performed automatically using ROUGE, which is a popular tool for evaluating automatic summaries.
Our summarisation approach outperforms all baselines (best baseline score: 0.1594; our score 0.1653). Further improvements are achieved when query types are taken into account.
The quality of extractive summarisation in the medical domain can be significantly improved by incorporating domain knowledge and statistics derived from a specialised corpus. Such techniques can therefore be applied for content selection in end-to-end summarisation systems.
Automatic summarisation; extractive summarisation evidence based medicine; medical document summarisation
This paper presents a novel approach to searching electronic medical records that is based on concept matching rather than keyword matching.
The concept-based approach is intended to overcome specific challenges we identified in searching medical records.
Queries and documents were transformed from their term-based originals into medical concepts as defined by the SNOMED-CT ontology.
Evaluation on a real-world collection of medical records showed our concept-based approach outperformed a keyword baseline by 25% in Mean Average Precision.
The concept-based approach provides a framework for further development of inference based search systems for dealing with medical data.
Electronic medical records; Information retrieval; Semantic search and inference; Health informatics.
Causal models of physiological systems can be immensely useful in medicine as they may be used for both diagnostic and therapeutic reasoning.
In this paper we investigate how an agent may use the theory of belief change to rectify simple causal models of changing blood sugar levels in diabetes patients.
We employ the semantic approach to belief change together with a popular measure of distance called Dalal distance between different state descriptions in order to implement a simple application that simulates the effectiveness of the proposed method in helping an agent rectify a simple causal model.
Our simulation results show that distance-based belief change can help in improving the agent’s causal knowledge. However, under the current implementation there is no guarantee that the agent will learn the complete model and the agent may at times get stuck in local optima.
Distance-based belief change can help in refining simple causal models such as the example in this paper. Future work will include larger state-action spaces, better distance measures and strategies for choosing actions.
Belief Change; Belief Update; Belief Revision; Causal Models; Glucose Metabolism; Diabetes
Automated text summarisers that find the best clinical evidence reported in collections of medical literature are of potential benefit for the practice of Evidence Based Medicine (EBM). Research and development of text summarisers for EBM, however, is impeded by the lack of corpora to train and test such systems.
To produce a corpus for research in EBM summarisation.
We sourced the “Clinical Inquiries” section of the Journal of Family Practice (JFP) and obtained a sizeable sample of questions and evidence based summaries. We further processed the summaries by combining automated techniques, human annotations, and crowdsourcing techniques to identify the PubMed IDs of the references.
The corpus has 456 questions, 1,396 answer components, 3,036 answer justifications, and 2,908 references.
The corpus is now available for the research community at http://sourceforge.net/projects/ebmsumcorpus.
Evidence Based Medicine; corpora; text summarisation; natural language processing.
Effective management of chronic diseases such as prostate cancer is important. Research suggests a tendency to use self-care treatment options such as over-the-counter (OTC) complementary medications among prostate cancer patients. The current trend in patient-driven recording of health data in an online Personal Health Record (PHR) presents an opportunity to develop new data-driven approaches for improving prostate cancer patient care. However, the ability of current online solutions to share patients’ data for better decision support is limited. An informatics approach may improve online sharing of self-care interventions among these patients. It can also provide better evidence to support decisions made during their self-managed care.
To identify requirements for an online system and describe a new case-based reasoning (CBR) method for improving self-care of advanced prostate cancer patients in an online PHR environment.
A non-identifying online survey was conducted to understand self-care patterns among prostate cancer patients and to identify requirements for an online information system. The pilot study was carried out between August 2010 and December 2010. A case-base of 52 patients was developed.
The data analysis showed self-care patterns among the prostate cancer patients. Selenium (55%) was the common complementary supplement used by the patients. Paracetamol (about 45%) was the commonly used OTC by the patients.
The results of this study specified requirements for an online case-based reasoning information system. The outcomes of this study are being incorporated in design of the proposed Artificial Intelligence (Al) driven patient journey browser system. A basic version of the proposed system is currently being considered for implementation.
Advanced Prostate Cancer; Self-care; Patient Journey; PHR; Case-based reasoning