A 34-year-old Indian student who immigrated to Australia five years ago presented with a four-week history of neck pain. Physical examination revealed two firm fixed cervical lymph nodes in the anterior triangle and midline region which were tender on palpation and erythematous on inspection. Cording phenomenon was found on ZN staining of FNA sample and mycobacterium tuberculosis (M.tb ) PCR confirmed the diagnosis with incomplete resistance to isoniazid. Patient was treated with other three first line antituberculosis medications for nine months with an excellent outcome. Prednisolone was also used as adjunctive therapy and tapered during the course of treatment.
Scrofuloderma; Tuberculosis; Cording phenomenon
Mycoplasma pneumoniae is common agent causing community acquired pneumonia in children. However, the course of illness is usually benign and is rarely associated with pulmonary complications. We report a five-year-old child with massive pleural effusion and empyema secondary to Mycoplasma pneumonia infection. This potential yet rare source of infection should be considered in young patients where resolution of symptoms from pneumonia is delayed.
Mycoplasma pneumoniae; Pleural Effusion; Empyema
Cutaneous or umbilical endometriosis is a rare entity that is often overlooked because of chronic abdominal pain. We present a case of umbilical hernia that presented to the general surgeons due to chronic abdominal pain and nodule in the umbilicus, which was clinically diagnosed as umbilical papilloma.
A 48-year old multiparous Caucasian woman presented with painful nodule in the umbilicus for two and half years. The nodule was excised and the histopathological diagnosis was umbilicus endometriosis.
Umbilical endometriosis is a very rare disease but should be considered as a differential diagnosis in women presenting with umbilical swelling.
Endometriosis; Umbilical endometriosis; Papilloma
We report a case of laryngeal tuberculosis in a 47-year-old Korean man. Laryngeal tuberculosis is rare and currently accounts for less than 1% of all cases of tuberculosis. Clinical features of laryngeal tuberculosis include hoarseness, odynophagia and dyspnoea. Macroscopically, laryngeal tuberculosis may mimic laryngeal carcinoma, chronic laryngitis or laryngeal candidiasis. The diagnosis is often delayed due to a low index of clinical suspicion and hence may pose a significant public health risk. Laryngeal tuberculosis should be considered in the differential diagnosis of patients who present with any form of laryngeal lesion.
Larynx; Tuberculosis; Diagnosis
During a routine dissection in the Department of Anatomy of the Rural Medical College, Loni, we found a rare variation in branching pattern of the common carotid artery (CCA) and external carotid artery (ECA) bilaterally. The knowledge of possible anatomical variations of CCA and ECA are especially important in the surgeries of head, neck and face; and also for the radiologist to understand and interpret carotid system imaging when undertaking cerebral angiography. This case and the clinical significance of this variation are reported in this paper.
Common carotid artery; external carotid artery; superior thyroid artery,; linguo-facial trunk; ascending pharyngeal artery; occipital artery
Once a disease of developed countries, type 2 diabetes mellitus (T2DM) has become widespread worldwide. For people with T2DM, achievement of therapeutic outcomes demands the rational and quality use of medicine.
The primary aim of this study was to examine the prevalence of diabetes and prescribing patterns of anti-diabetic medications in Australia and Malaysia.
The most recent, publicly available, statistical reports (2004–2008) on the use of medicines published in Australia and in Malaysia were evaluated. Defined daily doses (DDDs/1,000 population/day) were derived from the reports and used to rank and compare individual drug use.
There was an increasing trend in the prevalence of diabetes in Australia, although there is a greater predicted increase in prevalence for Malaysia. While drugs used for the treatment of diabetes were not the most highly used drugs in Australia, their use increased during the study period, from 42.64 to 48.61 DDD/1,000/day. Anti-diabetic drugs were the most frequently dispensed class of drugs in Malaysia. Although the total consumption of anti-diabetic drugs in Malaysia decreased between 2006 and 2007 (from 40.30 to 39.72), this was followed by a marked increase to 46.69 in 2008. There was a marked reduction in the dispensing of insulin in Malaysia from 2004 to 2007 (7.77 to 3.23).
The use of drugs to treat diabetes does not reflect the usage patterns found in Australia. Effective drug use reviews are required to ensure impartial access in middle- and low-income countries.
Utilisation; drugs; diabetes; Malaysia; Australia; insulin; metformin
Diabetic patients are commonly hyperglycaemic on presentation. Admission hyperglycaemia is associated with adverse outcomes, particularly prolonged hospitalisation. Improving inpatient glycaemia may reduce length of hospital stay (LOS) in diabetic patients.
To determine whether in-hospital recognition and treatment of admission hyperglycaemia in diabetic patients is associated with reduced LOS.
Medical records were reviewed from 1 November 2011 to 31 May 2012 for 162 diabetic patients admitted with a blood glucose level (BGL) ≥11.1mmol/L. In-hospital outcomes were compared. Stepwise multiple regression was used to evaluate factors contributing to LOS.
Compared to the untreated individuals (n=67), hyperglycaemia treatment (n=95) was associated with a longer LOS (median eight vs. four days, p<0.01), higher HbA1c (9.0 vs. 7.3 per cent, p<0.01), more infections (50 vs. 25 per cent, p<0.01), and more patients with follow-up plans (35 vs. 10 per cent, p<0.01). Higher HbA1c was significantly related to more follow-up (ρs=0.30, n=110, p<0.01) with a trend to lower re-admission in those with follow-up plans (ρs=-1.41, n=162, p=0.07).
Recognition and treatment of admission hyperglycaemia in diabetic patients was associated with longer LOS than if untreated. Contributory factors to LOS include: illness severity, infections, and higher HbA1c. Although follow-up plans were few (27 per cent) for diabetic patients with hyperglycaemia, it was significantly more likely in those with higher HbA1c. Diabetic patients’ complexities require timely multidisciplinary team involvement. Improved follow-up care, particularly for hospitalised diabetic patients identified to have chronically poor glycaemic control, may help prevent future diabetic patient re-admissions.
hyperglycaemia; diabetes mellitus; glycaemic control; community management
Extended spectrum betalactamase (ESBL)-producing organisms are a major cause of hospital-acquired infections. ESBL-producing Escherichia coli (E. coli) have been recovered from the hospital environment. These drug-resistant organisms have also been found to be present in humans as commensals. The present investigation intended to isolate ESBL-producing E. coli from the gut of already infected patients; to date, only a few studies have shown evidence of the gut microflora as a major source of infection.
This study aimed to detect the presence of ESBL genes in E.coli that are isolated from the gut of patients who have already been infected with the same organism.
A total of 70 non-repetitive faecal samples were collected from in-patients of our hospital. These in-patients were clinically diagnosed and were culture-positive for ESBL-producing E. coli either from blood, urine, or pus. Standard microbiological methods were used to detect ESBL from clinical and gut isolates. Genes coding for major betalactamase enzymes such as bla
TEM, and bla
SHV were investigated by polymerase chain reaction (PCR).
ESBL-producing E. coli was isolated from 15 (21 per cent) faecal samples of the 70 samples that were cultured. PCR revealed that out of these 15 isolates, the bla
CTX-M gene was found in 13 (86.6 per cent) isolates, the bla
TEM was present in 11 (73.3 per cent) isolates, and bla
SHV only in eight (53.3 per cent) isolates. All 15 clinical and gut isolates had similar phenotypic characters and eight of the 15 patients had similar pattern of genes (bla
CTX-M, and bla
SHV) in their clinical and gut isolates.
Strains with multiple betalactamase genes that colonise the gut of hospitalised patients are a potential threat and it may be a potential source of infection.
Stool; colonisation; ESBL E.coli
The health care for patients having two or more long-term medical conditions is fragmented between specialists, allied health professionals, and general practitioners (GPs), each keeping separate medical records. There are separate guidelines for each disease, making it difficult for the GP to coordinate care. The TrueBlue model of collaborative care to address key problems in managing patients with multimorbidity in general practice previously reported outcomes on the management of multimorbidities. We report on the care plan for patients with depression, diabetes, and/or coronary heart disease that was embedded in the TrueBlue study.
A care plan was designed around diabetes, coronary heart disease, and depression management guidelines to prompt implementation of best practices and to provide a single document for information from multiple sources. It was used in the TrueBlue trial undertaken by 400 patients (206 intervention and 194 control) from 11 Australian general practices in regional and metropolitan areas.
Practice nurses and GPs successfully used the care plan to achieve the guideline-recommended checks for almost all patients, and successfully monitored depression scores and risk factors, kept pathology results up to date, and identified patient priorities and goals. Clinical outcomes improved compared with usual care.
The care plan was used successfully to manage and prioritise multimorbidity. Downstream implications include improving efficiency in patient management, and better health outcomes for patients with complex multimorbidities.
Multimorbidity; care plans; collaborative care; diabetes; heart disease; depression
Our study retrospectively reviewed the presentation, neuro-radiological findings, and outcomes of eight adult patients presenting at our institution with subarachnoid haemorrhage (SAH), which was subsequently proven to be due to cortical venous thrombosis (CVT).
We reviewed the case records and neuroimaging findings of eight patients diagnosed with SAH and CVT over a span of two years at our institution, a tertiary care centre in Western India. All details pertaining to their presentation, clinical findings, neuroimaging, management, and outcome following therapy with anticoagulants were collected until patient discharge.
There were a total of eight patients, with the average age being 34 years (range 25–42). Only one patient was female. Six patients had a history of recent binge drinking. None of the patients had a past or family history of common risk factors for thrombosis. All patients presented acutely, with headache (n=6) and seizures (n=6) being the most common presenting features, occurring in three-quarters of the patients examined. Non-contrast computed tomography (NCCT) was the initial imaging study for all but one of the patients and showed cortical SAH (cSAH) without basilar haemorrhage. Magnetic resonance imaging/magnetic resonance venography (MRI/MRV) confirmed the underlying CVT. Unfractionated heparin was used in all cases. Seven patients improved and were discharged on oral anticoagulation. The eighth patient died.
Localised cSAH with sparing of basal cisterns can be a presentation for CVT. In patients with cSAH, MRI/MRV can be useful to make a diagnosis of CVT. Anticoagulation for CVT, even in the presence of SAH was related to seven out of eight patients being discharged.
Cortical venous thrombosis; subarachnoid haemorrhage; non-contrast CT
Neck of femur (NOF) fractures are the most common injury among elderly patients and a significant burden on our healthcare system.
This study aimed toevaluate if an Australian rural hospital serviced by general surgeons can meet the established standards of care for the management of NOF fractures by undertaking surgery within 48 hours.
An audit of patients presenting to an Australian rural hospital with NOF fractures over a seven-year period. Patients were excluded if they were transferred or suffered peri-prosthetic or multi-trauma-related fractures. Outcomes included time to surgery, length of stay, and in-hospital mortality, and were compared to three similar Australian studies from hospitals with specialist orthopedic units. Descriptive statistics and meta-analysis were performed.
Overall, 182 patients presented with NOF fractures and 114 met our inclusion criteria. Only 12 per cent of patients were transferred. Patients were mostly female (74 per cent) and elderly (mean age 84.0 years). A total of 79 per cent of patients were operated on within48 hours; other studies reported 67–86 per cent. Mean length of stay was 11.9 days (versus 7.7–13.7), and in-hospital mortality was 4 per cent (versus 2–7 per cent).
This audit suggests that an Australian rural hospital serviced by general surgeons can meet the established standards of care for management of most NOF fractures. Some post-surgery outcomes are similar to those reported by larger centers with specialized orthopedics units.
Neck of femur; hip fractures; hip surgery; rural health; aged care; health outcome
More than 169,000 people live in residential aged care facilities (RACFs). As people age they use health services, particularly general practitioner (GP) services, more frequently but many GPs do not attend patients in RACFs.
To examine GPs’ perceptions of barriers to providing care to patients in RACFs.
This study was conducted in June 2014 in the Bayside Medicare Local (BML) region in Victoria, Australia; all participants were drawn from this region. Two focus groups (FGs) were conducted. One was for GPs (n=5) that have a specific interest in practicing in RACFs, the other with RACF staff (n=8) representing public, private, and not-for-profit aged care providers. Results were presented to the Royal Australian College of General Practitioners (RACGP) National Standing Committee for General Practice Advocacy and Support for feedback and validation of the findings against national perspectives of the effect of remuneration on the provision of GP services in RACFs.
Remuneration problems are a barrier to the provision of GP services to patients in RACFs. These problems can be grouped into: direct remuneration, opportunity cost, additional administrative burden, and unremunerated work. GPs’ perceptions of the effects of these problems on willingness to practice in RACFs are described.
Innovative models of remuneration for GPs attending RACFs are needed to ameliorate the problems identified. Such models need to capture and pay for activities that are time consuming but often unremunerated.
General practice; residential aged care; remuneration; access to care
The ansa cervicalis is a loop of nerves that is usually formed by the union of ventral rami of spinal nerves C1, C2, and C3. It is located in the carotid triangle of the neck, lying superficial to the carotid sheath. During routine dissection, unilateral variation of the ansa cervicalis was observed. The superior root, arising from hypoglossal nerve, was initially bifurcated and later united to form a single superior root. IN addition, the inferior root consisted of fibres arising from the spinal accessory nerve, C1, C2 and C3 spinal nerves that joined separately. Fibres from the spinal accessory and C1 joined to form a single root. Thus, a ‘triple form’ of ansa cervicalis was observed. An interconnection was observed between the C2 and C3 fibres. Knowledge of such anatomical variations is important for surgery, clinical intervention or trauma involving the carotid triangle or the structures within or deep to this region.
Ansa cervicalis; inferior root; spinal accessory nerve; superior root; spinal nerves
Previous studies conducted in Australian hospital settings suggest high variability in assessments, investigations, and management of diabetic foot infections and poor adherence to widely accessible evidence-based protocols and guidelines. Diabetic foot complications require a multidisciplinary approach and often involve both medical and surgical teams during inpatient care.
The aim of this clinical audit was to better understand the scope of diabetes-related foot complications, evaluate whether current assessment and management strategies are in line with best practice guidelines, and to formulate future models of care.
A retrospective review of patients was carried out between 12 July 2012 and 11 July 2013. Recorded assessments of inpatient care, including risk factors, surgery, length of stay, interdepartmental referrals, and antibiotic administration were reviewed.
There were 24 admissions in 12 months (total patients n=19). Fifty-eight per cent of patients were admitted to the medical ward. More than one-quarter had evidence of osteomyelitis. While one patient required intensive care unit (ICU) management, there was no inpatient mortality. Two patients experienced significant delay to undergo initial surgical intervention presumably because of failed medical treatment. Clinical data was recorded poorly, especially regarding neuropathy, HbA1c, and clinical examination findings. Twelve per cent of patients did not undergo any follow-up. The average length of stay was 12 days. One-half of the cohort was not evaluated by the endocrinology department.
This audit highlights the need for improved care for patients with diabetic foot complications and better coordination among the multidisciplinary teams involved.
Diabetes; ulceration; audit
Exercise has shown positive training effects on obesity-related inflammation, however, resistance training has shown mixed results concerning adipocytokine levels.
The purpose of this pilot study was to explore the effects of resistance training on blood adipocytokine concentrations in obese youth, with specific examination of the relationship between these biomarkers and improved fitness (i.e., aerobic capacity, muscular strength).
Fourteen obese adolescents (16.1 ±1.6 y; BMI: 32.3 ±3.9 kg/m2) participated in a 16-week resistance training intervention. Body composition, fasting blood concentrations of interleukin-6 (IL-6), tumour necrosis factor-alpha (TNF-ɑ), adiponectin, and leptin were measured pre- and post-training. Aerobic capacity was assessed via a maximal discontinuous exercise test. The rate of gain in muscular strength was calculated as the slope of progression in 1-repetition maximum throughout the intervention.
Resistance training increased lean mass (total, trunk) and decreased per cent body fat (total, trunk). The training also caused moderate clear decreases in IL-6 and TNF-ɑ concentrations. A small increase in adiponectin was also observed before and after intervention. When the group was stratified by changes in aerobic capacity, there were substantially larger decreases in leptin levels for those with improved capacity. Correlation analyses also revealed a negative relationship between log-transformed leptin and aerobic capacity at rest. Improvement in quadriceps strength was positively correlated with IL-6 and TNF-ɑ, while improvement in shoulder adductor strength was positively correlated with IL-6 only.
Resistance training improved adipocytokine markers, which were partially associated with improved physical fitness. Specifically, the relationship between strength improvements and IL-6 and TNF-ɑ suggests an exercise-induced signalling pathway that results in overall adaptive decreases in systemic inflammation in obese youth.
Exercise; paediatric obesity; inflammation; fitness
On their journey to “becoming” doctors, medical students encounter a range of health professionals who contribute to their socialisation into clinical practice. Amongst these individuals are registered nurses (RNs) in clinical practice who are often employed by medical schools as clinical tutors. These RNs will encounter medical students on campus and later in the clinical setting.
This qualitative study explored RNs’ perceptions of their contribution to medical students’ developing professional identities in order to provide a greater understanding of this process and ultimately inform future curriculum.
This qualitative study took place in 2012 at one Australian medical school as part of a broader study exploring medical students’ professional identity development from the perspectives of their teachers and trainers. Eight of the nine RNs involved in teaching procedural skills were interviewed. Recorded interviews were transcribed verbatim. Data were analysed inductively by the research team.
Two major themes emerged: RNs as change agents and RNs as facilitators of medical students’ transition to the clinical environment. RNs as change agents related to their role modelling good practice, being patient-centred, and by emphasising factors contributing to good teamwork such as recognising and respecting individual professional roles. They facilitated students’ transition to the clinical environment often through personal narratives, by offering advice on how to behave and work with members of the healthcare team, and by being a point of contact in the hospital.
Based on their descriptions of how they role modelled good practice and how they facilitated students’ transition to clinical practice, we believe that RN clinical tutors do have the experience and expertise in clinical practice and a professional approach to patients to contribute to medical students’ developing professional identities as future doctors.
Medical students; registered nurses; professional identity development
The progression of chronic kidney disease (CKD) can be attributed to various factors, including lack of medical services, delayed referral, lack of awareness about the disease, drugs, and financial support.
To compare the pharmacoeconomic-related direct medical and non-medical costs among hospitalised pre-dialysis and dialysis patients.
A prospective observational study was conducted on the inpatients admitted to the Department of Nephrology. Patients undergoing maintenance dialysis or initiated on renal replacement therapy were included in the dialysis patients group and other CKD patients in the pre-dialysis group. The data pertaining to the pharmacoeconomic-related direct medical and non-medical costs were collected from the patient records, medical bills, and other relevant sources.
Out of 100 patients, 43 were in the pre-dialysis group and 57 were in the dialysis group. The median direct medical costs (INR 4,731.62, USD $76.47) for dialysis group patients were significantly higher than for the pre-dialysis group (INR 1,820.95, USD $29.43). The median direct non-medical costs (INR 550, USD $8.88) for pre-dialysis group patients were not significantly higher than for the dialysis group (INR 480, USD $7.75).
There was a significant difference in the median direct total costs between pre-dialysis and dialysis patients. The number of medications per prescription and length of hospital stay are the factors that influence the median direct total costs.
Chronic kidney disease; dialysis; economics; cost; hospitalisation
Minocycline is widely used as a first-line agent for papulopustular acne, and has previously been reported as causing stains on teeth that are still forming. This article reports a case of staining to only the crowns of unerupted third molars in a girl prescribed minocycline at age 16 for papulopustular acne. We review the literature in the area of minocycline teeth staining, consider the role of minocycline as a first-line agent for papulopustular acne, and outline strategies on the prevention of minocycline teeth staining. The case highlights current deficiencies in the disclosure information for minocycline, and provides information that is relevant to practitioners who may prescribe this drug.
minocycline; staining; unerupted; crowns; third molars