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
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
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
Scrub typhus is an acute febrile illness caused by the intracellular parasite Orientia tsutsugamushi. Although most cases present with mild symptoms and signs and recover spontaneously, some cases can be severe with multi-organ dysfunction and a protracted course, which may be fatal if left untreated. Apart from fever and constitutional symptoms, atypical presentations allow this disease to mimic several common conditions. We report a case of scrub typhus in an 18-year-old male who presented with severe polyarthritis involving all large joints and a massive lower gastrointestinal bleed from ulcers in the terminal ileum, secondary to vasculitis in the small bowel. This combination of pathologies has not previously been reported in cases of scrub typhus. The patient improved following surgical intervention and specific anti-rickettsial therapy with azithromycin.
Scrub typhus; polyarthritis; small bowel bleed
We present an interesting case of a young man with coronary artery vasospasm complicating scombroid fish poisoning illness. The initial presentation included tachycardia and significant hypotension. A 12-lead ECG showed sinus tachycardia with marked widespread ST segment depression and ST elevation in aVR. Symptoms subsequently improved with intravenous fluid rehydration, antihistamines, and glyceral trinitrate. The underlying pathogenesis and treatment of this rarely described manifestation of the fish poisoning illness is discussed.
Coronary artery vasospasm; scombroid fish poisoning
The prevalence, degree, and patterns of hearing loss associated with chronic kidney disease (CKD) reported by various studies differ significantly. The effects of haemodialysis and duration of disease on hearing loss remain unclear.
The aim of this study was to determine the prevalence and degree of hearing loss in CKD patients on haemodialysis.
This study included 120 CKD patients on haemodialysis. Information regarding age, gender, duration of disease, subjective hearing loss, exposure to ototoxic drugs, comorbidities like diabetes, hypertension, and hypothyroidism, renal functions, electrolytes and number of haemodialysis sessions received were obtained. An equal number of age and sex matched controls were used to determine prevalence of hearing loss in CKD patients after subjecting both groups to pure tone audiometry. We compared CKD patients with and without hearing loss for association of hearing loss with disease duration, number of haemodialysis, and blood parameters.
Hearing loss was present in 41.7 per cent of CKD patients, significantly higher than controls (p=0.001), and was mild in the majority of patients. Impairment was noted across high and low frequencies of audiometric testing. Median duration of disease was the same (18 months) among CKD patients with and without hearing loss (p=0.62). CKD patients with hearing loss received 72 haemodialysis compared to 122 sessions by those without hearing loss (p=0.04).
Mild sensorineural hearing loss is common in CKD. Hearing loss has no specific pattern as it prevails at high and low frequencies. Hearing loss may be inversely associated with the number of haemodialysis sessions but not with duration of disease.
CKD; hearing loss; haemodialysis; high frequency loss; low frequency loss
Toxicity from accidental and intentional ingestion of yellow phosphorus, ubiquitously present in fireworks and rodenticides, has recently become more frequent. Gastrointestinal, renal, neurologic, and cardiovascular manifestations are common, with mortality of 23 per cent to 73 per cent. Reports of haematological abnormalities are rare. We report only the second case of severe neutropenia secondary to selective myelosuppression in a 14-year-old girl following intentional ingestion of yellow phosphorus. Leucocyte counts recovered spontaneously without further complications. Our case indicates that, besides hepatic and renal function monitoring, physicians should meticulously monitor blood counts in such cases for early detection of marrow suppression. Further studies are required to elucidate the complex mechanisms and significance of this unusual toxicity of yellow phosphorus.
yellow phosphorus; myelosuppression; neutropenia
An abnormal course of a nerve either through or around a muscle may yield multiple or anomalous muscle innervation. Further, if nerves are inappropriately trapped within the confines of a muscle or irregular boundaries, variant emergence of a nerve could give rise to symptoms of an entrapment neuropathy. Upon routine dissection in the Department of Anatomy at the American University of Antigua College of Medicine, bilateral variants in the emergence of the sciatic nerve from the pelvis to the gluteal compartment were discovered in an elderly adult female cadaver. In the left gluteal compartment, the sciatic nerve had a high division where the peroneal division exited the pelvis superior to the piriformis muscle while the tibial division exited inferior to the piriformis. In the right gluteal compartment, the peroneal division was observed to have exited the pelvis between a split piriformis muscle before it joined the tibial division of the sciatic nerve. Knowledge of such variations in the course of the sciatic nerve may improve diagnosis and treatment of pathologies in this region.
Sciatic nerve; tibial nerve; peroneal nerve; anatomical variation
Internal hernia is herniation of a viscus, usually in the small bowel, through a normal or abnormal aperture within the peritoneal cavity. Its incidence has been reported to be one to two per cent. Internal hernias are classified based on location, and the hernial orifice can be either congenital or acquired. Paraduodenal hernias are the most common type (53 per cent). Paraduodenal hernia is often a misnomer and is referred to as a mesocolic hernia. Left and right mesocolic hernias are common, while middle and transverse types are rare. We are reporting a rare congenital middle mesocolic hernia presenting as a complete transection of the small intestine due to blunt injury to the abdomen.
Paraduodenal; internal hernia; blunt injury abdomen
Virulent serotypes of Klebsiella pneumoniae are recognised to cause metastatic infections at various sites. Prevalence of this invasive syndrome has been observed worldwide with predominance in Asian series. However, reports in an Australian setting have been limited. We report two cases of fulminating community-acquired invasive Klebsiella pneumoniae liver abscess syndrome occurring in two Caucasian patients, from two different, distant suburbs in Western Australia with no known clinical comorbidities prior to the hospital presentation and no history of recent travel overseas. The interval between both admissions was 18 days, where only one patient survived.
Interventional radiology; invasive liver abscess syndrome; Klebsiella pneumoniae
Evidence from several Western studies has shown an alarmingly high and inappropriate rate of prescription of proton pump inhibitors (PPIs), which may be associated with increased healthcare costs and adverse outcomes. PPI prescribing patterns remain largely unknown in well-developed healthcare systems in Southeast Asia.
We aimed to determine the prevalence of inappropriate prescription of PPI among elderly patients without documentation of valid indications, in a tertiary teaching hospital in Singapore.
We carried out a retrospective clinical records review of 150 elderly patients aged ≥65 years that had been admitted to two internal medicine wards between 25 May 2011 and 28 June 2011 to determine the appropriateness of indications for PPIs prescribed at hospital discharge. PPI indications were categorised as “valid”, “likely invalid”, and “probable” based on current clinical literature. Pre-admission and discharge prescriptions were reviewed to determine continuation of pre-admission and new PPI prescriptions at discharge. Data on clinical characteristics and concurrent use of ulcerogenic medications were collected.
From a total of 150 patients, 80 (53 per cent) received prescriptions for PPIs. Of these, 65 (81.2 per cent) had no valid documented indications (i.e., the indication was classed as “likely invalid”); 10 (12.5 per cent) had valid indications; and in five cases (6.2 per cent) the indication was “probable”. The most common “likely invalid” indication was primary gastrointestinal bleeding prophylaxis (GIP) among low-dose aspirin users in 28 patients (43 per cent) of invalid PPI prescriptions.
Inappropriate prescribing of PPIs without documented valid indications was prevalent among elderly patients at our tertiary teaching hospital in Singapore, providing evidence that shows a similar trend to PPI prescribing to data from Western countries.
Proton pump inhibitors; prescribing; elderly; valid indications
Knowledge of peripheral nerve morphology, location, and variation is important for facilitating appropriate diagnosis and intervention. We present a unique case of absence of the inferior gluteal nerve and high division of the sciatic nerve. In this instance, the common peroneal nerve was found piercing the piriformis muscle and emerging distally in the form of two trunks: thin medial and thick lateral. The medial trunk presented an interesting course, supplying the gluteus maximus muscle before joining the lateral trunk to form the common peroneal nerve. Additionally, the arteria nervi ischiadisci was also observed accompanying and supplying the tibial nerve passing inferior to the piriformis. These variations are important for clinicians and surgeons for some radiological diagnoses and surgical procedures in the lower limb.
Gluteus maximus; sciatic nerve; common peroneal nerve; inferior gluteal nerve; piriformis; arteria nervi ischiadisci
Hepatic tuberculosis (HTB) is commonly encountered in patients with widespread miliary disease. Isolated affection of the liver is extremely rare. We present a case of a young woman who presented with a subacute afebrile hepatic failure. Investigations including a liver biopsy proved that the presentation was due to granulomatous hepatitis secondary to mycobacterial infection of the liver. It is important that tuberculosis (TB) be kept in mind especially in endemic areas even in atypical clinical scenarios by clinicians, radiologists, and pathologists. Use of anti-tuberculous drugs in such cases is usually successful and must be instituted early.
Isolated Hepatic Tuberculosis; Mycobacterium tuberculosis; extra pulmonary tuberculosis
The incidence of venous aneurysm is less than arterial aneurysms. Most are incidental findings with no major clinical significance. However, popliteal vein aneurysms (PVA) may be potentially life threatening, as they can be a source of pulmonary embolism and potentially even death. We report a case of right PVA in a 67-year-old male cadaver. Information from this case study may contribute to an improved understanding of these phenomena, including early detection of these or similar thromboembolic events.
Popliteal vein; aneurysm; popliteal fossa; pulmonary embolism
Supernumerary kidney is the rarest of all renal anomalies; fewer than 80 cases have been reported in the literature over the years. Supernumerary kidneys are most commonly located on the left side of the abdomen. Different pathologic conditions are reported to affect supernumerary kidneys and they may be associated with malformations of the upper urinary tract and genital tract. Because of their infrequent occurrence and reporting, they frequently cause diagnostic challenges. Here we report a case in a 14-year-old male patient of unilateral supernumerary kidney on the right side of the abdomen with multiple calculi, mal-rotation and a gross hydronephrotic left kidney.
Hydronephrosis; renal anomalies; Supernumerary kidney
Haemotoxic snakebite, presenting with coagulopathy and bleeding manifestations, is quite common. Thrombotic manifestations are infrequently observed. We describe the unusual case of a young male who developed deep vein thrombosis (DVT) of the left lower limb following snakebite, despite an ongoing coagulopathy. Investigations revealed leucocytosis, prolonged 20-minute whole blood clotting time (20’WBCT), prolonged prothrombin time (PT), and activated partial thromboplastin time (aPTT). Doppler study revealed thrombosis of common femoral vein, superficial femoral, and profunda femoris veins. The patient underwent two fasciotomies and received anticoagulation after which patency of the veins was restored. Doppler sonographic imaging in patients with haemotoxic snakebite who present with increasing local swelling may assist with early anticoagulation therapy that has a potential to be limb-saving.
Snake bite; DIC; DVT; Doppler ultrasound
During the routine dissection of upper limbs of a Caucasian male cadaver, variations were observed in the brachial plexus. In the right extremity, the lateral cord was piercing the coracobrachialis muscle. The musculocutaneous nerve and lateral root of the median nerve were observed to be branching inferior to the lower attachment of coracobrachialis muscle. The left extremity exhibited the passage of the median nerve through the flat tendon of the coracobrachialis muscle near its distal insertion into the medial surface of the body of humerus. A variation in the course and branching of the nerve might lead to variant or dual innervation of a muscle and, if inappropriately compressed, could result in a distal neuropathy. Identification of these variants of brachial plexus plays an especially important role in both clinical diagnosis and surgical practice.
Brachial plexus; Lateral cord; Coracobrachialis; Median nerve
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
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
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