Conference abstracts

Authors: Nicholas Hannah (1), Catherine Mitchell (2), Tony Huang (3), Siddharth Sood (4), Alex Boussioutas (5)

Affiliations: 1. The Royal Melbourne Hospital, 2. University of Melbourne, 3. Peter MacCallum Cancer Centre, 4. Northern Health, 5. Alfred Health

Abstract

Introduction: PSMA is a promising imaging target in non-prostatic malignancy. Studies have demonstrated uptake of 68Ga-PSMA on position emission tomography (PET) in HCC. The diagnostic accuracy and utility of this finding remains unclear. We aimed to characterize the distribution of PSMA expression within HCC tumours and benign liver lesions to better understand the role PSMA may play in diagnosis and management of HCC.

Methods: Stored liver tissue specimens from our tertiary institution between 01/12/2017-01/03/2023 with a histological diagnosis of HCC, dysplastic nodule, hepatic adenoma or focal nodular hyperplasia (FNH) were retrieved. PSMA immunohistochemistry (IHC) was performed. An expression score where the expression intensity and the distribution were combined for scoring was developed: negative, weak, moderate, strong.

Results: The study included 29 samples, comprising 23 cases of HCC and 6 benign lesions (4 adenomas, 1 FNH, 1 dysplastic nodule). Among the HCC cases, the median age was 71 years (IQR 59 – 77), with 18 being male (78%) and 16 with cirrhosis (70%). Hepatitis B virus (HBV) was the most common cause of liver disease (n=7, 30%). Surgical resections n = 7 (30%), while n = 16 (70%) were biopsy. Within the HCC samples, PSMA staining the endothelial compartment of tumours was detected in 21 cases (91%, Fig 1), and canalicular in two, with expression score of negative in 0, weak in 2 (8%), moderate in 6 (25%), and strong in 15 (65%). Among benign liver lesions, the canalicular compartment exhibited predominant expression, with weak expression in the dysplastic nodule, moderate in the FNH, and strong in all 4 hepatic adenomas. Predominant endothelial expression was significantly higher in HCC (91%) compared to background parenchyma and benign lesions (4%), p<0.0001. Endothelial expression accurately discriminated HCC from benign tissue, with moderate/strong expression showing sensitivity 91%, specificity 84%, positive predictive value (PPV) 84%, and negative predictive value (NPV) 92%. Strong expression was associated with advanced HCC in 11 of 15 cases (73.3%) compared to 1 of 8 cases with early-stage (12.5%, p = 0.009).

Conclusions: PSMA expression within the endothelial compartment accurately discriminates HCC from benign tissue. Exhibiting high sensitivity, specificity, PPV and NPV. Strong expression is significantly associated with more advanced stage disease. Correlating this finding with PSMA PET uptake is necessary, Hepatocellular Carcinoma Imaging Using PSMA PET/CT (HepaSMART) clinical trial underway with this aim (NCT05095519). The presence on neovascular structures may render PSMA a potential theranostic target.

Authors: Megan L Allen (1,2); Kara Allen (1,2); Janette Wright (3)

Affiliations: 1. The Royal Melbourne Hospital, 2. University of Melbourne

Abstract

Introduction: RMH cares for high-acuity, complex patients, so perioperative critical clinical incidents (CI) are common. Clinical incident debriefing (CID) may benefit patients, clinicians, and organisations [1]. We investigated baseline staff experiences and distress to develop a CID program to meet clinician needs. Primary outcomes were baseline psychological safety and burnout and CID program feasibility evaluation.

Methods: All anaesthetists (and trainees; N=111) were invited to participate in the baseline survey. The survey investigated psychological safety, past CI management, clinician burnout, and clinician distress (K6+ screening tool [2]). After analysing the survey results, we conducted four focus group sessions. These were recorded, transcribed, and thematically analysed.

Results: Fifty-five doctors responded to the survey (49.5%); 75% (N=41) were consultants. While psychological safety was high, trainees reported lower scores than specialists, with 32% at risk of burnout. A recent CI (<6 months) was reported by 78% of consultants and 36% of trainees (38% occurring after hours). Participation in formal CID was considered useful or somewhat useful (75%). Logistics were cited as the main barrier to CID, and the purpose of the debrief was not always explicit (clinician wellbeing vs. clinical review).

Conclusions and impact: We partnered with RMH Wellbeing to optimise the perioperative CID process, focussing on staff wellbeing. This included staff “check-in” training, developing a welfare box for after-hours CID support (including resources and reporting support) and offering a post-CI defuse session conducted by a trained facilitator. We plan to conduct a post-implementation evaluation and iterative refinement.

Authors: Caroline Chen (1,2), Courtney Ierano (1,2), Lisa Hall (1), Ron Cheah (1,2), Josephine Wen (1,2), Zohal Rashidzada (1,2), Karin Thursky (1,2), Rod James (1,2)

Affiliations: 1. Guidance Group, The Royal Melbourne Hospital 2. National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne 3. School of Public Health, University of Queensland

Abstract

Background: The auditing of antimicrobial prescribing is an essential element of antimicrobial stewardship (AMS) programs. The Hospital National Antimicrobial Prescribing Survey (NAPS) provides a standardised way to measure antimicrobial prescribing and also contributes to national surveillance.

Methods: All Australian hospitals were eligible to participate throughout 2022. Auditors were required to assess each prescription against several key indicators, including compliance with prescribing guidelines and appropriateness.

Results: A total of 411 hospitals participated, representing 42.5% of all eligible Australian hospitals, with 34,073 antimicrobial prescriptions. An indication was documented in 85.3% of prescriptions; this figure was substantially higher amongst hospitals with an electronic medication management (EMM) system (92.3% vs 77.5%) and for treatment compared with prophylaxis prescriptions (87.3% vs 78.6%).

A review or stop date was documented in 53.7% of prescriptions; this figure was higher amongst hospitals with an EMM (54.9% vs 45.0%) and in surgical prophylaxis compared with all other treatment types (79.6% vs 50.2%). 24.8% of prescriptions were non-compliant with guidelines and 21.7% inappropriate.

The most common indications for prescribing were surgical and medical prophylaxis (22.8%), community acquired pneumonia (9.7%) and cystitis (5.7%). Common indications with the highest rates of inappropriateness were chronic obstructive pulmonary disease (42.4%), surgical prophylaxis (39.6%) and aspiration pneumonia (23.7%).

The most commonly prescribed antimicrobials were cefazolin (11.5%), ceftriaxone (9.3%) and amoxicillin-clavulanic acid (8.1%).

Conclusions and impact: The NAPS continues to be widely adopted across Australia and enables the meaningful identification of areas for practice improvement and shapes AMS program opportunities at a local and national level.

Authors: Yin Yuan (1,2,3,4), Sarah T. Diepstraten (1,2), Fiona Brown (1,2), Veronique Litalien (1,2), Angela Georgiou (1,2), Thomas E. Lew (1,2,3,4), Andreas Strasser (1,2), Gemma L. Kelly (1,2*), Andrew H. Wei (1,2,3,4*), Andrew W. Roberts (1,2,3,4*)

Affiliations: 1. The Walter and Eliza Hall Institute, 2. The University of Melbourne, 3. The Royal Melbourne Hospital, 4. The Peter MacCallum Cancer Centre, (*) Senior co-authors

Abstract

Introduction: Acute myeloid leukaemia (AML) has poor prognosis, especially if TP53 is mutated (TP53m). Activation of the stimulator of interferon genes (STING) pathway canonically induces type-1 interferon production by T cells but may also drive apoptosis in other cells. We aimed to investigate the cell-intrinsic effects of STING agonists in AML.

Methods: We tested the small molecule STING agonist diABZI. Drug sensitivity assays were performed using human AML-derived cell lines and primary patient samples. STING expression was measured by intracellular flow cytometry. In vivo testing in immunocompromised mice used cell line and patient-derived xenografts (PDX). All comparisons were prespecified and differences reported are statistically significant.

Results: In primary samples, leukaemic blasts from 26 patients demonstrated significantly higher levels of STING protein than normal B, T and NK cells. AML blasts from 11/18 samples were highly sensitive to 100nM diABZI, whereas normal lymphocytes were resistant. Knockout experiments in AML cell lines confirmed that diABZI-induced cell death was STING dependent, but independent of TP53. In vivo, diABZI prolonged survival in MOLM-13 TP53 wildtype and knock-out cell line models, especially when combined with the pro-apoptotic standard-of-care agent venetoclax. In a TP53m AML PDX model, diABZI mono- and combination therapy induced rapid reduction in bone marrow leukemic burden and improved survival.

Conclusions: STING agonists exert tumour intrinsic, potent, and TP53-independent activity against primary AML, with efficacy enhanced by venetoclax.

Significance and impact: Our data demonstrates the potential of STING agonists as a novel therapy for AML, especially against TP53m disease, supporting planned clinical trial investigation.

Authors: Jordan Jones (1, 2) , Kate Drummond (1,2) , Andrew Morokoff (1, 2)

Affiliations: 1. Department of Neurosurgery, The Royal Melbourne Hospital 2. Department of Surgery, University of Melbourne

Abstract

Aim: Liquid biopsy based on circulating tumour DNA (ctDNA) is a novel tool in clinical oncology to assess prognosis, tumour burden and treatment resistance. Despite significant progress seen in other cancers, ctDNA analysis in glioma has been limited by low levels of circulating DNA and poor sensitivity. In this study, we report the use of digital droplet PCR and a novel next generation sequencing technique on longitudinal blood samples in glioma patients.

Methods: In a prospectively collected cohort of gliomas, including patients from a novel Phase 0 trial of an IDH1 inhibitor, we analysed matched plasma samples and tumour tissue samples. Circulating cell free DNA was extracted from the plasma and analysed with AVENIO, a custom panel and ddPCR

Results: We found glioma associated mutations in 93% of plasma samples including common drivers such as EGFR amplification. Concordance between plasma and tissue was 52%, with 25% of mutations detected in the plasma only, suggesting ctDNA may complement tissue biopsy in providing a complete genomic characterisation of a tumor and overcome the spatial heterogeneity encountered on biopsy. Mutations in the mismatch repair genes were most frequently detected following temozolomide treatment and were observed prior to their appearance in tissue at the time of progression. IDH mutations could be detected in >90% of plasma samples in patients harbouring tumours with that mutation.

Conclusion: We show that novel sequencing techniques can detect low concentrations of glioma ctDNA and show clinical utility in diagnosis, monitoring, early detection of chemo-resistance and genomic personalised profiling.

Authors: Rahul D Barmanray (1,2,3), Mervyn Kyi (1,2,3), Peter G Colman (1,2,3), Lois Rowan (1), Mayurapriya Raviskanthan (1), Lucy Collins (1), Laura Donaldson (1), Stephanie Montalto (1), Joshua Tsan (1), Emily Sun (1), Minh Le (1), Leon J Worth (4,5), Benjamin Thomson (6), Spiros Fourlanos (1,2,3)

Affiliations: 1. Department of Diabetes & Endocrinology, The Royal Melbourne Hospital, 2. Department of Medicine RMH, University of Melbourne 3. Australian Centre for Accelerating Diabetes Innovations, University of Melbourne 4. National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne 5. Victorian Healthcare Associated Infection Surveillance System Coordinating Centre, Doherty Institute 6. Department of General Surgery, The Royal Melbourne Hospital

Abstract

Objective: To investigate the effect of early intervention with an electronic specialist-led “proactive” model of care on glycemic and clinical outcomes.

Methods: The Specialist Treatment of Inpatients: Caring for Diabetes in Surgery (STOIC-D Surgery) randomized controlled trial was performed at the Royal Melbourne Hospital. Eligible participants were adults admitted to a surgical ward during the study with either known diabetes or newly detected hyperglycemia (at least one random blood glucose result >=11.1 mmol/L). Participants were randomized 1:1 to standard diabetes care or the intervention consisting of an early consult by a specialist inpatient diabetes team using electronic tools for patient identification, communication of recommendations, and therapy intensification. The primary outcome was median patient-day mean glucose (PDMG). The key secondary outcome was incidence of health care–associated infection (HAI).

Results: Between 12 February 2021 and 17 December 2021, 1,371 admissions met inclusion criteria, with 680 assigned to early intervention and 691 to standard diabetes care. Baseline characteristics were similar between groups. The early intervention group achieved a lower median PDMG of 8.2 mmol/L (interquartile range [IQR] 6.9–10.0 mmol/L) compared with 8.6mmol/L (IQR 7.2–0.3 mmol/L) in the control group for an estimated difference of 20.3 mmol/L (95%CI 20.4 to 20.2 mmol/L, P<0.0001). The incidence of HAI was lower in the intervention group (77 [11%] vs. 110 [16%]), for an absolute risk difference of 24.6% (95%CI 28.2 to 21.0, P=0.016).

Conclusions: In surgical inpatients, early diabetes management intervention with an electronic specialist-led diabetes model of care reduces glucose and HAI.

Authors: Erin D Bicknell (1), Laura Ferguson (1), Alisha da Silva (1), Tiffany Theoharidis (1), Khyati Gohil (1), Jennifer Langford (1), Melissa Clarke (1), Anne McGann (2), Wendy F Bower(1,2,3)

Affiliations: 1. Physiotherapy Department, The Royal Melbourne Hospital 2. Subacute Ambulatory Care Services, The Royal Melbourne Hospital 3. University of Melbourne

Abstract

Introduction: Benign Paroxysmal Positional Vertigo (BPPV) is common in older adults. BPPV prevalence and feasibility of routine physiotherapy assessment in subacute inpatients is unknown. The objective of this study was to ascertain BPPV prevalence, describe characteristics, and examine feasibility of implementing routine BPPV physiotherapy assessment in older subacute inpatients.

Methods: Inpatients aged ≥50 years sustaining a fall within 6 months were assessed for BPPV. Demographic, falls, medical history, Clinical Frailty Score, Functional Ambulation Classification, de Morton Mobility Index, Modified Falls Efficacy Scale, De Jong Gierveld Loneliness Scale, short Dizziness Handicap Inventory [DHI] versions, 6-metre walk test, and Timed Up and Go Test results were collected. Implementation was evaluated through process evaluation and surveys completed by study physiotherapists.

Results: Over 9 months, 572 participants met inclusion criteria, 447 received physiotherapy and 301 completed ≥ one BPPV assessment. BPPV prevalence was 6%, with 35% reporting current dizziness or unsteadiness. There were no differences between BPPV positive and negative for demographic, medical history, functional or patient-reported outcomes. There was a statistically significant difference in DHI scores (5-item p= <0.001; 8-item p= 0.001). Overall, 67% of eligible patients underwent BPPV assessment; 146 could not be assessed. Physiotherapists perceived BPPV management to be acceptable (88%), appropriate (90%) and feasible (76%) however constrained by patient-factors, time required and environmental barriers.

Conclusions: Assessing and treating BPPV was feasible. Physiotherapists perceive BPPV assessment as important but difficult amongst competing priorities and patient-factors. Subjective symptoms may not indicate BPPV risk, however, the 5-item DHI may identify need for assessment.

Authors: Aimee Dow (1), Lani Wilson (1), Casey Peiris (1,2)

Affiliations: 1. The Royal Melbourne Hospital, 2. La Trobe University

Abstract

Introduction: Aboriginal and/or Torres Strait Islander (Indigenous) peoples are seven times more likely to discharge from a hospital against medical advice compared to non-Indigenous Australians. Accordingly, improvements in practices, services and/or culturally safe care are needed to improve outcomes and reduce the burden of disease among Indigenous peoples. The aim of this review was to investigate the effectiveness of hospital interventions to improve outcomes.

Methods: Five databases were systematically searched to identify studies in a hospital setting that evaluated an intervention to improve the hospital experience and health outcomes of Australian Indigenous peoples. Two independent reviewers completed the screening, data extraction, risk of bias assessment, thematic qualitative analysis and GRADE certainty of evidence assessment.

Results: 12 reports of 11 studies, including 6085 Australian Indigenous peoples were included. Nine studies evaluated interventions that involved employment of Indigenous health staff and two targeted non-Indigenous staff. There was moderate certainty evidence from three cohort studies with 4351 participants that interventions involving Indigenous health staff reduced self-discharge rates in various settings. Qualitative analysis of five studies revealed patients valued having Indigenous health workers as they enhanced communication and provided advocacy. Interventions focused only on non-Indigenous staff did not demonstrate improvements.

Conclusions: Including Indigenous health workers into routine care improves outcomes for Indigenous peoples.

Significance and impact: Incorporating Indigenous health workers, liaison officers and/or interpreters into routine care may help close the gap in healthcare differences.

Authors: Oneil G Bhalala (1,2), Jessica Beamish (3), Dhamidhu Eratne 3,4), Patrick Summerell (3), Tenielle Porter (5), Simon M. Laws (5), Matthew J.Y. Kang (3,4), Aamira J. Huq (1), Wei-Hsuan Chiu (4), Claire Cadwallader (6), Mark Walterfang (3,4,7,8), Sarah Farrand (3,4), Andrew H Evans (1), Wendy Kelso (3), Leonid Churilov (1), Rosie Watson (1,2), Nawaf Yassi (1,2), Dennis Velakoulis (3,4), Samantha M Loi (3,4)

Affiliations: 1. Department of Medicine, RMH, University of Melbourne, 2. Population Healthy and Immunity Division, Walter and Eliza Hall Institute, 3. Neuropsychiatry Centre, The Royal Melbourne Hospital, 4. Department of Psychiatry, University of Melbourne, 5. Centre for Precision Health, Edith Cowan University, 6. Memory and Aging Center, UCSF Weill Institute for Neurosciences, University of California, USA, 7. Florey Institute of Neuroscience and Mental Health, 8. School of Medical and Health Sciences, Edith Cowan University

Abstract

Introduction: Young-onset neurocognitive symptoms result from a heterogeneous group of neurological and psychiatric disorders which present a diagnostic challenge. To identify such factors, we analysed the BeYOND (Biomarkers in Younger-Onset Neurocognitive Disorders) cohort, a study of individuals less than 65 years old presenting with neurocognitive symptoms for a diagnosis and who have undergone cognitive and biomarker analyses.

Methods: Sixty-five participants (median age at assessment of 56 years, 45% female) were recruited during their index presentation to the Royal Melbourne Hospital Neuropsychiatry Centre, a tertiary specialist service in Melbourne, Australia, and categorised as either early-onset Alzheimer’s disease (EOAD, n=18), non-AD neurodegeneration (nAD-ND, n=23) or primary psychiatric disorders (PPD, n=24). Levels of neurofilament light chain, glial fibrillary acidic protein and phosphorylated-tau 181, apolipoprotein E genotype and late-onset AD polygenic risk scores were determined. Information-theoretic model selection identified discriminatory factors.

Results: Neurofilament light chain, glial fibrillary acidic protein and phosphorylated-tau 181 levels were elevated in EOAD compared to other diagnostic categories. A multi-omic model selection identified that a combination of cognitive and blood biomarkers, but not the polygenic risk score, discriminated between EOAD and PPD (AUC≥0.975, 95% CI: 0.825-1.000). Phosphorylated-tau 181 alone significantly discriminated between EOAD and nAD-ND causes (AUC=0.950, 95% CI: 0.877-1.00).

Conclusions and impact: Discriminating between EOAD, nAD-ND and PPD causes of young-onset neurocognitive symptoms is possible by combining cognitive profiles with blood biomarkers. These results support utilising blood biomarkers for the work-up of young-onset neurocognitive symptoms and highlight the need for the development of a young-onset AD-specific polygenic risk score.

Authors: Joanne Davis (1,2), Mandy Ludford-Menting (1,2), Rachel M Koldej (1,2), David S Ritchie (1,2,3)

Affiliations: 1. ACRF Translational Research Laboratory, The Royal Melbourne Hospital, 2. Department of Medicine, The University of Melbourne, 3. Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital

Abstract

Introduction: Bruton’s tyrosine kinase inhibitors (BTKi), including ibrutinib, are highly effective for treating Chronic Lymphocytic Leukaemia (CLL). Ibrutinib treatment can improve T cell immunity, despite its off-target effects on other kinase pathways. We investigated the effect of both in vitro and in vivo BTKi treatment on T cell phenotype and function in CLL patients.

Methods: We performed immune subset phenotyping, intracellular cytokine secretion, T cell degranulation, and cell-trace violet proliferation assays, using baseline and long-term treatment (> 12 months) peripheral blood mononuclear cells (PBMC) from CLL patients on ibrutinib or zanubrutinib therapy (n = 15), and age-matched healthy donors (HD, n = 7). In vitro analysis was performed on treatment-naïve CLL patients and HD (n = 10). Samples were acquired at the Melbourne Cytometry platform and analysed using FlowJo software. Statistical analysis was performed using Prism V9.0 (GraphPad).

Results: In vitro treatment of T cells with ibrutinib reduced cytokine secretion, proliferation and degranulation. However, T cells from CLL patients have abnormal hyperproliferative responses that were reduced to HD levels after ibrutinib treatment. Ibrutinib-induced suppression of T cell proliferation prevented T cell exhaustion and normalised CD8+ and CD4+ T cell exhaustion markers in CLL patients on long-term BTKi treatment.

Conclusion: Ibrutinib therapy for the treatment of CLL can contribute to disease control and improved T cell fitness, and may improve immunotherapy outcomes in patients. New directions in checkpoint inhibitor therapies in combination with BTKi treatment will be discussed.

Significance and impact: Ibrutinib treatment of CLL patients may restore long-term immune function.

Authors: Tina Thompson (1,2), Natalie Morgan (3), Sarah Parsons (3,4), Dominica Zentner (1,2,5), Ingrid Winship (1,2), Bryony Thompson (1,7), Kunal Verma (6), Jitendra Vohra (1,2,5)

Affiliations: 1. Genomic Medicine, The Royal Melbourne Hospital, 2. Department of Medicine, University of Melbourne, 3. Victorian Institute of Forensic Medicine, 4. Department of Forensic Medicine, Monash University, 5. Department of Cardiology, The Royal Melbourne Hospital, 6. Monash Medical Centre; 7. Department of Pathology, The Royal Melbourne Hospital

Abstract

Introduction: The incidence of sudden cardiac death (SCD) in patients with schizophrenia is 3 to 4 times higher than in the general population. While the majority of SCD in patients with schizophrenia are due to ischaemic or structural heart disease, many deaths remain unexplained. In recent reviews of premature deaths in patients with schizophrenia, these deaths were postulated to be secondary to malignant cardiac arrhythmias.

Methods: A retrospective study conducted jointly by the Victorian Institute of Forensic Medicine (VIFM) and the Department of Genomic Medicine, Royal Melbourne Hospital (RMH), was designed to identify novel genomic loci that link schizophrenia and sudden unexplained death. Cases included deceased patients over a five-year period (2016-2021) with an in-life diagnosis of schizophrenia and an unascertained cause of death, after comprehensive post-mortem histopathological and toxicological assessment. Individuals also needed a source of DNA to be available.

Results: 37 individuals met the study inclusion criteria, age range 18-65 years; 25 male and 12 female. 13 next of kin (NOK) consented to involvement in the study. 12 individuals underwent whole exome sequencing (WES) via a research platform. Two clinically actionable results were detected - a likely pathogenic DES variant and a DPYD pharmacogenomic variant. Both families chose to receive results.

Conclusion: Genes that are currently associated with inherited arrhythmia syndromes were not found in the study group. The pathogenic DES would likely have been found had the family accepted referral that was offered to a Cardiac Genetics service, at the time of death.

Authors: Kath Feely (1,2,3,4), Louise Mogg (1), Jenni Medland (1), Joanne Rowe (2)

Affiliations: 1. The Royal Melbourne Hospital, 2. The Royal Children’s Hospital, 3. Peter Mac Callum Cancer Centre, 4. The Royal Women’s Hospital

Abstract

Introduction: Despite focus on disability data in Australian policy, there is no standardized approach for collecting disability status. To address this, Parkville precinct public hospitals in Melbourne launched a co-design project to create a disability identification questionnaire. This project aimed to develop the questionnaire and determine how to present the data to staff and provide reports to empower patients to disclose their disabilities and improve patient-centered care.

Methods: A three-question disability identification questionnaire was integrated into the Health Hub and Electronic Medical Records (EMR) systems. Nine months later, we evaluated its acceptability through an online survey based on the Theoretical Framework of Acceptability (TFA) and qualitative interviews with patients and staff. EMR data was analyzed to assess the questionnaire’s uptake.

Results: >22,000 patients engaged with the questionnaire, with 47% completing in Health Hub, 19% identified as having a disability and 74% of these used Health Hub to report their disability. Feedback from 1,327 patients indicated a low burden for completion, high opportunity cost, and strong overall acceptability (4.3/5), though perceived effectiveness was rated the lowest. Staff feedback showed strong overall acceptability (4.2/5) with high ratings for perceived effectiveness and self-efficacy.

Conclusions: Accessible disability data enhances visibility for clinical staff and supports a more inclusive environment. Reports generated from this data facilitate proactive support for patients. Feedback is guiding further refinement of the tool to better meet community needs.

Significance and impact: The finalised questions will be distributed by Victoria's Department of Health, offering a model for other organisations to adopt similar practices.

Authors: Dalyia Abu-Ghazaleh, Nadine Abu-Ghazaleh, Alex Gorelik (2), Daniel Buchanan (1,2), Ingrid Winship (1,2), Finlay Macrae (1,2)

Affiliations: 1. Genomic Medicine, The Royal Melbourne Hospital, 2. Department of Medicine, University of Medicine

Abstract

Introduction: Gynaecological malignancies, including ovarian and endometrial cancers, are prevalence in patients with Lynch Syndrome. Efforts for universal germline mutation screening in this population are hampered by the lack of accurate estimates of the true prevalence of LS amongst patients with gynaecological malignancies.

Methods: MEDLINE (Ovid), Embase, and Web of Science were searched. Prevalence was calculated by random effects meta-analysis models. I2 score was used to assess heterogeneity across studies. Meta-regression was performed for between-study variance.

Results: A total of 35 studies were included in this review. The overall pooled yield of LS screening was 2.4% based on all methods of detection. The prevalence was higher in patients with endometrial cancer compared to ovarian cancers. Studies performing universal germline tests on all patients reported higher proportions as opposed to studies only performing germline tests on participants with tumours with mismatch repair deficiency or microsatellite instability. Selected cohorts of gynaecological malignancies had a higher prevalence of germline LS diagnoses.

Conclusion: The prevalence of LS in patients with gynaecological malignancies is approximately 2.4%, similar to that of colorectal cancer patients. Our study support the implementation of universal germline screening for LS.

Significance and impact: This is an update to a systematic review and meta-analysis performed in 2019 of the prevalence of LS across endometrial malignancies. It also includes data on ovarian malignancies. Our study provides accurate estimates of LS prevalence across gynaecological malignancies as reported in the literature and supports universal germline testing.

Authors: Nadine Abu-Ghazaleh, Dalyia Abu-Ghazaleh, Alex Gorelik (2), Daniel Buchanan (1,2), Ingrid Winship (1,2), Finlay Macrae (1,2)

Affiliations: 1. Genomic Medicine, The Royal Melbourne Hospital, 2. Department of Medicine, University of Medicine

Abstract

Introduction: sebaceous neoplasms are rare skin tumours involving the sebaceous glands with an incidence rate of 1 per 100000 patients years. MTS is a phenotypic variant of Lynch Syndrome (LS) which is the most common hereditary colorectal cancer (CRC) syndrome. Universal germline testing of individuals with newly diagnosed sebaceous tumours or sebaceous adenomas for LS has been discussed previously. While it's wise from a clinical perspective, it is essential to have a precise estimate of the actual prevalence of LS among patients with sebaceous adenomas and carcinomas.

Methods: MEDLINE (Ovid), Embase, and Web of Science were searched. Prevalence was calculated by random effects meta-analysis models. I2 score was used to assess heterogeneity across studies. Meta-regression was performed for between-study variance.

Results: A total of 9 studies were included in this review. The overall pooled yield of LS screening was 6.6% based on all methods of detection. Studies that tested for all four mismatch repair genes and population based studies reported highest pooled prevalence. Studies performing universal germline tests on all patients reported higher proportions as opposed to studies only performing germline tests on participants with tumours with mismatch repair deficiency or microsatellite instability.

Conclusion: LS prevalence across multiple ethnic, geographic, and clinical populations is remarkably similar. Universal germline testing of patients provides the highest returns for LS identification.

Significance and impact: Our study supports the implementation of universal germline screening for LS. This is the first systematic review and meta-analysis to look at the prevalence of LS in patients with sebaceous malignancies.

Authors: Emma Bidgood, Joanna Huang, Elise Murphy, Ralley Prentice, Beth Hede, David Russell

Affiliation: The Royal Melbourne Hospital

Abstract

Introduction: Peripheral parenteral nutrition (PPN) provides an alternative nutrition support strategy to centrally administered parenteral nutrition (PN) for specific patients requiring short-term PN. Previous studies have demonstrated limited utilisation of PPN and variations in complication rates. This study aimed to evaluate PPN complications and usage at this center.

Methods: This was a single-center retrospective observational study of all adult patients who received at least 1 day of PPN from June 2018 to December 2023. Demographic and clinical data were collected including complications, indications for PN and reason for PPN, duration of therapy, reason for cessation of PPN, nutritional status, energy and protein provision, and central line insertion rates.

Results: A total of 381 patients were included, median age 62 [IQR 28-74] years, 235 males (61.7%). The most common indication for PN was ileus (n=153, 40%), followed by gastrointestinal obstruction (n=93, 24%). The median time on PPN was 3 [2-4] days. Patients received a median of 65% [55-75] of energy and 58% [50-69] of protein requirements with PPN. Malnutrition was diagnosed in 47.5% (n=181) of this cohort. Total complication rates were 8% (n=31) with cannula infiltration being the most common complication (6.6%, n=25). 213 (56%) patients proceeded to central line insertion.

Conclusion: PPN proved to be a safe and effective therapy for short-term PN when managed by a nutrition support team. PPN has the potential to attenuate short-term nutritional deficits and prevent CVAD insertion in selected patients, making it a valuable therapy in type 1 intestinal failure.

Authors: Aliya Bryce (1,2), Sara Davison (1), Bart J Currie (1,3), Johanna M Birrell (4), Robert W Baird (1), Asanga Abeyaratne (3,5,6), Sandawana William Majoni (3,5,6), Teana Brewster-O’Brien (5), Steven YC Tong (7,8.)

Affiliations: 1. Department of Infectious Diseases, Royal Darwin Hospital, 2. The Royal Melbourne Hospital, 3. Menzies School of Health Research, Charles Darwin University, 4. Northern Territory Centre for Disease Control, NT Health, 5. Department of Nephrology, Royal Darwin Hospital, 6. Flinders University and Northern Territory Medical Program, Royal Darwin Hospital Campus, 7. Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute, 8. Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute

Abstract

Introduction: Staphylococcus aureus bloodstream infections (SAB) are associated with high levels of morbidity and mortality, particularly in patients receiving haemodialysis (HD). In the Northern Territory of Australia, HD patients receive thrice-weekly supervised oral Trimethoprim-Sulfamethoxazole (co-trimoxazole) during the monsoonal wet season as prophylaxis against the tropical disease melioidosis. This study investigated whether seasonal co-trimoxazole usage correlated with an associated reduction in rates of SAB in HD patients.

Methods: In this single centre, retrospective cohort study, episodes of SAB from 1st Jan 2017 – Dec 31st 2022 in adults ≥ 18years were obtained from laboratory databases. These were cross-referenced against an electronic nephrology database to identify HD patients. Rates of SAB were compared during the wet (November 1st – April 30th) and dry seasons. Incidence rates were calculated from local haemodialysis point prevalence data and census data.

Results: There were 304 SABs during the study period with 52 (17%) in HD patients. The median age of HD patients with SAB was 53.1 years, 34/52 (65%) were female and 39/52 (75%) Aboriginal Australians. Wet season incidence in HD patients equated to 1528/100,000person years compared to 3438/100,000person years in the dry. In non-dialysing adults (n=252), there was no seasonal difference with 50.4% (127/252) of SAB episodes occurring during the wet season.

Conclusions: SAB rates in HD patients were 56% lower during the monsoonal wet season when patients routinely receive prophylactic co-trimoxazole.

Significance and impact: This novel observation in a high-risk patient group highlights a potential therapeutic to reduce the disproportionate burden of SAB in HD patients.

Authors: Bernarda Cavka, John Cunningham, Patrick Elias, Alper Yataganbaba

Affiliations: The Royal Melbourne Hospital

Abstract

Aim: To evaluate the efficacy and safety of an international first spine virtual fracture Clinic (SVFC) pioneered at The Royal Melbourne Hospital.

Methods: A study was conducted comparing outcomes prior to (January to December 2021) and following (July 2022 to November 2023) implementation of the SVFC at RMH. The primary aim was to investigate the effects of a telephone-based SVFC on outpatient clinic activity, represented by the proportion of referrals discharged without requiring in-person clinic attendance. Secondary aims included comparing SVFC outcomes with traditional outpatient clinics (appointment utilisation, loss to follow-up rates, and duration of care) and safety of the new model of care (missed or misdiagnoses, unplanned operations, and complications).

Results: A total of 91.9% (n=666) of referrals managed by the SVFC were discharged without in-person clinic attendance. Compared to outpatient clinic management (n=150 referrals), SVFC implementation was associated with reductions in the average number of consultations per referral (1.8 versus 2.4, p<0.001), appointments not attended (5% versus 13%, p<0.001), referrals lost to follow-up (0 versus 10.7%, p<0.001) and a shorter duration of care (median 48 days versus 58 days, p<0.001). A total of 65 patients (8.1%) were redirected to in-person clinics, three of whom underwent surgical intervention, demonstrating that the SVFC does not substitute for in-person care when required. No diagnostic errors, complications or adverse events were identified.

Conclusion: This study demonstrates that an SVFC is an effective and safe alternative management pathway for stable spine fractures with a low risk of adverse outcomes.

Authors: Karanjeet Chauhan (1,2), Georgia Rejack (2), Derek Chew (2), Stephen J Nicholls (2), Hui-Chen Han (2)

Affiliations: 1. The Royal Melbourne Hospital, 2. Victorian Heart Hospital, Victorian Heart Institute, Monash University

Abstract

Introduction: Simulation-based training (SBT) in cardiology has emerged as a popular adjunct to traditional teaching to develop clinical and procedural skills within a controlled environment. In this systematic review, we aim to evaluate the evidence for SBT in cardiology with a focus on real-world outcomes.

Methods: This systematic review was designed following the PRISMA guidelines. The literature search was performed using MEDLINE, Cochrane and EMBASE by two independent reviewers. Studies utilising SBT to teach medical professionals skills pertaining to cardiology were included, with a particular emphasis on factors linked to SBT that may result in positive outcomes.

Results: A total of 3014 studies between January 2000 to December 2023 were obtained. After critical review, 33 studies (2061 participants) were included. Fourteen studies evaluated in-vivo procedure-based outcomes. 4 of these showed significant reductions in fluoroscopy time, 3 showed reductions in radiation dose, 4 showed improved procedural proficiency, and 2 showed reductions in real-world complication rates. Conversely, one study (12 participants) found increased real-world complication rates associated with SBT. Nineteen studies evaluated knowledge-based outcomes, seventeen of which showed significant improvements in test scores following SBT.

Conclusion: SBT in cardiology, particularly when structured and supervised, improves patient outcomes, procedural skill and knowledge acquisition. However, the indiscriminate use of SBT, particularly when unsupervised, does not appear to be beneficial.

Significance and impact: Current evidence does suggest that the indiscriminate use of high-fidelity simulation training alone is not superior to conventional training. There is a need for a more nuanced approach to integrate SBT within cardiology training.

Authors: Ron Cheah (1,2), Rod James (1,2), Courtney Ierano (1,2), Noleen Bennett (1,2), Logesh Palani (2), Caroline Chen (1,2), Karin Thursky (1,2)

Affiliations: 1. National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, The University of Melbourne, 2. RMH Guidance Group, The Royal Melbourne Hospital

Abstract

Introduction: Antimicrobial Stewardship (AMS) services are responsible for promoting judicious antimicrobial use. Despite being an essential service that should be embedded in all healthcare settings, some regional and remote hospitals struggle with securing the necessary expertise to perform essential AMS activities such as auditing and feedback.

The QI NAPS is an auditing tool that can be used to measure compliance with guidelines, monitor antimicrobial use and drive prescribing improvements. It was designed to be used by all clinicians including those without infectious diseases (ID) or AMS expertise.

Methods: Data were obtained from the QI NAPS data repository from 2016 to 2022 to identify user demographics, indications and antimicrobials, and AMS interventions performed in regional or remote settings.

Results: The QI NAPS has been used by 128 healthcare facilities in 7 Australian states and territories. Auditors are mainly non-expert clinicians (n=104, 67.5%) and most prescriptions audited were in regional or remote areas; 81.5% of all prescriptions (n=15,345).

Conclusions: QI NAPS bridges the gap in AMS expertise in regional and remote settings by enabling all clinicians to contribute to AMS initiatives.

Significance and impact: QI NAPS empowers clinicians in regional and remote settings, including those without ID or AMS expertise to improve antimicrobial prescribing. This enables improvements in the quality and safety of patient care and contributes to antimicrobial resistance control efforts.

Authors: Kai Sin Chin (1,2), Kim Fendel (1,3), Laura Gilbertson (1), Dina LoGiudice (1), Leonid Churilov (4), Nawaf Yassi (1,2,4), Rosie Watson (1,2,4).

Affiliations: 1. The Royal Melbourne Hospital, 2. The Walter and Eliza Hall Institute, 3. Alfred Health, 4. The University of Melbourne.

Abstract

Introduction: Australia has a rich migration history, with one in three older people coming from a culturally and linguistically diverse (CALD) background. However, limited literature exists on the clinical experience among CALD patients with dementia. This study aimed to investigate the clinical characteristics and service provision for CALD patients presenting to the Memory Clinic.

Methods: A retrospective analysis was conducted. All consecutive patients who presented to the Memory Clinic between September 2016 and June 2018 were included. Data collected included patient demographics, medical history, cognitive test scores, non-cognitive symptoms, clinical diagnoses, and length of follow up.

Results: 301 patients were included and 48.5% were from a CALD background, the majority being Italian. CALD patients were more likely to be living with family (73.3% vs 57.4%, OR [odds ratio] 2.1) and less likely to have attended education beyond primary level (26.7% vs 83.9%, OR 14.3). Cognitively, CALD patients performed worse on Mini-Mental State Examination (median MMSE 18 vs 25) and were more likely to be diagnosed with dementia (46.6% vs 31.0%, OR 1.9) at their initial assessments. Additionally, CALD patients were less likely to be referred for neuropsychology (28.8% vs 50.3%, OR 0.40).

Conclusions: The study findings highlight important differences in clinical characteristics between CALD and non-CALD patients with dementia in Memory Clinic.

Significance: Given the recent approval of anti-amyloid therapies in mild Alzheimer’s disease, more research is warranted to improve dementia diagnosis in CALD patients and ultimately promote more equitable and culturally inclusive dementia care.

Authors: Wei-Hsuan Chiu (1,2), Anita Goh (3), Dhamidhu Eratne (1,2), Charles Malpas (4), Matthew Kang (1,2), Courtney Lewis (2), Christa Dang (3), Wendy Kelso (2), Dennis Velakoulis (2), Samantha M Loi (1,2), and The MiND Study Group

Affiliations: 1. Department of Psychiatry, University of Melbourne, 2. Neuropsychiatry Centre, The Royal Melbourne Hospital, 3. National Ageing Research Institute, 4. Department of Medicine, University of Melbourne

Abstract

Introduction: Neuropsychiatric symptoms (NPS) are highly prevalent in young onset dementia (YOD) and often predate the onset of cognitive impairments. Due to a significant overlap in neuropsychiatric symptomatology, differentiating NPS in YOD from primary psychiatric disorders (PPD) remains a common diagnostic challenge. This study aimed to explore the roles of neuronal and glial biomarkers and their reactivity with NPS and cognition in YOD, PPD, and cognitively normal (CN) older adults.

Methods: This study recruited 66 participants through The MiND Study from October 2022 to October 2023. Blood samples were collected and analysed for plasma neurofilament light chain protein (NfL) and glial fibrillary acidic protein (GFAP). Neuropsychiatric and cognitive assessments were administered.

Results: In YOD, higher plasma NfL levels predicted more impairments in memory recall (B [95% CI] = -0.06 [-0.11, -0.004]) and emotion recognition (B = -0.04 [0.09, -0.003]) and greater emotional apathy (B = 0.12 [0.03, 0.21]). In PPD, no evidence of a linear relationship of plasma NfL or GFAP levels with NPS or cognitive measures was observed.

Conclusions: The connections of NfL to both cognitive and non-cognitive symptoms provide a more holistic understanding of the impact of neurodegeneration in YOD. The pathophysiology of PPD might involve different biological mechanisms compared to neurodegenerative conditions.

Significance and impact: The distinct roles of NfL and GFAP in different conditions, neurodegenerative vs psychiatric, highlight the need for condition-specific diagnostic and therapeutic strategies. Understanding the broader implications of these biomarkers across various contexts can aid in developing more comprehensive approaches to mental and cognitive health.

Authors: Katherine Clarke (1), Belinda Bilney (2), Annette Joosten (2)

Affiliations: 1. The Royal Melbourne Hospital, 2. School of Physiotherapy, Australian Catholic University

Abstract

Introduction: Experiencing a stroke is a distressing event for the stroke survivor, however little is known about the survivor experience of the phenomenon of acute stroke, or of acute stroke care. Understanding the first 48 hours of the acute stroke experience from the perspective of the stroke survivor can inform the delivery of person-centred care and identify future acute stroke healthcare priorities.

Methods: A descriptive phenomenological approach using semi-structured interviews was conducted with fourteen participants within seven days of their stroke. Interviews were transcribed verbatim and data analysis was completed using the Framework of 7 Steps (Colaizzi, 1978). All themes and significant statements were organised into a detailed description of the phenomenon of acute stroke and acute stroke care.

Results: Three global themes described their experiences: navigating the unchartered territory of acute stroke, the importance of human connection, and the stroke survivor’s perspective of the right care. Participants transitioned through varied physical and emotional stages in their early stroke experience. Remaining connected to their friends and families was important, and they valued the expertise of hospital staff.

Conclusions: It is feasible to complete qualitative research in the acute stroke setting. Navigating an acute stroke involves managing physical disability, working through complex emotions, and a reliance on health professionals, family and friends.

Significance and impact: Clinicians need to provide timely, individualised, and person-centred care to stroke survivors in the acute setting. Key aspects of this care bundle include clear information provision, early rehabilitation as indicated, and facilitating connection with family and friends.

Authors: Jason Cottle (1), Anna L Drozdik (2), Katharine A Rimes (2)

Affiliations: 1. The Royal Melbourne Hospital, 2. Department of Psychology, King’s College London, UK, 3. Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK

Abstract

Sexual and gender minorities (SGMs) experience a higher mental health burden compared to their cisgender, heterosexual counterparts. Role models and mentors are important for wellbeing and development; however, little evidence exists exploring their impact on SGM people. This systematic scoping review identifies their association with mental and physical wellbeing. Eight databases (Medline, Embase, Cochrane CENTRAL, ERIC, Science Citation Index, Scopus, EPub and PsychInfo) were searched for eligible publications from 2000 to 2022.

Two researchers identified studies, extracted data, completed quality appraisals using CASP checklists, and grouped data into outcomes relating to role model impact. From 501 citations, 12 studies (n = 1468 SGM people aged 15–63 years) were included.

Positive role models and mentors encouraged identity acceptance through destigmatisation and positive affirmation, increased SGMs’ psychological wellbeing through improved psychological safety and self-confidence and improved their sexual health knowledge.

Potential role models and mentors displaying negative behaviours could cause stigmatisation, as well as reduce identity acceptance and psychological safety. Information regarding the perceived influence of role models and mentors on substance abuse and other physical health outcomes was limited.

SGMs report greater benefits from relationships with others of shared minority status, providing incentives to match mentees with role models and mentors who share or empathise with their experiences of marginalization.

Authors: Alisha da Silva (1,2), Catherine Granger (1, 2), Shaza Abo (1,2), Janne Sheehan (2), Elizabeth Barson (3), Lisa Beach (2), Gemma Pound (4,5), Yasmine Ali Abdelhamid (6,7), Kate Fetterplace (7,8), Natalie Fini (1), Mark Merolli (1), Evelyn Sloan (1), Selina Parry (1, 2)

Affiliations: 1. Department of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, 2. Department of Physiotherapy, The Royal Melbourne Hospital, 3. Department of Psychology, Peter MacCallum Cancer Centre, 4. Department of Physiotherapy, St Vincent’s Hospital Melbourne, 5. Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 6. Intensive Care Unit, The Royal Melbourne Hospital, 7. Department of Critical Care, Melbourne Medical School, The University of Melbourne, 8. Department of Clinical Nutrition, The Royal Melbourne Hospital

Abstract

Introduction: Around 90% of people survive intensive care unit admission. However, people can experience poor mental health, physical weakness and/or cognitive issues. This study aimed to 1) explore recovery from the perspective of persons post life-threatening illness, caregivers, and clinicians and 2) co-design a rehabilitation intervention to support long-term recovery.

Methods: An experience-based co-design study guided by the Behaviour Change Wheel and Template for Intervention Description and replication. Between August 2021-February 2022, nine semi-structured interviews and two series of iterative workshops were conducted with persons post life-threatening illness (48 hours), caregivers and clinicians from two tertiary hospitals. The first workshops explored recovery. In the second workshops, a rehabilitation intervention prototype was co-designed. Data were analysed via reflective thematic analysis.

Results: Forty people participated; 15 persons post life-threatening illness (60.0% male, mean age 56.0 (SD 17.7) years, mean 2.2 (SD 1.3) years post-admission), two caregivers and 23 multidisciplinary clinicians. It was identified that after hospital discharge, there was a burden of residual physical and psychological symptoms, adjustment to disabilities, isolation from hospital services and increased family reliance. The co-designed prototype involved screening, a tailored remote physical and psychological intervention and online resources for clinicians and patients/caregivers.

Conclusions: The transition from hospital to home was identified as a crucial timepoint for intervention. Subsequently, the co-designed intervention will be piloted.

Significance and impact: Unmet healthcare needs exist for persons post life-threatening illness after hospital discharge. Resources and upskilling are needed within the community for clinicians, persons post life-threatening illness and caregivers.

Authors: Aruska D’Souza (1), Jacqueline E. Kay (1), Alana Jacob (1), Marlena Klaic (2),Celia Marston (1,3), Rose Goonan (1), Hannah Crowley (1), Catherine L Granger (1)

Affiliations: 1. The Royal Melbourne Hospital, 2. The University of Melbourne, 3. Allied Health, Peter MacCallum Cancer Centre

Abstract

Aim: To determine the feasibility (fidelity, practicality, satisfaction and limited efficacy) of twice-daily physiotherapy, occupational therapy and allied health assistant therapy on the Acute Care of the Elderly (ACE) ward compared to patients in General Medicine (GM) and Geriatric Rehabilitation (GR) wards who received standard care.

Method: Prospective study of older adults on three inpatient wards. Allied health on the ACE ward aimed to deliver at least twice daily physiotherapy, occupational therapy or allied health assistant therapy. Primary outcome was the number of allied health sessions/weekday (fidelity, practicality). Secondary outcomes were discharge destination, patient and clinician satisfaction, and changes in patient function (Modified Iowa Level of Assistance, Short Performance Physical Battery, Katz Activities of Daily Living and Lawton Instrumental Activities of Daily Living; limited efficacy).

Results: Over a 5-month period, 430 eligible older adults were admitted to the three wards. At least twice-daily therapy was provided on 72% (n=757) of ACE therapy sessions. More patients were discharged home from ACE (74%) than GR (57%, p=0.002) or GM (50%, p<0.001). Patients on ACE had significant improvements in functional measures (p<0.001); moderate/large effect sizes were observed (compared to mostly small/moderate effect sizes on GM and GR wards (p<0.05)). Higher satisfaction was recorded from ACE staff than GM, but there were no differences to GR staff. There was no difference in patient satisfaction.

Discussion: Delivery of twice-daily therapy was feasible and associated with improved patient outcomes; further research is required to determine if twice-daily therapy will yield similar outcomes in GR and GM.

Authors: Jessica Elliott (1,2), Shalini Ahlawat (1), H Miles Prince (1, 2), Glen Kennedy (3), Jillian Wells (4), Gillian Huang (4), Jenny Collins (1), Peter Bardy (5), Carrie Van Der Weyden (1), David Ritchie (1), Amit Khot (1,2)

Affiliations: 1. Clinical Haematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 2. University of Melbourne, 3. Royal Brisbane and Women’s Hospital, 4. Westmead Hospital, 5. Royal Adelaide Hospital

Abstract

Introduction: Advanced-stage Mycosis Fungoides (MF) and Sezary syndrome (SS) portends poor prognosis, with allogeneic stem cell transplantation (alloHSCT) the only currently available curative treatment option. Emerging evidence suggests alloHSCT outcomes may vary by histologic subtype.

Methods: A retrospective review of allograft outcomes for SS/MF was performed at four Australian transplant centres from 01/01/2008–31/12/2019, with focus on comparative outcomes by disease sub-type. Primary outcomes were overall survival (OS), treatment-requiring relapse (TRR), time-to-next-treatment (TTNT), and treatment-free survival (TFS).

Results: Twenty-six patients underwent alloHSCT (17MF, 9SS) with median follow-up 5-years. Compared with MF, SS patients had significantly longer TTNT (median not-reached vs 24-months, p=0.02), and superior 5-year outcomes, including: lower TRR (11.1% vs 73.9%, p=0.02), higher TFS (88.9% vs 15.7%, p=0.005), and higher OS (100% vs 52.4%, p=0.04). Disease subtype was the only independent predictor of TTNT (OR 0.1, 95% CI 0.0–0.9, p=0.04) and TFS (OR 0.05, 95% CI 0.0–0.7, p=0.03), with a benefit noted in SS.

Conclusions and Significance and impact: SS and MF have significantly different relapse and survival outcomes following alloHSCT, with superior survival and relapse outcomes seen in the SS cohort. Early referral for consideration of transplant should be undertaken in patients with SS, to identify candidates for transplant and avoid the toxicities of intervening therapies. Despite less favourable outcomes, a subset of MF patients (including with those with relapsed disease) achieved long-term survival comparing favourably to the prognosis in advanced-stage MF, indicating that transplant remains a beneficial intervention for a subgroup of these patients.

Authors: Lucas Hall (1), Aimee Dow (1), Katherine Burns (2), Joyce Sadek (2), Deana Sikovska (2), Ashleigh Allen (2), Jacqueline Allman (1), Monika Page (1)

Affiliations: 1. The Royal Melbourne Hospital, 2. Latrobe University

Abstract

Introduction: The environmental impact of packaging waste created from the RMH food service system is unknown. This study aimed to quantify the volume of tray-line packaging waste and explore current disposal methods and its environmental impact.

Methods: The patient menu ordering system (CBORD) was used to retrospectively quantify packaged menu items served on the tray-line between 01/03/23 – 29/02/24 at the city campus. The packaged weight of all menu items was multiplied by the number of times they were plated and served to patients. Packaging was grouped in to general waste, co-mingled recycling, paper and cardboard recycling and compost to allow for environmental impact analysis.

Results: Packaging waste was analysed for 1,068 main meals and 712 mid-meals over 365 days. Sixteen tonnes of food packaging waste was sent to patients, all of which was sent to landfill. Of this waste, 9.4 tonnes (60%) had the potential to be recycled and diverted from landfill. Recyclable paper and cardboard packaging contributed to 5.6 tonnes of carbon emissions.

Conclusion: There is currently no recycling system in place at the RMH city campus food service system to redirect recyclable tray-line packaging waste from landfill. Implementation of a recycling system could divert significant packaging waste from landfill and reduce carbon emissions.

Significance and impact: As per the RMH Strategic Plan 2020-2025, the organisation will need to reduce carbon emissions by 17% every 5 years to reach the targets agreed to in the Paris Agreement. Implementing sustainability measures, such as package recycling within the food service system may contribute to achieving this target.

Authors: Gil-Gyu Han (1), Rahul D Barmanray (1,2), Jiehao Wang (2), Joanne Young (1), Kerryn Griffett (1), Sara Linton (1), Mervyn Kyi (1,2), Peter G Colman (1), Leon J Worth (1), Spiros Fourlanos (1)

Affiliations: 1. The Royal Melbourne Hospital, 2. Western Health

Abstract

Introduction: Hypoglycaemia is a common inpatient complication; however, systematic exploration of adherence to its protocol is lacking. We aimed to characterise adherence to and efficacy of the Royal Melbourne Hospital (RMH) hypoglycaemia protocol and understand factors associated with recurrent hypoglycaemia.

Methods: This study explored a population subset from the Diabetes IN-hospital: Glucose and Outcomes (DINGO) prospective cohort study, a 26-week study involving the RMH cohort with ≥2 random capillary measurements (https://doi.org/10.1210/clinem/dgae051). Admissions with level 2 hypoglycaemia (blood glucose [BG] <3.0 mmol/L) formed the study population. Stratification was into groups experiencing 1 vs. >1 hypoglycaemia episodes; treatment efficacy and factors contributing to hypoglycaemia were assessed.

Results: Of 230 hypoglycaemia episodes, 1% demonstrated adherence to the RMH hypoglycaemia policy. Initial treatment with rapid acting carbohydrate was completed in 73%, but long-acting carbohydrates were administered in only 39%. Early BG monitoring following treatment occurred within the recommended timeframe in 89%, but hourly BG post treatment occurred in just 1%. Compared to the single episode group, recent glycaemic medication changes were more frequent in the recurrent population (23% vs 43%). Appropriate medical reviews were more likely in those with single episode (54%) vs. those with recurrent episodes (12%).

Conclusion and impact: We identified high lack of adherence to the RMH hypoglycaemia protocol, with recent glycaemic medication changes and omission of medical reviews as associated iatrogenic factors for recurrent hypoglycaemia in the inpatient setting. Both simplifying the protocol and promoting its adherence has a likely beneficial role in increasing the efficacy of the hypoglycaemia treatment.

Authors: Sabrina Hernandez (1,2), Claire Tipping (3), Adam Deane (4), Michael Wei (5), Wendy Bower (1), Alex Adamides (5), Anais Charles-Nelson (2), Jonathan Tomkins (1) Jane Larkin (1) and Carol Hodgson (2,6)

Affiliations: 1. Allied Health Department, The Royal Melbourne Hospital, 2. School of Public Health and Preventive Medicine, Monash University, 3. Physiotherapy Department, The Alfred Hospital, 4. Intensive Care Unit, The Royal Melbourne Hospital, 5. Department of Neurosurgery, The Royal Melbourne Hospital, 6. Australian and New Zealand Intensive Care-Research Centre, Monash University

Abstract

Introduction: Mobilisation practices following aneurysmal subarachnoid haemorrhage (aSAH) are poorly described. The aim of this study was to summarise current acute mobilisation practices, outcomes and barriers in this cohort.

Method: A prospective, observational study was conducted at RMH. Clinical severity was dichotomised using the World Federation Scale for Neurological Surgeons (Grade I-II “good”; III-V “poor”). Mobilisation outcomes during physiotherapy sessions were captured by the Mobility Scale for Acute Stroke (MSAS). Data was collected for a maximum of 14 days post aneurysm repair.

Results: Over 18 months, 102 patients were recruited (68%’’good”) with 410 physiotherapy sessions completed. Mean age was 57 (SD12) years, 69 (68%) females, 46 were admitted to ICU and 39 ventilated at baseline. Patients who were mobilised (n=90, 88%) received 4 (IQR 2, 6) sessions. A median MSAS score of 36.0 (IQR 30.0, 36.0) and 10.0 (IQR6.0, 19.5) was achieved for patients with “good” and “poor” grade respectively (p<0.001). By two weeks post-repair, 50 (49%) patients walked independently.

Of the 603 sessions attempted by physiotherapists, mobilisation was prevented 32% (n=193) of the time. Barriers included drowsiness (25%), haemodynamic instability (22%), and mechanical ventilation (18%). Mobilisation was ceased early in 34 sessions, primarily due to increased headache (n=6), hypotension (n=6) and light-headedness (n=6).

Conclusions: Two weeks post aSAH repair most patients were mobilised but more than half did not walk independently. Drowsiness and physiological instability limited mobilisation.

Significance and impact: This preliminary study has clarified mobilisation practices following aSAH; targeted dosage and timing of mobilisation interventions warrant further study.

Authors: Courtney Ierano (1,2), Karin Thursky (1,2), Rod James (1,2), Lisa Hall (1,2,3), Caroline Chen (1,2), Michael Malloy (4), Logesh Palani (1,2), Abukari Yakubu (1,2), Noleen Bennett (1,2)

Affiliations: 1. RMH Guidance Group, The Royal Melbourne Hospital, 2. National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 3. School of Public Health, University of Queensland, 4. Victorian Hospital Acquired Infection Surveillance System (VICNISS), The Royal Melbourne Hospital

Abstract

Introduction: Residential aged care facilities (RACFs) are an important community setting for monitoring antimicrobial resistance and use, however there are limited resources to support such initiatives. The Aged Care NAPS is a standardised surveillance tool that all Australian RACFs can use to monitor the prevalence of infections and antimicrobial use. Adoption of the Aged Care NAPS also supports facilities to meet national accreditation standards.

Methods: Multicentre study with retrospective analysis of data collected from Australian RACFs via the Aged Care NAPS audits from June 1, to December 31, 2022.

Results: Data from 743 RACFs (27.5% of all Australian RACFs) were included. On the survey day, 3.0% (n=1,293) of residents had signs and/or symptoms of a suspected infection and 12.5% (n=5,441) were prescribed at least one antimicrobial. Of all antimicrobial prescriptions (n = 8,373), 18.8% (n=1,574) were for prophylactic use. The most common indications for antimicrobial prescriptions were for skin, soft tissue or mucosal conditions (22.1%) and cystitis (14.6%). The most common prophylactic indication was for cystitis (24.3%). Clotrimazole (21.7%), cefalexin (19.6%), trimethoprim (5.7%) and molnupiravir (5.6%) were the most commonly prescribed antimicrobials. Many antimicrobials (40.3%) were prescribed for topical administration.

Conclusions: With over a quarter of all Australian RACFs contributing in 2022, the Aged Care NAPS is a feasible platform to monitor and benchmark antimicrobial use.

Significance and impact: Findings such as prolonged durations, topical antimicrobials and high use of prophylaxis (especially for the urinary tract) can drive local quality improvement. These AMS initiatives are critical to improve resident outcomes.

Authors: Matthew Kang (1,2), Dhamidhu Eratne (1,2), Philip Mitchell, Malcolm Hopwood, Dennis Velakoulis (1,2)

Affiliations: 1. Neuropsychiatry Centre, The Royal Melbourne Hospital, 2. Department of Psychiatry, University of Melbourne

Abstract

Background: Recent methodological developments allow us to measure small amounts of brain-specific proteins in the blood, including neurofilament light chain (NfL), a marker of axonal pathology, and glial fibrillary acidic protein (GFAP), a marker of astrocytic activation. Given the evidence of potential astroglial pathology and neuronal dysfunction in bipolar disorder, we investigated plasma NfL and GFAP levels in people with bipolar depression and compared them with unaffected individuals.

Method: This cross-sectional study included 216 individuals. We used bootstrapped general linear models (GLM) to compare plasma NfL and GFAP levels between people with bipolar depression and healthy controls, adjusting for age, sex, and weight. We examined associations between these biomarkers and clinical variables.

Results: GFAP and NfL levels were elevated in people with bipolar depression (n = 120) compared to healthy controls (n = 96). The duration of illness was positively associated with NfL, whilst age of onset was positively associated with GFAP.

Conclusions: This study found elevated levels of plasma NfL and GFAP in bipolar depression compared to unaffected individuals, with significant associations with the duration of illness and age at onset, suggesting a degree of neuronal injury and astrocytic dysfunction in bipolar depression.

Significance and impact: These biomarkers may reflect specific illness stages, including neuroprogression and the later onset of bipolar disorder, further informing the literature on the pathophysiology of bipolar disorder. and identifying potential treatment targets.

Authors: Emilia Kim, Eugenia Hong

Affiliation: Clinical Trials Pharmacy, The Royal Melbourne Hospital

Abstract

Introduction: Monoclonal antibodies (mAbs) have become an invaluable class of therapeutics, offering targeted treatments for a wide range of diseases. Despite the expansion in development, investigational mAbs often lack adequate safety data for appropriate hazard classification. mAbs pose potential occupational risks to healthcare workers in clinical trial setting. Our research aims to create a standardised procedure tailored to the needs of the clinical trial settings for handling investigational mAbs safely.

Methods: This research consisted of three parts: a literature review; developing a flowchart to assess the risk of investigational mAbs and applying the flowchart to evaluate the risk of current investigational mAbs undergoing clinical trials.

Results: The literature review revealed the scarcity of evidence and ongoing debates concerning the occupational risks associated with mAbs. The risk of exposure is heightened for healthcare workers involved in dose preparation and administration of investigational mAbs due to lack of safety data. For the development of the flowchart, four primary criteria were considered to stratify an investigational mAb: clinical trial phase, toxicity, immunogenicity and the extent of manipulation required for dose preparation.

A total of 18 investigational mAbs used in the clinical trials conducted at The Royal Melbourne Hospital were reviewed and 95% was identified as high or moderate-risk.

Conclusion: Given the risks associated with dose preparation and administration of investigational mAbs, the flowchart will assist in classifying the risk of mAbs to optimise the safe handling practices for healthcare workers.

Significance and impact: Identifying the risk of handling investigational mAbs will assist in implementing the appropriate safe handling recommendations.

Authors: Valeriya Kuznetsova (1,2,3), Harsh Oza (2), Hannah Rosenfeld (1,2), Carmela Sales (2), Sam van der Linde (1), Izanne Roos (2,3), Stefanie Roberts (2,3), Fiore D’Aprano (4), Samantha M Loi (5,6), Mark Dowling (1,7), Michael Dickinson (1,7), Tomas Kalincik (2,3), Simon J Harrison (1,7), Mary Ann Anderson (1,7,8), Charles B Malpas (2,3,4)

Affiliations: 1. Centre of Excellence for Cellular Immunotherapy and Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, 2. Neuroimmunology Centre, Department of Neurology, The Royal Melbourne Hospital, 3. Clinical Outcomes Research (CORe) Unit, Department of Medicine (RMH), University of Melbourne, 4. Melbourne School of Psychological Sciences, University of Melbourne, 5. Neuropsychiatry, The Royal Melbourne Hospital, 6. Department of Psychiatry, University of Melbourne, 7. Sir Peter MacCallum Department of Oncology, University of Melbourne, 8. Division of Blood Cells and Blood Cancer, Walter and Eliza Hall Institute

Abstract

Introduction: Immune effector cell-associated neurotoxicity syndrome (ICANS) is a common consequence of chimeric antigen receptor T-cell (CAR-T) therapy, with a wide range of cognitive presentations and an uncertain recovery trajectory. The study investigated cognitive and psychological recovery in adult haematology patients after CAR-T.

Methods: Twenty patients completed a cognitive assessment and a self-report measure of psychopathology before receiving CAR-T for treatment of lymphoma (95%) or leukaemia (5%). The assessment was repeated one-month, six-months, and one-year post-CAR-T. Seven (35%) patients experienced ICANS. Bayesian repeated measures analysis of covariance examined the effect of interaction between ICANS group and time of the assessment on change in cognition and psychopathology. Models were adjusted for age, education, and sex.

Results: ICANS patients declined in executive function, while non-ICANS patients remained stable (BF10=524.0). The ICANS group had lower scores at one-month (BF10=9.5, η2=0.4), but no group difference was detected at six-months or one-year. There was no evidence for an effect of ICANS on change on any other cognitive domain. Analyses of individual tests, showed an effect of ICANS group over time for tests of lexical retrieval (BF10=8.1), verbal memory (BF10=67.3), and auditory attention span (BF10=9.2). There was no change in psychopathology, irrespective of ICANS group.

Conclusions: ICANS patients had a reduction in executive function, verbal memory, and the auditory attention span, which persisted one-month post-CAR-T but resolved within six-months. Stable self-reported symptoms of psychopathology indicate good psychological tolerance of neurological toxicity.

Significance and impact: Long-term cognitive monitoring is not indicated for ICANS patients unless symptoms persist beyond six-months.

Authors: Jennifer Langford, Hannah Furlong

Affiliation: The Royal Melbourne Hospital

Abstract

Introduction: The RMH established a student-led outcome measure service for community-based individuals with LLA in 2023. The objectives were to monitor client function and prosthetic use to improve treatment outcomes and provide students with opportunities to prepare for workforce participation. In this novel service, students led the collection of outcome measures, underpinning clients’ status and funding applications. A program evaluation was conducted to understand the students’, clinicians’ and clients’ experiences. To our knowledge, there are no previous reports of student-led clinics for amputee cohorts.

Methods: Physiotherapy and Prosthetic students undertaking clinical placements completed reliability training in administering amputee-specific functional tests and surveys. Under the guidance of Prosthetists, students collected outcome measure data from clients at the RMH amputee clinic. Students, clients and clinicians were subsequently invited to participate in a targeted survey exploring their experience in the service.

Results: Seventeen students participated in the service where 120 outcome measures were collected from 41 clients. No adverse events were reported. Client data confirmed enjoyment working with students and perceived this benefited their care. Clinicians, who were Prosthetists, reported improved data availability for funding requests and outcome measure results aided in treatment provision. All students completed the survey and described benefits from participating in the program. These included understanding amputee management, skill development, experiencing multidisciplinary collaboration and improved interpersonal skills.

Conclusions: This student-led service was feasible and a positive experience for stakeholders. Findings supported continuation of the newly-implemented service.

Significance: Student-led services provide beneficial learning opportunities and enhance patient care.

Authors: Chuan-Whei Lee (1,2), David Moore (1), Rohit D'Costa (1), Hannah Rotherham (1), Ned Douglas (1,2), Wen Kwang Lim (1,2), Jai Darvall (1,2)

Affiliations: 1. The Royal Melbourne Hospital, 2. University of Melbourne

Abstract

Introduction: The Royal Melbourne Hospital (RMH) Perioperative Multidisciplinary Meeting (PMDM) is a forum where referred high-risk patients are discussed by perioperative specialists. Recommendations are made to proceed to or defer surgery. We explored whether implicit recognition of the end of life (EOL) impacted PMDM recommendations.

Methods: Retrospective cohort study of cases presented at the RMH PMDM from 1/11/2019-31/12/2022. Aims to compare 1) PMDM recommendation, 2) proceeding to surgery, 3) mortality, by illness phase (EOL: early-mid palliative/late palliative/terminal vs not EOL: curative). Illness phases were retrospectively assessed based on deidentified PMDM case slides.

Results: There were 175 PMDM cases (164 participants) discussed. Illness phases were assessed as curative 19%, early/mid palliative phase 58%, late palliative/terminal phase 23%. Surgery was recommended in 38% of PMDM cases with no difference between EOL vs not at EOL phases (39% vs 33%, p=0.69). Surgery proceeded after 45% of cases with no difference between EOL vs not at EOL phases (44% vs 49%, p=0.69). Mortality was 30% with significant differences between illness phase (curative 17% vs early-mid palliative 27% vs late palliative/terminal 47%, p=0.02). Survival analysis demonstrated patients in the late palliative/terminal phase had a four-fold increased mortality (hazard ratio vs. curative phase 3.98 [95% CI: 1.47–10.78, p = 0.006])

Conclusion: Illness phases had no impact on PMDM recommendation or undergoing surgery. Late palliative/terminal phases modulated survival following PMDM presentation.

Significance and impact: A significant proportion of high-risk patients considered for surgery were at the EOL. When not explicitly recognised, EOL assessments did not affect decision-making.

Authors: Jessica Librandi, Carrie Service, Mervyn Kyi, Anand Ramakrishnan

Affiliation: The Royal Melbourne Hospital

Abstract

Introduction: Effective management of post-operative hyperglycaemia in patients with diabetes undergoing head and neck (HN) surgery can improve outcomes. A protocol including routine pre-operative HbA1c screening with referral to endocrinology was implemented in this cohort. This study aimed to determine if this protocol reduced hyperglycaemia in patients with Type 2 Diabetes Mellitus (T2DM) undergoing HN free flap (FF) reconstruction.

Methods: This retrospective observational study included all patients who underwent a major HN resection with FF reconstruction (excluding scalp) at RMH. Data were compared using electronic medical records during the designated study period (June 2022 to January 2024).

Results: 108 patients were included (HbA1c protocol, n=57 and historical controls, n=51), 29 patients (26.8%) had pre-existing T2DM or HbA1c greater than 6.5% and 4 patients (3.7%) had an incidental diagnosis of T2DM. 52 (91.2%) patients underwent HbA1c screening post protocol implementation, compared to 19 (37.3%) patients in the historical control group. Overall, 1958 post-operative blood glucose levels (BGLs) were analysed. Compared to the historical controls, there was a reduction in inpatient mean (SD) day glucose from 10.4mmol/L (2.8) to 8.9mmol/L (2.4) (p<0.001). The proportion of inpatient days with BGLs greater than 15mmol/L reduced from 21.8% to 6.2% (p<0.001).

Conclusion: Pre-operative HbA1c screening and protocol based endocrinology referrals is associated with reduced post-operative hyperglycaemia in patients with T2DM undergoing HN surgery with FF reconstruction.

Significance and impact: Results of this study informs the ongoing use of the implemented protocol in the HN surgery cohort and supports the adoption of this protocol in other surgical areas.

Authors: Elizabeth Lockie (1,2), Amy Sylivris (1), Sanjay Pandanaboyana (3,4), Anita Skandarajah (1,2,5), John Zalcberg (2,6,7), Benjamin Loveday (1,2,5)

Affiliations: 1. The Royal Melbourne Hospital, 2. The University of Melbourne, 3. Freeman Hospital, Newcastle upon Tyne, UK, 4. Population Health Sciences Institute, Newcastle University, UK, 5. Peter MacCallum Cancer Centre, 6. Monash University, 7. Alfred Health

Abstract

Introduction: Surgery with chemotherapy offers the only chance of long-term survival in pancreatic cancer (PC). Studies have demonstrated that resection rates vary by region. This study investigated if increasing resection rate (RR) at a population level increases overall survival, and modelled the interaction between RR, perioperative mortality and survival.

Methods: A systematic review of population level RR and survival (including resected and not resected patients) was conducted to generate a regression for survival versus RR. The number of survivors at one year was modelled using this regression with varying resection and perioperative mortality rates.

Results: Nineteen studies were eligible (518,622 patients). There was significant strong association between RR and one-year (r² 0.46, p = 0.001), but not three- or five-year survival. There was a negative significant association between 90-day perioperative mortality and RR (r² -0.58, p = 0.007). Chemotherapy increased in resected group with increasing RR. One-year survival was significantly associated with overall chemotherapy (r² = 0.63; p=0.004), but the effect was not as positive as with RR (regression slope 0.26 versus 0.94 respectively). The model demonstrated more patients alive at one year with increasing RR even with higher perioperative mortality.

Conclusions and significance: Increasing RR at a population level was associated with improved one-year survival of the overall PC population. Some of this benefit was likely attributable to more (neo)adjuvant chemotherapy, but this effect was weaker than that for RR. Defining a benchmark RR should align with patient-centred healthcare, and may help ensure equitable access to high quality care.

Authors: Louise Lord (1,2), Jesslyn Ha (3), Marianne Jovanovic (3), John Coutsouvelis (2), Kirstie Galbraith (2)

Affiliations: 1. Pharmacy, The Royal Melbourne Hospital, 2. Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 3. Pharmacy, Monash Health

Abstract

Background: Research in clinical practice is crucial for healthcare professional development, spanning undergraduate (UG), professional registration (PRP), and postgraduate (PG) learning. Appropriate supervision is a key factor for research success, yet the specific skills and attributes required remain unclear. This study aimed to identify 1) the important skills and attributes for pharmacy research supervision from both learner and supervisor perspectives and 2) to highlight areas for supervisor support and development.

Design: A mixed methods approach was used to maximize recruitment. Pharmacy UG, PRP, and PG students at a local university and their supervisors were invited to participate in an anonymous electronic survey. Additionally, pharmacists (residents) and supervisors in a foundation residency program at a tertiary hospital participated in a Delphi panel. Both methods gathered data on demographics, supervisory skills and attributes, and supervisors’ development needs.

Results: A total of 27/353 students (UG:19/103, PRP:4/237, PG:4/13) and 20/175 supervisors completed the survey, while 12/14 residents and 10/19 supervisors completed the Delphi. Both learners and supervisors identified 'prior research experience' and 'methodology expertise' as important skills. The key attributes across all groups were being 'approachable and supportive,' 'able to provide clear direction,' and 'able to provide constructive feedback.' The most common needs for supervisor development were research design and analysis.

Conclusion and significance: Pharmacy learners and supervisors prioritise similar skills and attributes for effective research supervision. The outcomes of this study have already informed the development of new training resources and will continue to guide research development opportunities for both learners and supervisors alike.

Authors: Finlay Macrae (1,5), Trevor Lockett (2), Karen Harrap (2), Brooke Flanders (1), Virginia Bird (1), Alex Boussioutas (3,4,5), Mark Appleyard (6), David Williams (7), Sophie Zaloumis (5), Arun Gupta (1), Suresh Sivanesan (1), Aysha Al-Ani (1), Ralley Prentice (1), Don Cameron (8), Allan Spigelman (9), Digsu Koye (5), Patrick Lynch (10), Julie Clarke (2)

Affiliations: 1. The Royal Melbourne Hospital, 2. CSIRO Australia, 3. Alfred and Monash University, 4. Peter MacCallum Cancer Centre, 5. University of Melbourne, 6. Royal Brisbane & Women’s Hospital, 7. St Vincent’s Hospital, NSW, 8. Royal Children’s Hospital, 9. University of New South Wales, 10. MD Anderson Cancer Center, USA

Abstract

Introduction: Butyrate may reduce colorectal cancer risk and can be delivered to the colon using butyrylated starch (HAMSB).

Methods: A randomised, double-blind, placebo-controlled crossover trial in patients with familial adenomatous polyposis. Participants ingested 40g of HAMSB, or low amylose starch (LAMS) (each from Ingredion, Bridgewater NJ, USA) for six months, in random order followed by a six month washout. Polyps were measured by videocolonoscopy. At baseline, two tattoos were placed: tattoo 1 (polyps cleared at each scope); and tattoo 2, (polyps left in situ). The primary endpoint was total number of polyps. Secondary endpoints were polyp counts by size and within the tattooed areas. Generalised linear mixed models estimated the ratio of mean polyp counts in intervention vs placebo periods.

Results: 72 participants were randomised (33 female) with 49 participants completing the study. In the intention to treat analysis HAMSB reduced the total number of polyps by 10% (95% CI: 0.77-1.06) and small polyps by 12% (95% CI: 0.71-1.1). Polyps in tattoo 1 were reduced 22% (95% CI: 0.58-1.05, P=0.106) especially small polyps: 28% (95% CI: 0.5-1.03, P=0.074). Polyps in tattoo 2 were not consistently affected by treatment. In the per protocol analysis the effects were stronger especially for small polyps – 21% (95% CI: 0.62-1.0, P=0.051.

Conclusion: HAMSB reduced the growth of small polyps without causing regression or growth of existing polyps. The trial failed to reach its primary endpoint but secondary endpoints were protective.

Impact: The effects are likely relevant to prevention of sporadic colorectal neoplasia

Authors: Shakeel Manuel (1,2), Yasmine Ali Abdelhamid (1,2), Kimberley Haines (1,3), Sophie Witherspoon (4,5), Fiona McCormack (2), Sue Hookey (2), Tim Fazio (2), Matthew Maiden (1, 2)

Affiliations: 1. University of Melbourne, 2. The Royal Melbourne Hospital, 3. Western Health, 4. Royal Darwin Hospital, 5. University of Sydney

Abstract

Introduction: Healthcare integration is receiving increased attention as hospitals work to enhance patient-centred care. Improving communication between general practitioners (GPs) and the intensive care unit (ICU) may help optimise patient care. However, ICU medical staff contact GPs for less than 1% of patients admitted to ICU. This project aimed to evaluate the barriers to communication and strategies to overcome them.

Methods: As part of a quality improvement project, we conducted interviews with medical staff from the RMH ICU and GPs recruited through the RMH GP Liaison Group and informal networks. Quantitative data were analysed using descriptive statistics. Thematic analysis was conducted for the qualitative data.

Results: There were 51 ICU medical staff, and 47 GPs that participated in interviews. GPs report being rarely contacted by the ICU. 46 (98%) GPs were willing to receive a phone call from ICU medical staff, with 20 (42%) wanting to be contacted whenever their patients are admitted to an ICU. Every intensivist was willing to contact GPs, with 24 (47%) recommending that this should occur for every patient admitted to ICU. Two major themes were identified: “Establishing contact between GPs and intensivists” and “ensuring quality of communication”. Each had numerous sub-themes exploring barriers and solutions.

Conclusion and significance: The insights of both intensivists and GPs derived from this study have informed a new strategy to increase the rate of communication between ICU staff and GPs, which is being trialled in Q3 2024 in the RMH ICU.

Authors: Loredana Marchione, Spencer Ambrose, Matthew Chesini, Sarah Morrison, Luke Garrone, Kathleen Nicholls

Affiliation: The Royal Melbourne Hospital

Abstract

Background: Academic education surrounding rare diseases (RDs) is lacking. RDs affect fewer than one in 2,000 people. Despite collectively being the most common medical condition, in crowded medical school curricula, individual RDs receive little attention.

Method: Ten medical students commencing their first clinical year at the Royal Melbourne Hospital participated in a patient partner rare disease program. Individual patients with a RD were allocated to each student. Throughout the year students anonymously undertook serial prospectively designed questionnaires. Qualitative thematic analysis was used for freeform responses.

Results: At baseline, most students indicated no prior knowledge of RDs. Freeform student responses identified three main concepts: challenges faced by patients, low understanding of RDs within medical education, and benefits of including RDs in medical education. The perceived issues identified by students of patients living with RDs included delayed diagnosis after multiple presentations; poor medical understanding; non-specific treatment; geographical barriers to care; ethical challenges surrounding genetic testing.

Conclusions: The findings reinforce the need to include broad RD education in medical school curricula. Insight into the world of RDs will allow students to gain familiarity and exposure to the diverse challenges associated with managing RDs.

Significance and impact: Within the context of medical education, exposure to RDs can provide students with an educationally rich experience, exposing them to genomics, cellular biology and psychology of chronic disease. Statistically all practising clinicians are likely to care for patients with RDs, therefore, it is likely that exposure in student years will benefit both student and future patients in the long-term.

Authors: Celia Marston (1), Jennifer Philip (2), Deidre Morgan (3), Meera Agar (4)

Affiliations: 1. The Royal Melbourne Hospital, 2. University of Melbourne, 3. Flinders University, 4. University of Technology Sydney

Abstract

Background: Optimal support for family carers of people with advanced cancer is critical to facilitate hospital discharge home. The Carer Support Needs Assessment Tool -Intervention (CSNAT-I) can benefit carers in this setting but implementation has been difficult because of poor alignment with usual practice and organisational cultures. Occupational therapists are well positioned to deliver a carer-led intervention in the acute hospital discharge setting. This study aims to understand occupational therapists’ experiences with and responses to adopting the CSNAT-I into their usual practices.

Methods: Focus groups and individual interviews were conducted across all stages of a program of CSNAT-I implementation, collecting data from occupational therapists delivering the intervention at a specialist cancer centre and general hospital. Inductive thematic analysis of data occurred.

Results: Seventeen occupational therapists participated in six focus groups and eight interviews. Four themes emerged representing the longitudinal changes experienced in how they intervened (worked) with carers and their response and modifications to the intervention:

• Patients used as conduits to carers’ needs,
• How well do I meet carers’ needs,
• Looking for entry points to approach carers; and
• Fitting the CSNAT-I into my practice.

Conclusion: Occupational therapists viewed the CSNAT-I as a positive addition to discharge planning practice. Their intent to change practice was limited by factors they could not control, so they modified the intervention rather than rejecting it. Findings will inform modelling and testing of the delivery model of the CSNAT-I in future research and ultimately improve its fit into acute contexts.

Authors: Kylie Martin (1,2), Vijay Venkatraman (2,3), Patricia Robertson (2,3), Sven-Jean Tan (1,2), Timothy D Hewitson (1,2) and Nigel D Toussaint (1,2)

Affiliations: 1. Department of Nephrology, The Royal Melbourne Hospital, 2. Department of Medicine (RMH), University of Melbourne, 3. Department of Radiology, The Royal Melbourne Hospital

Abstract

Introduction: Higher tissue sodium concentration ([Na+]) is associated with increased cardiovascular mortality. Associations between cardiovascular surrogate markers, biochemical measures of sodium and volume and quality of life measures with 23-Sodium Magnetic Resonance Imaging (23Na MRI)-determined tissue [Na+] are yet to be elucidated across the chronic kidney disease (CKD) spectrum.

Methods: A cross-sectional study of 52 patients (28 CKD, 24 dialysis) using 23Na MRI to determine whole tissue, skin, muscle and bone [Na+]. Statistical analysis included independent sample t-tests, univariate and multiple linear regression.

Results: Whole tissue [Na+] [median mmol/L equivalents (IQR)] was higher in dialysis patients compared to CKD [40.84 (36.31 – 53.12) vs 37.59 (30.76 – 41.20), P = 0.04]. Muscle [Na+] was higher in dialysis patients compared to CKD [46.25 (40.88 – 55.67) vs 41.70 (36.53 – 46.56), P = 0.04]. Whole tissue [Na+] and skin [Na+] was positively associated with brain-natriuretic peptide and troponin I respectively. Residual urinary volume was significantly higher in CKD patients compared to HD and PD patients (P < 0.001). There was a negative correlation between muscle [Na+] and Kidney Disease Quality of Life physical composite score.

Conclusion: Tissue [Na+] accumulation is significantly different in people across the CKD spectrum and is associated with surrogate cardiovascular markers and quality of life scores.

Significance: 23Na MRI provides insights into the pathophysiology of tissue [Na+] and is an emerging imaging biomarker for clinical outcomes in people with CKD.

Authors: Sally Mongta, Joel Ernest, Marian Lieschke

Affiliation: Parkville Cancer Clinical Trials Unit

Abstract

Introduction: The strategic benefits of an Internal Audit Program (IAP) within clinical trials extend beyond compliance. Parkville Cancer Clinical Trials Unit (PCCTU) has embedded internal auditing introducing an IAP for Investigator Initiated (IIT) and Cooperative Oncology Group (COG) Trials.

Methods: The Internal Audit Group (IAG) made up of enthusiastic PCCTU staff conduct quarterly reviews on IIT and COG trials on targeted areas of risk; identifying compliance issues, inefficiencies in process and areas of risk that might otherwise go unnoticed. Audit tools were developed to guide and record key areas for review. 12 months post implementation of the IAP, auditors participated in an experience survey to ascertain additional benefits of the program.

Results: Survey results demonstrate that Internal auditing is beneficial beyond the identification of deficiencies. The IAP promotes a positive audit culture and state of audit readiness. Education sessions, directed by audit findings aid awareness about internal process, regulatory requirements, and risk management strategies.

For the auditors, participating in an IAP fosters significant professional growth and offers the opportunity to develop critical thinking and problem-solving skills, while consolidating knowledge on internal policies and processes. Auditors reported positive impacts on their own trial coordination performance and ability to support team members effectively.

Conclusions: While an IAP is instrumental in improving quality by identifying and addressing deficiencies in compliance, it also supports operational efficiency, enhances performance, fosters a culture of continuous improvement, educates and promotes professional growth for auditors. These benefits collectively contribute to the overall success and reliability of clinical trials.

Authors: Adrianne Natoli, Ethan Hunt, Emma Hays, Eloise Thompson, Samantha Ioannidis, David J Read, Toni D Withiel, Celia Marston

Affiliation: The Royal Melbourne Hospital

Abstract

Introduction: Interventions that bridge primary care and specialist health services to deliver evidence-based treatments are a critical component in concussion management. This study aimed to:(1) evaluate the implementation of Australia’s first occupational therapy led concussion clinic model into usual practice by examining acceptability and fidelity among clinicians and service users, and (2) explore the feasibility of using effectiveness measures to facilitate longer-term clinic evaluation.

Methods: A large tertiary trauma hospital service in Melbourne, Australia. Participants were patients referred to the concussion clinic and occupational therapists working in the service. Prospective, single-site, mixed methods design was employed. Acceptability outcomes were evaluated using clinician interviews and the Client Satisfaction Questionnaire-8. Clinic fidelity was assessed by service usage data. Long-term patient-outcomes assessed concussion (Rivermead Post Concussive Questionnaire) and mood symptoms (Patient Health Questionnaire-9). and Participation in activities of daily living (Community Integration Questionnaire-Revised).

Results: Over eighteen months seventy-three percent (n=177) patients were referred to the clinic, and 75% attended. Adherence to protocol was achieved, however completion rate of post-treatment measures was low. Almost half of the patients required specialist referrals beyond the clinic model for persistent symptoms. Interviewed occupational therapists (n=6) viewed the clinic as a “safety net for patients”; believed they were “learning as we go”, the “clinic had potential to grow”, but “we could be doing more”. High attendance rates and patient satisfaction further supported clinic acceptance at an end user level.

Conclusion and impact An occupational therapy-led concussion clinic is accepted by patients and clinicians to capture immediate needs of people with concussion after discharge. However coordinated pathways to multi-disciplinary care are needed to address long term needs of people with persistent concussion symptoms and problems returning to daily activities.

Authors: Jared Ou-Young (1,2), Colin Royse (1,2), Bernhard Riedel (3,4), James Griffiths (5,6), Paul Balcos (1,2), Jingfei Wu (1,2), Andrea Bowyer (1,2)

Affiliations: 1. Department of Surgery, University of Melbourne, 2. Department of Anaesthesia, The Royal Melbourne Hospital, 3. Department of Anaesthesia, Perioperative Medicine, and Pain Medicine, Peter MacCallum Cancer Centre, 4. Department of Critical Care, University of Melbourne, 5. Department of Anaesthesia, Royal Women’s Hospital, 6. Department of Pharmacology, University of Melbourne

Abstract

Introduction: The Postoperative Quality of Recovery Scale (PostopQRS) Registry was established in March 2021 to provide a platform for participating sites to enter postoperative recovery data across multiple domains; physiology, nociception, emotion, activities of daily living, and cognition (Australian Register of Clinical Registries, ACSQHC-ARCR-879). We report the feasibility and initial data from the first 338 patients.

Methods: RMH ethical approval was granted (62528/MH-2020), and convenience sampling of surgical schedules identified eligible patients at the RMH, Peter MacCallum Cancer Centre, and Royal Women’s Hospital. Consenting patients completed the PostopQRS survey preoperatively, and on postoperative days 1,3,7, and 30. Recovery in any PostopQRS domain at a particular timepoint was defined as a return to preoperative baseline scores, or better. Achieving overall recovery required patients to recover in all domains.

Results: As of July 2024, 415 patients were approached for inclusion, and 345 consenting patients were recruited (n(RMH)=151, n(PMCC)=171, n(RWH)=23). 7 patients had cancelled procedures after recruitment. 338 patients were analysed. Surgical procedures consisted of hepatopancreatobiliary and upper gastrointestinal (n=115), colorectal (n=121), gynaecological (n=26), urological (n=44), and vascular (n=32). Each surgical cohort varied perioperatively and had distinct recovery trajectories. Registry follow-up rates were 98%, 91%, 93%, and 93% for days 1, 3, 7, and 30 respectively.

Conclusion: Three years after inception, the PostopQRS Registry provides a feasible and effective platform to collect and analyse recovery data. Surgical cohorts receive specific perioperative care and have diverse recovery trajectories.

Significance: The registry provides benchmark surgical recovery data to answer future research questions.

Authors: Sarah Park (1), Karin Thursky (1,2,3), Lenna Zosky-Shiller (1), Rodney James (1,2,3), Ron Cheah (1,2,3), Lisa Hall (3,4), Courtney Ierano (1,2,3)

Affiliations: 1. Melbourne Medical School, University of Melbourne, 2. National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 3. RMH Guidance Group, The Royal Melbourne Hospital, 4. School of Public Health, The University of Queensland

Abstract

Introduction: Skin and soft tissue infections (SSTIs) are among the most common indications for antimicrobial prescribing in hospitals. Inappropriate antimicrobial use can lead to increased morbidity, unnecessary hospital readmission and increased antimicrobial resistance. This study aims to assess the quality of antimicrobial prescribing practices in SSTI management within Australian hospitals to provide guidance for future practice.

Methods: A retrospective analysis was conducted with data from the National Antimicrobial Prescribing Survey (NAPS). SSTI prescribing data from Hospital NAPS (2013-2022) and surgical site infection data from Surgical NAPS (2016-2022) datasets were analysed. Variables assessed included guideline compliance, appropriateness as per the structured NAPS algorithm and reasons for inappropriateness.

Results: From the Hospital NAPS dataset, 40,535 antimicrobial prescriptions for SSTIs were analysed. The most common indication was cellulitis (34.1%; n=13,822), and the most prescribed antimicrobial was flucloxacillin (18.8%; n=7,638). SSTI indications had a lower rate of guideline compliance, but a higher rate of appropriateness compared to all other indications for antimicrobial prescriptions (guideline compliance 66.3%, n=21,035 vs 67.4%, n=156,285 appropriateness 75.6%, n=30,639 vs 72.7%, n=209,383). The most common reason for inappropriateness was incorrect dose or frequency (29.3%; n=2,367). From the Surgical NAPS dataset, 5,674 prescriptions for surgical site infections were analysed. 68.2% (n=3,867) were deemed appropriate. The most common reason for inappropriateness was incorrect dose or frequency (27.7%; n=350).

Conclusions: As SSTIs are a common indication for antimicrobial prescribing in Australian hospitals, identifying effective antimicrobial stewardship strategies to optimise antimicrobial use for SSTI management is therefore recommended to improve patient outcomes.

Authors: Yeung-Ae Park (1,2,3), Michael Christie (4), James King (5,6), Angeline Shen (1,2), Christopher J Yates (1,2)

Affiliations: 1. Department of Diabetes & Endocrinology, The Royal Melbourne Hospital, 2. Department of Medicine (RMH) University of Melbourne, 3. Endocrinology & Diabetes Units, Monash Health, 4. Department of Pathology, The Royal Melbourne Hospital, 5. Department of Neurosurgery, The Royal Melbourne Hospital, 6. Department of Surgery (RMH) University of Melbourne

Abstract

Introduction: Pituitary tumours are the second most common intracranial neoplasms.1 Advancements in transcription factor (TF) immunohistochemistry (IHC) enabled accurate pituitary tumour classification.2 Yet, TF IHC is limited by economic and labour burdens. We aimed to identify the prevalence of non-functioning pituitary adenoma (NFPA) subtypes with TF IHC.

Methods: In a retrospective observational study, inpatients with pituitary tumour ICD codes between 1st January 2021 and 9th March 2024 at the Royal Melbourne Hospital, Victoria, were identified. NFPA without prior TF IHC were identified and re-evaluated with TF IHC.

Results: Pituitary tumours were confirmed on histopathology in 106 patients, with NFPA comprising 66.4%. In 11/13 null cell adenomas, TF IHC was not performed. Retrospective additional TF IHC revised the diagnosis of all null cell adenomas (11/11) to gonadotroph adenomas (91%) and a silent corticotroph adenoma (9%). The prevalence of gonadotroph adenomas and null cell adenomas without additional TF IHC was 69% and 18.3%, respectively, compared with 83.1% and 2.8% with additional TF IHC. Gonadotroph adenomas comprised 55% of all resected pituitary tumours.

Conclusions: TF IHC led to accurate subtyping of NFPA and increased detection of gonadotroph adenomas. Retrospective TF IHC should be considered in hormone-immunonegative NFPA, which may have prognostic implications.3

Significance: The Royal Melbourne Hospital Pituitary Tumour Tissue Bank contains over 500 specimens, including 120 labelled as null cell adenomas. We hypothesise that most of these are gonadotroph adenomas after TF IHC. The gonadotroph adenoma tissues will enable comprehensive bioinformatic analyses of this understudied and most commonly resected pituitary tumour subtype.

Authors: Prashanth Ramachandran (1,2), Eike Steinig (2), Marcelina Krysiak (2), Kirti Deo (2), Janath Fernando (2), Chhay Lim (2), Andrew Duncan (3), Jacqueline Prestedge (2), Ramla Maalim (4), Amy Crowe (5), Diana Velasquez Reyes(2), Jean Moselen(7), Leon Caly (7), Monica Slavin (2,8), Rachel Woolstencroft (8), Justin Ng (1), Lyndell Lim (9,10), Jemma Taylor (2), Georgia McCluskey (7), Katherine Bond (4), Chuan Lim (7), Deborah Williamson (2,7), Tim Stinear (11)

Affiliations: 1. Department of Neurology, The Royal Melbourne Hospital, 2. Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute, 3. Department of Neurology, St.Vincent's Hospital, 4. Department of Microbiology, The Royal Melbourne Hospital, 5. Department of Microbiology, St. Vincent's Hospital, 7. Victorian Infectious Diseases Reference Laboratory, The Royal Melbourne Hospital at the Peter Doherty Institute, 8. Department of Infectious Disease, The Peter Maccallum Cancer Centre, 9. Department of Ophthalmology, The Royal Melbourne Hospital, 10. Centre for Eye Research Australia, University of Melbourne, 11. Department of Microbiology and Immunology, The University of Melbourne at the Peter Doherty Institute

Abstract

Introduction: Neurological and ocular inflammatory diseases heavily burden healthcare systems, leading to severe health outcomes. Precise diagnoses are essential for effective interventions. Current diagnostic methods can lack sensitivity. Metagenomic next-generation sequencing (mNGS) is a hypothesis-free assay for detecting infections. The Doherty Institute-based, MRFF-funded MetaGP program aims to develop a clinically accredited mNGS assay.

Aims: Conduct an analytical assessment of mNGS against a microbiological composite endpoint.

Methods: Cerebrospinal fluid, brain biopsy tissue and vitreous fluid were collected from the Royal Melbourne Hospital, Peter McCallum Cancer Centre, St. Vincent’s Hospital Melbourne and the Victorian Infectious Diseases Reference Laboratory. Results from orthogonal testing for all samples were reviewed, as well as clinical history for consented patients. Post extraction, both DNA and RNA underwent library preparation and sequencing on the Illumina NextSeq. Data was processed through a custom built mNGS pipeline, Cerebro.

Results: From 2022-2024, 78 samples were collected. True positives n=44, true negatives n=34. 48% were DNA viruses, 20% were RNA viruses, 30% were bacterial infections and 2% were fungal/parasitic infections. The mNGS assay demonstrated a sensitivity of 91%, specificity of 100%, and negative predictive value of 89%.

Conclusion: mNGS demonstrates a high sensitivity, specificity and negative predictive value compared to a composite of direct testing methods. Results were biased by a high number of viral cases. Further work is underway to improve the accuracy of the assay against a more diverse range of pathogens.

Significance: mNGS has the potential to improve diagnostic accuracy for patients with neurological and ocular inflammatory diseases.

Authors: Zohal Rashidzada (1,2), Courtney Ierano (1,2), Caroline Chen (1,2), Rod James (1,2), Karin Thursky (1,2,3)

Affiliations: 1. RMH Guidance Group, The Royal Melbourne Hospital, 2. National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, 3. Departments of Infectious Diseases and Health Services Research, Peter MacCallum Cancer Centre

Abstract

Introduction: Sepsis is a leading cause of in-hospital mortality. While early treatment with antimicrobials is critical, there is concern that the imperative to administer these rapidly may result in inappropriate antimicrobial use. Broad-spectrum antimicrobial use must be balanced with its unintended consequences, such as toxicity and development of resistance. We aimed to analyse antimicrobial prescribing, guideline compliance, and appropriateness in Australian hospitalised patients with sepsis.

Method: Data from the Hospital National Antimicrobial Prescribing Survey (NAPS) was reviewed from 2013-2022. NAPS data was submitted using a standardised tool to assess guideline compliance and appropriateness of prescriptions. Inclusion criteria included age >18 years, oral or intravenous administration, and a documented indication of sepsis (including bacteraemia).

Results: There were 12,599 sepsis prescriptions audited from 647 hospitals across Australia. Antimicrobial appropriateness was higher in the sepsis group than for other indications (non-sepsis related) (83% vs 72%, p < 0.001). In patients with sepsis, appropriateness was higher in major cities (85%), than in regional (79%) or remote (72%) settings. The most commonly prescribed antimicrobials were ceftriaxone (14%) and piperacillin/tazobactam (14%). The most common reasons for inappropriateness were incorrect dose/frequency (53%) and spectrum too broad (47%). Appropriateness rates have remained stable over 10 years, despite an increasing number of audited prescriptions.

Conclusions and impact: The Hospital NAPS data identified high rates of antimicrobial appropriateness in sepsis, compared to other indications. Regional and remote settings are a potential area for improvement. Antimicrobial stewardship interventions should target incorrect dosing and broad-spectrum treatment in sepsis, to ensure appropriate de-escalation.

Authors: Bhavi Ravindran (1,2), Vivian Leung (3,5), Jodie McVernon (1,5), Kylie Carville (1,5), Caroline Marshall (3,4,5)

Affiliations: 1. Victorian Infectious Diseases Reference Laboratory, The Royal Melbourne Hospital at the Peter Doherty Institute, 2. National Centre for Epidemiology and Population Health, Australian National University, 3. Infection Prevention and Surveillance Service, The Royal Melbourne Hospital, 4. Victorian Infectious Diseases Service, The Royal Melbourne Hospital, 5. Department of Infectious Diseases, University of Melbourne, The Peter Doherty Institute

Abstract

Introduction: Hospital-onset bloodstream infections (HOBSIs) develop 48 hours or more after hospital admission and are associated with significant morbidity and mortality. Currently, Staphylococcus aureus bacteraemias and central line associated bloodstream infections are reportable through mandatory surveillance, but other bloodstream infections are not. This study provides an overview of the epidemiology of HOBSIs at RMH.

Methods: All patients admitted to RMH between 1 August 2020 and 31 July 2023 with HOBSI were included. HOBSI was defined as any growth of an organism from a blood culture obtained 48 hours or more after admission. Information collected included age, organism and dates of admission, discharge and positive blood culture, ward and treating unit.

Results: There were 1,207 HOBSI episodes among 794 patients. Median patient age was 63 years, 59% were male and median length of stay was 29 days. Within the 794 patients, the most commonly isolated organisms were Staphylococcus epidermis (189, 24%), Escherichia coli (127, 16%), Enterococcus faecium (87, 11%) and Staphylococcus aureus (79, 10%).

Most episodes occurred in the haematology ward (449, 37%) or intensive care unit (202, 17%). Within ICU, 15% were haematology patients.

Of HOBSI episodes, there were differences in the median onset days between S. aureus and E. coli (6 vs 13, p <0.001). There were no differences in age or length of stay.

Discussion: This study highlights the current HOBSI epidemiology and demonstrates a significant disease burden not captured through current surveillance methods. There is ongoing work to determine the feasibility of expanding surveillance activities and understanding measures of preventability.

Authors: Thomas Reilly (1), Maria Di Biasi (2), Mark Walterfang (1,2)

Affiliations: 1. Neuropsychiatry Centre, The Royal Melbourne Hospital, 2. The University of Melbourne

Abstract

Introduction: Niemann-Pick disease type C (NPC) is a rare genetic lysosomal storage disorder with a clinically heterogeneous phenotype that primarily affects the brain, liver and spleen. Most cases of NPC are diagnosed in childhood, but a subset of patients who are diagnosed in adulthood present with psychiatric symptoms and are misdiagnosed as schizophrenia or mood disorders. Neuroimaging studies in NPC show a predilection for neurodegeneration in the subcortical nuclei, the cerebellum and subcortical white matter. We aimed to explore how NPC affects the connectivity of networks and hypothesised a state of widespread dysconnectivity, particularly in subcortical areas.

Methods: This cross-sectional neuroimaging study used diffusion weight magnetic resonance imaging (dMRI) study to perform whole brain tractography in 9 adult patients with NPC and 71 matched healthy controls. Connections between 84 unique brain regions were modelled with streamlines and weighted according to fiber bundle capacity. Statistical testing by each connection allowed identification of significantly affected networks and regions in NPC.

Results: We observed diffusive dysconnectivity in NPC with that primarily affects left fronto-temporal and subcortical networks in NPC. Globally and regionally, NPC showed reductions in the strength and extent of connections, particularly in the thalamus and dorsal striatum.

Conclusions: This is the first study to show that left fronto-temporal and subcortical networks are markedly affected in NPC.

Significance and impact: These findings may facilitate early diagnostic differentiation, monitoring and prognostication. We can better understand the neural correlates of neuropsychiatric symptoms in NPC.

Authors: Stefanie Roberts (1,2), Valeriya Kuznetsova (1,2,3), Tomas Kalincik (1,2), Charles Malpas (1,2,4)

Affiliations: 1. Neuroimmunology Centre, Department of Neurology, The Royal Melbourne Hospital, 2. Clinical Outcomes Research Unit, Department of Medicine, University of Melbourne, 3. Centre for Excellence for Cellular Immunotherapy and Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, 4. Melbourne School of Psychological Sciences, University of Melbourne

Abstract

Introduction: Current guidelines recommend that patients with multiple sclerosis (MS) who screen positively on the SDMT should be prioritised for specialist neuropsychological consultation. This approach, however, limits opportunities to identify and manage other neuropsychological symptoms that produce perceived cognitive dysfunction, including depression, anxiety and fatigue. This study aimed to determine the prevalence of such symptoms in MS patients who screen negatively on the SDMT.

Methods: Medical records were reviewed for all MS patients referred to the Cognitive Neuroimmunology Clinic, Royal Melbourne Hospital. Cases were excluded if an SDMT was not recorded or if standard-care questionnaires of neuropsychological symptoms were incomplete.

Results: A total of 74 patients were included. Most patients screened negatively on the SDMT (78%). Most positive and negative screen patients provided a cognitive complaint (88% and 98%). Many patients across both positive and negative screens scored in the clinical range for fatigue (75% and 81%), depression (31% and 22%), and anxiety (38% and 17%). Half of patients were subsequently referred for management of non-cognitive symptoms in both positive and negative screen patients (44% and 55%), most frequently to clinical psychology (31% and 40%). There were no significant differences between groups for any of the neuropsychological symptoms or management pathways.

Conclusions: Subjective cognitive complaint without a positive cognitive screening result still requires neuropsychological management in patients with MS.

Significance and impact: The use of screening tools to determine referral eligibility to specialist neuropsychological services risks overlooking other driving factors of perceived cognitive dysfunction and may subsequently reduce opportunity for intervention.

Authors: Fatima S Saeed (1,2), Joanne E Davis (1,2), Rachel M Koldej (1,2), David S Ritchie (1,2,3)

Affiliations: 1. ACRF Translational Research Laboratory, The Royal Melbourne Hospital, 2. Department of Medicine, The University of Melbourne, 3. Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital

Abstract

Introduction: An allogeneic haematopoietic stem cell transplant (aHSCT) is used to treat blood conditions such as acute myeloid leukaemia (AML) and myelodysplastic syndrome (MDS). However, this treatment has side effects, including acute Graft versus Host Disease (aGVHD). Previous research identified suppression of tumorigenicity 2 (ST2) and regenerating islet-derived 3 alpha (REG3α) as prognostic biomarkers for aGVHD, yet it is unclear whether these are predictive if measured before transplant.

Aims: This study aimed to determine whether ST2 and REG3α are predictive for transplant-related outcomes if measured before an aHSCT and if a pro-inflammatory immune profile is correlated to these.

Methods: Patients with AML or MDS who had undergone an aHSCT at the RMH and who were given myeloablative (MAC), fludarabine/melphalan or reduced-intensity (RIC) conditioning were included in this study (n = 62). Blood samples were collected at pre-transplant, day 0 and day 14. Protein serum levels were measured using enzyme-linked immunosorbent assays. Immunophenotyping using 30-plex spectral cytometry was performed on peripheral blood mononuclear cells collected pre-transplant.

Results: MAC/RIC patients displayed a dichotomisation in ST2 levels at day 0, where some patients displayed a significant increase in serum levels compared to pre-transplant levels. A similar trend was found in REG3α.

Conclusion: It is hypothesised that patients with elevated levels of ST2 and REG3α will be at an increased risk of developing transplant-related complications.

Significance and impact: If we can identify patients at risk of developing transplant-related complications, we can place commence prophylactic medication and increase clinical monitoring earlier.

Authors: Anna Marie Santomartino (1), Gina Trakman (1), Kate Furness (1), Hilda Griffin (2), Louise Colaci (2)

Affiliations: 1. La Trobe University, 2. Department of Clinical Nutrition, The Royal Melbourne Hospital

Abstract

Introduction: Patients requiring enteral nutrition (EN) after hospital admission are managed under the outpatient Home Enteral Nutrition (HEN) service. This study aimed to describe the emergency department (ED) presentations of HEN patients at RMH.

Methods: This single-center, retrospective audit included all RMH HEN patients with feeding tubes who presented to RMH ED with an EN/tube-related issue during the study period (01/01/2022-31/12/2023). Data included patient demographics, type and indication for feeding tubes and details of ED presentations (reason, day/time and subsequent hospital admissions).

Results: Of the 164 patients under the HEN service (median [IQR] age 66 [51.75, 71] years, 53% males), indications for HEN included head and neck cancer (40%), disorders of gut brain interaction (19%) and dysphagia (19%). Long-term feeding tubes such as gastrostomies and transgastric jejunostomies (62.5%) were most common. Thirty-two patients (19.5%) presented to ED with EN/tube-related issues across 67 ED presentations. The most common reason for presentation was gastrointestinal (22%) followed by mechanical (16%) complications. Twenty-three (34%) of presentations occurred during business hours and 17 (25%) were possibly preventable. Forty ED presentations (60%) resulted in a subsequent hospital admission, with eight patients requiring at least two admissions (median [IQR] length of stay 4 [2, 6] days).

Conclusions: ED presentations amongst RMH HEN patients are common, with some potentially avoidable. A third of patients presented during business hours, indicating opportunities to manage these complications in an outpatient multidisciplinary team (MDT).

Significance and impact: Further support in an outpatient MDT setting may reduce ED presentations in the HEN population.

Authors: Carrie Service, Alana Jones, Felix Sim, David Rowe, Elizabeth Leslie, Brett Anderson, Lauren Davies, Lyndsey Hoogenhoot, Aruska D’Souza, Yasmine Umar, Anand Ramakrishnan

Affiliation: The Royal Melbourne Hospital

Abstract

Introduction: ERAS protocols have improved patient outcomes, though less is known regarding patients undergoing head and neck (HN) surgery with free flap (FF) reconstruction. The aim of this study was to determine if ERAS+ (with prehabilitation) reduces LOS and other important hospital outcomes.

Methods: A multidisciplinary peri-operative care pathway using ERAS Society guideline alongside a prehabilitation program was delivered by allied health and nursing to all patients who underwent a major HN resection (excluding scalp) with FF reconstruction. Data was collected for 80 consecutive patients who were treated according to ERAS+ protocol from May 2023-June 2024 and compared to 50 consecutive patients who were treated prior to ERAS+ implementation (May 2022-December 2022). Outcomes of interests were LOS, post-operative complications, ICU admissions, readmissions and time to removal of Indwelling Catheter (IDC) and Nasogastric Tube (NGT).

Results: A total of 130 patients were included. A median LOS of 15.5 (95% CI 14-18) was observed in pre ERAS+ group and 14.0 (95% CI 12-16) days in ERAS+ group. There were no change to complications, return to theatre, ICU or readmissions. Time to IDC & NGT removal, oral fluid & oral diet commencement were all reduced in the ERAS+ cohort (p<0.05).

Conclusion: ERAS+ improved some post-operative patient milestones without increasing hospital complications or readmissions but did not significantly change LOS.

Significance and impact: ERAS+ may enable patients to achieve important clinical milestones sooner without increasing hospital complications. Further research should investigate LOS with adequate power to detect a change and measure the patient and clinician perspectives.

Authors: Arun Sharma (1), Riley Batchelor (1, 2, 3), Sinjini Biswas (1), Abbey Grbac (1), Samuel Norman (1), Thomas Moran (1), Isaac Park (1), Simon Thackray (1), Ravindran Iyer (1), Matthew Brooks (1), Prasanna Venkataraman (4), Jeffrey Lefkovits (1,3), Anoop Koshy (1)

Affiliations: 1. Department of Cardiology and The University of Melbourne, The Royal Melbourne Hospital, 2. Department of Cardiology, Alfred Health, 3. School of Public Health and Preventive Medicine, Monash University, 4. Baker Heart and Diabetes Institute

Abstract

Background: Coronary Artery Calcium (CAC) scoring is a robust predictor of cardiovascular risk, but its adoption is hindered by inconsistent clinical guidelines, absence of subsidies in Australia, and variable costs to patients. These challenges limit accessibility for patients and adherence with clinical guidelines. This systematic review aims to highlight discrepancies between Australian and international standards.

Methods: Electronic databases (MEDLINE, PubMed) were systematically searched. Following PRISMA guidelines – 117 titles/abstracts were screened, 12 full texts reviewed, and 9 included. Descriptive and qualitative data was used to compare guidelines around 3 key themes – eligibility for CAC screening, thresholds for pharmacotherapy and timing for repeat assessment.

Results: There is consensus between international guidelines that CAC scoring is most beneficial for risk stratifying asymptomatic intermediate cardiovascular risk patients. Variability is evident in CAC thresholds for commencing preventive therapy: CSANZ and SCCT suggest aspirin for patients with CAC scores ≥100, whilst the ACC/AHA and ESC are less definitive. SCTT recommends statins for scores of 0-100, whilst CSANZ and ACC both recommend it for scores ≥100. Guidelines concur on deferring repeat CAC screening for a score of 0 for 5 years, with CSANZ uniquely recommending a 3-year re-scan for scores of 101-400 or in diabetic patients. (Fig. 1)

Conclusion: International guidelines are comparable in identifying suitable patients for CAC scoring and re-screening recommendations. Discrepancies between international and CSANZ guidelines regarding CAC thresholds to initiative pharmacotherapy highlight the need for higher quality evidence to inform clinical care.

Authors: Keeran Shivakumar (1), Emily Sun (1), Ocean Ma (2), Latika Gupta (3,4), Jessica Day (1,5,6)

Affiliations: 1. Department of Rheumatology, The Royal Melbourne Hospital, 2. School of Medicine, University of Melbourne, 3. Division of Musculoskeletal and Dermatological Sciences, Centre for Musculoskeletal Research, School of Biological Sciences, The University of Manchester, UK, 4. Department of Rheumatology, Royal Wolverhampton Hospitals NHS Trust, UK 5. Inflammation Division, Walter and Eliza Hall Institute, 6. Department of Medical Biology, The University of Melbourne

Abstract

Introduction: Idiopathic inflammatory myopathies are autoimmune disorders characterised by muscle and extramuscular manifestations. Classification is challenging due to their rarity and evolving criteria. The 2017 EULAR/ACR criteria, though updated, have limitations, including the exclusion of interstitial lung disease and inadequate differentiation between anti-synthetase syndrome and immune-mediated necrotising myopathy. This study assesses their effectiveness as a classification system in the literature.

Methods: A systematic review of IIM classification criteria from January 1, 2021, to May 18, 2023, analysed MEDLINE and EMBASE for English-language studies on adult IIM, excluding those with fewer than ten patients or involving juveniles.

Results: Of 2,789 studies, 380 were included: 217 on mixed IIM subtypes and 163 on specific subtypes (18 ASyS, 102 dermatomyositis, 33 inclusion body myositis, 9 IMNM, 1 overlap). The review found 313 observational studies, 9 RCTs, and 59 experimental studies. Bohan/Peter and EULAR/ACR were most common (31% and 23%). One-third used multiple criteria, while 34% of experimental and 19% of observational studies lacked detail. B&P was predominant for dermatomyositis, the 2011 ENMC criteria for IBM, and seven criteria for IMNM.

Conclusions: The diverse criteria and continued use of the 1975 B&P criteria underscore the absence of a universally accepted IIM framework. The absence of criteria in many studies diminishes their clinical relevance.

Significance and impact: International consensus on classification is crucial for consistent research and clinical practice. The EULAR/ACR criteria, while advancing the field, inadequately address subtypes like IMNM and ASyS, highlighting the need for global standardisation to integrate historical data and improve clinical relevance.

Authors: Gurtej Singh (1,3), Nicholas Mingos (1), Maeve Slevin (2), Jonathan P. Segal (1,4), Ashok Raj (1)

Affiliations: 1. Department of Gastroenterology and Hepatology, The Royal Melbourne Hospital, 2. Department of Anatomical Pathology, The Royal Melbourne Hospital, 3. School of Clinical Medicine, University of New South Wales, 4. Department of Medicine, The University of Melbourne

Abstract

Background: Renal cell carcinoma (RCC) accounts for 2.8% of cancer diagnoses in Australia, with 25-30% of patients presenting with distant metastases at diagnosis. Common metastasis sites include the lungs, lymph nodes, bone, and liver, leading to poorer prognosis. Gastric metastases are extremely rare, with an incidence of less than 1%. This report presents a unique case of a patient with metastatic RCC to the stomach, manifesting as upper gastrointestinal bleeding.

Case: A 73-year-old woman with a history of multiple sclerosis presented with haematemesis and melaena. She had a one-year history of fatigue, 20 kg unintentional weight loss, and a month of right-sided abdominal pain. Laboratory studies showed anaemia, leukocytosis, and hypercalcaemia. Oesophagogastroduodenoscopy revealed three sessile fundic gland polyps with recent bleeding, which were treated with adrenaline injection, hot snare, soft coagulation, and endo-clips. Computed tomography showed a 7 cm right kidney mass with extrarenal extension and extensive liver and lung metastases. Gastric polyp histology indicated high-grade malignant spindle cells consistent with sarcomatoid RCC. Further biopsy was unnecessary due to the polypectomy histology. The patient’s gastrointestinal bleeding resolved, but three weeks later, liver metastases ruptured, leading to a palliative approach.

Discussion: Gastric metastases from any primary cancer are rare, occurring in 0.2-0.7% of cases. RCC commonly metastasizes to the lung, bone, and liver, with stomach involvement being exceptionally rare. Management includes endoscopic resection, surgery, immunotherapy, and chemotherapy, with treatment tailored to individual patient contexts. This case underscores the importance of histologic analysis in patients with systemic symptoms to avoid unnecessary biopsies.

Authors: Sangavi Sivagnanasundram (1), Steven Bentley (2), Lokman Pang (1), Karl Vaz (3), Stephanie Kuo (1), Susan Fisher (1), Gina McLachlan (3), Amy Clarke (4), Jacqui Montgomery (2), Melanie O’Keefe (2), Linda Ciccarelli (3), Christy Atkinson (1), Michael Christie (1), Bryony Thompson (1), Paul James (1)

Affiliations: 1. The Royal Melbourne Hospital, 2. Australian Genome Research Facility, 3. Austin Health, 4. Melbourne Genomics Health Alliance

Abstract: Background: The assessment of pharmacogenomic genes can play a pivotal role in the detection of any potential drug-gene interactions in high-risk individuals. This project is part of Melbourne Genomics Health Alliance’s multi-site clinical change projects (CCP) with the purpose of addressing implementation challenges across various clinical settings.

Aim: We aim to identify whether the use of low pass whole genome sequencing (WGS) in renal and liver transplant patients will help inform pre-transplant planning focusing on pharmacogenomics and relevant co-morbidities. We also aim to inform families of any relevant monogenic findings.

Methods: Low pass (~5x) WGS and Illumina Global Screening Array (GSA) were performed by Australian Genome Research Facility (AGRF) and analysed. Using modified ACMG/AMP guidelines, only LP/P variants were reported in genes relevant to the patient (Transplant Co-morbidities and Kidneyome or Liverome SuperPanels). An in-depth pharmacogenomic analysis was performed using Illumina’s DRAGEN and PharmCat and reported according to the Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines.

Results: We have recruited over 100 transplant patients of which 73 have been reported. Of these, 30 patients had a clinically actionable finding. An overview of our findings will be presented. Of note, we identified a germline variant in a renal transplant which has led to a diagnosis of Dent’s Disease and a normal metaboliser phenotype for tacrolimus in a pre-transplant renal patient.

Conclusion: Whilst this study is still ongoing, we can acknowledge that these results indicate the benefit of low pass WGS in informing transplant planning and post-operative care in transplant patients.

Authors: Justin Siew Yoong Tu (1), Ashleigh Witt (1,2), Christina Giudice (3), Stefan Heinze (3), Kanishka Rangamuwa (2,4)

Affiliations: 1. Department of Respiratory Medicine, The Royal Melbourne Hospital, 2. Department of Medicine, University of Melbourne, 3. Department of Radiology, The Royal Melbourne Hospital, 4. Department of Respiratory Medicine, Northern Health

Abstract

Introduction: Superior Vena Cava Obstruction (SVCO) is a radiographic finding in patients with mediastinal masses, and may be accompanied by signs and symptoms of Superior Vena Cava Syndrome (SVCS). Although endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the preferred means of obtaining a biopsy, the risk of complications of this procedure in patients with SVCO is unknown.

Methods: A retrospective review was conducted on all patients undergoing EBUS-TBNA by the Royal Melbourne Hospital respiratory department from 1st January to 31st December 2021. Characteristics and symptoms of patients with features of SVCS were noted. Pre-procedural CT imaging was reviewed, and evidence of SVCO was classified by anatomical location and degree of obstruction.

Results: 245 linear EBUS procedures were performed. SVCO of moderate severity or greater (>50% obstruction) was present in 11 patients, mild severity (<50% obstruction) in 13, indeterminate but likely in 4, indeterminate but unlikely in 20, and absent in 197 patients. Rates of complications were low across the cohort without a significant difference between patients with SVCO and those without (4% vs 7%). Amongst the 24 patients with SVCO, the original radiology reports mentioned obstruction in only 4 patients, and clinical assessment of SVCS was rarely documented.

Conclusion: In this comparison of patients undergoing linear EBUS, the presence of SVCO was not associated with greater complications. Furthermore, our study suggests that SVCO is underreported and under-assessed in our cohort of patients both clinically and radiologically.

Significance and impact: This study suggests EBUS to be a safe procedure in patients with SVCO.

Authors: Ray Wang (1,2,3,4,5), Brintha Krishnamoorthi (5), Jason Tjahyadi (4), Ailie Connell (4,6), Cherie Chiang (1,2,7), Debra Renouf (5), Rahul Barmanray (1,2,3), Mervyn Kyi (1,2,3), Spiros Fourlanos (1,2,3)

Affiliations: 1. Department of Diabetes & Endocrinology, The Royal Melbourne Hospital, 2. Department of Medicine (RMH), The University of Melbourne, 3. Australian Centre for Accelerating Diabetes Innovations (ACADI), The University of Melbourne, 4. Department of Endocrinology & Diabetes, Eastern Health, 5. Department of Diabetes & Endocrinology, Peninsula Health, 6. Department of Chemical Pathology, Eastern Health, 7. Department of Chemical Pathology, The Royal Melbourne Hospital

Abstract

Introduction: Continuous glucose monitors (CGM) are commonly used by people living with type 1 diabetes (T1D). However, routine in-hospital use is not recommended due to accuracy concerns when acutely unwell. We aimed to determine inpatient CGM accuracy.

Methods: In this multi-centre retrospective observational study, we compared CGM glucose with reference blood glucose (capillary point-of-care [POC], blood gas [GAS], plasma) in patients with T1D and multi-day acute admissions during 2020-2023 across three Victorian health services. Patients requiring dialysis or admitted under paediatric/obstetric/palliative care/psychiatry units were excluded.

Absolute difference between time-matched pairs (±7 minutes) of CGM and reference blood glucose was divided by reference glucose; the mean of these results determined mean absolute relative difference (MARD). Consensus error grid (CEG) analysis was also performed.

Results: An initial 7,358 glucose pairs from 311 admissions were analysed, with overall MARD 11.5%. After excluding glucose measures with potential for time (from CGM Reader/Receiver devices, requiring user date/time set-up) or source inaccuracy (from manually recorded POC measures rather than networked glucose meters), the remaining 2,535 glucose pairs yielded an overall MARD 12.6%, with >99% of glucose pairs within “clinically acceptable” zones A and B of CEG.

Conclusions: Amongst adult inpatients with T1DM, CGM agreed relatively well with blood glucose (MARD 12.6%). To avoid pitfalls in inpatient CGM accuracy assessment, we recommend automated recording of glucose measures and prospective confirmation of correct CGM Reader/Receiver date/time settings.

Significance: Inpatient use of CGM demonstrates reasonable accuracy. Prospective studies of inpatient CGM use evaluating safety and glycaemic impact are required.

Authors: John Wark (1,2), Alexandra Gorelik (2), Ahmed Elsayed (2), Shanton Chang (3), Ralph Audehm (4), Sarah Price (1), Steve Snow (5), Rahul Barmanray (1,2), Christopher Yates (1,2), Lucy Collins (1), Cherie Chiang (1)

Affiliations: 1. Department of Diabetes & Endocrinology, The Royal Melbourne Hospital, 2. Department of Medicine, University of Melbourne, 3. School of Computing and Information Systems, University of Melbourne, 4. Department of General Practice and Primary Care, University of Melbourne, 5. Praxhub

Abstract

Introduction: The aim of the Community Fracture Capture (CFC) Learning Hub is to address the treatment gap in osteoporosis, by enhancing the knowledge and confidence of primary care physicians (PCPs) in osteoporosis management. The CFC Learning Hub is an innovative online education tool designed to offer a secure and flexible learning environment. It features an interactive discussion forum, case studies contributed by participants, a knowledge repository, and real-time interaction with bone specialists and senior PCP facilitators.

Methods: The program was implemented over four 6-week cycles with small groups of PCPs, focusing on topics such as osteoporosis treatment, monitoring, and complex cases. Evaluation methods included online surveys and backend analytics to measure knowledge gains, activity levels, overall engagement.

Results: 55 PCPs participated, with evaluation data from 35 respondents indicating that 91% enrolled to either enhance patient care or gain insights from experts. The majority of participants (82%) were satisfied with the content, noting that live webinars and small-group learning were particularly beneficial. Confidence in applying osteoporosis management guidelines rose from <50% at the start to over 97% by program end. Most participants preferred education after work (66%) or weekends (28%), there was a preference for live webinars (26%) over on-demand video (17%). 89% of participants expressed a high likelihood of recommending the training, and 57% found the platform user-friendly.

Conclusions: The CFC Learning Hub bridges significant gaps in osteoporosis management and provides a user-friendly, interactive, time-flexible educational experience.

Significance: The program highlights the value of collaborative development in improving healthcare delivery.

Authors: Josephine Wen (1,2), Courtney Ierano (1,2), Noleen Bennett (1,2,3), Michael Malloy (1,2,3), Lisa Hall (1,2,4), Karin Thursky (1,2), Rod James (1,2), Caroline Chen (1,2)

Affiliations: 1. RMH Guidance Group, The Royal Melbourne Hospital, 2. National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 3. Victorian Hospital Acquired Infection Surveillance System (VICNISS), The Royal Melbourne Hospital, 4. School of Public Health, University of Queensland

Abstract

Introduction: The National Antimicrobial Prescribing Survey (NAPS) program is governed by the Royal Melbourne Hospital Guidance Group, and is widely adopted throughout Australian hospitals and aged care homes to audit the quality of antimicrobial prescribing. This study aimed to review topical antimicrobial prescribing practices in 2022.

Methods: All topical antimicrobial prescription data collected from Australian facilities from January 1-December 31 were included in the descriptive analysis.

Results: A total of 1,666 (4.9%) topical antimicrobial prescriptions were audited through the Hospital NAPS (n=34,073). An indication was documented for 75% of prescriptions, whilst only 32.8% had a review/stop date documented. Overall, 30.9% of prescriptions were non-compliant with guidelines and 29.8% of prescriptions were deemed to be inappropriate.

The Surgical NAPS dataset included 980 (7.6%) topical antimicrobial prescriptions for surgical prophylaxis (n=12,875). Of these, 24.5% of prescriptions were procedural doses and 75.5% were post-procedural doses. Overall, 67.1% of topical prescriptions were non-compliant with guidelines and 75.1% of prescriptions were deemed to be inappropriate. Of the 736 inappropriate topical antimicrobial prescriptions, auditors deemed prophylaxis was not required in 46.1% of cases.

The Aged Care NAPS dataset included 3,376 (40.3%) topical antimicrobial prescriptions (n=8,373); 47% were 'as needed' prescriptions and 44.1% continued for greater than 6 months. An indication was documented for 75.9% of prescriptions, whilst only 36.1% had a review/stop date documented.

Conclusions/Impact: NAPS data reveals high rates of inappropriate topical antimicrobial prescribing within Australian hospitals, especially in surgical settings. Further research in the aged care sector is required to better understand usage appropriateness.

Authors: Kym Wittholz (1, 2), Kate Fetterplace (1, 2), Amalia Karahalios (3), Yasmine Ali Abdelhamid (2, 4), Lisa Beach (1), David Read (5), René Koopman (6), Jeffrey J Presneill (2, 4), Adam M Deane (2, 4)

Affiliations: 1. Clinical Nutrition, Department of Allied Health, The Royal Melbourne Hospital, 2. Department of Critical Care, Melbourne Medical School, The University of Melbourne, 3. Center of Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, 4. Intensive Care Unit, The Royal Melbourne Hospital, 5. Department of Trauma and General Surgery, The Royal Melbourne Hospital, 6. Center for Muscle Research, Department of Anatomy and Physiology, The University of Melbourne

Abstract

Introduction: β-Hydroxy-β-Methylbutyrate (HMB) is a nutrition supplement that may attenuate muscle wasting from critical illness. This trial aimed to determine the feasibility of administering a blinded nutritional supplement in the intensive care unit (ICU), and continuing it after ICU discharge.

Methods: Single-center, parallel group, blinded, placebo-controlled, randomized, feasibility trial. After a traumatic injury necessitating admission to ICU, participants were randomized to receive an enteral study supplement of 3 grams HMB (intervention), or placebo, daily for 28 days or until hospital discharge. Primary outcome was feasibility of administering the study supplement. Secondary outcomes included the change in quadriceps muscle thickness, measured weekly using ultrasound and analyzed using a linear mixed model.

Results: Fifty randomized participants (intervention, n=26 and placebo, n=24) showed comparable baseline characteristics. Participants received 862 (84.3%) of the 1022 prescribed supplements during hospitalization with 543 (62.8%) delivered via enteral feeding tube. The median [IQR] number of study supplements successfully administered per participant were intervention: 19.5 [13.0, 24.0] and placebo: 16.5 [8.5, 23.5]. Marked loss of quadriceps muscle thickness occurred in both groups; with the point estimate favoring attenuated muscle loss with the intervention, albeit with wide confidence intervals [mean intervention difference after 28 days (95% CI): 0.26 (-0.13, 0.64) cm].

Conclusion: A blinded, placebo-controlled, randomized clinical trial of daily enteral HMB supplementation for up to 28 days in hospital is feasible.

Impact: The results of this pilot trial may inform the design of a larger study to precisely estimated the impact of HMB on muscle mass and functional outcomes.

Authors: Belinda Woods (1), Nicole Giofre (1), Cristina Bussolaro (1), Eloise Thompson (1), Celia Marston (1), Dr Sarah Milsome (2)

Affiliations: 1. Department of Allied Health, The Royal Melbourne Hospital, 2. No affiliation

Abstract

Introduction: An Occupational Therapy community therapy service (CTS) used the Canadian Occupational Performance Measure (COPM) to determine impact of interventions. There is limited research reporting patient outcomes in the community rehabilitation context. The aim of this study was to evaluate the impact of OT on self-reported occupational performance and satisfaction for patients attending community rehabilitation; and secondly to identify the most common goals prioritised by patients.

Method: Retrospective analysis of usual care was conducted with a cohort of outpatients receiving OT. Data was collected over a 12-month period using the COPM before (time 1) and after (time 2) their participation in OT. Wilcoxon test for difference pre and post therapy results were calculated. The goals of participants were analysed and reported descriptively.

Results: The Wilcoxon test showed significantly higher patient rated performance (Z=-11.77, p<.001) and satisfaction (Z=-11.80, p<.001) at time 2, after occupational therapy intervention. Self care goals were identified as priorities by 90% of patients, productivity goals were identified as priorities by 69% of participants and leisure goals by 47% of patients.

Conclusion: Findings indicate that OT has meaningful and significant impact on patient outcomes in the community rehabilitation context and that the goals identified by patients are broad.

Significance: This is one of the first studies to report the outcomes of occupational therapy intervention in a CTS context. Future research should examine trends for different diagnostic groups to better understand effective interventions to target specific populations.

Authors: Alexa Yao (1,2), Jai Darvall (1,2), Earlene Silvapulle (1)

Affiliations: (1) Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, (2) Monash University School of Public Health and Preventive Medicine

Abstract

Introduction: Postoperative cardiovascular complications affect hundreds of thousands of Australians annually. Current risk prediction tools have variable accuracy, prompting interest in additional parameters such as functional capacity.

Methods: We conducted a single-centre prospective cohort study, recruiting adults aged 65+ undergoing elective non-cardiac surgery. Functional capacity was assessed using the Duke Activity Status Index (DASI) questionnaire, with reasons for limitations identified preoperatively. These reasons were categorised as cardiorespiratory or non-cardiorespiratory, and regressed against DASI scores and postoperative cardiovascular complications.

Results: In our recruited 66 patients, non-cardiorespiratory reasons had the greatest impact on DASI scores with gait aid use and patient-reported weakness reducing DASI scores by 20.69 points (95% CI 14.62–26.75, p<0.001) and 7.67 points (95% CI 1.91–13.42, p=0.010) respectively. Among cardiorespiratory reasons, only dyspnoea significantly impacted the DASI score, reducing it by 7.42 points (95% CI 1.42–13.42, p=0.016). We did not find non-cardiorespiratory reasons to be associated with an increased risk of 30-day cardiovascular complications.

Conclusion: Low DASI scores are associated with postoperative cardiac complications. However, the disproportionate impact of non-cardiorespiratory reasons on DASI scores suggests that predictive performance may improve by distinguishing between these reasons.

Significance and impact: Incorporating specific reasons for functional capacity limitations could enhance cardiac risk models and improve the identification of high-risk patients who most benefit from preoperative testing, optimisation of comorbidities, secondary prevention, and closer postoperative monitoring.

Authors: Jenny Jia Yu (1,2), Kai Sin Chin (1,2), Paula Loveland (1,2),  Leonid Churilov (1), Samantha M Loi (4,5), Nawaf Yassi (1,2,3), Rosie Watson (1,2)

Affiliations: 1. Department of Medicine (RMH), The University of Melbourne, 2. Population Health and Immunity Division, Walter and Eliza Hall Institute, 3. Department of Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, 4. Neuropsychiatry Centre, The Royal Melbourne Hospital, 5. Department of Psychiatry, University of Melbourne

Abstract

Introduction: Apathy is an important feature of Lewy body dementia (LBD). Existing data on the prevalence of apathy in LBD is heterogenous. Therefore, we aim to estimate the prevalence of apathy in LBD through systematic review and meta-analysis.

Methods: Five databases were searched for relevant articles using key terms “lewy body”, “Parkinson’s disease dementia” (PDD), “mild cognitive impairment” (MCI), “neuropsychiatric symptoms”, “apathy”, and their synonyms. Articles reporting prevalence of apathy in MCI and dementia stages of dementia with Lewy bodies (DLB), PDD and LBD were included. Random effect meta-analysis was performed to determine prevalence of apathy.

Results: The search identified 7477 articles, 46 met the inclusion criteria. The pooled prevalence of apathy in LBD (DLB and PDD, n = 3940) was 58% (95% confidence interval (CI) 51 – 64%, I2 = 95.3%), in DLB (n = 2169) 58% (95% CI 52 – 64%, I2 = 86.5%) and in PDD (n = 1557) 56% (95% CI 43 – 70%, I2 = 97.6%). The pooled prevalence of apathy in LB-MCI (n = 316) was 49% (95% CI 34 – 65%, I2 = 88.4%) and PD-MCI (n = 337) was 40% (95% CI 29 – 51%, I2 = 51.1%).

Conclusion: Apathy is an important and prevalent feature of LBD throughout the disease continuum.

Significance: The high prevalence of apathy in prodromal disease supports its utility in early DLB diagnosis. Future research should aim to prospectively validate apathy as a component of diagnostic criteria in prodromal disease and focus on earlier identification and management strategies for apathy in LBD.

Back to contents ↑