Internal medicine journal
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Internal medicine journal · Nov 2013
Heightened clinical suspicion of pulmonary embolism and disregard of the D-dimer assay: a contemporary trend in an era of increased access to computed tomography pulmonary angiogram?
Prospective studies have shown that utilising qualitative D-dimers in those with a low Wells pre-test probability (PTP) of pulmonary embolism (PE) have significantly reduced the number of computed tomography pulmonary angiograms (CTPA) being performed. These studies have been based on a PE prevalence of approximately 6% in the low PTP group. ⋯ The overall prevalence of PE in subjects undergoing CTPA was significantly lower compared with data in the literature. The authors recommend warranted clinical suspicion of PE should be confirmed by a senior physician prior to placing a patient in the PE work-up pathway. In such patients, the qualitative D-dimer assay should be utilised if PTP is low, and the exclusionary efficiency of the D-dimer will be improved in the setting of higher PE prevalence in this subgroup. Hospitals should audit local PE prevalence, as cost-benefit analyses raises questions about the effectiveness of D-dimers when PE prevalence is very low in the low PTP subgroup.
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Internal medicine journal · Nov 2013
Impact of the 2009 Melbourne heatwave on a major public hospital.
In the week following the onset of the 2009 heatwave in Melbourne, Australia, The Alfred Hospital observed a significant increase in total hospital admissions (adjusted incidence rate ratio (IRR) 1.11, P = 0.046), emergency department presentations (IRR 1.15, P < 0.01) and general medical admissions (IRR 1.81, P < 0.01). Under the general medical unit there was a rise in the number of deaths (IRR 3.9, P < 0.01), and patients with a broad range of disorders, particularly of the endocrine/metabolic (IRR 2.2, P < 0.01), circulatory (IRR 1.9, P < 0.01) and genitourinary (IRR 2.6, P < 0.01) systems.
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Internal medicine journal · Nov 2013
Teaching Junior Medical Officers safe and effective prescribing.
Medication errors are an iatrogenic threat to patient safety, and recently graduated Junior Medical Officers (JMOs) are a common source of these errors. A ward-based, physician-led, small-group interactive teaching session was developed to improve JMOs competence in prescribing. The ability of JMOs to detect problems in mock medication charts before and after the teaching session was assessed, with the majority improving after the intervention, a result sustained on re-testing later in the year. The teaching sessions were well received by JMOs.
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Thrombotic microangiopathy (TMA) is a microvascular occlusive disorder characterised by platelet aggregation, thrombocytopenia and end-organ damage. It is commonly idiopathic, although several drug classes, including cytotoxic chemotherapy, have been implicated. Several of cases of gemcitabine-induced TMA have been documented with incidence likely to increase with the escalating use of gemcitabine. We report the cases of two patients who developed TMA while on gemcitabine chemotherapy.
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Internal medicine journal · Oct 2013
ReviewRenal transplantation in indigenous Australians of the Northern Territory: closing the gap.
Chronic kidney disease causes high morbidity and mortality among Indigenous Australians of the Northern Territory (NT). Studies have shown chronic kidney disease rates of 4-10 times higher in indigenous than non-indigenous Australians and prevalent dialysis rates of 700-1200 per million population. For most patients with end-stage renal failure, renal transplantation provides the optimal treatment for people with end-stage renal disease. ⋯ Available options to avoid relocation include peritoneal dialysis, home haemodialysis and community health centre dialysis, but the acceptance rates for these are low, hence renal transplantation would provide the best option. There is evidence of identified barriers to renal transplantation for indigenous people of the NT. This review explores published data on why rates of renal transplantation in indigenous people of the NT are low and the reasons for poor outcomes highlighting possible areas of improvement.