Armadale Health Service

OBJECTIVE: To identify biomarkers which distinguish severe sepsis/septic shock from uncomplicated sepsis in the Emergency Department (ED). METHODS: Patients with sepsis underwent serial blood sampling, including arrival in the ED and up to three subsequent time points over the first 24 hours. Messenger RNA (mRNA) levels of 13 genes representing arms of the innate immune response, organ dysfunction or shock were measured in peripheral blood leucocytes using quantitative PCR, and compared with healthy controls. Serum protein concentrations of targets differentially expressed between uncomplicated sepsis and severe sepsis/septic shock were then measured at each time point and compared between the two patient groups. RESULTS: Of 27 participants (median age 66 years, (IQR 35, 78)), 10 had uncomplicated sepsis and 17 had sepsis with organ failure (14 septic shock; 3 had other sepsis-related organ failures). At the time of first sample collection in the ED, gene expression of Interleukin (IL)-10 and Neutrophil Gelatinase Associated Lipocalin (NGAL) were significantly higher in severe sepsis than uncomplicated sepsis. Expression did not significantly change over time for any target gene. Serum concentrations of IL-6, IL-8, IL-10, NGAL and Resistin were significantly higher in severe sepsis than uncomplicated sepsis at the time of first sample collection in the ED, but only IL-8, NGAL and Resistin were consistently higher in severe sepsis compared to uncomplicated sepsis at all time points up to 24 h after presentation. CONCLUSIONS: These mediators, produced by both damaged tissues and circulating leukocytes, may have important roles in the development of severe sepsis. Further work will determine whether they have any value, in addition to clinical risk parameters, for the early identification of patients that will subsequently deteriorate and/or have a higher risk of death.

Approximately one quarter of patients undergoing breast conserving therapy for breast cancer will require a second operation to achieve adequate clearance of the margins. A number of techniques to assess margins intraoperatively have been reported. This systematic review examines current intraoperative methods for assessing margin status. The final pathology status, statistical measures including accuracy of tumour margin assessment, average time impact on the procedure and second operation rate, were used as criteria for comparison between studies. Although pathological methods, such as frozen section and imprint cytology performed well, they added on average 20-30 min to operation times. An ultrasound probe allows accurate examination of the margins and delivers results in a timely manner, yet it has a limited role with DCIS where calcification is present and in multifocal cancer. Further research is required in other intraoperative margin assessment techniques, such as mammography, radiofrequency spectroscopy and optical coherence tomography.

OBJECTIVES: 1 To develop a training package for ultrasonic cardiac output monitor (USCOM) cardiac output assessments and determine the number of proctored studies necessary for skill acquisition. 2 To develop criteria for acceptance of cardiac output results obtained with the USCOM. 3 To evaluate the reliability of USCOM cardiac output assessments in the ED. METHODS: The authors developed an audiovisual training package. Four emergency physicians and one geriatrician subsequently underwent hands-on training, and skill acquisition was assessed at the fifth, 10th, 15th and 20th examinations. Six image-scoring criteria were developed to assess acoustic image quality. Upon completion of training a protocol was developed to optimize interassessor reliability. Two trained emergency physicians then performed blinded examinations on ED patients using the protocol and interassessor reliability was evaluated. RESULTS: During training average image score improved between the fifth and 20th assessed patient from 4.6 (95% CI 4.0-5.3) to 5.5 (95% CI 5.0-6.0, Pt-test=0.02) out of 6 and average intra-assessor cardiac output difference improved from 17% (95% CI 4-25) to 5% (95% CI 0-11, Pt-test=0.02). Analysis of 52 cardiac output assessments in 21 ED patients demonstrated excellent interassessor correlation (r=0.96, 95% CI 0.90-0.98, P<0.001). The average interassessor difference in cardiac output and index was 0.2 L/min (4%, 95% CI 3-6) and 0.1 L/min/m2 (4%, 95% CI 2-6), respectively. CONCLUSION: Emergency physicians with no prior ultrasonographic experience can be trained to obtain reliable cardiac output estimations upon conscious ED patients with the USCOM over the course of 20 patient assessments.

INTRODUCTION: The burden of cardiovascular disease (CVD) is rapidly increasing in developing countries, however access to cardiac rehabilitation and secondary prevention (CR/SP) in these countries is limited. Alternative delivery models that are low-cost and easy to access are urgently needed to address this service gap. The objective of this study is to investigate whether a smartphone and social media-based (WeChat) home CR/SP programme can facilitate risk factor monitoring and modification to improve disease self-management and health outcomes in patients with coronary heart disease (CHD), after percutaneous coronary intervention (PCI) therapy. METHODS AND ANALYSIS: We propose a single-blind, randomised controlled trial of 300 patients post-PCI with follow-up over 12 months. The intervention group will receive a smartphone-based and WeChat-based CR/SP programme providing education and support for risk factor monitoring and modification. SMART-CR/SP incorporates core components of modern CR/SP: physical activity tracking with interactive feedback and goal setting; education modules addressing CHD understanding and self-management; remote blood pressure monitoring and strategies to improve medication adherence. Furthermore, a dedicated data portal and a CR/SP coach will facilitate individualised supervision and counselling. The control group will receive usual care but no formal CR/SP programme. The primary outcome is change in exercise capacity measured by 6 minute walk test distance. Secondary outcomes include knowledge and awareness of CHD, risk factor status, medication adherence, psychological well-being and quality of life, major cardiovascular events, re-hospitalisations and all-cause mortality. To assess the feasibility and patients' acceptance of the intervention, a process evaluation will be performed at the conclusion of the study. ETHICS AND DISSEMINATION: Ethics approval was granted by both the Human Research Ethics Committee of Fudan University Zhongshan Hospital (HREC B2016-058) and Curtin University Human Research Ethics Office (HRE2016-0120). Results will be disseminated via peer-reviewed publications and presentations at conferences. CLINICAL TRIAL REGISTRATION NUMBER: ChiCTR-INR-16009598; Pre-results.

BACKGROUND: Guidelines recommend an initial intravenous (IV) fluid bolus of 30 ml/kg isotonic crystalloid for patients with sepsis and hypotension. However, there is a lack of evidence from clinical trials to support this. Accumulating observational data suggest harm associated with the injudicious use of fluids in sepsis. There is currently equipoise regarding liberal or restricted fluid-volume resuscitation as first-line treatment for sepsis-related hypotension. A randomised trial comparing these two approaches is, therefore, justified. METHODS/DESIGN: The REstricted Fluid REsuscitation in Sepsis-associated Hypotension trial (REFRESH) is a multicentre, open-label, randomised, phase II clinical feasibility trial. Participants will be patients presenting to the emergency departments of Australian metropolitan hospitals with suspected sepsis and a systolic blood pressure of < 100 mmHg, persisting after a 1000-ml fluid bolus with isotonic crystalloid. Participants will be randomised to either a second 1000-ml fluid bolus (standard care) or maintenance rate fluid only, with the early commencement of a vasopressor infusion to maintain a mean arterial pressure of > 65 mmHg, if required (restricted fluid). All will receive further protocolised fluid boluses (500 ml or 250 ml, respectively), if required during the 6-h study period. The primary outcome measure is total volume administered in the first 6 h. Secondary outcomes include fluid volume at 24 h, organ support 'free days' to day 28, 90-day mortality, and a range of feasibility and process-of-care measures. Participants will also undergo serial measurement, over the first 24 h, of biomarkers of inflammation, endothelial cell activation and glycocalyx degradation for comparison between the groups. DISCUSSION: This is the first randomised trial examining fluid volume for initial resuscitation in septic shock in an industrialised country. A pragmatic, open-label design will establish the feasibility of undertaking a large, international, multicentre trial with sufficient power to assess clinical outcomes. The embedded biomarker study aims to provide mechanistic plausibility for a larger trial by defining the effects of fluid volume on markers of systemic inflammation and the vascular endothelium. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry, ID: ACTRN12616000006448. Registered on 12 January 2016.

BACKGROUND: Spontaneous pneumothorax can be managed initially by observation, aspiration or chest drain insertion. AIMS: To determine the clinical features of spontaneous pneumothorax in patients presenting to the emergency department (ED), interventions, outcomes and potential risk factors for poor outcomes after treatment. METHODS: Retrospective chart review from ED of three major referral and two general hospitals in Australia of presentations with primary spontaneous pneumothorax (PSP) or secondary spontaneous pneumothorax (SSP). Main outcomes were prolonged air leak (>5 days) and pneumothorax recurrence within 1 year. RESULTS: We identified 225 people with PSP and 98 with SSP. There were no clinical tension pneumothoraces with hypotension. Hypoxaemia (haemoglobin oxygen saturation measured by pulse oximetry ≤92%) occurred only in SSP and in older patients (age >50 years) with PSP. Drainage was performed in 150 (67%) PSP and 82 (84%) SSP. Prolonged air leak occurred in 16% (95% confidence interval 10-23%) of PSP and 31% (21-42%) of SSP. Independent risk factors for prolonged drainage were non-asthma SSP and pneumothorax size >50%. Complications were recorded in 11% (7.5-16%) of those having drains inserted. Recurrences occurred in 5/91 (5%, 1.8-12%) of those treated without drainage versus 40/232 (17%, 13-23%) of those treated by drainage, of which half occurred in the first month after drainage. CONCLUSION: Pneumothorax drainage is associated with substantial morbidity including prolonged air leak. As PSP appears to be well tolerated in younger people even with large pneumothoraces, conservative treatment in this subgroup may be a viable option to improve patient outcomes, but this needs to be confirmed in a clinical trial.

OBJECTIVES: We aimed to provide 'adequate analgesia' (which decreases the pain score by ≥2 and to <4 [0-10 scale]) and determine the effect on patient satisfaction. METHODS: We undertook a multicentre, cluster-randomised, controlled, intervention trial in nine EDs. Patients with moderate pain (pain score of ≥4) were eligible for inclusion. The intervention was a range of educational activities to encourage staff to provide 'adequate analgesia'. It was introduced into five early intervention EDs between the 0 and 6 months time points and at four late intervention EDs between 3 and 6 months. At 0, 3 and 6 months, data were collected on demographics, pain scores, analgesia provided and pain management satisfaction 48 h post-discharge (6 point scale). RESULTS: Overall, 1317 patients were enrolled. Logistic regression (controlling for site and other confounders) indicated that, between 0 and 3 months, satisfaction increased significantly at the early intervention EDs (OR 2.2, 95% CI 1.5 to 3.4 [P < 0.01]) but was stable at the control EDs (OR 0.8, 95% CI 0.5 to 1.3 [P = 0.35]). Pooling of data from all sites indicated that the proportion of patients very satisfied with their pain management increased from 42.9% immediately pre-intervention to 53.9% after 3 months of intervention (difference in proportions 11.0%, 95% CI 4.2 to 17.8 [P = 0.001]). Logistic regression of all data indicated that 'adequate analgesia' was significantly associated with patient satisfaction (OR 1.4, 95% CI 1.1 to 1.8 [P < 0.01]). CONCLUSIONS: The 'adequate analgesia' intervention significantly improved patient satisfaction. It provides a simple and efficient target in the pursuit of best-practice ED pain management.

OBJECTIVE: The objective of the present paper was to identify factors associated with job satisfaction and burnout among staff working in mental health services for older people. METHODS: A postal survey was distributed to staff members from eight mental health services for older people in Western Australia. Staff focus groups identified causes of work stress. RESULTS: The response rate was 33% (116/349). Teamwork, social support and clear roles had a positive effect on job satisfaction. Community staff members had higher job satisfaction than ward staff. Nurses reported higher burnout and lower job satisfaction than other mental health professionals. Staff members working in newer models of service delivery had higher job satisfaction than those working in more traditional models. CONCLUSION: Surveys and focus groups were an effective means of identifying factors associated with job satisfaction in mental health staff members. Newer models of service delivery with team building and supportive management may improve the workplace for staff.

Older adults recently discharged from hospital are at high risk of functional decline and falls. A tailored fall prevention education provided at hospital discharge aimed to improve the capacity of older adults to engage in falls prevention activities. What remains unknown are the factors affecting behaviour change after hospital discharge. This study identified the perceived barriers and enablers of older adults to engagement in fall prevention activities during the 6-month period post-discharge. An exploratory approach using interpretative phenomenological analysis focused on the lived experience of a purposive sample (n = 30) of participants. All were recruited as a part of an RCT (n = 390) that delivered a tailored fall prevention education program at three hospital rehabilitation wards in Perth, Australia. Data were collected at 6-month post-discharge using semi-structured telephone surveys. Personal stories confirmed that some older adults have difficulty recovering functional ability after hospital discharge. Reduced physical capability, such as experiences of fatigue, chronic pain and feeling unsteady when walking were barriers for participants to safely return to their normal daily activities. Participants who received the tailored fall education program reported positive effects on knowledge and motivation to engage in fall prevention. Participants who had opportunities to access therapy or social supports described more positive experiences of recovery compared to individuals who persevered without assistance. A lack of physical and social support was associated with apprehension and fear toward adverse events such as falls, injuries, and hospital readmission. The lived experience of participants following hospital discharge strongly suggested that they required more supports from both healthcare professionals and caregivers to ensure that their needs were met. Further research that evaluates how to assist this population to engage in programs that will mitigate the high risk of falls and hospital readmissions is required.

OBJECTIVE: To determine the feasibility of using a biomarker panel of myoglobin, creatinine kinase MB (CK-MB) and cardiac troponin I (cTnI) to identify patients with suspected acute coronary syndrome (ACS) who are suitable for discharge within 2 h. METHODS: We took blood at presentation and at 2 h from patients with suspected ACS and non-diagnostic electrocardiogram who were admitted to the ED short stay ward for serial electrocardiogram and troponin testing. We used a point-of-care device that gives rapid estimation of myoglobin, CK-MB and cTnI (Triage cardiac panel). These results were compared with the results of our standard hospital cardiac troponin T assay. Patients were followed up by telephone at 30 days. RESULTS: The study group comprised 100 patients (61 men) with mean age of 58 years. Six had a troponin-positive ACS during their ED stay. One additional patient died of a myocardial infarction within the follow-up period. The Triage panel at 2 h after presentation predicted 12-h cardiac troponin T elevation (sensitivity 100%, negative predictive value 99%) and 30-day events (sensitivity 86%, negative predictive value 97%). The majority of patients were ultimately suitable for discharge. CONCLUSION: Serial myoglobin, CK-MB and cTnI have the potential to identify patients who are suitable for early discharge and outpatient work-up. A large multicentre study is required.

INTRODUCTION: The Surviving Sepsis Campaign guidelines recommend administration of appropriate antibiotics within 1 h in patients with severe sepsis, with two sets of blood cultures taken prior to administration. OBJECTIVE: We evaluated the effect of introducing a Sepsis Early Alert Tool (SEAT) in the ED. Outcomes were antibiotic timing, antibiotic choice and obtaining adequate blood cultures. METHODS: A retrospective chart review compared consecutive severe sepsis presentations admitted to ICU via the ED during two equivalent 6 month periods before and after SEAT introduction. RESULTS: The analyses included 55 patients before and 45 following SEAT introduction. The groups were similar in age, sex, triage category, sepsis source, Acute Physiology and Chronic Health Evaluation III scores and hospital mortality. The percentage receiving antibiotics within 60 min of triage increased from 24% (95% CI 13-37%) to 44% (95% CI 30-60%), P = 0.03. Median time from triage to first antibiotic was 105 (IQR 65-170) min and 85 (IQR 50-140) min before and after SEAT introduction, respectively, P = 0.15. Percentages receiving antibiotics within 60 min of first recognition of severe sepsis were 67% (95% CI 53-79%) and 71% (95% CI 56-84%) before and after SEAT introduction, P = 0.83. The percentage having two sets of blood cultures drawn prior to antibiotic administration increased from 18% (95% CI 9-34%) to 44% (95% CI 27-60%), P = 0.008. Appropriateness of antibiotics was 58% (95% CI 44-71%) and 75% (95% CI 60-87%) before and after SEAT implementation, P = 0.09. CONCLUSION: The introduction of a SEAT in the ED is associated with earlier recognition of severe sepsis and improvements in quality of care.

Objectives: To examine the perceptions of elder abuse among older Australian adults and general practitioners, a topic that has not been explored to the same extent as elsewhere. Methods: Forty‐eight general practitioners, 40 independent older adults, 38 older adult caregivers and 36 older care‐receivers completed a modified version of Moon and Williams’ (1993) questionnaire, which describes 10 potential elder abuse scenarios. Results: Split‐plot analysis of variance showed significant differences in the perceptions of severity of elder abuse scenarios across groups and gender. General practitioners tended to view the scenarios as less severe than the older‐aged groups. Within the older adult groups, caregivers generally perceived the scenarios as less abusive. Females generally perceived sexual abuse scenarios as more severe compared to males. Conclusions: With such differences in views evident, the development of effective assessment strategies will require more targeted efforts to increase the awareness of elder abuse in the community.

OBJECTIVE: To compare two methods of risk stratification for suspected acute coronary syndrome (ACS) in the ED. METHODS: A prospective observational multicentre study was undertaken of patients undergoing evaluation in the ED for possible ACS. We compared the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (NHF/CSANZ) guideline and the Thrombolysis in Myocardial Infarction (TIMI) risk score for differentiating high- and low-risk patients. Composite outcome was all cause death, myocardial infarction or coronary revascularisation within 30 days. RESULTS: Of 1758 enrolments, 223 (13%) reached the study outcome. Area under the receiver operator characteristic (ROC) curve was 0.79 (95% CI 0.76-0.81) for the NHF/CSANZ group and 0.71 (0.68-0.75) for TIMI score based on initial troponin result (P<0.001), and 0.82 (95% CI 0.80-0.84) and 0.76 (0.73-0.79) respectively when the 8-12 h troponin result is included (P=0.001). Thirty day event rates were 33% for NHF/CSANZ high-risk vs 1.5% for combined low/intermediate risk (P<0.001). For TIMI score, 30 day event rates were 23% for a score ≥2 and 4.8% for TIMI<2 (P<0.001). The NHF/CSANZ guideline identified more patients as low risk compared with the TIMI risk score (61% vs 48%, P<0.001). CONCLUSIONS: The NHF/CSANZ guideline is superior to the TIMI risk score for risk stratification of suspected ACS in the ED.

Simon Brown and Stephen Macdonald argue that patients with stroke should not be given thrombolysis outside clinical trials, but Graeme Hankey says the benefits are clear in carefully selected patients

Neural plasticity—the ability to alter a neuronal response to environmental stimuli—is an important factor in learning and memory. Short-term synaptic plasticity and long-term synaptic plasticity, including long-term potentiation and long-term depression, are the most-characterized models of learning and memory at the molecular and cellular level. These processes are often disrupted by neurodegeneration-induced dementias. Alzheimer’s disease (AD) accounts for 50% of cases of dementia. Vascular dementia (VaD), Parkinson’s disease dementia (PDD), dementia with Lewy bodies (DLB), and frontotemporal dementia (FTD) constitute much of the remaining cases. While vascular lesions are the principal cause of VaD, neurodegenerative processes have been established as etiological agents of many dementia diseases. Chief among such processes is the deposition of pathological protein aggregates in vivo including β-amyloid deposition in AD, the formation of neurofibrillary tangles in AD and FTD, and the accumulation of Lewy bodies composed of α-synuclein aggregates in DLB and PDD. The main symptoms of dementia are cognitive decline and memory and learning impairment. Nonetheless, accurate diagnoses of neurodegenerative diseases can be difficult due to overlapping clinical symptoms and the diverse locations of cortical lesions. Still, new neuroimaging and molecular biomarkers have improved clinicians’ diagnostic capabilities in the context of dementia and may lead to the development of more effective treatments. Both genetic and environmental factors may lead to the aggregation of pathological proteins and altered levels of cytokines, such that can trigger the formation of proinflammatory immunological phenotypes. This cascade of pathological changes provides fertile ground for the development of neural plasticity disorders and dementias. Available pharmacotherapy and disease-modifying therapies currently in clinical trials may modulate synaptic plasticity to mitigate the effects neuropathological changes have on cognitive function, memory, and learning. In this article, we review the neural plasticity changes seen in common neurodegenerative diseases from pathophysiological and clinical points of view and highlight potential molecular targets of disease-modifying therapies.

OBJECTIVES: Sepsis is acute organ dysfunction in the setting of infection. An accurate diagnosis is important to guide treatment and disposition. Tissue oxygen saturation (StO2) can be estimated noninvasively by near-infrared spectroscopy (NIRS), and may be an indicator of microcirculatory dysfunction in early sepsis. We aimed to determine the utility of StO2 for sepsis recognition and outcome prediction among patients presenting to the emergency department (ED) with infection. PATIENTS AND METHODS: A multicentre, prospective, observational cohort study recruited patients who were being admitted to hospital with infection. StO2 was measured in the ED using a handheld NIRS device, Inspectra 300. Outcomes were sepsis, defined as an increase in sequential organ failure assessment score of at least 2 points within 72 h, and composite in-hospital mortality/ICU admission at least 3 days. RESULTS: A cohort of 323 participants, median age 64 (interquartile range: 47-77) years, was recruited at three Australian hospitals. 143 (44%) fulfilled the criteria for sepsis and 22 (7%) died within 30 days. The mean ± SD StO2 was 74 ± 8% in sepsis and 78 ± 7% in nonsepsis (P < 0.0001). StO2 correlated with the peak sequential organ failure assessment score (Spearman's ρ -0.27, P < 0.0001). Area under the receiver operating characteristic curve was 0.66 (95% confidence interval: 0.60-0.72) for sepsis and 0.66 (0.58-0.75) for the composite outcome. StO2 less than 75% had an odds ratio of 2.67 (1.45-4.94; P = 0.002), for the composite outcome compared with StO2 at least 75%. CONCLUSION: NIRS-derived StO2 correlates with organ failure and is associated with outcome in sepsis. However, its ability to differentiate sepsis among ED patients with infection is limited. NIRS cannot be recommended for this purpose.

AIM: The Thrombolysis in Myocardial Infarction (TIMI) risk score (range 0-7), used for emergency department (ED) risk stratification of patients with suspected acute coronary syndrome (ACS), underestimates risk associated with ECG changes or cardiac troponin elevation. A modified TIMI score (mTIMI, range 0-10), which gives increased weighting to these variables, has been proposed. We aimed to evaluate the performance of the mTIMI score in ED patients with suspected ACS. METHODS: A multicentre prospective observational study enrolled patients undergoing assessment for possible ACS. TIMI and mTIMI scores were calculated. The study outcome was a composite of all-cause death, myocardial infarction or coronary revascularisation within 30 days. RESULTS: Of the 1666 patients, 219 (13%) reached the study outcome. Area under the receiver operating characteristic curve for the composite outcome was 0.80 (0.76 to 0.83) for the mTIMI score compared with 0.71 (0.67 to 0.74) for the standard TIMI score, p<0.001, but there was no significant difference for death or revascularisation outcomes. Sensitivity and specificity for the composite outcome were 0.96 (0.92 to 0.98) and 0.23 (0.20 to 0.26), respectively, at score 0 for TIMI and mTIMI. At score <2, sensitivity and specificity were 0.82 (0.77 to 0.87) and 0.53 (0.51 to 0.56) for mTIMI, and 0.74 (0.68 to 0.79) and 0.54 (0.51 to 0.56) for standard TIMI, respectively. CONCLUSIONS: mTIMI score performs better than standard TIMI score for ED risk stratification of chest pain, but neither is sufficiently sensitive at scores >0 to allow safe and early discharge without further investigation or follow-up. Observed differences in performance may be due to incorporation bias.

A focused cardiac ultrasound performed by an emergency physician is becoming part of the standard assessment of patients in a variety of clinical situations. The development of inexpensive, portable handheld devices promises to make point-of-care ultrasound even more accessible over the coming decades. Many of these handheld devices are beginning to integrate artificial intelligence (AI) for image analysis. The integration of AI into focused cardiac ultrasound will have a number of implications for emergency physicians. This perspective presents an overview of the current state of AI research in echocardiography relevant to the emergency physician, as well as the future possibilities, challenges and risks of this technology.

Endoscopy of the upper gastrointestinal tract (GIT) is a common medical examination. One of the rare but serious, albeit fatal complications of gastroscopy is venous air embolism. We performed a literature search with the keywords "air embolism", "gastroscopy", and "endoscopy". There were 14 cases of air embolism associated with gastroscopy. The median age was 66 years old (range 4 months-80 years old). The main presenting symptoms were neurological (n=9) and respiratory compromise (n=7). The main investigation used for diagnosis were CT (n=10) and ECHO (n=6). The main risk factor identified was mucosal breach (n=9). Hyperbaric oxygen therapy was used in four cases. The mortality rate is 57.1%. Air embolism is a very rare complication and is often overlooked. Rapid diagnosis is vital for successful treatment. It should be considered in any patient with sudden onset of severe cardiopulmonary and/or neurologic decompensation during gastroscopy.

Objective: To assess the impact of a regional/rural crisis assessment and treatment service (CAT) on admissions into an acute adult inpatient psychiatric facility. Methods: Relevant data for admissions into an acute adult inpatient psychiatric facility in the 18 month periods before and after the establishment of a CAT were compared. Data extracted from available clinical records were transferred into an appropriately structured pro forma for statistical analysis. Results: There were 69 and 53 index inpatient unit admissions in the two time periods. The majority of these were for single, unemployed men aged in their 30s. Although statistically non-significant, the results appear to suggest that there were proportionately fewer readmissions and that admissions were likely to be influenced by illness severity and diagnostic considerations in the period following the establishment of the CAT. The establishment of CAT did not appear to have had much impact on the duration of psychiatric hospitalization. Conclusions: Crisis assessment and treatment services operating within a re-gional/rural integrated mental health setting appear to have only limited impact on hospitalization for psychiatric crisis presentations. There is a need for further studies looking at a broader range of outcome variables in the assessment of the impact of CAT on psychiatric hospitalization in such settings.