Casey Hospital

Abstract Rationale Initial reports of case fatality rates (CFRs) among adults with coronavirus disease (COVID-19) receiving invasive mechanical ventilation (IMV) are highly variable. Objectives To examine the CFR of patients with COVID-19 receiving IMV. Methods Two authors independently searched PubMed, Embase, medRxiv, bioRxiv, the COVID-19 living systematic review, and national registry databases. The primary outcome was the “reported CFR” for patients with confirmed COVID-19 requiring IMV. “Definitive hospital CFR” for patients with outcomes at hospital discharge was also investigated. Finally, CFR was analyzed by patient age, geographic region, and study quality on the basis of the Newcastle-Ottawa Scale. Measurements and Results: Sixty-nine studies were included, describing 57,420 adult patients with COVID-19 who received IMV. Overall reported CFR was estimated as 45% (95% confidence interval [CI], 39–52%). Fifty-four of 69 studies stated whether hospital outcomes were available but provided a definitive hospital outcome on only 13,120 (22.8%) of the total IMV patient population. Among studies in which age-stratified CFR was available, pooled CFR estimates ranged from 47.9% (95% CI, 46.4–49.4%) in younger patients (age ≤40 yr) to 84.4% (95% CI, 83.3–85.4%) in older patients (age >80 yr). CFR was also higher in early COVID-19 epicenters. Overall heterogeneity is high (I2 >90%), with nonsignificant Egger’s regression test suggesting no publication bias. Conclusions Almost half of patients with COVID-19 receiving IMV died based on the reported CFR, but variable CFR reporting methods resulted in a wide range of CFRs between studies. The reported CFR was higher in older patients and in early pandemic epicenters, which may be influenced by limited ICU resources. Reporting of definitive outcomes on all patients would facilitate comparisons between studies. Systematic review registered with PROSPERO (CRD42020186997).

Preclinical testing is a crucial step in evaluating cancer therapeutics. We aimed to establish a significant resource of patient-derived xenografts (PDXs) of prostate cancer for rapid and systematic evaluation of candidate therapies. The PDX collection comprises 59 tumors collected from 30 patients between 2012-2020, coinciding with availability of abiraterone and enzalutamide. The PDXs represent the clinico-pathological and genomic spectrum of prostate cancer, from treatment-naïve primary tumors to castration-resistant metastases. Inter- and intra-tumor heterogeneity in adenocarcinoma and neuroendocrine phenotypes is evident from bulk and single-cell RNA sequencing data. Organoids can be cultured from PDXs, providing further capabilities for preclinical studies. Using a 1 x 1 x 1 design, we rapidly identify tumors with exceptional responses to combination treatments. To govern the distribution of PDXs, we formed the Melbourne Urological Research Alliance (MURAL). This PDX collection is a substantial resource, expanding the capacity to test and prioritize effective treatments for prospective clinical trials in prostate cancer.

This study was a qualitative investigation aimed at exploring clinical educator’s perceptions of the clinical education experience and barriers to providing more clinical education. An online questionnaire was sent to physiotherapy clinical educators at hospital and community sites operated by Southern Health in Victoria, Australia. Using the responses, a framework involving key themes “motivators for delivering clinical education,” “consequences of delivering clinical education,” and “beneficiaries of clinical education” was constructed. Motivation for delivering clinical education was consistently reported as duty or responsibility. Consequences of delivering clinical education were comprised of positive effects on department profile, educator professional development, student professional development, and development of the physiotherapy profession, and negative effects on non-clinical tasks. The effect of clinical education on workload was seen as both positive and negative, depending on student ability, attitude, and quantity, as well as on staffing levels. These consequences were distributed across a range of beneficiaries of clinical education, inclusive of students, educators, patients, the department, and the profession. Strategies aimed at enhancing the positive aspects and managing the negative aspects for the clinical educator may be more successful in increasing capacity for student placements.

BACKGROUND: Blastomycosis is an endemic mycosis caused by the dimorphic fungus Blastomyces dermatitidis. Although this disease primarily involves the lungs, the clinical spectrum of blastomycosis can range from subclinical infection to extrapulmonary dissemination. The central nervous system (CNS) form of blastomycosis is primarily treated with an amphotericin B formulation, but associated toxicities of this agent preclude its use in some patients. Voriconazole is a broad-spectrum triazole antifungal that has emerged as a potential treatment option for CNS blastomycosis because of its excellent penetration into the cerebrospinal fluid and brain tissue. OBJECTIVE: To evaluate evidence for the use of voriconazole in the treatment of CNS blastomycosis. DATA SOURCES: A literature search was performed using MEDLINE, EMBASE, Cochrane Database, and PubMed (all up to April 2009). Search terms included voriconazole, blastomyces, blastomycosis, CNS, cerebral, and central nervous system. STUDY SELECTION AND DATA EXTRACTION: English-language clinical trials, case reports, treatment guidelines, and background material were searched for voriconazole safety and efficacy data. References of reviewed articles were examined and used to identify additional sources. DATA SYNTHESIS: A search of the literature yielded 2 published case reports and 2 case series documenting a total of 7 cases of CNS blastomycosis. In all cases, CNS blastomycosis was successfully treated sequentially with amphotericin B followed by voriconazole. To date, no clinical trials have evaluated the use of voriconazole in treating CNS blastomycosis. Ages of the patients with documented cases of CNS blastomycosis ranged from 14 months to 63 years. In at least 5 cases, CNS blastomycosis presented as lesions in the brain detected by magnetic resonance imaging. One case presented as focal splenic lesions. The remaining 2 were diagnosed based on neuroimaging studies or positive spinal fluid serology. Prior to receiving voriconazole, patients were treated with an amphotericin B formulation combined in some situations with either fluconazole or itraconazole. Subjects underwent treatment with voriconazole for an average of 11 months, with disease remission or stabilization detected in all cases. CONCLUSIONS: Further studies are needed to fully elucidate the role of voriconazole in the treatment of CNS blastomycosis. It nonetheless may be considered as an azole option for either follow-up therapy after liposomal amphotericin B therapy or as salvage therapy in patients intolerant of amphotericin B or other azoles.

OBJECTIVE: To assess whether electrocardiogram (ECG) interpretation accuracy improves with advancing years of emergency medicine training. METHODS: A prospective cross-sectional double-blinded study of emergency medicine trainees attending teaching sessions in ACEM accredited Victorian hospitals. Subjects completed a survey about level of training, rotations completed and ECG training. They were then asked for the 'main diagnosis' on 10 clinically significant ECG. Those in their fourth year of advanced training onwards, or in active preparation for fellowship examination (senior trainees) were compared with trainees in earlier years (other trainees). RESULTS: There were 122 trainees surveyed in total. In the present study, 48/122 were senior trainees and 74/122 were other trainees. The overall accuracy of ECG interpretation was 67.5% (95% confidence interval [CI] 63.2-71.8%) for the senior trainees and 49.6% (95% CI 45.2-53.9%) for the others. Results for some of the individual ECG were: left bundle branch block: 81.3% (95% CI 69.9-92.6%) seniors and 58.1% (95% CI 46.6-69.7%) others; ventricular tachycardia: 43.8% (95% CI 29.3-58.2%) seniors and 37.8% (95% CI 26.5-49.2%) others; and ventricular fibrillation: 70.8% (95% CI 57.6-84.1%) seniors and 63.5% (95% CI 52.2-74.9%) others. CONCLUSION: There is an improvement in ECG interpretation accuracy with advancing years of emergency medicine training in Victoria. There exists, however, a low level of accuracy for some critical ECG diagnoses. There is a call by trainees for more formalized and regular ECG education to begin earlier in their training.

BACKGROUND: In the year after birth one in six women has a depressive illness, and 30% are still depressed, or depressed again, when their child is 2 years old, 94% experience at least one major health problem (e.g. back pain, perineal pain, mastitis, urinary or faecal incontinence), 26% experience sexual problems and almost 20% have relationship problems with partners. Women with depression report less practical and emotional support from partners, less social support overall, more negative life events, and poorer physical health. Their perceptions of factors contributing to depression are lack of support, isolation, exhaustion and physical health problems. Fewer than one in three affected women seek help in primary care despite frequent contacts. METHODS/DESIGN: PRISM aims to reduce depression and physical health problems of recent mothers through primary care strategies to increase practitioners' response to these issues, and through community-based strategies to develop broader family and community supports for recent mothers. Eligible local governments will be recruited and randomised to intervention or comparison arms, after stratification (urban/rural, size, birth numbers, extent of community activity), avoiding contiguous boundaries. Maternal depression and physical health will be measured six months after birth, in a one year cohort of mothers, in intervention and comparison communities. The sample size to detect a 20% relative reduction in depression, adjusting for cluster sampling, and estimating a population response fraction of 67% is 5740 x 2. Analysis of the physical and mental health outcomes, by intention to treat, will adjust for the correlated structure of the data.

BACKGROUND AND PURPOSE: The recently described Galdakao-modified supine Valdivia position for percutaneous nephrolithotomy (PCNL) has become increasingly popular. We have made further modifications to this and describe our recent experience compared with our previous prone cases. PATIENTS AND METHODS: From April 2011, all patients undergoing PCNL have been placed in the modified supine position. A suction beanbag is used to secure the patient and improve renal access. Data on patient age, comorbidities, stone size, operative time, radiation exposure, complications, stone clearance, and length of stay was collected, analyzed, and compared with data from our previous year's prone surgery. RESULTS: Thirty-six patients in each group underwent 41 PCNLs. The groups were well matched for age, sex, and comorbidity. The supine patients tended to have a higher body mass index. Stones in the supine group were larger (32.6 vs 25.7 mm, P=0.0402), and the operative time was shorter (86.2 vs 116.6 min, P=0.003). Radiation time was similar in the two groups, but the dose was higher in the supine group. Stone clearance rates, length of stay (2.5 days), and complications were similar. Nineteen (46%) patients underwent simultaneous lower urinary tract procedures including 4 (10%) with complete staghorn calculi for which ureterorenoscopy was used to fragment ureteral and upper renal pole stones. CONCLUSIONS: The modified supine position for PCNL has a number of advantages for the patient and staff compared with the prone position. Despite a more obese study group with larger stones, we have maintained stone clearance rates and significantly reduced operative time with no increase in complications. The technique has been easy to learn and teach. A major advantage has been simultaneous access to the lower urinary tract for ureteroscopy and stent placement, and this has helped with complete stone clearance.

WHAT IS KNOWN AND OBJECTIVES: Changes to medication regimens and failure to involve patients in management of their medications whilst in hospital may result in medication errors or non-adherence at home after discharge. Self-administration of medications programmes (SAMP) have been used to address this issue. The objective of this study was to assess the impact of a SAMP on elderly hospital inpatients' competence to manage medications and their medication adherence behaviours. METHODS: The SAMP comprised three stages: education, progressing to supervised self-administration and finally to independent self-administration. Decisions to progress patients to the next level, and whether they passed or failed the SAMP, were made by the ward pharmacist and nursing staff. The Drug Regimen Unassisted Grading Scale (DRUGS) was used to assess patients' competence to manage medications at various time points. Tablet count and the Tool for Adherence Behaviour Screening (TABS) were used as adherence measures. RESULTS AND DISCUSSION: Participants (n = 24) with a mean age of 77.4 years, were mainly female and generally had a high level of functioning. They were prescribed a mean of 9.0 medications at the time of commencing the SAMP. Twenty-two of the 24 participants successfully completed the SAMP. DRUGS scores at discharge improved significantly (P<0.001) compared with that before commencement of medication self-administration. Participants reported a significant decrease (P = 0.02) in non-adherent behaviour and a trend towards improved adherent behaviour (P=0.08) after participation in the SAMP. WHAT IS NEW AND CONCLUSION: An inpatient SAMP improved elderly patients' ability to competently manage and adhere to their prescribed medications regimen. This finding needs to be confirmed in a larger controlled trial.

OBJECTIVE: Compare pain relief from non-opioid, codeine and oxycodone analgesic regimens in adults with moderate pain from limb injury. METHOD: Double-blind, randomised, controlled, non-inferiority trial. Three regimens of six tablets, each included 2 × 500 mg paracetamol and 2 × 200 mg ibuprofen with 2 × 100 mg thiamine (non-opioid), 2 × 30 mg codeine (codeine) or 2 × 5 mg oxycodone tablets (oxycodone). PRIMARY OUTCOME: difference in mean visual analogue scale (VAS) change between groups at 30 min, with a limit of inferiority of 13. Secondary outcomes included mean change in VAS rating from baseline to 30 min for each group, patient satisfaction, need for additional analgesia and adverse events. Pain ratings taken at 60 and 90 min for patients still in ED are described. RESULTS: Of 182 patients randomised, non-opioid, codeine and oxycodone numbers were 61, 62 and 59. Differences (95% CI) between groups at 30 min were as follows: non-opioid versus codeine -2.6 (-8.8 to 3.6); non-opioid versus oxycodone -2.7 (-9.3 to 3.9); codeine versus oxycodone 0.1 (-6.6 to 6.4). Mean VAS reductions for non-opioid, codeine and oxycodone were -13.5, -16.1 and -16.2 mm, respectively. Satisfaction with analgesia was reported by 77.6% (64.7-87.5), 81.0% (67.2-89.0) and 73.6% (59.7-84.7) and adverse events by 3.3% (0.4-11.3), 1.6% (0.4-8.7) and 16.9% (8.4-29.0), respectively. Mean VAS reductions at 60 and 90 min were as follows: -23.2 and -18.7 mm for non-opioid; -30.7 and -33.3 mm for codeine; and -26.1 and -31.7 mm for oxycodone. CONCLUSION: At 30 min, analgesic effects of non-opioid, codeine and oxycodone groups were non-inferior.

BACKGROUND: Information on the management of chronic obstructive pulmonary disease (COPD) in Australia, especially the extent of adherence to the COPD-X Plan, is sparse. AIM: To evaluate COPD patient adherence to treatment recommendations and healthcare provider adherence to the COPD-X Plan. METHODS: Cross-sectional study of patients admitted to a secondary care hospital with an acute exacerbation of COPD over a 6-month period. Data were collected from patient interviews and medical notes. RESULTS: Participants (n= 45) aged 72 ± 11.5 years (mean ± SD) had a mean FEV(1) % predicted 52.2 ± 18.7. At the time 11 (24.4%) patients continued to smoke; 25 (55.6%) had never participated in a pulmonary rehabilitation programme; and 23 (51.1%) self-reported poor adherence to some COPD medications. Inhaler technique was deemed suboptimal in 25 (55.6%) patients. Only 11 (24.4%) patients had received any instructions from their doctor regarding management of exacerbations. The use of medications not supported by the COPD-X guidelines were: long-term prednisolone (11, 24.4%) and prophylactic antibiotics (3, 6.7%). CONCLUSION: Management of COPD in Australia by both patients and providers remains suboptimal despite the publication and wide dissemination of the COPD-X Plan, suggesting the need to intensify both patient and provider education in COPD management.

OBJECTIVE: Exercise, yoga, and tai chi are commonly used complementary approaches for health and wellness. This review aims to synthesize the evidence for exercise, yoga, and tai chi in the outpatient treatment of major depressive disorder. STUDY SELECTION: A systematic search of the Ovid MEDLINE, EMBASE, PsycINFO, and Cochrane databases was conducted for randomized controlled trials of exercise, yoga, and tai chi for major depressive disorder. DATA EXTRACTION: Standardized mean differences were calculated and meta-analyzed using a random effects multilevel modeling framework. Heterogeneity and subgroup analysis was conducted. RESULTS: Twenty-five studies were included for final analysis (exercise: 15, yoga: 7, tai chi: 3). Overall, meta-analysis showed a moderate significant clinical effect. However, when only studies (6 studies) with the lowest risk of bias were included, the overall effect size was reduced to low to moderate efficacy. Overall quality of evidence was low. Heterogeneity and publication bias were high. CONCLUSIONS: The current meta-analysis of outpatient exercise, yoga, and tai chi for treatment of major depressive disorder suggests that adjunctive exercise and yoga may have small additive clinical effects in comparison to control for reducing depressive symptoms. The evidence for tai chi is insufficient to draw conclusions. The concerns with quality of studies, high heterogeneity, and evidence of publication bias preclude making firm conclusions.

Amplifications of the androgen receptor (AR) occur in up to 80% of men with castration-resistant prostate cancer (CRPC). Recent studies highlighted that these amplifications not only span the AR gene but usually encompass a distal enhancer. This represents a newly recognised, non-coding mechanism of resistance to AR-directed therapies, including enzalutamide. To study disease progression before and after AR amplification, we used tumour samples from a castrate-sensitive primary tumour and castrate-resistant metastasis of the same patient. For subsequent functional and genomic studies, we established serially transplantable patient-derived xenografts (PDXs). Whole genome sequencing showed that alterations associated with poor prognosis, such as TP53 and PTEN loss, existed before androgen deprivation therapy, followed by co-amplification of the AR gene and enhancer after the development of metastatic CRPC. The PDX of the primary tumour, without the AR amplification, was sensitive to AR-directed treatments, including castration, enzalutamide, and apalutamide. The PDX of the metastasis, with the AR amplification, had higher AR and AR-V7 expression in castrate conditions, and was resistant to castration, apalutamide, and enzalutamide in vivo. Treatment with a BET inhibitor outperformed the AR-directed therapies for the metastasis, resulting in tumour regression for some, but not all, grafts. Therefore, this study provides novel matched PDXs to test potential treatments that target the overabundance of AR in tumours with AR enhancer amplifications. © 2021 The Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

BACKGROUND: Serially transplantable patient-derived xenografts (PDXs) are invaluable preclinical models for studying tumor biology and evaluating therapeutic agents. As these models are challenging to establish from prostate cancer specimens, the ability to preserve them through cryopreservation has several advantages for ongoing research. Despite this, there is still uncertainty about the ability to cryopreserve PDXs of prostate cancer. This study compared three different cryopreservation protocols to identify a method that can be used to reproducibly cryopreserve a diverse cohort of prostate cancer PDX models. METHODS: One serially transplantable prostate cancer PDX from the Melbourne Urological Research Alliance cohort was used to compare three cryopreservation protocols: slow freezing in fetal calf serum (FCS) with 10% dimethyl sulfoxide (DMSO), FCS with 10% DMSO supplemented with the Rho-associated kinase (ROCK) inhibitor Y-27632 and vitrification. The efficiency of the slow freezing protocols was then assessed in 17 additional prostate cancer PDXs. Following cryopreservation, PDXs were re-established in host mice that were either intact and supplemented with testosterone or castrated. Graft take rate, tumor growth, histological features, and transcriptome profiles before and after cryopreservation were compared. RESULTS: Slow freezing maintained the viability and histological features of prostate cancer PDXs, and the addition of a ROCK inhibitor increased their growth following cryopreservation. Using the slow freezing method, we re-established 100% of PDXs grown in either testosterone-supplemented or castrated host mice. Importantly, the long-term tumor growth rate and transcriptome profile were maintained following cryopreservation. CONCLUSION: This study has identified a protocol to reliably cryopreserve and re-establish a diverse cohort of serially transplantable PDXs of prostate cancer. This study has the potential to significantly improve the practicality of maintaining PDX models. Cryopreservation may also increase the accessibility of these important resources and provide new opportunities for preclinical studies on a broader spectrum of prostate tumors.

OBJECTIVE: Patients, families and community members would like emergency department wait time visibility. This would improve patient journeys through emergency medicine. The study objective was to derive, internally and externally validate machine learning models to predict emergency patient wait times that are applicable to a wide variety of emergency departments. METHODS: Twelve emergency departments provided 3 years of retrospective administrative data from Australia (2017-2019). Descriptive and exploratory analyses were undertaken on the datasets. Statistical and machine learning models were developed to predict wait times at each site and were internally and externally validated. Model performance was tested on COVID-19 period data (January to June 2020). RESULTS: There were 1 930 609 patient episodes analysed and median site wait times varied from 24 to 54 min. Individual site model prediction median absolute errors varied from±22.6 min (95% CI 22.4 to 22.9) to ±44.0 min (95% CI 43.4 to 44.4). Global model prediction median absolute errors varied from ±33.9 min (95% CI 33.4 to 34.0) to ±43.8 min (95% CI 43.7 to 43.9). Random forest and linear regression models performed the best, rolling average models underestimated wait times. Important variables were triage category, last-k patient average wait time and arrival time. Wait time prediction models are not transferable across hospitals. Models performed well during the COVID-19 lockdown period. CONCLUSIONS: Electronic emergency demographic and flow information can be used to approximate emergency patient wait times. A general model is less accurate if applied without site-specific factors.

UNLABELLED: What's known on the subject? and What does the study add? Radiation exposure is a cause of cancer. Increasing use of CT scans has increased patient exposure to ionizing radiation which may increase long-term risk of cancer. Not all scans performed may be medically necessary. Up to 30% of patients presenting with renal/ureteric colic have been estimated to receive too much radiation. At least 30% of patients attending for stone surgery have exceeded the recommended annual radiation dosage. Many Australian radiology providers do not routinely record CT radiation dose. Radiation dose varies widely between individual patients and between radiology providers. Image intensifiers may be an additional significant source of radiation exposure. Implementing guidelines and informing patients of their cumulative radiation exposure should reduce exposure and risk. SUMMARY: At least 44% of a group of patients undergoing stone operations have been exposed to high levels of radiation, mostly from repeated CT scans, over a short period with possible increased risk of developing cancer. We suggest ways in which that risk can be reduced. OBJECTIVE: • To assess radiation exposure in patients attending for surgery for urinary tract stones. PATIENTS AND METHODS: • Fifty-eight consecutive patients attending for stone surgery were asked to provide their radiological imaging over the preceding year. • Radiation dosage was recorded where available. Individual radiology providers were contacted to provide additional data. RESULTS: • The median number of radiological investigations was six (range 2-15). • Patients had attended 12 different providers on 22 sites. Only three providers routinely recorded computed tomography (CT) radiation dose. • Up to 26 patients (44%) were subjected to at least 50 mGy radiation in the course of their treatment with at least eight (13.8%) receiving over 100 mGy from CT scans alone. • CT and image intensifier radiation dose varied considerably between providers even for the same patients. CONCLUSIONS: • Many patients with urinary tract stones are subjected to relatively high doses of radiation in the course of their investigation and treatment. This may have later malignant consequences. • Many providers in Australia are not recording radiation dose and patients seem to have many unnecessary scans. • Suggestions on improved management are made which could significantly reduce radiation exposure.

Abstract Background Induction of labour (IOL) is common practice and different methods carry different effectiveness and safety profiles. Objectives To compare the effectiveness, and maternal and perinatal safety outcomes of IOL with vaginal misoprostol versus vaginal dinoprostone using individual participant data from randomised clinical trials. Search strategy The following databases were searched from inception to March 2023: CINAHL Plus, ClinicalTrials.gov, Cochrane Pregnancy and Childbirth Group Trial Register, Ovid Embase, Ovid Emcare, Ovid MEDLINE, Scopus and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). Selection criteria Randomised controlled trials (RCTs), with viable singleton gestation, no language restrictions, and all published and unpublished data. Data collection and analysis An individual participant data meta‐analysis was carried out. Main results Ten of 52 eligible trials provided individual participant data, of which two were excluded after checking data integrity. The remaining eight trials compared low‐dose vaginal misoprostol versus dinoprostone, including 4180 women undergoing IOL, which represents 32.8% of all participants in the published RCTs. Of these, 2077 were assigned to low‐dose vaginal misoprostol and 2103 were assigned to vaginal dinoprostone. Compared with vaginal dinoprostone, low‐dose vaginal misoprostol had a comparable rate of vaginal birth. Composite adverse perinatal outcomes did not differ between the groups. Compared with vaginal dinoprostone, composite adverse maternal outcomes were significantly lower with low‐dose vaginal misoprostol (aOR 0.80, 95% CI 0.65–0.98, P = 0.03, I 2 = 0%). Conclusions Low‐dose vaginal misoprostol and vaginal dinoprostone for IOL are comparable in terms of effectiveness and perinatal safety. However, low‐dose vaginal misoprostol is likely to lead to a lower rate of composite adverse maternal outcomes than vaginal dinoprostone.

OBJECTIVE: An observational study on the current diagnostic and procedural utility, as well as impact of point-of-care ultrasound (POCUS) in the emergency department (ED). BACKGROUND: Point-of-care ultrasound (POCUS) has been recognised as a useful non-invasive bedside tool in providing valuable information, as well as its utility in procedural guidance for clinicians. However, its current prevalence and utility in ED remain unknown. METHODS: In October 2016, a 31-day prospective observational study was performed in three Monash Health Emergency Departments in Melbourne, Australia. Data regarding patients' presenting complaints, frequency, operators' qualifications and POCUS module were collected and analysed. Factors associated with diagnostic impacts were identified. RESULTS: A total of 390 (2.1%) POCUS examinations were performed among 18,355 presentations in the three Monash Health EDs during the study period. POCUS was performed as a diagnostic tool in 344 (88.2%) and procedural guidance in 46 (11.8%) cases. eFAST/AAA and bedside echocardiography were the two most frequently utilised diagnostic modules. Overall, the majority of diagnostic POCUS cases were indicated for abdominal pain (35.3%), chest pain (14.0%) and trauma mainly traffic accidents (5.8%). Procedural POCUS was most commonly used for vascular access (71.7%), where dyspnoea (21.6%) was the most common presenting complaint. The majority of the cases were performed by FACEMs (Fellows of Australasian College of Emergency Medicine) (66.4%). CONCLUSIONS: Despite known diagnostic and procedural values, the prevalence of POCUS in ED was found to be lower than what was expected. The prevalence was shown to be proportional to the level of clinical expertise among the operators. Training and utility of POCUS among physicians and trainees should be further advocated and supported.

BACKGROUND: Virtual communication has become common practice during the coronavirus disease 2019 (COVID-19) pandemic because of visitation restrictions. AIMS: The authors aimed to evaluate overall family satisfaction with the intensive care unit (FS-ICU) care involving virtual communication strategies during the COVID-19 pandemic period. METHODS: In this prospective multicentre study involving three metropolitan hospitals in Melbourne, Australia, the next of kin (NOK) of all eligible ICU patients between 1 July 2020 and 31 October 2020 were requested to complete an adapted version of the FS-ICU 24-questionnaire. Group comparisons were analysed and calculated for family satisfaction scores: ICU/care (satisfaction with care), FS-ICU/dm (satisfaction with information/decision-making) and FS-ICU/total (overall satisfaction with the ICU). The essential predictors that influence family satisfaction were identified using quantitative and qualitative analyses. RESULTS: Seventy-three of the 227 patients' NOK who initially agreed completed the FS-ICU questionnaire (response rate 32.2%). The mean FS-ICU/total was 63.9 (standard deviation [SD], 30.8). The mean score for satisfaction with FS-ICU/dm was lower than the FS-ICU/care (62.1 [SD, 30.3) vs 65.4 (SD, 31.4); P < 0.001]. There was no difference in mean FS-ICU/total scores between survivors (n = 65; 89%) and non-survivors (n = 8, 11%). Higher patient Acute Physiology and Chronic Health Evaluation III score, female NOK and the patient dying in the ICU were independent predictors for FS-ICU/total score, while a telephone call at least once a day by an ICU doctor was related to family satisfaction for FS-ICU/dm. CONCLUSIONS: There was low overall family satisfaction with ICU care and virtual communication strategies adopted during the COVID-19 pandemic. Efforts should be targeted for improving factors with virtual communication that cause low family satisfaction during the COVID-19 pandemic.

Endometriosis is a common gynaecological condition; cutaneous endometriosis is a subtype of endometriosis. Although cutaneous endometriosis involving the abdominal wall is not common, preoperative diagnosis of cutaneous endometriosis can be easily mistaken for a suture granuloma, lipoma, abscess, cyst or hernia. We report two common surgical presentations of this gynaecological condition.

OBJECTIVES: To identify the best population, design of the intervention, and to assess between-group biochemical separation, in preparation for a future phase III trial. DESIGN: Investigator-initiated, parallel-group, pilot randomized double-blind trial. SETTING: Eight ICUs in Australia, New Zealand, and Japan, with participants recruited from April 2021 to August 2022. PATIENTS: Thirty patients greater than or equal to 18 years, within 48 hours of admission to the ICU, receiving a vasopressor, and with metabolic acidosis (pH < 7.30, base excess [BE] < -4 mEq/L, and Pa co2 < 45 mm Hg). INTERVENTIONS: Sodium bicarbonate or placebo (5% dextrose). MEASUREMENTS AND MAIN RESULT: The primary feasibility aim was to assess eligibility, recruitment rate, protocol compliance, and acid-base group separation. The primary clinical outcome was the number of hours alive and free of vasopressors on day 7. The recruitment rate and the enrollment-to-screening ratio were 1.9 patients per month and 0.13 patients, respectively. Time until BE correction (median difference, -45.86 [95% CI, -63.11 to -28.61] hr; p < 0.001) and pH correction (median difference, -10.69 [95% CI, -19.16 to -2.22] hr; p = 0.020) were shorter in the sodium bicarbonate group, and mean bicarbonate levels in the first 24 hours were higher (median difference, 6.50 [95% CI, 4.18 to 8.82] mmol/L; p < 0.001). Seven days after randomization, patients in the sodium bicarbonate and placebo group had a median of 132.2 (85.6-139.1) and 97.1 (69.3-132.4) hours alive and free of vasopressor, respectively (median difference, 35.07 [95% CI, -9.14 to 79.28]; p = 0.131). Recurrence of metabolic acidosis in the first 7 days of follow-up was lower in the sodium bicarbonate group (3 [20.0%] vs. 15 [100.0%]; p < 0.001). No adverse events were reported. CONCLUSIONS: The findings confirm the feasibility of a larger phase III sodium bicarbonate trial; eligibility criteria may require modification to facilitate recruitment.