Yunos N.M.,Sunway University |
Bellomo R.,Austin Hospital |
Bellomo R.,Monash University |
Hegarty F.C.,Austin Hospital |
And 3 more authors.
JAMA - Journal of the American Medical Association | Year: 2012
Context: Administration of traditional chloride-liberal intravenous fluids may precipitate acute kidney injury (AKI). Objective: To assess the association of a chloride-restrictive (vs chloride-liberal) intravenous fluid strategy with AKI in critically ill patients. Design, Setting, and Patients: Prospective, open-label, sequential period pilot study of 760 patients admitted consecutively to the intensive care unit (ICU) during the control period (February 18 to August 17, 2008) compared with 773 patients admitted consecutively during the intervention period (February 18 to August 17, 2009) at a university-affiliated hospital in Melbourne, Australia. Interventions: During the control period, patients received standard intravenous fluids. After a 6-month phase-out period (August 18, 2008, to February 17, 2009), any use of chloride-rich intravenous fluids (0.9% saline, 4% succinylated gelatin solution, or 4% albumin solution) was restricted to attending specialist approval only during the intervention period; patients instead received a lactated solution (Hartmann solution), a balanced solution (Plasma-Lyte 148), and chloride-poor 20% albumin. Main Outcome Measures: The primary outcomes included increase from baseline to peak creatinine level in the ICU and incidence of AKI according to the risk, injury, failure, loss, end-stage (RIFLE) classification. Secondary post hoc analysis outcomes included the need for renal replacement therapy (RRT), length of stay in ICU and hospital, and survival. Results: Chloride administration decreased by 144 504 mmol (from 694 to 496 mmol/patient) from the control period to the intervention period. Comparing the control period with the intervention period, the mean serum creatinine level increase while in the ICU was 22.6 μmol/L (95% CI, 17.5-27.7 μmol/L) vs 14.8 μmol/L (95% CI, 9.8-19.9 μmol/L) (P=.03), the incidence of injury and failure class of RIFLE-defined AKI was14% (95% CI, 11%-16%; n=105) vs 8.4% (95% CI, 6.4%-10%; n=65) (P<.001), and the use of RRT was 10% (95% CI, 8.1%-12%; n=78) vs 6.3% (95% CI, 4.6%-8.1%; n=49) (P=.005). After adjustment for covariates, this association remained for incidence of injury and failure class of RIFLE-defined AKI (odds ratio, 0.52 [95% CI, 0.37-0.75]; P<.001) and use of RRT (odds ratio, 0.52 [95% CI, 0.33-0.81]; P=.004). There were no differences in hospital mortality, hospital or ICU length of stay, or need for RRT after hospital discharge. Conclusion: The implementation of a chloride-restrictive strategy in a tertiary ICU was associated with a significant decrease in the incidence of AKI and use of RRT. Trial Registration: clinicaltrials.gov Identifier: NCT00885404 ©2012 American Medical Association. All rights reserved.
Clouston D.,Focus Pathology |
Bolton D.,Austin Hospital
BJU International | Year: 2012
• This is the first of a two part series reviewing the nature and clinical significance of in situ cellular proliferations in the prostate gland. • This first part examines prostatic intraepithelial neoplasia (PIN), while the second part in the next supplement discusses intraductal carcinoma and ductal adenocarcinoma of the prostate. • PIN is a precursor lesion in the development of some forms of adenocarcinoma of the prostate. In the 1990s, high-grade PIN (HGPIN) on biopsy was a significant predictor of carcinoma, but this was due to incomplete sampling with sextant biopsies. With more extensive sampling in the last decade, the likelihood of identifying cancer after a diagnosis of HGPIN is not significantly different from a benign diagnosis. • In several recent studies, it is now recognised that multifocal HGPIN is a better predictor of cancer than unifocal HGPIN. Most cases of cancer will be detected in the vicinity of the HGPIN, but up to 40% of cancers will occur in different sextants. • In assessing potential markers for carcinoma in men with HGPIN on biopsy, α-methylacyl coenzyme-A racemase (AMACR) has emerged as a promising diagnostic tool. • HGPIN with strong staining for AMACR is associated with a higher rate of cancer detection in subsequent biopsies compared with AMACR-negative HGPIN. Also, AMACR positivity in HGPIN is more commonly seen adjacent to carcinoma, and this may provide guidance as to the site of future biopsies. © 2012 The Authors © 2012 BJU International.
Quanjer P.H.,Erasmus Medical Center |
Brazzale D.J.,Austin Hospital |
Boros P.W.,National Tuberculosis and Lung Diseases Research Institute |
Pretto J.J.,John Hunter Hospital
European Respiratory Journal | Year: 2013
The aim of this study was to determine the diagnostic and interpretative consequences of adopting the Global Lungs Initiative (GLI) 2012 spirometric prediction equations. We assessed spirometric records from 17 572 subjects (49.5% females), aged 18-85 years, from hospitals in Australia and Poland. We calculated predicted forced expiratory volume in 1 s (FEV1), forced expiratory volume (FVC), FEV1/ FVC and lower limits of normal (LLN) using European Community for Steel and Coal (ECSC), National Health and Nutrition Examination Survey (NHANES) III and GLI 2012 equations. Obstruction was defined as FEV1/FVC
Bagshaw S.M.,University of Alberta |
Bellomo R.,Austin Hospital
Current Opinion in Critical Care | Year: 2010
Purpose of Review: This review will summarize and discuss the role of cystatin C in the diagnosis of acute kidney injury. Recent Findings: Cystatin C is easily measured and has the characteristics of an ideal marker of kidney function. Data suggest that cystatin C is modified by age, sex, muscle mass, obesity, smoking status, thyroid function, inflammation, and malignancy. These factors suggest the need for age-specific and sex-specific reference standards. Cystatin C-based glomerular filtration rate estimates may perform better than creatinine in selected patient populations (elderly, children, transplantation, cirrhosis, malnourished). Cystatin C has been evaluated for the early diagnosis of acute kidney injury (AKI) in several populations. Serum cystatin C has value for the diagnosis of acute kidney injury; however, it has often performed similarly to creatinine. Urinary cystatin C has potential as an early marker. Summary: Cystatin C is an accurate biomarker for the early detection of AKI, and may, in selected populations, be superior to creatinine; however, data have been inconsistent. It also has reasonable discrimination for important outcomes such as death and renal replacement therapy (RRT). Additional studies are needed that focus on the cost-effectiveness of earlier detection of AKI with cystatin C compared with creatinine, and whether these biomarkers have complementary value. © 2010 Wolters Kluwer Health | Lippincott Williams &Wilkins.
Egi M.,Okayama University |
Finfer S.,University of Sydney |
Bellomo R.,Austin Hospital
Chest | Year: 2011
Hyperglycemia is common in critically ill patients, with approximately 90% of patients treated in an ICU developing blood glucose concentrations > 110 mg/dL (6.1 mmol/L). Landmark trials in Leuven, Belgium, suggested that targeting normoglycemia(a blood glucose concentration of 80-110 mg/dL [4.4-6.1 mmol/L]) reduced mortality and morbidity, but other investigators have not been able to replicate these findings. Recently, the international multicenter Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation (NICE-SUGAR) study reported increased mortality with this approach, and recent meta-analyses do not support intensive glucose control for critically ill patients. Although the initial trials in Leuven produced enthusiasm and recommendations for intensive blood glucose control, the results of the NICE-SUGAR study have resulted in the more moderate recommendation to target a blood glucose concentration between 144 mg/dL and 180 mg/dL (8-10 mmol/L). As critical care practitioners pay greater attention to glycemic control, it has become clear that currently used point-of-care measuring systems are not accurate enough to target tight glucose control. Unresolved issues include whether increased blood glucose variability is inherently harmful and whether even moderate hypoglycemia can be tolerated in the quest for tighter blood glucose control. Future research must first address whether intensive glucose control can be delivered safely, and whether computerized decision support systems and newer technologies that allow accurate and continuous or near-continuous measurement of blood glucose can make this possible. Until such time, clinicians would be well advised to abide by the age-old adage to "first, do no harm." © 2011 American College of Chest Physicians.
McDonald C.F.,Austin Hospital
Internal medicine journal | Year: 2013
Chronic obstructive pulmonary disease (COPD) is characterised by progressive airflow limitation in the presence of identifiable risk factors. Inflammation is the central pathological feature in the pathogenesis of COPD. In addition to its pulmonary effects, COPD is associated with significant extrapulmonary manifestations, including ischaemic heart disease, osteoporosis, stroke and diabetes. Anxiety and depression are also common. Spirometry remains the gold standard diagnostic tool. Pharmacologic and non-pharmacologic therapy can improve symptoms, quality of life and exercise capacity and, through their effects on reducing exacerbations, have the potential to modify disease progression. Bronchodilators are the mainstay of pharmacotherapy, with guidelines recommending a stepwise escalating approach. Smoking cessation is paramount in managing COPD, with promotion of physical activity and pulmonary rehabilitation being other key factors in management. Comorbidities should be actively sought and managed in their own right. Given the chronicity and progressive nature of COPD, ongoing monitoring and support with timely discussion of advanced-care planning and end-of-life issues are recommended. © 2013 The Authors; Internal Medicine Journal © 2013 Royal Australasian College of Physicians.
Peyton P.J.,Austin Hospital |
Peyton P.J.,University of Melbourne |
Chong S.W.,Austin Hospital
Anesthesiology | Year: 2010
When assessing the accuracy and precision of a new technique for cardiac output measurement, the commonly quoted criterion for acceptability of agreement with a reference standard is that the percentage error (95% limits of agreement/mean cardiac output) should be 30% or less. We reviewed published data on four different minimally invasive methods adapted for use during surgery and critical care: pulse contour techniques, esophageal Doppler, partial carbon dioxide rebreathing, and transthoracic bioimpedance, to assess their bias, precision, and percentage error in agreement with thermodilution. An English language literature search identified published papers since 2000 which examined the agreement in adult patients between bolus thermodilution and each method. For each method a meta-analysis was done using studies in which the first measurement point for each patient could be identified, to obtain a pooled mean bias, precision, and percentage error weighted according to the number of measurements in each study. Forty-seven studies were identified as suitable for inclusion: N studies, n measurements: mean weighted bias [precision, percentage error] were: pulse contour N = 24, n = 714: -0.00 l/min [1.22 l/min, 41.3%]; esophageal Doppler N = 2, n = 57: -0.77 l/min [1.07 l/min, 42.1%]; partial carbon dioxide rebreathing N = 8, n = 167: -0.05 l/min [1.12 l/min, 44.5%]; transthoracic bioimpedance N = 13, n = 435: -0.10 l/min [1.14 l/min, 42.9%]. None of the four methods has achieved agreement with bolus thermodilution which meets the expected 30% limits. The relevance in clinical practice of these arbitrary limits should be reassessed. © 2010, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins.
Lim E.J.,Austin Hospital
World journal of gastroenterology : WJG | Year: 2012
Hepatitis C (HCV)-infected patients have a poorer survival post-liver transplantation compared to patients transplanted for other indications, since HCV recurrence post-transplant is universal and commonly follows an aggressive course. There is increasing evidence that in the non-transplant setting, induction of hepatocyte apoptosis is one of the main mechanisms by which HCV drives liver inflammation and fibrosis, and that HCV proteins directly promote apoptosis. Recent studies have shown that post-liver transplant, there is a link between high levels of HCV replication, enhanced hepatocyte apoptosis and the subsequent development of rapidly progressive liver fibrosis. Although the responsible mechanisms remain unclear, it is likely that immunosuppressive drugs play an important role. It is well known that immunosuppressants impair immune control of HCV, thereby allowing increased viral replication. However there is also evidence that immunosuppressants may directly induce apoptosis and this may be facilitated by the presence of high levels of HCV replication. Thus HCV and immunosuppressants may synergistically interact to further enhance apoptosis and drive more rapid fibrosis. These findings suggest that modulation of apoptosis within the liver either by changing immunosuppressive therapy or the use of apoptosis inhibitors may help prevent fibrosis progression in patients with post-transplant HCV disease.
Page D.E.,University of Melbourne |
Taylor D.M.,Austin Hospital
British Journal of Anaesthesia | Year: 2010
BackgroundWe compared the efficacy, acceptability, and safety of a topical vapocoolant alkane spray and 1 plain s.c. lidocaine in reducing pain from i.v. cannulation.MethodsThis was a non-blinded, randomized, controlled trial, in a large emergency department. Adult patients requiring i.v. cannulation were enrolled. The vapocoolant was administered from a pressure pack, at a distance of 12 cm for 2 s, and cannulation was undertaken within 15 s. Alternatively, 1 plain lidocaine 0.2 ml was administered s.c. using a 27 G needle, and cannulation was undertaken after a minimum of 30 s. The primary outcomes were anaesthetic administration and cannulation pain (0-100 mm visual analogue scale). Convenience of anaesthetic use and patient satisfaction were measured using a five-point Likert scale.ResultsOne hundred and ten patients were enrolled in each group. The groups did not differ in age, gender, cannulation anxiety, cannulator experience, cannulation indication or site, or cannula size. Median anaesthetic administration pain scores were 0 and 11 mm in the vapocoolant and lidocaine groups, respectively (P<0.001). Median cannulation pain scores were 9 and 0 mm, respectively (P<0.001). Vapocoolant was associated with greater cannulation success (83.6 vs 67.3, P=0.005), less time to administer (median 9.0 vs 84.5 s, P<0.001), and more staff convenience (median 5 vs 4, P<0.001). Median patient satisfaction was 4 in both groups. Unexpected events were rare and minor.ConclusionsAlthough vapocoolant reduces cannulation pain less than lidocaine, it has a number of important advantages. Vapocoolant offers a useful alternative in the emergency department setting. © The Author 2010. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
Kao Y.H.,Austin Hospital
CardioVascular and Interventional Radiology | Year: 2014
Modern advances in interventional radiology and nuclear medicine may now allow for safe and effective 90Y radioembolization to sites other than the liver. A general theory of predictive dosimetry based on the MIRD schema is proposed, adapted from the original partition model for liver 90Y radioembolization. © 2013 Springer Science+Business Media and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).