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Emergency Departments in NSW and across Australia continue to face significant challenges relating to overcrowding and access block. These conditions are projected to deteriorate as the number of patients needing emergency treatment, particularly older patients with cardiovascular presentations (chest pain, shortness of breath) and other chronic medical conditions, continue to increase. The people of NSW urgently need innovative solutions, as part of an overall strategy, to improve ED patient flow and access to timely care. Decisions regarding hospital admission or discharge are critical to ED functioning, meeting patient expectations, resource management and patient outcomes. These disposition decisions are typically made after a series of nursing and medical assessments, which for many patients take several hours. This can cause patient dissatisfaction and increased anxiety, especially for patients with chronic conditions The aim of this project is to facilitate earlier disposition decision making in patients’ journeys through the hospital system in order to reduce ED length of stay, allow patients to access acute medical care earlier and ultimately reduce the burden of ED overcrowding. We propose to implement and evaluate the clinical effectiveness of a novel disposition decision support tool based on State-wide data analysis. It is designed to be used by emergency clinicians at the earliest time possible in patient care to significantly improve timeliness and appropriateness of disposition decision making. The project will be undertaken as a pragmatic randomised control trial and process evaluation at facilities within Sydney Local Health District, with a plan to implement across other LHDs in collaboration with the NSW Agency for Clinical Innovation and E-Health NSW. It is one of twelve priority areas for action identified by the current New South Wales Government (https://www.nsw.gov.au/premiers-priorities ) and most importantly, will bring data analytics to the bedside in order to improve ED patient processes and outcomes for the future.

The objective of the study is to determine whether tourniquet use during total knee replacement results in superior intra-operative and post-operative outcomes when compared to not using a tourniquet. All participants will be undergoing total knee replacement for advanced osteoarthritis. Participants will be followed up for one year following surgery. Outcomes include knee extension strength, pain and analgesia requirements, self-reported physical function and quality of life, blood loss and replacement, surgeon satisfaction with the intra-operative visual field, operation and anaesthetic time, tourniquet inflation time, complications including revision surgery, cement mantle quality, patient satisfaction, and hospital length of stay.

The primary objective of this RCT is to compare the short-term (8-weeks) effects of a protocol developed by a commercial organisation which combines commercially pre-prepared meals and structured exercise programme with a programme which include standard dietary guidelines with a structured exercise programme on body composition changes (body weight and fat mass). The secondary objective is to examine biological factors (fitness and blood profile) and psychosocial well-being and facilitators and barriers to completing the intervention programme and its acceptability.

Background: There is plenty of literature available regarding the harmful effects of smoking and the potentially significant positive influence of counselling in the pre-operative period on long-term cessation. There are, however, few studies and guidelines about this in the Australian healthcare system. Hypothesis and aim: Our study hypothesis is that counselling regarding the advantages of quitting smoking in the pre-admission clinic leads to long-term smoking cessation, and we aim to prove this through our study among smokers undergoing elective surgery in the Armadale Health Service. Methods: We will conduct a non-randomised controlled trial among smokers having elective surgery in the Armadale hospital from April 2018 onwards, aiming to recruit 247 smokers who received pre-operative advice to stop smoking, constituting the intervention group, and 247 who underwent surgery prior to April 2018, who did not receive such advice, comprising the control group, by means of telephone interviews. The primary outcome will be the quitting status 6 months after surgery. The data would be analysed using unpaired chi-squared test. This study will be able to detect a significant increase in quit rates after counselling with a type I error of 0.05 and a power of 0.8. Significance: If we are able to show a significant improvement in long-term quit rates after pre-operative counselling, we can create guidelines for our hospital and provide evidence for the Australian health system to make the provision of tailored advice and support to stop smoking during routine pre-anaesthetic check-ups a necessary standard of care. This could be the beginning of an intensive “Quit Smoking Before Surgery” campaign. As a large proportion of smokers would present themselves for surgery at some point in their lives, this might be an easy and highly effective method of reducing the prevalence of this harmful habit in our society.

Children presenting to the emergency department with lacerations is very common. We wish to conduct a study that compares two types of stitching techniques (called 'deep dermal suturing' and 'simple interrupted suturing'). Both of these methods are commonly used, however it has not been concluded which technique is better for healing lacerations in the child population. Participants will be assigned to receive either the deep dermal technique or the simple interrupted technique to close their wound. Participants (or their family or guardians) will not be aware of which group they are in. After the stitching is complete, the wound will be bandaged for up to 7 days, and participants will be instructed not to remove the bandage or inspect the wound at any time. Participants will be asked to return to an assigned clinic 3 days, 7 days and 3 months after the initial presentation. Here, wounds will be assessed by staff and stitches may be removed (this may require anaesthesia or sedation). If the wounds are found to have incomplete wound closure or dehiscence, a second suture will be administer and patients will be asked to come back at day 14 for reassessment. Three months later, the scar from the wound will be photographed, and medical staff will be asked to rate the appearance of the scar. We aim to determine which of these two methods are superior, considering the economic cost, infection rates, cosmetic outcome and time for wound closure. With these factors in consideration, we hypothesise that there is a clinically significant difference between the deep dermal absorbable and simple interrupted nonabsorbable sutures.

The primary aim of this study is to compare the success rates of the new POP pessary compared to the conventional PVC ring pessary. Treatment success will be defined as retention of the pessary at 6 months follow-up. The secondary objectives are to evaluate subjects’ ability to perform self-care during pessary use, subjects’ satisfaction with pessary treatment and complications. Compared to surgery, vaginal pessaries have been the subjects of minimal scientific research. In particular, long-term vaginal pessary usage has been poorly studied.Whilst there are various shaped vaginal pessaries available it is standard clinical practice is to use a polyvinyl chloride (PVC) ring pessary that is usually changed or replaced every 6 months. With currently available pessaries, the overall retention rate of vaginal pessaries is low, due to discomfort, inconvenience, vaginal discharge or dislodgement. The failure rate (i.e. discontinuation with pessary usage) vary from 27% to 74%. The limited efficacy of currently available vaginal pessaries is well recognized. In our unit we have conducted two studies relevant to vaginal pessary use. They were the vaginal dimensions based on vaginal casts taken from 60 women with pelvic organ prolapse and also biofilm formation on vaginal pessaries after 6 months of use. In order to reduce discharge associated with pessary use patients can be instructed in ‘self-care’ of their pessary by learning how to remove, clean and replace their pessary. However, some women find if difficult to remove and replace traditional PVC ring pessaries. Based on the results of these studies, we have developed a more anatomically shaped pessary. The additional ‘fold points’ in the rim of the pessary and a loop at the caudal end of the new pessary were incorporated into the design to enhance patients’ self-care during pessary use. The ‘fold points’ in the new pessary will make it more flexible (relative to the PVC pessary) during removal and replacement. A loop attached to the caudal aspect of the new pessary will facilitate removal of the pessary by the patient. With the above features, we have hypothesized that the new POP pessary will be at least 30% more successful than the conventional PVC ring pessary.

Difficult or failed intubation is a major and life threatening complication that may occur during induction of general anaesthesia. Thorough preoperative airway assessment is an important component of establishing a safe plan to secure patients’ airways perioperatively. Ultrasound technology is rapidly evolving and becoming more accessible as costs decrease and devices become both more portable and user-friendlier. The use of the ultrasound in airway assessment has been described as early as the 1980s, and recently there has been increasing interest in the use of this technology among anaesthetists worldwide. Ultrasound used in conjunction with clinical airway assessment has multiple advantages and there is a rapidly growing body of evidence supporting its use. Ultrasound can be used to view the majority of the upper airway structures, including the mouth, tongue, oropharynx, hypopharynx, hyoid bone, larynx, vocal cords, cartilages, trachea and oesophagus. In this prospective observational study we will assess the upper airway of patients presenting for surgery requiring endotracheal intubation in a tertiary hospital for potential difficult airway. This will be done both clinically and using an M- Turbo SonoSite ultrasound machine. We will measure the hyomental distance in neutral and the hyperextended position and will assess the anterior neck thickness at the level of the hyoid and thyrohoid membrane. Pre operative results and perioperative airway management including any difficulties with intubation will be documented and compared accordingly. The objectives of this study are to determine the utility of the use of the ultrasound to predict a difficult intubation, and examine the association, if any, between ultrasound measurements and difficult airway clinical screening tests.

Overweight and obesity are major global public health issues identified to contribute to disease burden by increasing the risk of diabetes and cardiovascular disease and their associated complications. Over half the adult female Australian population are classified as being overweight or obese with women of reproductive age having one of the highest rates of weight gain in Australia. At Westmead Hospital in 2014/15, 42.7% of the 5600 women who gave birth there were overweight or obese, approximately 50% had excessive gestational weight gain (GWG) and over 400 developed gestational diabetes. There are a number of well documented adverse outcomes associated with excessive weight gain and overweight and obesity during pregnancy and these risks increase with increasing BMI. Furthermore, growing evidence indicates the fetus of an overweight mother on an unhealthy diet is ‘programmed’ via epigenetics to lifelong obesity and ill-health. Interventions to prevent childhood obesity must begin during pregnancy. Women who are able to keep their gestational weight gain to within the recommended limits, whether obese or of normal weight, show significantly reduced rates of foetal and maternal complications. Due to the frequency of contact of health professions during the antenatal period, it is an ideal time to take the opportunity to intervene and make changes that mothers perceive will optimise the outcome for themselves and their offspring. A recent Cochrane review (2015), indicated that intense diet and exercise can reduce the risk of excessive GWG, with some studies reporting 5kg lower GWG, and a significant reduction in macrosomia, which has obvious implications for neonatal adiposity. Furthermore, it has been shown that the use of SMS text messaging are effective in promoting weight loss and appropriate GWG. We hypothesize that an early and intense dietary and lifestyle intervention, i.e. utilising frequent patient contact via mobile phone technology and face-to-face support, will reduce GWG, GDM, post-partum weight retention and infant adiposity, compared to standard antenatal care.

First episode psychosis (FEP) may lead to devastating, chronic illness. For many individuals with FEP, a progressive worsening of symptoms, decline in cognition, and associated reduction in quality of life is often observed. There is evidence to suggest that this illness progression can be diminished, and perhaps even averted, if appropriate treatments are given at the early stages of illness. N-acetyl cysteine (NAC) is a supplement form of an amino acid antioxidant found naturally in foods such as meat, fish and green leafy vegetables. NAC is currently used for treating some respiratory conditions and paracetamol overdose. NAC boosts the body’s antioxidant defences. There is evidence that the antioxidant defences are impaired in people who suffer from psychotic disorders. Antipsychotic medication is currently the best treatment for FEP; however, sometimes these medications are not effective at treating all of the symptoms of psychosis such as negative and cognitive symptoms. Several studies have shown a significant benefit for NAC in schizophrenia and bipolar disorder when it has been used in addition to antipsychotics; however, its benefits have not yet been determined for individuals with FEP. In this project we will test if NAC administered to young people who have experienced FEP can help to reduce some of the symptoms they experience. We will also investigate whether NAC can help to prevent this early psychotic experience from developing into a chronic disorder. Young people between the ages of 15 - 25 years admitted to the Early Psychosis Prevention and Intervention Centre for treatment of first episode of psychosis (N=162) will be randomised to 2000 mg daily NAC or placebo for 26 weeks, with a further 26-week non-treatment follow-up period, as an addition to treatment as usual (TAU). The primary outcome is reduction in global symptom severity. A range of symptomatic, functioning, quality of life, neuropsychological, neuroimaging and blood biomarkers of inflammation, oxidative and nitrostative stress measures will be included as secondary outcomes. Through this study, we will not only determine the clinical efficacy of NAC as an adjunct treatment for FEP, but potentially unlock some of the neurobiological mechanisms underpinning psychotic disorders.

Insulin initiation and/or titration for type 2 diabetes (T2DM) is a resource intensive process requiring a referral to a credentialed diabetes educator (CDE) for insulin dose adjustment (IDA). To address the challenges in IDA, we have developed an innovative mobile health (mhealth) based model of care to support the patients and clinicians in diabetes specialist outreach and telehealth clinics (REMODEL-IDA: REthinking MOdel of Diabetes care utilising EheaLth – Insulin Dose Adjustment). Advances in mhealth have enabled to redesign traditional models of healthcare delivery. This model aims to improve glycaemic management, improve healthcare service delivery efficiency and improve the patients’ experience. A two-arm pilot randomised controlled trial will be conducted for 3 months with 44 participants, randomised at a 1:1 ratio to receive either the mhealth-based model of care (intervention) or routine care (control), in diabetes specialist outreach and telehealth clinics. The intervention arm will exchange glycaemic management information via a Mobile-based Disease Management System (MDMS) developed for T2DM outpatients. They will receive advice for insulin titration from the CDE via the mobile-app and receive automated text-message prompts for better self-management based on their glycaemic management. The routine care arm will be followed up via telephone calls. The primary outcome is change in HbA1c, a marker of glycaemic management, at 3 months. Patient and healthcare provider satisfaction, and time required by health care providers in both arms will be collected. This study will guide the conduct of a large-scale implementation study.