ORCID Profile
0000-0002-8669-5944
Current Organisations
Flinders Medical Centre
,
University of South Australia
,
Flinders University
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Publisher: Wiley
Date: 09-2006
DOI: 10.1002/J.2055-2335.2006.TB00608.X
Abstract: The Cockroft‐Gault and Modification of Diet in Renal Disease (MDRD) approaches are commonly used to estimate renal function. An optimised version of the Cockroft‐Gault equation also exists. The MDRD approach occasionally generates renal function estimates that are vastly different from the Cockroft‐Gault approach. Due to its ready availability, prescribers are beginning to use the MDRD approach for dosing of renally cleared drugs, despite contrary recommendations. To examine differences in renal function estimates between the MDRD against the Cockroft‐Gault and optimised Cockroft‐Gault approaches for a group of elderly hospitalised patients. To examine factors driving these differences and if these differences cause clinically significant differences in the dosing of enoxaparin and gentamicin. Renal function for 1067 inpatients was calculated. Patients were grouped into quartiles based on the proportional difference between the MDRD against the Cockroft‐Gault and optimised Cockroft‐Gault approaches, respectively. Clinically significant dosing was defined as 2 mg/kg instead of 1 mg/kg for enoxaparin, and ≥ 75% difference for gentamicin dosing. As the proportional difference in renal function estimates between the MDRD and the Cockroft‐Gault approach increased, patients were progressively older and lighter (p 0.01). As the difference increased compared to the optimised Cockroft‐Gault version, patients were progressively older, shorter, lighter and female (p 0.01). Enoxaparin and gentamicin doses from the MDRD approach led to significantly greater doses in 8% and 23% of patients respectively compared to Cockroft‐Gault, and 15% and 37% of patients respectively compared to the optimised Cockroft‐Gault approach. This occurred predominantly in very elderly patients ( 80 years). The use of MDRD to calculate drug doses in an elderly population leads to greatly increased doses being prescribed compared to the currently recommended approach of using Cockroft‐Gault. This is largely in older patients, who are most at risk of experiencing adverse effects from increased doses. The appropriateness of MDRD for drug dosing in an elderly hospitalised population needs to be assessed urgently, against the possibility that it greatly overestimates renal function in these patients.
Publisher: Wiley
Date: 09-2015
DOI: 10.1002/JPPR.1134
Publisher: Wiley
Date: 06-2013
DOI: 10.1111/IMJ.12157
Abstract: We have assessed whether glucose concentration and patient outcome are related in hospitalised patients when glycaemia is quantified in detail. Continuous glucose monitoring was performed on 47 consecutive subjects with an acute exacerbation of chronic obstructive pulmonary disease. Length of hospital stay increased by 10% for each mmol/L increase in mean glucose (P = 0.01). In a multivariable analysis, mean glucose was independently associated with length of hospital stay (P = 0.02). These data add weight to evidence that hyperglycaemia may adversely affect patient outcomes in hospitalised patients.
Publisher: Wiley
Date: 02-2022
DOI: 10.1111/IMJ.15687
Abstract: We assessed hospitalisations for gastrointestinal bleeding directly related to primary prevention aspirin in lower risk patients for a 6‐month period in three South Australian hospitals. Those with related underlying pathology or concurrent causative medication were excluded. Identified patients ( n = 22) carried little co‐morbidity, 41% received prior proton‐pump inhibitors and 68% were aged years. Mean hospital admission cost was $6769 (95% confidence interval $5198–$8340), with projected state and national annual costs of $0.57 and $8.12 million respectively. In light of recent guideline changes, clinicians need to vigorously assess the need for primary prevention aspirin.
Publisher: Wiley
Date: 03-2009
DOI: 10.1002/J.2055-2335.2009.TB00704.X
Abstract: High‐dose prednisolone is the mainstay of treatment for acute exacerbations of chronic obstructive pulmonary disease (COPD). Hyperglycaemia is a dose‐related adverse effect of prednisolone. Recent evidence suggests that the presence of hyperglycaemia during COPD exacerbations may impair recovery. To develop a successful management strategy, more information is needed on the nature of prednisolone‐induced hyperglycaemia in COPD exacerbations. To determine the characteristics of prednisolone‐induced hyperglycaemia in patients experiencing COPD exacerbations and receiving high‐dose prednisolone (20 mg or more daily). A prospective study of patients hospitalised for COPD exacerbations and receiving high‐dose prednisolone. Eligible patients with COPD exacerbations and receiving highdose prednisolone were ided into 3 groups – diabetic, non‐diabetic and pre‐diabetic. The capillary blood glucose levels for the 3 groups were measured daily at 7 am, noon, 5 pm and 9 pm for up to 4 days of treatment. These blood glucose levels were compared with the retrospective blood glucose levels of diabetic patients hospitalised for reasons other than COPD exacerbations and not receiving prednisolone (control). Compared to the diabetic control group (n = 117), the mean daily blood glucose levels were 2 mmol/L higher in diabetic COPD patients receiving prednisolone (n = 7 p 0.05). Pre‐diabetic COPD patients receiving prednisolone (n = 6), experienced a mean daily blood glucose level similar to that of the diabetic control group, while the non‐diabetic COPD patients (n = 6) were largely unaffected. In both diabetic and pre‐diabetic COPD patients there was a delayed blood glucose level peak at 5 pm that was 4 mmol/L higher than the 7 am blood glucose level (p 0.05 for both). This pattern was not evident in the diabetic control group. In both the diabetic and pre‐diabetic COPD patients the recovery of blood glucose levels to baseline occurred within 24 hours. Prednisolone‐induced hyperglycaemia influenced blood glucose levels in pre‐diabetic COPD patients to the same extent as diabetic COPD patients, while the non‐diabetic COPD patients were largely unaffected. The hyperglycaemic effect was transient, lasted for less than 24 hours and followed a distinct daily pattern.
Publisher: SAGE Publications
Date: 26-10-2016
Abstract: Background: The immediate postoperative warfarin sensitivity for patients receiving heart valve prostheses is increased. Established warfarin initiation protocols may lack clinical applicability, resulting in dosing based on clinical judgment. Objective: To compare current practice for warfarin initiation with a known warfarin initiation protocol, with doses proportionally reduced to account for the increased postoperative sensitivity. Methods: We compared the Mechanical Heart Valve Warfarin Initiation Protocol (Protocol group) with current practice (clinical judgment—Empirical group) for patients receiving mechanical heart valves in an observational before-and-after format. End points were the time to achieve a stable therapeutic international normalized ratio (INR), doses held in the first 6 days, and overanticoagulation in the first 6 days. Results: The Protocol group (n = 37) achieved a stable INR more rapidly than the Empirical group (n = 77 median times 5.1 and 8.7 days, respectively P = 0.002). Multivariable analysis indicated that the Protocol group (hazard ratio [HR] = 2.22 P = 0.005) and men (HR = 1.76 P = 0.043) more rapidly achieved a stable therapeutic INR. Age, serum albumin, amiodarone, presence of severe heart failure, and surgery type had no impact. Protocol patients had fewer doses held (1.1% vs 10.1%, P 0.001) and no difference in overanticoagulation (2.7% vs 9.1%, P = 0.27). Conclusion: The Mechanical Heart Valve Warfarin Initiation Protocol provided a reliable approach to initiating warfarin in patients receiving mechanical aortic or mitral valves.
Publisher: SAGE Publications
Date: 12-2003
DOI: 10.1345/APH.1A372A
Publisher: AMPCo
Date: 03-2012
DOI: 10.5694/MJA11.10853
Abstract: To determine if the improvement in inpatient glycaemic control observed with basal-bolus insulin (BBI) over sliding-scale insulin (SSI) in the formal study setting translates to routine clinical conditions. Cross-sectional study in which capillary blood glucose levels (BGLs) were prospectively measured four times daily for up to 8 days in 124 patients with type 2 diabetes admitted to a tertiary teaching hospital and treated with BBI between November 2008 and May 2010. Data from the BBI treatment group were compared with retrospective data from 96 patients treated with SSI between June 2001 and May 2006. Mean daily BGL independent effect of insulin regimen on mean daily BGL. Mean baseline BGL was not significantly different in patients receiving BBI and SSI (mean ± SD, 11.3 ± 4.1 v 10.6 ± 4.3 mmol/L P = 0.23). After the first full day of therapy, mean daily BGL for patients receiving BBI was 1.6 ± 3.7 mmol/L lower than baseline BGL, and it remained 1.6-2.4 mmol/L lower than baseline throughout the study (P < 0.001). In contrast, there was no significant change in BGL for patients receiving SSI. Random effects regression analysis indicated that BBI was associated with a significantly lower mean daily BGL than SSI, independent of other variables (P < 0.001). The incidence of hypoglycaemia (BGL < 4 mmol/L) was significantly greater in patients receiving BBI than SSI (3.3% v 1.4% P < 0.001), but there was no significant difference for severe hypoglycaemia (BGL < 2.8 mmol/L) (0.3 v 0.5% P = 0.3). Under routine clinical conditions, BBI is effective and safe across a range of patients and appears to be superior to SSI. Clinical improvements reflected those seen in a strict formal study setting.
Publisher: Wiley
Date: 02-2000
DOI: 10.1046/J.1460-9592.2000.00475.X
Abstract: The 5-HT3 antagonists are effective in reducing postoperative nausea and vomiting (PONV) associated with paediatric tonsillectomy. Although prophylactic tropisetron can reduce the incidence of PONV by half, the resulting level of over 40% is still unacceptably high. The aim of this study was to evaluate the effect of adding dexamethasone to tropisetron. In a blinded study, 59 children (mean age 6.1 years) were administered 0.1 mg.kg-1 up to 2 mg of tropisetron and 66 children (mean age 5.7 years) received the same dose of tropisetron plus 0.5 mg.kg-1 up to 8 mg of dexamethasone. Both drugs were given intravenously during induction of anaesthesia for tonsillectomy. During the inpatient stay of 24 h, the incidence of postoperative vomiting in the tropisetron alone group was 53% compared with 26% in the combination group (P=0.002, chi-squared). A significant reduction in nausea from 53% to 30% was also observed (P=0.02). Parents completed a daily diary for 5 days following discharge. Delayed vomiting occurred in 27% and 11% of the tropisetron and combination therapy groups, respectively (P=0.025) Sixteen percent and 9%, respectively, required medical attention (P=0.27). Tropisetron plus dexamethasone is more effective than tropisetron alone in reducing the incidence of PONV following paediatric tonsillectomy.
Publisher: Oxford University Press (OUP)
Date: 26-08-2015
DOI: 10.1093/AJH/HPU120
Abstract: Research on associations between blood pressure, brain structure, and cognitive function has produced somewhat inconsistent results. In part, this may be due to differences in age ranges studied and because of sex differences in physiology and/or exposure to risk factors, which may lead to different time course or patterns in cardiovascular disease progression. The aim of this study was to investigate the impact of sex on associations between blood pressure, regional cerebral volumes, and cognitive function in older in iduals. In this cohort study, brachial blood pressure was measured twice at rest in 266 community-based in iduals free of dementia aged 68-73 years who had also undergone a brain scan and a neuropsychological assessment. Associations between mean blood pressure (MAP), regional brain volumes, and cognition were investigated with voxel-wise regression analyses. Positive associations between MAP and regional volumes were detected in men, whereas negative associations were found in women. Similarly, there were sex differences in the brain-volume cognition relationship, with a positive relationship between regional brain volumes associated with MAP in men and a negative relationship in women. In this cohort of older in iduals, higher MAP was associated with larger regional volume and better cognition in men, whereas opposite findings were demonstrated in women. These effects may be due to different lifetime risk exposure or because of physiological differences between men and women. Future studies investigating the relationship between blood pressure and brain structure or cognitive function should evaluate the potential for differential sex effects.
Publisher: Mary Ann Liebert Inc
Date: 03-2013
Abstract: Previous studies have assessed the efficacy of basal-bolus insulin (BBI) in hospitalized patients by measuring four finger-prick blood glucose levels (BGLs) per day. The aim of this study was to investigate whether this BGL monitoring regimen provides an accurate reflection of glycemia in hospitalized patients administered BBI. We hypothesized that, as three of four readings are preprandial, finger-prick BGLs would underestimate the mean glucose concentration. Twenty-six consecutive consenting subjects with type 1 (n=3) or type 2 (n=23) diabetes mellitus admitted to the hospital and administered insulin glargine once daily and rapid-acting insulin before meals underwent continuous glucose monitoring for up to 72 h. Finger-prick BGLs were performed before each main meal (0700, 1200, and 1700 h) and at 2100 h. Mean daily glucose concentration was not significantly different when assessed by continuous glucose monitoring and finger-prick BGLs (9.6±2.4 vs. 9.6±2.7 mmol/L, P=0.84). A Bland-Altman plot revealed some variability but no bias between the two methods of measurement of glucose concentration. There were 88 postprandial hyperglycemic excursions recorded on continuous glucose monitoring 61 (69%) were identified by finger-prick BGL monitoring. There were 10 glucose excursions <4 mmol/L during continuous glucose monitoring only one was detected by finger-prick BGL monitoring. Traditional finger-prick BGL monitoring provides a reasonable approximation of mean daily glucose concentration in the majority of hospitalized patients receiving BBI but underestimates the prevalence of postprandial hyperglycemia and hypoglycemia.
Publisher: Elsevier BV
Date: 11-2023
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2005
Publisher: SAGE Publications
Date: 1994
DOI: 10.1177/106002809402800101
Abstract: To compare the use of in-line filtration with the addition of heparin/hydrocortisone (hep/hc) to the infusate for both phlebitis prevention and intravenous(iv) line survival in peripheral iv catheters. This study was specific for a patient group receiving prolonged courses of iv antibiotics. Analysis of the two endpoints for conventional short iv catheters (short lines) versus long (30 cm) iv catheters (long lines) was also performed. Patients with cystic fibrosis receiving intermittent iv antibiotics were randomly allocated to receive their drugs either through an in-line filter using a drug-free infusate or with no filter and an infusate containing heparin 500 units and hydrocortisone 10 mg/L. Infusion sites were assessed daily. Both the hep/hc and filter groups were similar in terms of phlebitis incidence and iv line survival when analyzed separately for both short and long lines. Long lines displayed markedly prolonged survival times and reduced phlebitis compared with short lines. The effectiveness of iv filters in excluding the large particle load introduced by iv antibiotics and hence in reducing the subsequent phlebitis makes them a useful alternative to the use of hep/hc. The use of filters in this patient group may offer advantages in terms of ease of use and a possible decrease in hep/hc-related problems. Long lines offer practical advantages over short lines for patients requiring longer term iv access.
Publisher: Wiley
Date: 12-2015
DOI: 10.1002/JPPR.1132
Publisher: Therapeutic Guidelines Limited
Date: 08-2001
Publisher: Wiley
Date: 10-1993
DOI: 10.1111/J.1365-2125.1993.TB00380.X
Abstract: A non-blinded, randomized, cross-over investigation of the pharmacokinetic interaction between tobramycin and ticarcillin was performed in 18 healthy cystic fibrosis (CF) patients with normal renal function. On consecutive mornings the patients were given either tobramycin intravenously (i.v.) over 3-5 min (TOB phase), or tobramycin i.v. over 3-5 min followed immediately by ticarcillin infused i.v. over 20-30 min (TOB+TIC phase). Capillary blood s les were taken 30 min and 330 min after administration of the tobramycin dose in each phase. Tobramycin was measured in serum by fluorescence polarization immunoassay (TDx). There were decreases in serum tobramycin concentrations of 11% at 30 min (P < 0.001) and 330 min (P = 0.012) when measured in the presence of ticarcillin. No difference in elimination half-life was found (TOB phase 95 +/- 13 min, TOB+TIC phase 95 +/- 13 min, P = 0.86). The volume of distribution and clearance of tobramycin increased by 14% (P < 0.001) and 13% (P < 0.001), respectively, in the presence of ticarcillin. This interaction appears to be of minor clinical importance but pharmacokinetic studies of tobramycin should exclude concurrent use of ticarcillin.
Publisher: SAGE Publications
Date: 12-09-2022
DOI: 10.1177/19322968221124114
Abstract: Interventional studies investigating blood glucose (BG) management in intensive care units (ICU) have been inconclusive. New insights are needed. We assessed the ability of a new metric, the Glycemic Ratio (GR), to determine the relationship of ICU glucose control relative to preadmission glycemia and mortality. Retrospective cohort investigation (n = 4790) in an adult medical-surgical ICU included patients with minimum four BGs, hemoglobin (Hgb), and hemoglobin A1c (HbA1c). The GR is the quotient of mean ICU BGs (mBG) and estimated preadmission BG, derived from HbA1c. Mortality displayed a J-shaped curve with GR (nadir GR 0.9), independent of background glycemia, consistent for HbA1c .5% vs .5%, and Hgb g/dL vs g/dL and medical versus surgical. An optimal range of GR 0.80 to 0.99 was associated with decreased mortality compared with GR above and below this range. The mBG displayed a linear relationship with mortality at lower HbA1c but diminished for HbA1c .5%, and dependent on preadmission glycemia. In adjusted analysis, GR remained associated with mortality (odds ratio = 2.61, 95% confidence interval = 1.48-4.62, P = .0012), but mBG did not (1.004, 1.000-1.009, .059). A single value on admission was not independently associated with mortality. The GR provided new insight into malglycemia that was not apparent using mBG, or an admission value. Mortality was associated with acute change from preadmission glycemia (GR). Further assessment of the impact of GR deviations from the nadir in mortality at GR 0.80 to 0.99, as both relative hypo- and hyperglycemia, and as duration of exposure and intensity, may further define the multifaceted nature of malglycemia.
Publisher: Oxford University Press (OUP)
Date: 05-2010
Publisher: Wiley
Date: 05-2001
DOI: 10.1002/PPUL.1060
Abstract: Our objective was to compare the efficacy, safety, and microbiology of once-daily intravenous (IV) tobramycin with conventional 8-hourly tobramycin/ceftazidime IV therapy for acute Pseudomonas aeruginosa (PA) pulmonary exacerbations in cystic fibrosis (CF). CF patients with PA-induced pulmonary exacerbations were allocated to receive either once-daily tobramycin (Mono) or conventional therapy with tobramycin/ceftazidime given 8-hourly (Conv). The two longitudinal groups received therapy in a double-blind, randomized manner over a period of 2 years. Tobramycin doses were adjusted to achieve a daily area under the time-concentration curve of 100 mg x hr/L in both groups. Results were assessed for both short-term changes (efficacy and safety after 10 days of IV antibiotics during acute exacerbations) and long-term changes (efficacy, safety, and sputum microbiology between study entry and exit). Pulmonary function tests (PFTs) on admission were similar in both groups. After 10 days of IV antibiotics, absolute mean improvements in percent of predicted PFTs were 12.8, 12.1, and 13.7 for forced expiratory volume in 1 sec (FEV(1)), forced vital capacity (FVC), and forced expired flow between 25--75% of FVC (FEF(25--75%)) in the Conv group (n = 51 admissions) compared to 10.6, 9.9, and 10.6 in the Mono group (n = 47)(P or =8 mg/L in both groups. No short- or long-term changes in audiology or serum creatinine were found in either group. After 10 days of IV therapy, the urinary enzyme N-acetyl-beta-d-glucosaminidase/creatinine ratios increased in both groups (P0.05). This increase was greater in the Conv compared to the Mono group (P < 0.05). We conclude that this pilot study indicates once-daily tobramycin therapy to be as effective and safe as conventional 8-hourly tobramycin/ceftazidime therapy. Combination antibacterial therapy appears to offer no clinical advantage over once-daily tobramycin monotherapy. Tobramycin once-daily monotherapy is a potential alternative to conventional IV antibacterial therapy which deserves further investigation, including the impact on susceptibility of PA to tobramycin.
Publisher: Wiley
Date: 06-1994
DOI: 10.1111/J.1440-1754.1994.TB00635.X
Abstract: Two cases are reported of coagulopathy in association with the administration of piperacillin to patients with cystic fibrosis. In both cases the coagulopathy was associated with the development of a serum sickness-like illness with fever, rash and abnormal liver function tests occurring on day 12 and day 16 of treatment, respectively. On withdrawal of the piperacillin, both the serum sickness and the coagulopathy resolved rapidly, without sequelae.
Publisher: Wiley
Date: 09-2012
DOI: 10.1002/J.2055-2335.2012.TB00170.X
Abstract: To compare the adverse effect profile in the 1‐hour post‐administration period for a 3‐minute gentamicin 40 mg/mL bolus with a 30‐minute gentamicin 1 mg/mL infusion. Australian guidelines recommend that IV gentamicin doses greater than 240 mg need to be diluted and infused over 20 to 120 minutes, while lower doses can be administered as a bolus using the undiluted injection solution (40 mg/mL) over 2 to 5 minutes. Patients receiving at least 2 gentamicin doses of 240 mg or greater were administered an undiluted IV bolus (40 mg/mL) over 3 minutes on one occasion and a 1 mg/mL infusion over 30 minutes on another in a randomised crossover design. Patients were assessed for pain, swelling and redness at the injection site, tinnitus, dizziness, headache and nausea at 0, 15, 30 and 60 minutes after administration of the gentamicin dose. 47 patients completed the study. Mean administration rates in the bolus and infusion arms were 105 ± 27 mg/min and 12 ± 8.1 mg/min, respectively. During the bolus phase, more patients complained of increased pain at the injection site immediately after completion of the bolus dose (34% vs 9%, p 0.01), but this effect had dissipated at the 15‐minute assessment (4% vs 4%). There were no differences in any other parameters at any of the assessment times. Bolus gentamicin of up to 480 mg (undiluted 40 mg/mL injection) administered over 3 minutes can be used as an alternative to a diluted gentamicin infusion, but may cause transient IV site pain.
Publisher: Wiley
Date: 04-1999
DOI: 10.1046/J.1440-1754.1999.T01-1-00335.X
Abstract: To investigate the efficacy and tolerance of 12-hourly dosing with 2 mg 4 mL-1 of inhaled budesonide versus placebo in patients admitted to hospital with moderate/severe croup. Eighty-two children hospitalised with croup received either 2 mg 4 mL-1 of budesonide or placebo 12 hourly (maximum four doses) via Ventstream nebuliser in a randomised, double-blind manner. Croup scores were performed at 0, 2, 6, 12, 24, 36 and 48 h from initial nebulisation whilst the patient remained hospitalised. Follow-up assessments were made 1 and 3 days after discharge. Improvement was observed in the budesonide group over the 12-h dosing interval when compared to placebo (P = 0.04). Time to attain a significant clinical improvement was superior in the budesonide group (P = 0.01). Three days after discharge seven of 32 placebo-treated patients and one of 34 budesonide-treated patients had sought further medical follow-up (P = 0.02). Twelve-hourly dosing with inhaled budesonide significantly improved symptoms of croup as well as decreased relapse rates when compared with placebo.
Publisher: SAGE Publications
Date: 23-06-2015
Abstract: Background: Heart failure (HF) has been associated with an elevated international normalized ratio (INR) in patients on warfarin. Objectives: Compare warfarin sensitivity during hospital admission for HF exacerbation and chronic obstructive pulmonary disease (COPD) exacerbation with admissions unrelated to HF or COPD (controls) as well as during disease stability. Methods: We conducted a case-controlled observational study. Patients admitted to a tertiary teaching hospital for HF exacerbation (n = 37), COPD exacerbation (n = 26), and admissions unrelated to HF or COPD (controls, n = 60) were included. Warfarin sensitivity (INR per daily mg dose of warfarin) at admission was compared to periods of disease stability and also compared between the 3 groups. Results: The increase in warfarin sensitivity at admission was 94% for HF patients ( P 0.0001), 59% for COPD ( P = 0.003) patients, and 24% for controls ( P = 0.002). HF patients with New York Heart Association (NYHA) class 3 and 4 and NYHA class 1 and 2 experienced changes in warfarin sensitivity of 125% ( P = 0.006) and 50% ( P = 0.13) at admission. HF patients had higher warfarin sensitivity at admission (mean = 1.62 [SD = 1.27]) compared to the control group (0.91 [0.52], P 0.0001) and COPD group (1.03 [0.79], P = 0.04). and required greater intervention with vitamin K than controls (14% vs 0%, P = 0.007). Conclusion: HF and COPD patients were more sensitive to warfarin during disease exacerbation, with HF exacerbation having the largest impact, resulting in clinically significant management implications.
Publisher: Wiley
Date: 2000
DOI: 10.1046/J.1460-9592.2000.00401.X
Abstract: In this patient, parent and investigator blinded, randomized, placebo-controlled study, children undergoing tonsillectomy (mean age 6.4 years) received either intravenous placebo (n=36) or tropisetron 0.2 mg.kg-1 up to 5 mg (n=35) at induction of anaesthesia with halothane, nitrous oxide and oxygen. Morphine and paracetamol were given in theatre for postoperative pain. Episodes of vomiting were recorded during the first 24 h after surgery. Intravenous tropisetron was significantly (P<0.001, chi-squared) more effective than placebo in controlling the incidence and frequency of emesis during the first 24 h: vomiting was reduced from 89% to 46% and the mean number of vomits from 4.6 to 2.4. Minor side-effects occurred equally in both the placebo and active groups. Intravenous tropisetron is an effective and safe antiemetic for reducing postoperative vomiting in children undergoing tonsillectomy or adenotonsillectomy.
Publisher: SAGE Publications
Date: 07-1992
Publisher: Wiley
Date: 12-2013
DOI: 10.1002/J.2055-2335.2013.TB00274.X
Abstract: Guidelines recommend re‐initiating post‐operative warfarin at the previous maintenance dose. This results in prolonged re‐establishment of a therapeutic international normalised ratio (INR). Modelling warfarin initiation and subsequent INR response using previously published data indicated that re‐initiation with twice the maintenance dose for 3 days may provide a rapid alternative. To compare the time to a stable therapeutic INR for conventional maintenance dose re‐initiation of warfarin with a loading dose strategy. Warfarin maintenance doses were adjusted by using the standardised maintenance dose – a theoretical dose resulting in an INR of 2.5. The test group was re‐initiated on warfarin doses twice their standardised maintenance dose on Days 1, 2 and 3 and on Day 4 reverted to their maintenance dose. The guideline group was re‐initiated on warfarin doses equivalent to their standardised maintenance dose on these days. The test group (n = 17) achieved a therapeutic INR more rapidly than the guideline group (n = 23 p 0.001) with median times to therapeutic INR of 3 and 6 days respectively. After 3 doses the test group INR on Day 4 was in the therapeutic range (2.1±0.4) and significantly higher than the guideline group (1.7±0.5 p = 0.002). No patient in the test group experienced an elevated INR (maximum INR 3.3). INR response to the warfarin re‐initiation dose was dependent on the magnitude of the induction dose relative to the maintenance dose. The loading dose strategy achieved a stable therapeutic INR more rapidly than conventional practice. Prospective investigation in surgical patients is needed to confirm its clinical applicability.
Publisher: Wiley
Date: 12-2019
DOI: 10.1002/JPPR.1567
Publisher: Informa UK Limited
Date: 2006
Publisher: Therapeutic Guidelines Limited
Date: 06-2004
Publisher: Wiley
Date: 17-02-2017
DOI: 10.1111/DOM.12859
Abstract: Prednisolone causes hyperglycaemia predominantly between midday and midnight. Consequently, glargine-based basal-bolus insulin regimens may under treat daytime hyperglycaemia and cause nocturnal hypoglycaemia. We investigated whether an isophane-based insulin regimen is safer and more effective than a glargine-based regimen in hospitalized patients. Fifty inpatients prescribed ≥20 mg/day prednisolone acutely with (1) finger prick blood glucose level (BGL) ≥15 mmol/L or (2) BGLs ≥10 mmol/L within the previous 24 hours were randomized to either insulin isophane or glargine before breakfast and insulin aspart before meals. The initial daily insulin dose was 0.5 U/kg bodyweight or 130% of the current daily insulin dose. Glycaemic control was assessed using a continuous glucose monitoring system. On Day 1, there were no significant differences in percentage of time outside a target glucose range of 4 to 10 mmol/L (41.3% ± 5.5% vs 50.0% ± 5.7%, P = .28), mean daily glucose (10.2 ± 0.7 vs 10.8 ± 0.8 mmol/L, P = .57) or glucose <4 mmol/L (2.2% ± 1.1% vs 2.0% ± 1.3%, P = .92) in patients randomized to isophane and glargine. In patients treated for 3 days, the prednisolone dose was reduced ( P = .02) and the insulin dose was increased over time ( P = .02), but the percentage of time outside the 4 to 10 mmol/L glucose range did not differ over time ( P = .45) or between groups ( P = .24). There were no differences in the efficacy or safety of the isophane and glargine-based insulin regimens. We recommend an initial daily insulin dose of 0.5 units/kg bodyweight if not on insulin, a greater than 30% increase in pre-prednisolone insulin dose and larger insulin dose adjustments in patients with prednisolone-induced hyperglycaemia.
Publisher: SAGE Publications
Date: 07-1994
Publisher: The Endocrine Society
Date: 06-2011
DOI: 10.1210/JC.2010-2729
Abstract: Endogenous glucocorticoid excess (Cushing's syndrome) predominantly increases postprandial glucose concentration. The pattern of hyperglycemia induced by prednisolone has not been well characterized. Our objective was to define the circadian effect of prednisolone on glucose concentration to optimize management of prednisolone-induced hyperglycemia. This was a cross-sectional study in a teaching hospital. Participants included 60 consecutive consenting subjects with chronic obstructive pulmonary disease admitted to hospital: 13 without known diabetes admitted for other indications and not treated with glucocorticoids (group 1), 40 without known diabetes admitted with an exacerbation of chronic obstructive pulmonary disease and treated with prednisolone (group 2, prednisolone = 30 ± 6 mg/d), and seven with known diabetes treated with prednisolone (group 3, prednisolone = 26 ± 9 mg/d). Interstitial glucose concentration was assessed during continuous glucose monitoring. Significantly more subjects in group 2 [21 of 40 (53%), P = 0.02] and group 3 [seven of seven (100%), P = 0.003] recorded a glucose of at least 200 mg/dl (≥11.1 mmol/liter) during continuous glucose monitoring than in group 1 [one of 13 (8%)]. The mean glucose concentration between 2400-1200 h for group 3 (142 ± 36 mg/dl) was significantly greater than in the other two groups (P < 0.005), whereas mean glucose concentrations between 2400-1200 h in group 1 (108 ± 16 mg/dl) and group 2 (112 ± 22 mg/dl) were not significantly different. In contrast, the mean glucose concentrations between 1200-2400 h for group 2 (142 ± 25 mg/dl) and group 3 (189 ± 32 mg/dl) were both significantly greater than group 1 (117 ± 14 mg/dl, P < 0.05 for both comparisons). Prednisolone predominantly causes hyperglycemia in the afternoon and evening. Treatment of prednisolone-induced hyperglycemia should be targeted at this time period.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-1990
DOI: 10.1097/00007691-199011000-00008
Abstract: A high serum digoxin concentration (8.9 nmol/L) was recorded in a child suspected of swallowing digoxin tablets (Lanoxin PG 62.5 micrograms). The finger-prick blood s le was taken approximately 3.5 h postingestion. The child remained asymptomatic, and subsequent s les taken 5.5 and 23 h postingestion revealed zero digoxin concentrations. It was postulated that the initial blood s le may have been taken from a finger that was contaminated with digoxin from handling the tablets. To test this hypothesis, blood s les were taken from fingers of volunteers after handling various tablets, including digoxin, carbamazepine, paracetamol, and theophylline. Apparently, toxic digoxin concentrations were found for all volunteers handling digoxin tablets, though no volunteers were taking digoxin. Swabbing or not swabbing the finger with alcohol made minimal difference. Finger-prick s les from volunteers handling other tablets revealed falsely high and often "toxic" concentrations of the respective drugs, although values varied markedly. Caution should be exercised by those taking finger-prick blood s les, or interpreting drug concentrations from these s les, if the patient may have handled the tablets prior to the s le being taken.
Publisher: Wiley
Date: 09-1988
DOI: 10.1111/J.1365-2125.1988.TB05285.X
Abstract: The effect of erythromycin on the pharmacokinetics of phenytoin was studied in eight healthy volunteers using a balanced randomised cross-over design. Volunteers received a single oral dose of 400 mg of phenytoin sodium during each phase. During the treatment phase, the phenytoin sodium dose was administered 4.5 days after the commencement of a 7 day course of erythromycin base (250 mg every 6 h). There was no significant difference between the control and treatment phases (P greater than 0.05) with respect to the area under the plasma phenytoin concentration-time curve, the fraction of phenytoin unbound in plasma, the area under the unbound phenytoin concentration-time curve, the elimination half-life of phenytoin or the fraction of the dose excreted in urine as free and conjugated hydroxyphenylphenylhydantoin. This single dose study indicated that the intrinsic clearance of unbound phenytoin was unaffected by the concurrent administration of erythromycin.
Publisher: Wiley
Date: 29-09-2021
Abstract: The aim of this study is to compare metrics specific for stress‐induced hyperglycemia (SIH) with glucose for predicting ischemic stroke outcome. This observational retrospective study (n = 300) included patients acutely hospitalized for ischemic stroke over a 3.8‐year period. We assessed the association between acute ischemic stroke outcome with the stress hyperglycemia ratio (SHR, relative increase in glycemia) and glycemic gap (GG, absolute increase in glycemia) using admission values and 5‐day maximum values, along with incidence of poor outcome above recognized clinical thresholds of glucose 10 mmol/L, SHR 1.14, and GG 2.5 mmol/L. At admission, only SHR was associated with outcome after adjustment for clinical covariates (odds ratio [OR] = 2.88 95% CI: 1.05‐7.91 P = .041), while glucose or GG were not. Admission SHR ≥ 1.14 was also an indicator of poor outcome (39.1% vs 23.4%, P = .016), but not glucose ≥10 mmol/L or GG ≥ 2.5 mmol/L. All 5‐day maximum glucose metrics were associated with outcome, as was any SHR ≥ 1.14 (40.9% vs 20.1%, P .001) or GG ≥ 2.5 mmol/L (42.9% vs 23.4%, P = .011), but not glucose ≥10 mmol/L. Increased comorbidity was strongly associated with worse outcome ( P .001) in all models. SHR provided the best prognostic insight at admission to assess the relationship between SIH and ischemic stroke outcome. Absolute glucose levels failed to account for natural interpatient variation in background glycemia and provided little prognostic insight. To assess the impact of SIH, future interventional studies need to be designed using designated markers of SIH such as SHR in preference to absolute glucose.
Publisher: Oxford University Press (OUP)
Date: 19-09-2009
Abstract: the Modification of Diet in Renal Disease (MDRD) method of renal function estimation has not been extensively assessed in elderly patients. We needed to assess which renal function estimate was most suited for drug dose estimation in our population. we compared MDRD with an optimised version of the Cockcroft-Gault (CG(opt)) method in a hospital population, using gentamicin clearance as a baseline. MDRD overestimated gentamicin clearance by 29% (P < 0.001, n = 68), while CG(opt) underestimated by 10% (P < 0.01). Overestimation by MDRD increased with increasing age. This was 12%, 26% and 69% in age groups 80 years respectively (P < 0.001). CG(opt) underestimated renal function by -5%, -16% and -4% respectively (P = NS). Bias and precision of renal function estimations for the three age groups were less for CG(opt) than for MDRD. Age significantly influenced MDRD overestimation in this population (P = 0.037). MDRD overestimated renal function as age increased. While CG(opt) underestimated renal function, this was of a smaller magnitude, consistent across age, and thus better suited for dose calculation, especially in the elderly. Larger-scale studies using gold standard markers of renal function estimation are urgently needed to determine the accuracy of MDRD in elderly hospitalised patients.
Publisher: The Endocrine Society
Date: 12-2015
DOI: 10.1210/JC.2015-2660
Abstract: Hyperglycemia in hospitalized patients is associated with increased morbidity and mortality. We examined whether critical illness is more strongly associated with relative or absolute hyperglycemia. The study was an observational cohort study. A total of 2290 patients acutely admitted to a tertiary hospital. The relative hyperglycemia (stress hyperglycemia ratio [SHR]) was defined as admission glucose ided by estimated average glucose derived from glycosylated hemoglobin. The relationships between glucose and SHR with critical illness (in-hospital death or critical care) were examined. In univariable analyses, SHR (odds ratio, 1.23 per 0.1 increment [95% confidence interval, 1.18-1.28] P < .001) and glucose (odds ratio, 1.18 per mmol/L [1.13-1.23] P < .001) were associated with critical illness. In multivariable analysis, the association was maintained for SHR (odds ratio, 1.20 per 0.1 increment [1.13-1.28] P < .001), but not glucose (odds ratio, 1.03 per mmol/L [0.97-1.11] P = .31). Background hyperglycemia affected the relationship between glucose (P = .002) and critical illness, but not SHR (P = .35) and critical illness. In patients with admission glucose ≤ 10 mmol/L, the odds ratio for critical illness was higher in the fourth (2.4 [1.4-4.2] P = .001) and fifth (3.9 [2.3-6.8] P < .001) SHR quintiles than in the lowest SHR quintile. SHR controls for background glycemia and is a better biomarker of critical illness than absolute hyperglycemia. SHR identifies patients with relative hyperglycemia at risk of critical illness. Future studies should explore whether basing glucose-lowering therapy on relative, rather than absolute, hyperglycemia improves outcomes in hospitalized patients.
Publisher: Wiley
Date: 03-2015
DOI: 10.1111/IMJ.12680
Abstract: Few studies have specifically investigated treatment of prednisolone-induced hyperglycaemia. To determine if a basal bolus insulin (BBI) protocol for inpatient hyperglycaemia is effective in patients prescribed acute prednisolone for an inflammatory disease. In a cross-sectional study, 66 patients with type 2 diabetes admitted to a general medical ward and treated with BBI for up to 5 days were studied. Twenty-four patients were taking prednisolone ≥10 mg/day to treat an acute inflammatory disease. The remaining 42 patients were a control group. The primary outcome was mean daily blood glucose level. There were no significant differences in glycosylated haemoglobin (8.1 ± 1.0 vs 8.1 ± 1.6%, P = 0.88), age (77 ± 11 vs 75 ± 14 years, P = 0.57), male sex (63 vs 60%, P = 0.81) or body mass index (30.0 ± 5.3 vs 30.2 ± 11.5 kg/m(2) , P = 0.90) between patients taking prednisolone and controls. Mean daily glucose concentration was higher in patients taking prednisolone than in controls (12.2 ± 0.3 vs 10.0 ± 0.1 mmol/L, P < 0.001). Blood glucose level was higher in patients on prednisolone at 1700 h (14.6 ± 0.6 vs 10.3 ± 0.3 mmol/L, P < 0.001) and 2100 h (14.5 ± 0.6 vs 10.5 ± 0.3 mmol/L, P < 0.001), with no significant differences at 0700 h and 1200 h. These findings occurred despite patients taking prednisolone receiving a higher daily insulin dose than controls (0.67-0.70 vs 0.61-0.65 U/kg, P = 0.001) because of higher doses of ultra-rapid-acting insulin at 1200 h and 1700 h. Hospitalised patients taking prednisolone had substantial afternoon and evening hyperglycaemia despite receiving BBI via a protocol for inpatient hyperglycaemia. Specific insulin regimens for prednisolone-induced hyperglycaemia are needed that recommend more insulin during this time period.
Publisher: American Astronomical Society
Date: 06-07-2012
Publisher: Therapeutic Guidelines Limited
Date: 04-2015
DOI: 10.18773/AUSTPRESCR.2015.016
Abstract: Long-term treatment with warfarin is recommended for patients with atrial fibrillation at risk of stroke and those with recurrent venous thrombosis or prosthetic heart valves. Patient education before commencing warfarin - regarding signs and symptoms of bleeding, the impact of diet, potential drug interactions and the actions to take if a dose is missed - is pivotal to successful use. Scoring systems such as the CHADS2 score are used to determine if patients with atrial fibrillation are suitable for warfarin treatment. To rapidly achieve stable anticoagulation, use an age-adjusted protocol for starting warfarin. Regular monitoring of the anticoagulant effect is required. Evidence suggests that patients who self-monitor using point-of-care testing have better outcomes than other patients.
Publisher: AMPCo
Date: 02-2011
Publisher: Wiley
Date: 09-08-2022
DOI: 10.1111/DME.14930
Abstract: Stress‐induced hyperglycaemia (SIH) is the acute increase from preadmission glycaemia and is associated with poor outcomes. Early recognition of SIH and subsequent blood glucose (BG) management improves outcomes, but the degree of SIH provoked by distinct diagnostic categories remains unknown. Quantification of SIH is now possible using the stress hyperglycaemia ratio (SHR), which measures the proportional change from preadmission glycaemia, based on haemoglobin A 1c (HbA 1c ). We identified eligible patients for eight medical ( n = 892) and eight surgical ( n = 347) categories. Maximum BG from the first 24 h of admission for medical, or postoperatively for surgical patients was used to calculate SHR. Analysis of variance indicated differing SHR and BG within both the medical ( p 0.0001 for both) and surgical cohort ( p 0.0001 for both). Diagnostic categories were associated with signature levels of SHR that varied between groups. Medically, SHR was greatest for ST‐elevation myocardial infarction (1.22 ± 0.33) and sepsis (1.37 ± 0.43). Surgically, SHR was greatest for colectomy (1.62 ± 0.48) and cardiac surgeries (coronary artery graft 1.56 ± 0.43, aortic valve replacement 1.71 ± 0.33, and mitral valve replacement 1.75 ± 0.34). SHR values remained independent of HbA 1c , with no difference for those with HbA 1c above or below 6.5% ( p 0.11 for each). BG however was highly dependent on HbA 1c , invariably elevated in those with HbA 1c ≥ 6.5% (p 0.001 for each), and unreliably reflected SIH. The acute stress response associated with various medical and surgical categories is associated with signature levels of SIH. Those with higher expected SHR are more likely to benefit from early SIH management, especially major surgery, which induced SIH typically 40% greater than medical cohorts. SHR equally recognised the acute change in BG from baseline across the full HbA 1c spectrum while BG did not and poorly reflected SIH.
Publisher: Wiley
Date: 06-2020
DOI: 10.1111/BCP.14345
Publisher: Hindawi Limited
Date: 04-2002
DOI: 10.1046/J.1365-2710.2002.00400.X
Abstract: To examine benzodiazepine prescribing for sleep induction in an elderly medical inpatient population to determine if hospital prescribing may have encouraged benzodiazepine use following discharge. Secondary objectives included assessment of quality of sleep in hospital compared with home and monitoring for possible benzodiazepine side-effects. Inpatient and discharge prescribing of benzodiazepines used for sleep induction were recorded in two medical wards over a 3-month period. A questionnaire was used to obtain information on patients' sleep patterns at home and in hospital. A follow-up telephone survey at 2-3 weeks post-discharge was made for those patients who were prescribed benzodiazepine at discharge. Benzodiazepines were prescribed for 20% of patients with 94% of prescriptions being for temazepam. Of the 54 patients prescribed benzodiazepines during admission, 57% were not taking a benzodiazepine at home prior to their hospital admission. At discharge, 14 patients were prescribed benzodiazepines for home use, eight of whom had not used them at home previously. On follow-up none of these eight patients expressed a desire to continue benzodiazepine use for sleep induction. There was a significant (P < 0.05) reduction in sleep onset latency and number of nocturnal awakenings in hospital when compared with home. There was no change in sleep duration and overall quality of sleep. There was an association between early morning insomnia and benzodiazepine use. Discharge prescribing of benzodiazepines was appropriately limited to temazepam and did not encourage home use in previous non-users. Benzodiazepines (primarily temazepam) were effective in the short term for inducing sleep in the hospital setting, with little evidence of side-effects.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2020
DOI: 10.1097/CCM.0000000000004133
Abstract: To determine whether relative hyperglycemia was associated with in-hospital mortality in critically ill patients independent of other prognostic variables and whether this association is affected by background glycemia. Prospective observational study. Mixed medical-surgical ICU in a metropolitan teaching hospital. From 2,617 admissions to ICU between January 27, 2016, and March 30, 2017, 1,262 consecutive patients who met inclusion and exclusion criteria were studied. Glycosylated hemoglobin was used to estimate average glucose concentration over the prior 3 months. Glucose concentration on ICU admission was ided by estimated average glucose concentration to calculate the stress hyperglycemia ratio, an index of relative glycemia. Risk of death score was calculated using data submitted to the Australia and New Zealand Intensive Care Society. In this study, there were 186 deaths (14.7%). Admission glucose was significantly associated with mortality in univariate analysis (odds ratio = 1.08 per mmol/L glucose increment p 0.001) but not after adjustment for risk of death score (odds ratio = 1.01 p = 0.338). In contrast, stress hyperglycemia ratio was significantly associated with mortality both in univariate analysis (odds ratio = 1.09 per 0.1 stress hyperglycemia ratio increment p 0.001) and after adjustment for risk of death score (odds ratio = 1.03 p = 0.014). Unlike admission glucose concentration, stress hyperglycemia ratio was significantly associated with mortality in patients with glycosylated hemoglobin less than 6.5% (odds ratio = 1.08 per 0.1 stress hyperglycemia ratio increment p 0.001) and glycosylated hemoglobin greater than or equal to 6.5% (48 mmol/mol) (odds ratio = 1.08 per 0.1 stress hyperglycemia ratio increment p = 0.005). Unlike absolute hyperglycemia, relative hyperglycemia, as assessed by the stress hyperglycemia ratio, independently predicts in-hospital mortality in critically ill patients across the glycemic spectrum. Future studies should investigate whether using measures of relative hyperglycemia to determine in idualized glycemic treatment targets improves outcomes in ICU.
Publisher: Wiley
Date: 10-1999
DOI: 10.1111/J.1445-5994.1999.TB01623.X
Abstract: A warfarin loading protocol adjusting doses for age was compared to both Fennerty's protocol (Fenn) and empirical dosing (Emp). Patients beginning warfarin were randomised to receive doses according to either the age adjusted (Age) protocol or Fenn. Data were retrospectively collected for patients who had begun warfarin in the previous six months to represent empirical dosing. The study was performed on inpatients being commenced on warfarin for the first time at two teaching hospitals. Endpoints were time to reach a stable, therapeutic International Normalised Ratio (INR) between 2-3, the number of patients experiencing an INR > or =4 in the first week and the number of patients who had a dose held in the first week. Thirty-five patients were assessed in the Age group, 28 in the Fenn group, and 123 patients for the Emp group. Patients using the Age protocol achieved a stable, therapeutic INR more rapidly than either the Fenn (p=0.003, log rank test) or Emp (p or =4 in the first week (p<0.05) as well as a lower proportion having doses held in the first week (p<0.01). There were no differences between Emp and Fenn for any of the endpoints. Adjustment of warfarin loading doses for age exhibits clear superiority over the use of Fenn or Emp. This becomes increasingly important as the average age of patients being warfarinised increases, with the recognition that atrial fibrillation requires anticoagulation. Fenn consistently overdosed elderly patients, especially those aged 80 years and older.
Publisher: SAGE Publications
Date: 06-2003
DOI: 10.1345/APH.1A372
Abstract: To examine the time taken to reach a stable international normalized ratio (INR), as well as the incidence of overanticoagulation of an age-adjusted warfarin initiation protocol. Inpatients and outpatients commencing warfarin therapy at 2 teaching hospitals were dosed according to the age-adjusted protocol. Data were collected prospectively. Time to reach a stable INR of 2–3 and the number of patients experiencing an INR ≥4 during the first week of warfarin therapy. Seventy-three patients were assessed at the completion of the 4-day titration protocol, 63% had achieved a stable INR. After an additional 2 days of empiric dosage adjustment by the attending physician, 86% of the subjects demonstrated a stable INR. Five patients (7%) experienced an INR ≥4. These patients had a nonsignificant trend toward a lower plasma albumin level compared with other patients (p = 0.057, Student's t-test). The INR-driven dose adjustments on days 3 and 4 of this protocol coped with other variables that have been shown to affect maintenance warfarin dosing. These included weight, gender, pharmacologic factors affecting clearance, and the presence of certain predesignated risk factors. The age-adjusted dosing protocol rapidly achieved a stable INR with minimal overanticoagulation. Patients with low serum albumin levels ( .0 g/dL) may be sensitive to the effects of warfarin during the loading phase.
No related grants have been discovered for Gregory Roberts.