Alfred Health

The recent NEJM Evidence trial questioned the benefit of enoxaparin for venous thromboembolism (VTE) prevention among older hospitalised medical patients. We conducted a retrospective, observational audit of 142 elderly inpatients at a large Australian tertiary institution; most received enoxaparin unless contraindicated, with excellent adherence to guidelines. Clinical events were rare with two VTE (1.4%) and five minor bleeds (3.5%) recorded and no major bleeding observed. Approximately 10% of patients were ambulant and prescribed thromboprophylaxis outside guideline criteria, yet bleeding rates were low. Our findings suggest high guideline compliance and minimal bleeding associated with enoxaparin prophylaxis in this population. There is a need for simple and practical risk stratification tools with clear ambulation definitions, routine mobility assessments where appropriate and consideration of patient-accepted approaches such as oral thromboprophylaxis options.

Over the last century, the awareness of air pollution awareness and its harm to public health have resulted in the implementation of new protective measures to try and limit exposure. Bushfires generate waves of air pollution with orders of magnitudes higher than normal background pollution, necessitating studies to understand the physiological impact. Previous work has strongly linked bushfire smoke to respiratory disease (chronic obstructive pulmonary disease COPD, asthma, lung cancer) cardiovascular disease (myocardial infarction, stroke), and increased susceptibility to infection (COVID-19). Nevertheless, the underlying mechanisms of pathogenesis remain unclear. There is little consensus on what in vitro and in vivo techniques are best used to examine disease mechanisms. Individual investigations are useful but a lack of standard methods creates variability and makes comparisons difficult. Developing adaptable in vitro and in vivo models that are replicable, physiologically relevant, and affordable may reduce variability enabling comparisons. These models should also be capable of integrating multiple types of pollutants or reference materials to develop standards that other studies can follow, facilitating comparisons. Here, we discuss advance in vitro and in vivo experimental models to study the impact of bushfire smoke exposure induced pathophysiology. The goal is to improve comparison and translation across studies, and to lay the groundwork for future research into the mechanisms that underpin bushfire smoke-induced pathogenesis to enable the development of preventative measures and effective therapies.

More older adults are living with an implantable cardioverter defibrillator (ICD). Deactivation rates for those approaching end-of-life are low, risking undue distress and an undignified death. This scoping review aimed to determine the availability and content of hospital guidance documents regarding ICD deactivation towards end-of-life. Guidelines' databases from two Australian states (Victoria and South Australia) were systematically searched between September 2022 to February 2023, to identify all documents that specified guidance for ICD deactivation at end-of-life. Relevant documents were analysed using a pre-specified data extraction tool. Following screening of 59,662 documents from 94 health services providing acute, aged or palliative care, 11 were included. Most were from public (10, 91%), metropolitan (eight, 73%) health services. Guidance on timing of ICD deactivation discussions was limited; only two (18%) documents advised discussion at time of insertion, one (9%) at generator change and six (55%) during advance care planning discussions. Recommended criteria for ICD deactivation varied: people with a terminal illness (two, 18%), with an active do not resuscitate order (five, 45%), receiving end-of-life care (11, 100%), or at the person's request (seven, 64%). Nine (82%) recommended consent dialogue that deactivation does not cause/hasten death (eight, 73%) or deactivate pacing (eight, 73%), aims to promote a peaceful death (eight, 73%) and that reactivation is possible (eight, 73%). There is a paucity of local health service guidance to support clinicians navigating ICD deactivation at end-of-life.

ABSTRACT Introduction Overweight and obesity are increasing rapidly in most countries. Underweight body mass index (BMI), though much less common, is also associated with adverse health outcomes. There is poor understanding of the implications of BMI in lymphoma patients. Recent international guidelines indicate that curative‐intent cancer treatment should not be modified for obesity alone, with no specific recommendations for low BMI patients. Our aim was to examine the impact of BMI on outcomes in a contemporary cohort of lymphoma patients. Methods We examined BMI in relation to baseline clinical features and outcomes in an Australasian cohort of 4686 lymphoma cases from the national registry. Results Patients with an overweight or obese BMI had no significant decrement in overall survival (OS) or progression free survival (PFS) compared to those with a normal BMI for any of the histological subtypes examined in this study. However, the minority of patients with underweight BMI demonstrated inferior OS for Hodgkin lymphoma (adjHR = 2.55, 95% CI = 1.05–6.19, p = 0.04) and OS (adjHR = 1.54, 95% CI = 1.02–2.32, p = 0.04) in diffuse large B‐cell lymphoma compared to patients with a normal BMI. Conclusion These findings support continued standard dosing in overweight and obese patients and identify poor outcomes requiring careful management in underweight populations. Trial Registration The authors have confirmed clinical trial registration is not needed for this submission.

Malformations of cortical development (MCDs) are a frequent cause of drug-resistant epilepsy and a common indication for resective epilepsy surgery. As magnetic resonance imaging (MRI) lacks sensitivity for subtle MCDs, supplemental diagnostic tools are needed. This study aimed to characterize scalp electroencephalographic (EEG) patterns in MCDs and investigate their association with surgical outcomes. This was a retrospective case-control study including patients who underwent inpatient video-EEG monitoring at two Australian hospitals. Cases were individuals with MCDs confirmed on MRI or histopathology; controls included patients with other focal epilepsies. Two epileptologists independently reviewed interictal and seizure-onset EEG patterns using a standardized classification framework. Patterns were compared between cases and controls and assessed with respect to postoperative seizure outcomes, adjusting for antiseizure medication reduction. We included 38 cases with MCDs (52.6% females, median age = 34 years) and 114 controls (45.6% females, median age = 41 years). Among interictal patterns, repetitive epileptiform discharges type 1 and type 2 were more prevalent in patients with MCDs than controls (p = .002 and .005, respectively). Focal fast epileptiform discharges were also more frequent in MCD patients, after excluding nonlesional focal epilepsy controls (p = .038). Among seizure-onset patterns, paroxysmal fast activity was more prevalent in MCDs (p < .001). Among 38 patients who underwent surgery, 70.0% of MCDs and 75.0% of controls had favorable outcomes. No EEG pattern predicted postoperative seizure outcomes. Distinct scalp EEG patterns may support differentiation of MCDs from other focal epilepsies. Larger prospective studies are needed to clarify their role in detecting MRI-negative MCD or guiding targeted imaging.

To provide a 10-year update on the best available evidence evaluating the impact of nurse practitioner services on cost, waiting times, patient satisfaction, representation rates, and length of stay in emergency and urgent care settings. Systematic review. The search was completed on January 28, 2025, in Embase (Elsevier), Medline (EBSCOhost), CINAHL (EBSCOhost), Cochrane Library (Wiley), Emcare (Ovid), Web of Science Core Collection (Clarivate) and Scopus (Elsevier). The data range (2014-2024) was used to limit the search. The search was conducted with results imported into Covidence. In Covidence, two reviewers conducted screening, data extraction, and quality appraisal of articles, and findings were analysed using a narrative synthesis approach. Eligible studies examined nurse practitioner services in emergency or urgent care settings, reporting outcomes of cost, waiting times, patient satisfaction, representation rates, and length of stay. Title and abstract screening were performed on 2329 records. Of these, 236 full-text articles were reviewed, and 17 underwent critical appraisal and data extraction. Narrative analysis of outcome measures yielded mixed results, with both favourable and unfavourable findings reported regarding nurse practitioner services. Global evaluation of nurse practitioner services in emergency care remains inconsistent. Nevertheless, emerging evidence supports their positive impact, particularly in improving patient outcomes. To effectively inform policy, workforce planning and clinical integration, there is a need for professional benchmarks that provide clear frameworks for the evaluation of patient-centred outcomes and operational impacts in emergency departments. Evidence related to nurse practitioner services in emergency and urgent care clinics highlights the positive impact of nurse practitioner services on patient wait times and satisfaction; however, there is limited and variable evidence of impact on health care costs and outcomes. This paper recommends that evaluating emergency nurse practitioner services requires homogeneous research using consistent professional benchmarks and evaluation frameworks. This systematic review follows the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. This study did not include patient or public involvement in its design, conduct, or reporting. PROSPERO 2025 CRD420250645148.

Abstract Background Personalized medicine promises to tailor treatments to the individual, but it carries a hidden risk: mistaking statistical noise for actionable clinical insight. Current machine learning approaches often provide predictions, but fail to inform clinicians when those predictions are unreliable. Objective Develop a deployment-readiness framework that integrates causal inference, interpretable effect-trees, and calibration assessment to distinguish actionable signal from unreliable variation, and to support treatment selection only when the estimated benefit is both reliable and clinically meaningful. Methods Using retrospective observational cohort EHR data from the INSPIRE perioperative dataset (N&gt;130,000 surgical operations, 2011–2020), we estimated treatment effects using causal forests with double machine learning, benchmarked against other causal methods to assess convergence. We used the estimated causal effects to create effect-trees and translated estimates into interpretable rules. We validated the treatment recommendations by assessing subgroup calibration to identify which groups were reliable for treatment selection. Results In a prostate procedures case study (neuraxial versus general anesthesia; total N=2,822), neuraxial anesthesia was associated with substantially lower post-operative opioid use (ATE = −1.38 opioid medications, 95% CI [−1.62, −1.15]). The effect-tree produced five clinically interpretable subgroups using BMI, ASA status, and age, with effects ranging from −1.10 to −1.59 opioid medications. Calibration analysis identified four of five subgroups as reliable for deployment (calibration error &lt; 0.08), while one small subgroup (N=250) showed higher calibration error (0.44), illustrating how the framework rates unreliable heterogeneity. Conclusions Individual prediction heterogeneity does not automatically justify clinical personalization. By combining effect-trees with calibration, this framework distinguishes actionable heterogeneity from noisy heterogeneity (detectable but unreliable). This approach transforms causal machine learning from a black box into a validated decision support system that enables selective deployment of treatment decision rules.

Phototherapy with narrowband ultraviolet B (UVB) is an effective treatment for vitiligo. However, it requires frequent in-office visits. Self-administered home-based UVB (HBUVB) therapy with a handheld or panel device is an alternative that has received limited research attention. The purpose of this systematic review and meta-analysis is to evaluate the effectiveness and safety of HBUVB in the treatment of vitiligo compared to in-office UVB (IOUVB). Searches were conducted on Medline, Cochrane and Embase from inception until 4th of August, 2024. Studies with primary data of patients being treated with a hand-held UVB device were included in this study. Efficacy as measured in number of patients achieving > 50% or > 75% repigmentation was the primary study outcome. Secondary outcomes analyzed were cost, adverse events and adherence. Eighteen studies were included with a total of 1341 vitiligo patients. Of these, four studies (148 HBUVB and 143 IOUVB) could be used for the meta-analysis. HBUVB was not inferior to IOUVB at achieving > 50% (OR 1.04, 95% CI 0.58-1.87) and > 75% repigmentation (OR 1.26, 95% CI 0.65-2.42). Home-based UVB was not associated with an increase in risk for either erythema or burning sensations when compared to IOUVB. There was a 14% lower rate of discontinuation amongst patients using HBUVB. Home-based UVB therapy is not inferior to in-office UVB therapy in efficacy or rate of adverse events and demonstrates favourable treatment adherence. This meta-analysis provides evidence supporting HBUVB as a safe and effective alternative to IOUVB in patients with vitiligo. PROSPERO registration number: (CRD42023478123).