Prince Charles Hospital

The Limit of Detection in the Emergency Department (LEGEND) rule-out strategy integrates high-sensitivity cardiac troponin assay concentrations with shared decision making to rapidly assess emergency patients with suspected acute coronary syndrome (ACS). We hypothesized that the LEGEND rule-out strategy would reduce length of stay (LOS), increase the proportion of patients safely discharged within 4 hours, reduce cardiac testing, and decrease hospital representations, while maintaining patient safety. We conducted a stepped-wedge cluster randomized controlled trial in 4 Australian emergency departments from August 2019 to July 2020. We included adult patients presenting with suspected ACS. We randomized sites to implement the LEGEND strategy. The primary outcome was LOS. Secondary outcomes included discharge from hospital within 4 hours, cardiovascular tests, representations, index, and 30-day events. The study included 9,944 patients, 5,347 in the standard care and 4,597 in the intervention arm. For patients in the LEGEND cohort (presentation troponin ≤2 ng/L), the mean LOS was 3.6 hours shorter in the intervention arm than the standard care arm (95% confidence interval [CI] 2.5 to 4.6 hours). The proportion of patients safely discharged within 4 hours increased by 22.9% (95% CI 19.5% to 26.3%), and cardiac testing decreased by 7.8% (95% CI 4.6% to 11.1%). There were no differences in representations, index events, or 30-day events. The LEGEND rule-out strategy safely ruled out acute myocardial infarction, reduced hospital LOS, increased the proportion of patients discharged within 4 hours, and reduced cardiac testing.

Obstructive sleep apnoea (OSA) is common in Australia but underexamined among First Nations peoples. We conducted a retrospective cross-sectional analysis of 1563 adult sleep studies in South East Queensland (2022-2023). Thirty-eight participants (2.4%) identified as First Nations, of whom 74% had OSA. Comorbidities were more frequent among the First Nations cohort, though small sample size limited certainty. These findings reveal both under-identification of First Nations status and a substantial OSA burden, emphasising the need for culturally informed, community-led approaches to OSA care in Queensland.

Haemorrhage and blood product usage are common in venoarterial extracorporeal membrane oxygenation (VA ECMO) and associated with increased mortality. A prospective, investigator-initiated, longitudinal observational cohort study on major haemorrhagic events in 12 ECMO centres from 3 continents for three predefined subgroups (VA ECMO initiated during cardio-pulmonary resuscitation (ECPR), after cardiothoracic surgery (CTS), for cardiogenic shock (CS)). The aim was to describe haemorrhagic complications as well as transfusion practice and anticoagulation for the whole population as well as the subgroups. In addition, independent baseline predictors for red blood cell (RBC) transfusions were evaluated. 545 prospective patients were included between 2019 and 2022 (ECPR 149, CTS 169, CS 227). Hospital mortality was 46%. Over 2796 days 406 major haemorrhage events in 286 (52%) patients were recorded. CTS and ECPR patients had more frequent events occurring earlier in their course. 88% received RBC transfusions (1.27 (95%CI 1.22 – 1.31) units/day) with significantly more transfusions for CTS and ECPR patients. Platelet transfusion rates were highest in the CTS group (0.58 (95%CI 0.53–0.64) units/day). Haemoglobin and platelet count prior to transfusion were independent of subgroups and averaged (78 g/L (IQR 73, 84), 58 × 10^9/L (IQR 37, 85), respectively). However, platelet count prior transfusion was only marginally higher on days with major haemorrhage (74 × 10^9/L (IQR 50, 104). Systemic anticoagulation was started within the first 24 h in 83% (95% CI 80–87%) of patients, most frequently in CS patients (90%, CI 85–95%). Independent baseline predictors for RBC transfusion were ECPR (IRR 1.50, 95%CI 1.19–1.89) and prior use of antiplatelets (IRR: 1.43, 95%CI 1.13–1.80). Myocarditis and pulmonary embolism were associated with a lower rate of transfusion when compared to myocardial infarct (IRR: 0.57 (0.37–0.89), IRR: 0.67 (0.45–1.00, respectively). Haemorrhagic complications differ in clinical subgroups and RBC transfusion exposure is by far higher than in other critically unwell populations. We identified ECPR and antiplatelet therapy as additional predictors. Transfusion practice for RBC and platelets is variable and does not always follow international guidelines.

This report details thelong-term follow-up of a patient previously reported from our centre with recurrent acute pancreatitis and episodic jaundice in the setting of three rare anatomic variants: gallbladder agenesis, ansa pancreatica, and a santorinicele. The index report described progressive main pancreatic duct dilatation and endoscopic findings consistent with intraductal papillary mucinous neoplasm (IPMN) despite non-diagnostic cross-sectional imaging. We now present the subsequent clinical course, including elective pancreaticoduodenectomy, definitive histopathology, and surveillance outcomes. Histopathology demonstrated a 30 mm grade 2 pancreatic colloid carcinoma arising in association with an intestinal-type IPMN involving both main and branch ducts (pT2N1). This occurred despite the absence of a discrete mass or guideline-defined high-risk features on cross-sectional imaging. The postoperative course was complicated, and later remnant duct dilatation raised concern for a late pancreaticojejunostomy stricture. The patient's symptoms subsequently improved, and duct calibre decreased on surveillance imaging, with computed tomography (CT) imaging in February 2025 confirming no recurrence of malignancy. This longitudinal case demonstrates that guideline-negative cross-sectional imaging does not exclude invasive carcinoma in suspected IPMN, particularly when pancreatitis and ductal variants confound interpretation. It supports individualised management, multidisciplinary assessment, and timely consideration of resection in selected patients.

Introduction: Interindividual variation in the lower limit of cerebral autoregulation (LLA) challenges fixed mean arterial pressure (MAP) targets. We assessed whether impaired cerebral autoregulation and hypoperfusion burden below the LLA are associated with acute kidney injury (AKI) after noncardiac surgery. Methods: Adults undergoing major noncardiac surgery had continuous intraarterial pressure and bifrontal nearinfrared spectroscopy monitoring. Bilateral frontoparietal near infrared spectroscopy monitoring of regional cerebral oxygen saturations (rSO2) and invasive MAP were captured intraoperatively and analysed using wavelet semblance. The LLA was defined as the MAP corresponding to the inflection point on semblance vs MAP plots, with semblance values >0.3 indicating impaired autoregulation. Hypoperfusion burden was quantified as the area under the curve for pressure values below the LLA (mmHg.min). The primary outcome was AKI (Kidney Disease: Improving Global Outcomes). Between group comparisons used t-tests or Wilcoxon rank–sum for continuous data and χ 2 /Fisher’s exact tests for categorical data; covariate adjusted associations were explored using multivariable logistic regression. Relevant ethics approvals were prospectively obtained (PAABLo: HREC/18/QPCH/48043, ACTRN12617001365358; Wavelet HREC/17/QPCH/33, ACTRN12617000834392) and all participants provided written informed consent. Results: One hundred and four patients contributed 19,416 monitored minutes. An LLA was identifiable in 85% (88/104). In those with a detectable LLA, the median LLA was 70 mmHg (IQR 56.3–77.5, Figure 1). Across all patients, 15% of monitored time occurred with mean arterial pressure below the LLA. AKI occurred in 16/101 (15.8%). Compared with patients without AKI, those with AKI had higher mean semblance consistent with impaired autoregulation (0.3 [IQR 0.2–0.4] vs 0.2 [0.1–0.3]; p=0.005), larger hypoperfusion burdens(AUC<LLA 235.7 mmHg.min [IQR 24.2–520.1] vs 42.0 mmHg.min [IQR 0.3–248.9]; p=0.033), and longer durations with pressure below the LLA (40.1 min [IQR 2.3–53.1] vs 9.8 min [IQR 0.5–39.2]; p=0.031). Conclusions: Impaired cerebral autoregulation and greater hypoperfusion burden below the patient specific LLA are associated with postoperative AKI. Marked interindividual LLA variability undermines one size fits all pressure targets and justifies randomised trials of personalised, autoregulation guided haemodynamic management.

AimTo explore the experiences and perceptions of nurse‐surgeons practicing in the Australian public health system.BackgroundNurse‐surgeons occupy a unique and innovative role within perioperative healthcare, yet their integration is often complex and underexplored in the existing literature.Sources of EvidenceThis qualitative study adhered to the consolidated criteria for reporting qualitative research checklist of the EQUATOR Network, involving five semistructured interviews analysed inductively through a reflexive thematic analysis. Ethical approval was obtained prior to the study.DiscussionParticipant interactions with supervisors were positive, while relationships with other nurses and physicians evolved from initial antagonism to mutual recognition of value. Facilitators for integration included awareness of the role, collaboration, a standardised national credentialing pathway and government involvement. The barriers consisted of geographical limitations, obstructive medical associations, financial challenges, tall poppy syndrome within nursing and a superiority complex among physicians.ConclusionThe study offers valuable insights into the nurse‐surgeons’ experiences and perceptions, highlighting essential barriers and facilitators to their integration in the healthcare system.Implications for Nursing PracticeFindings may guide healthcare institutions in fostering collaborative interprofessional interactions and implementing standardised credentialing pathways for nurse‐surgeons.Implications for Health PolicyThe insights may inform nursing associations and government bodies in addressing systemic barriers and advocating for policy changes to enhance surgical delivery in Australia and globally.