Princess Alexandra Hospital

BK polyomavirus (BKPyV) is a common opportunistic infection in kidney transplant recipients, typically reactivating in the context of immunosuppression. Although asymptomatic in immunocompetent individuals, reactivation in transplant recipients can cause BKPyV-associated nephropathy (BKPyVAN), a leading cause of graft dysfunction and loss. BKPyV viremia affects approximately 10%-15% of transplant recipients, and once BKPyVAN is established, the risk of graft failure can exceed 50%. The current standard of care involves immunosuppression reduction to restore virus-specific immunity, but this approach increases the risk of acute and chronic rejection. Intravenous immunoglobulin (IVIg), which contains antiviral and immunomodulatory antibodies, has been proposed as an adjunctive therapy, although evidence supporting its efficacy remains limited to small observational studies. The BEAT-BK trial is a multicenter, adaptive, randomized controlled trial comparing standard immunosuppression reduction with or without IVIg in kidney and simultaneous pancreas-kidney transplant recipients with BKPyV viremia or biopsy-confirmed BKPyVAN. The trial will enroll participants aged 2 y and older, randomizing them 1:1 to receive standard care alone or in combination with a total IVIg dose of 2 g/kg for 8 wk. An adaptive Bayesian design will permit interim analyses with the potential for early trial success or futility. The primary endpoint is a composite ordinal outcome at 12 wk, incorporating death, graft loss, estimated glomerular filtration rate decline, acute rejection, viral load, and degree of immunosuppression reduction. Secondary outcomes include viral clearance, development of BKPyVAN and donor-specific antibodies, infections, malignancy, quality of life, and cost-effectiveness. This trial will provide the first high-quality evidence on the role of IVIg in BKPyV management and inform clinical decision-making in posttransplant care.

Abstract The May Measurement Month (MMM) campaign was conducted in Australia in 2023 to raise awareness of raised blood pressure (BP). This article reports the results of the campaign. Adults aged ≥18 years were recruited through convenience sampling in metropolitan and regional Australia including hospitals, universities, pharmacies, libraries, and community centres. Three seated BP readings were taken on each participant, and a questionnaire collected information on demographics, lifestyle factors, and comorbidities. Hypertension was defined as a systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg, or being on BP-lowering medication. Controlled BP was defined as being on BP-lowering medication with a BP <140/90 mmHg. Multiple imputation was used to estimate missing BP readings. In total, 2284 were screened, with a mean age of 39.5 years and 52.1% of whom were female. Of all participants, 679 (29.7%) had hypertension, of whom 356 (52.4%) were aware, and 315 (46.4%) were on antihypertensive medication. Of those on antihypertensive medication, 156 (49.5%) had controlled BP, and of all participants with hypertension, 23.0% had controlled BP. The MMM campaign in Australia identified a substantial number of participants with untreated or inadequately treated hypertension. The MMM campaign continues to be a cost-effective strategy in Australia to screen participants for hypertension, assess BP control and refer participants to primary care physicians where appropriate. Further efforts from all stakeholders are essential to further improve the reach of the MMM campaign in Australia, to increase awareness and improve BP control in line with the National Hypertension Taskforce of Australia Roadmap.

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.

Although frailty appears higher in rural and socioeconomically disadvantaged areas, existing evidence often lacks adjustment for possible population confounders. This study examined the independent associations between geographic remoteness and area-level socioeconomic status with frailty. We constructed a 33-item frailty index using data from 5740 participants of the Island Study Linking Ageing and Neurodegenerative Disease (ISLAND), a web-based longitudinal cohort of adults aged 50 years and over in Tasmania, Australia. After linking participant postcodes to Modified Monash Model remoteness and Index of Relative Socioeconomic Advantage and Disadvantage, we examined frailty distribution and its associations with geographic and sociodemographic factors using descriptive statistics, spatial mapping and multivariable linear regression models. The analytical sample mean age was 69.3 years (SD = 8.0) and most were women (72%). Frailty index scores followed a gamma distribution (mean score = 0.16, SD = 0.09), increased with age and were highest in central and western areas of Tasmania. After adjustment for age, gender, education, retirement and migrant status, frailty index scores were significantly higher in rural towns (β = 0.011 [95% confidence interval, CI = 0.005, 0.016]) and remote communities (β = 0.023 [95% CI = 0.009, 0.038]) than regional centres. Similarly, after full adjustment, compared with areas of the highest socioeconomic advantage, frailty was significantly higher in areas of middle (β = 0.013 [95% CI = 0.007, 0.018]) or low (β = 0.024 [95% CI = 0.018, 0.030]) socioeconomic advantage. The distribution of frailty across Tasmania varied by geographic remoteness and socioeconomic disadvantage. Integrating frailty assessment into regional health planning may support targeted interventions for vulnerable subpopulations, particularly in rural and disadvantaged communities.

This paper investigates the effects of regulations aiming to optimise the multi-agency relationships, with a focus on the prescription choice between generic versus branded medications. In 2012, Italian legislators introduced two laws targeting general practitioners prescription behaviour, a soft (recommendations) law followed by a hard (mandatory) law to promote generic medication. We implement a regression discontinuity in time framework and an event study to quarterly administrative data for individuals with chronic kidney disease linked to data from their general practitioners in Emilia-Romagna, Italy. The results indicate that the policies were effective, but had modest effects on increasing the prescription of generic medications. Hard laws seem to have played a key role in driving this change. Heterogeneity checks provide evidence that less competition among GPs and interaction with specialists increased generic medication prescriptions.

A descriptive quantitative study. To determine how much and what type of exercises and training were provided as part of usual physiotherapy and occupational therapy to participants of the SCI-MT Trial (the Early and Intensive Motor Training for People with Spinal Cord Injuries Trial). This information is important because the SCI-MT Trial concluded that additional motor training is redundant if people with SCI receive equivalent usual care as what was provided to participants of the SCI-MT Trial. Fifteen spinal injury units across Europe and Australia. Data were collected on the time participants of both groups of the SCI-MT Trial (n = 220) attended physiotherapy and occupational therapy provided as part of usual care over the 10-week intervention period. The International Spinal Cord Injury Physical Therapy and Occupational Therapy Basic Data Set was used to capture time spent on activity and impairment directed categories of exercises and training. Participants attended a median (interquartile range) of 8.3 (6.2 to 11.4) hours of physiotherapy and occupational therapy per week. Approximately 70% of therapy time was spent actively exercising or training with a median of 3.8 h per week spent on activity-directedand 1.9 h per week spent on impairment-directedexercises and training. The results of this study detail the amount and type of physiotherapy and occupational therapy that needs to be provided as part of usual rehabilitation care to render additional motor training redundant.