[Department of Error] Department of Error

Pearson G, Shann F, Barry P, et al. Should paediatric intensive care be centralised? Trent versus Victoria. Lancet 1997; 349: 1213–17—In table 4 of this Early Report, the values for ventilated in first hour per 1000 <16 years should have been “0·65” in Trent and “0·50” in Victoria.

[Articles] Dexmedetomidine for prevention of delirium in elderly patients after non-cardiac surgery: a randomised, double-blind, placebo-controlled trial

For patients aged over 65 years who are admitted to the intensive care unit after non-cardiac surgery, prophylactic low-dose dexmedetomidine significantly decreases the occurrence of delirium during the first 7 days after surgery. The therapy is safe.

Maternal mortality trends in Australia

Maternal death is low and decreasing in Australia, but continuing surveillance is important

The death of a mother or a baby has significant short and long term impacts for the surviving family members and for the community and health workers who cared for them. The World Health Organization estimates that 303 000 women died in pregnancy and childbirth in 2015, with 99% of these deaths occurring in low income countries.1

In Australia, a series of reports regarding maternal deaths has been published over the past five decades; the first in the series covered the 1964–1966 triennium.2 These reports examine the deaths that occurred during pregnancy or within 42 days of the end of pregnancy. They are compilations of data sourced from multidisciplinary state maternal mortality review committees that undertake detailed reviews of each case.

The incidence of maternal death is expressed as a maternal mortality ratio (MMR). The MMR is the number of deaths due to complications of the pregnancy (direct deaths) or aggravation of existing disease processes by the pregnancy (indirect deaths) per 100 000 women giving birth. The calculation does not include deaths from unrelated causes that occur in pregnancy or the puerperium (incidental deaths) and deaths that occur more than 42 days after the end of a pregnancy.

The MMR in Australia is low; it has decreased from 41.2 in the 1964–1966 period to 7.1 in the years 2008–2012.3 The comparable figures are 14.7 for the period 2010–2012 in New Zealand4 and 9.0 for the period 2011–2013 in the United Kingdom.5

Until now, publications in the Maternal deaths in Australia series have been irregular. The Australian Institute of Health and Welfare (AIHW) established the National Maternity Data Development Project (NMDDP) in response to the recommendations in the 2008 Maternity Services Review from the Commonwealth and the subsequent 2010–2015 National Maternity Services Plan.6 A recent report regarding the progress of the NMDDP notes that sustainable data collection on national maternal mortality will be established to facilitate “consistent and regular national reporting” of maternal mortality in the future.6

The genesis of the almost sixfold reduction in maternal death rates in Australia is multifactorial, including the improved general health of the population and the availability of better health care options, such as the availability of antibiotics, blood transfusion, safer anaesthesia and effective diagnostic ultrasound. Advanced maternal age, maternal obesity and caesarean deliveries3,5 are all associated with an increase in the risk of maternal death, and any future growth in their incidence will threaten the efforts to further reduce the maternal mortality rate.

In the list of most common causes of death, infection, abortion and pre-eclampsia have been replaced by maternal cardiovascular disease and psychosocial health problems, while obstetric haemorrhage and thromboembolism remain prominent. The current method of classifying maternal deaths into direct, indirect and incidental deaths was first used in the report on the 1973–1975 triennium.7 Between that first 1973–1975 report and the most recent one for 2008–2012, 944 direct and indirect maternal deaths have been reported in Australia. Over that 48-year period, cardiovascular disease (MMR, 1.5), sepsis (MMR, 1.3) and obstetric haemorrhage (MMR, 1.1) have been the most prominent causes of death.

Aboriginal and Torres Strait Islander women are twice as likely to die in association with pregnancy and childbirth as other Australian women. In 2008–2012, the Aboriginal and Torres Strait Islander MMR was 13.8 compared with 6.6 for non-Indigenous Australian women who gave birth.3 The differential between the MMRs is decreasing and caution should be exercised in drawing conclusions due to the small numbers analysed. The leading causes of maternal deaths among Aboriginal and Torres Strait Islander women were cardiovascular conditions, sepsis and psychosocial conditions.

Women aged 35 years or over were more than twice as likely as their younger counterparts to die in association with pregnancy and childbirth, and those aged 40 years or more were over three times more likely to die in association with pregnancy and childbirth.3

Of the six most prominent causes of maternal death between 1973 and 2012, psychosocial death is the only group where the MMR is rising; the incidence of maternal death due to cardiovascular disease, obstetric haemorrhage, thromboembolism, hypertensive disorders and sepsis are all decreasing. Most of the deaths classified as psychosocial deaths are due to suicide, although some are related to fatal complications of substance misuse and homicide in domestic situations. While some of that apparent rise may be due to changes in the ascertainment of maternal deaths in general and to problems reporting both maternal suicide and deaths due to substance misuse in particular, it is clear that more needs to be done in this sphere. There is a growing belief that a significant portion of late maternal deaths are related to suicide; however, without a clear review of the cases by multidisciplinary committees, the relationship between pregnancy and suicide more than 42 days after the end of pregnancy remains speculative.

It is not clear whether the incidence of suicide in association with pregnancy is more or less common than in comparable non-pregnant women. This comparison is fraught, as the true denominator for pregnancy is not known due to lack of information regarding pregnancies lost as a result of miscarriage and termination. Given that caveat, the overall suicide rate in the 15- to 45-year-old Australian female population in 2006–2010 was 6.0 per 100 000 women,8 while the maternal mortality rate due to psychosocial issues in the same period was 0.9 per 100 000 women giving birth. A similar finding has recently been noted in the United States.9 Nevertheless, the apparently increasing incidence of psychosocial maternal death is a matter of concern, given that pregnant women are among the most medically supervised members of the population.

Screening during pregnancy for mental health, substance misuse and domestic violence problems is recommended,10 but it is not universally undertaken. All maternity care providers should commit to making these items a standard part of their care delivery. The follow-up of identified concerns by the relevant specialist services must be a priority and should continue for a significant period after the end of pregnancy. Similar screening attention is needed for women who had miscarriages and pregnancy terminations.

In many cases, an autopsy is necessary to understand the true cause of a maternal death. A number of causes of maternal death, such as amniotic fluid embolism and pulmonary thromboembolism, may be easily confused clinically. In the case of amniotic fluid embolism, for example, the diagnosis can only be confirmed by autopsy. The question of an autopsy should be pursued with the family by a senior clinician, and the presumption of a diagnosis that has been made in an intensive care unit or similar setting should not be an excuse to not request this critical form of investigation.

Maternal death is one of the few defined core sentinel events in health care; however, it is disturbing to find that a significant portion of these deaths have not been subjected to a root cause analysis or similar review. The application of a systematic review to identify gaps in hospital systems and health care processes, which are not immediately apparent and may have contributed to the occurrence of an event, should be applied to all maternal deaths, whether occurring in the public or private health systems.

The question of the presence or absence of contributory factors is now being actively pursued by some state and territory maternal mortality review committees, and similar questions are also being raised internationally. A consolidation of such information is yet to be published in an Australia-wide context. Experience with such review in New Zealand11 has shown that more than 50% of maternal deaths were associated with contributory factors, and 35% of the deaths were potentially avoidable.

The Victorian Consultative Council on Obstetric and Paediatric Mortality and Morbidity model12 appears to be of value, and examines two questions:

Were suboptimal care factors identified?
What was the relevance of any suboptimal care factors identified?

Suboptimal care factors may be classified as factors related to the woman, her family and social situation, factors related to access to care and factors related to professional care. Moreover, these factors may be classified as identified but unlikely to have contributed to the outcome (insignificant), identified and might have contributed to the outcome (possible), or identified and likely to have contributed to the outcome (significant).

It is critical to maintain a continuing intensive surveillance of maternal death — with particular reference to recognised risk factors — and to examine the contributory factors. Health departments must require that all direct and indirect maternal deaths are subjected to a systematic review. At present, data on late maternal deaths — occurring more than 42 days after the end of pregnancy — are not collected in all states and territories and are not reported nationally. Reviews of late maternal deaths and of severe maternal morbidity are future necessities, but the resources and methodologies are not yet available at a national level.

[Comment] Preventing postoperative delirium: all that glisters is not gold

Delirium is an important complication of surgery, affecting an estimated 30% of surgical patients in the intensive care unit (ICU).1 Postoperative delirium is distressing for patients and family members, and is associated with increased risk of further negative outcomes, including admission to institutions, dementia, and death.2 Unfortunately, many candidate pharmacological interventions to prevent postoperative delirium have failed.3 The cholinesterase inhibitor rivastigmine exemplifies the failures.

Hospital trial turns night into day for US doctors, patients

Picture: Dr Timothy Buchman talks to a colleague in Atlanta from the ‘Turning Night Into Day’ centre at Macquarie University

Night has become day for a group of US doctors and critical care nurses, who are using new technology to remotely monitor their intensive care patients in hospitals in Atlanta from a Sydney health campus.

The intensivists and nurses from US health provider Emory Healthcare are part of a clinical trial to assess the health benefits for both patients and doctors of having highly experienced clinicians available to provide senior support around the clock.

Taking advantage of remote intensive care unit (eICU) technology and the 14-hour time difference, the medical teams are essentially working the Atlanta night shift during the day in Sydney.

“We’re in Australia because we are trying to look at a different model of care,” Cheryl Hiddleson, the director of Emory’s eICU Centre, told Australian Medicine.

“We were having our clinicians up all night while they were trying to do other things during the day – that’s just what happens. We know that working the night shift is tough.

“This study is to look at our staff and see how the difference in the times that they are working makes to their performance and their health.”

Under the trial, senior intensivists and critical care nurses from Emory are based in Sydney for six to eight week rotations.

They work at MQ Health at Macquarie University, using eICU technology developed by health technology maker Royal Philips, to provide continuous night-time critical care oversight to high-risk patients in Emory’s six hospitals across the state of Georgia.

“We intensive care folk have one mission, and that’s to deliver the right care for the right patients at the right time,” Dr Timothy Buchman, the chief of Emory’s Critical Care Services, said.

“Almost everything we do has to be done with both speed and care. That’s easy in a big hospital at 10am on a Monday, but that task becomes a lot harder in a remote or rural hospital at unsocial hours – on weekends, holiday, or especially at night.

“There are fewer people, and less experienced people, and patients can become sicker around the clock. Patients and their families deserve the best care, and this is about bringing that senior support to the bedside.”

The day before Dr Buchman spoke to Australian Medicine, he helped treat a patient who had been airlifted to one of Emory’s Atlanta hospitals at 2am US time – 4pm in Sydney.

The patient was suffering severe pancreatitis and respiratory failure, and was being treated by a relatively junior doctor.

“I had a complete echo of the bedside monitor, and was able to guide the doctor through the treatment,” Dr Buchman said.

“The attending physician would have been at home, probably asleep. But I was able to go in as if I was there and help implement care plans.”

Two hours later, another patient came in from a smaller hospital, suffering post-operative haemorrhaging.

“She was deeply anaemic, but she was also a Jehovah’s Witness and so was refusing blood products,” Dr Buchman said.

“The other hospital said we needed experimental therapies, so we accepted her admission. I was able to evaluate her remotely and provide the level of care she needed. When I came in to work this morning, I was able to check on her condition again.”

The previous night, just before 1am, the family of a terminally ill cancer patient, who had been intubated earlier in the day, requested a meeting to evaluate his care.

“I was able to talk to them – they could see me, I could see them – and they decided to shift from aggressive care to comfort,” Dr Buchman said.

“The patient was able to die. His family were able to be there and it was able to occur in a timely fashion. The family had come to a decision and acceptance, and they could have that meeting when they needed it, instead of having to wait for hours.”

Emory already uses the eICU to provide senior support to smaller and remote hospitals throughout Georgia. The time difference trial is intended to see if the technology can help keep senior clinicians in the workforce.

“People do function a lot better when they can do night work in day time,” Dr Buchman said.

“This technology is important, but it is only an enabler. The people – the staff, the patients – are what is important, and this technology gives us the ability to use this accumulated wisdom during daylight for patients on the other side of the world who would not normally have access to this level of expertise.”

Maria Hawthorne

Antivax film dumped following outcry

A controversial film that claims US health authorities are covering up evidence linking a vaccine to autism has been withdrawn from screening at a central Victorian film festival.

The Castlemaine Local and International Film Festival has decided to dump the controversial show Vaxxed: From Cover-Up to Catastrophe following widespread calls, including from AMA President Dr Michael Gannon, for it to be scrapped from the festival’s line-up.

Earlier this week Dr Gannon called on organisers of the festival to dump the film because it made claims about the safety of vaccines that had been thoroughly discredited, could undermine efforts to protect children against infectious diseases and might add to distress and hardship for parents of children with autism and.

The film is written and directed by Andrew Wakefield, a former doctor who was struck off after being found to have falsified the results of a notorious 1998 study claiming to have a correlation between the MMR vaccine and autism. It purports to document the experiences of a former US Centers for Disease Control and Prevention employee who claims the CDC covered up data showing a statistically significant association between the MMR vaccine and autism in African American children.

But actor Robert De Niro pulled it from screening at New York’s Tribeca Film Festival amid widespread criticism, and the organisers of the Castlemaine Local and International Film Festival (CLIFF) have now followed suit.

The organisers, who had initially resisted calls to dump the film, said in a statement reported by the Bendigo Advertiser that they had decided to acquiesce to pressure because some had felt “personally and professionally threatened”.

“This is unacceptable. It is with the utmost regret, therefore, the CLIFF is compelled, for clear reasons of personal and public safety, to withdraw the screening from the CLIFF 2016 programme,” the organisers said in a statement.

The decision came amid strong criticism by Victorian Health Minister Jill Hennessy, Dr Gannon and other health experts of the claims made in the film.

Dr Gannon said assertions made in Vaxxed of a link between vaccines and autism had been held up to close public examination over a long period of time and proven to be false.

He said the makers of Vaxxed should not be given a platform to peddle their discredited claims.

“The director of the film’s an ex-colleague of mine called Dr Andrew Wakefield, who’s obviously decided that running a wellness clinic in exile in Cuba’s no longer floating his boat, and he’s going to make anti-vaccination films, having potentially damaged thousands of children in England and Wales with his false MMR scare campaign. He’s entirely discredited. Anyone he hangs around with is discredited,” the AMA President said.

Challenged over the right to present these claims in a film, Dr Gannon replied: “Not when it’s made by a charlatan, not when it’s made by someone who’s been entirely discredited by the scientific world, the medical world, someone who was struck off the medical register for having harmed people and been seen as being a danger to the community.

“That’s not the kind of person I’d be getting my scientific information from. And that’s not the kind of person who I would trust to fairly vet the claims of one person within a bureaucracy of tens of thousands of people.

“I would say censor and ban this rubbish.”

Ms Hennessy said it was important to challenge the myths peddled by anti-vaccination campaigners.

“We’ve got to keep challenging the anti-science myth pedalling that goes on around vaccination and a film that goes out there to say ‘vaccinations aren’t safe’ is really, really unhelpful, particularly in communities where the vaccination rates are in many circumstances lower than what the state average is,” Ms Hennessy said.

“Sadly, what you’ll see when you screen a film like this, you’ll see confirmation bias,” the AMA President said on ABC radio. “You’ll see people who want to believe that there’s something wrong here, and that will just get in their head. There are people who – for some strange reason – like believing in conspiracy theories.”

The AMA President lambasted the makers of the film for the “potential carnage” caused if it resulted in lower vaccination rates, and the harm it might inflict on families.

“Those families around Australia that struggle with the hardship of dealing with children afflicted by autism spectrum disorder, blaming them, setting them up, saying that they did something to injure their child’s brain development. I think that is so unfair,” he said.

Dr Gannon said the safety and efficacy of each vaccine was subject to rigorous examination, and it was vital that people remained confident in the safety and effectiveness of the National Immunisation Program.

“Every individual vaccine is subject to the closest level of scrutiny as to its effectiveness, both for individuals and a population level, and it’s safe,” he said. “I can assure your listeners that the health authorities do take this stuff extremely seriously [and] even small pockets of people who choose not to vaccinate their children, there is a cost to be had there.

“One, two, three per cent reductions in vaccination rates harm children. They put them in intensive care, they kill them. This is not scare-mongering. It is so important to maintain vaccination rates well above 90 per cent. It’s irresponsible to do anything that might threaten the public’s health.”

Adrian Rollins

‘Ban this rubbish’: antivax film trashed

A controversial film that claims US health authorities are covering up evidence linking a vaccine to autism should be banned, according to AMA President Dr Michael Gannon.

Dr Gannon said that although it was against his “natural instincts” to urge censorship, he called on organisers of film festival planning to screen the show Vaxxed: From Cover-Up to Catastrophe to drop it from their program.

The Castlemaine Local and International Film Festival has become the centre of a social media storm after including Vaxxed in its 2016 program.

The film was originally due to screen at New York’s Tribeca Film Festival until it was pulled by actor Robert De Niro under pressure from scientists and other filmmakers.

But Castlemaine Film Festival creative director David Thrussell has so far stuck by the film, which he argues presents “potentially compelling evidence from a whistleblower in the CDC”.

“The film is not an anti-vaccine film. It’s about a specific vaccine, and the allegations that this whistle-blower… produced results that potentially created evidence that that precise vaccine was potentially linked to autism. And they were pressured to suppress that information. That is what the documentary is about,” Mr Thrussell told ABC radio.

The film festival director said there was not a “definitive answer to this question, and I suggest other people don’t have definitive answers as well”, and by screening the film the festival was treating the audience as adults who can “make their own informed decision”.

But Dr Gannon said claims of a link between vaccines and autism had been held up to close public examination over a long period of time and proven to be false.

He said the makers of Vaxxed should not be given a platform to peddle their discredited claims.

“I would say censor and ban this rubbish.”

The AMA President lambasted the makers of the film for the “potential carnage” caused if it resulted in lower vaccination rates, and the harm it might inflict on families.

Dr Gannon said the safety and efficacy of each vaccine was subject to rigours examination, and it was vital that people remained confident in the safety and effectiveness of the National Immunisation Program.

Adrian Rollins

[Articles] Effect of regional versus local anaesthesia on outcome after arteriovenous fistula creation: a randomised controlled trial

Compared with local anaesthesia, BPB significantly improved 3 month primary patency rates for arteriovenous fistulae.

News briefs

Anti-Zika drugs on the way

Compounds that suppress Zika virus replication or prevent the death of cells infected by the virus have been reported online in Nature Medicine. Similar to dengue virus and chikungunya virus, Zika virus can cause flu-like symptoms in some individuals. Unlike dengue virus and chikungunya virus, Zika virus infection can also result in the congenital defect microcephaly in developing fetuses, and in Guillain–Barre disease in adults. Researchers from the Johns Hopkins University School of Medicine screened a library of approximately 6000 compounds that included US Food and Drug Administration-approved drugs and experimental therapies currently in clinical trials, and identified two classes of compounds: one inhibits the death of cells infected by Zika virus, the other blocks Zika virus replication in infected cells. The two classes of compounds showed activity in several relevant types of brain cells — including human neural progenitor cells and astrocytes — and in 3D brain organoid cultures. The compounds also worked when given either before or after exposure to Zika virus. Finally, the two classes of compounds showed even greater benefits when used together than when given individually. Further research is needed before these compounds can be considered for human treatment, especially of pregnant women. Essential next steps include testing the efficacy and safety of these lead compounds in animal models of adult and fetal Zika virus infection.

http://dx.doi.org/10.1038/nm.4184

Night surgery doubles risk of death

New research presented at the World Congress of Anaesthesiologists in Hong Kong late last month showed that patients who had surgery during the night were twice as likely to die as patients operated on during regular working hours. Patients operated on later in the working day or in the early evening also had a higher mortality risk, concluded the researchers from McGill University Health Centre in Montreal, Canada. A retrospective review of 30-day postoperative in-hospital mortality was carried out at the Jewish General Hospital in Montreal, which is also a teaching hospital. The study evaluated all surgical procedures for the past 5 years, from 1 April 2010 to 31 March 2015. A database was constructed collecting variables about surgical interventions. All elective and emergent surgical cases were included, except ophthalmic and local anaesthesia cases. The working day was divided into three time blocks (daytime, 07:30-15:29; evening, 15:30-23:29; nighttime, 23:30-07:29). The start time of the anaesthetic recorded by the circulating nurse was used to determine in which time block the operation began. There were 41 716 elective and emergency surgeries performed on 33 942 patients in 40 044 hospitalisations. Of these, 10 480 were emergency procedures; there were 3445, 4951, and 2084 emergency procedures with anaesthesia starting during the day, evening and night respectively. There were 226, 97 and 29 deaths during day, evening and night surgery respectively (79, 95, 29 mortalities for emergency surgery in the same time periods). The researchers found that after adjustment for age and ASA scores, the patients operated on at night were 2.17 times more likely to die than those operated on during regular daytime working hours, and patients operated on late in the day were 1.43 times more likely to die than those operated on during regular daytime working hours.

https://owncloud.wellbehavedsoftware.com/index.php/s/WcTAhN1rXCXPmwX#pdfviewer

[Correspondence] Global surgery initiative in Greece: more than an essential initiative

Conditions that are treated primarily or frequently with surgery constitute a substantial portion of the global disease burden. At the same time, development of safe, essential, life-saving surgical and anaesthesia care in low-income and middle-income countries has stagnated or regressed.1 In 2012, injuries caused nearly 5 million deaths and 270 000 women died from complications during pregnancy. Many of these injury-related and obstetric-related deaths, as well as deaths cause by abdominal emergencies, could be prevented by improved access to surgical care.