St. Vincent's Hospital Melbourne

Radiotherapy (RT) continues to play a key role in the management of head and neck cancer (HNC). Xerostomia remains a principal detriment to the quality of life (QoL) for 80 % of surviving patients receiving head and neck radiation. Radiation-induced injury to the salivary glands is dose-dependent, and thus efforts have been focused on decreasing radiation to the salivary glands. Decreased saliva production reduces both short-term and long-term quality of life in head and neck survivors by impacting on taste and contributing to dysphagia. Several radioprotective agents to the salivary gland have been investigated. Although not widely practiced, surgical transfer of the submandibular gland prior to RT is the mainstay of surgical options in preventing xerostomia. This review focuses on the strategies to improve xerostomia following radiation therapy in head and neck cancers.

Background: Given the chronic nature of psoriasis and the loss of response that can be observed with therapies over time, it is important to understand the long-;term efficacy of new treatments. Objective: To evaluate maintenance of Week 16 responses with bimekizumab treatment through Year 3, in patients with moderate to severe plaque psoriasis. Methods: Data were pooled from bimekizumab-treated patients in the 52-week (BE VIVID) and 56-week (BE READY and BE SURE) phase 3 studies, and their ongoing open-label extension (OLE), BE BRIGHT. Efficacy outcomes are reported through three years of bimekizumab treatment in patients with an efficacy response at Week 16. Missing data were imputed primarily using modified non-responder imputation (mNRI), with non-responder imputation and observed case data also reported. Results: A total of 989 patients were randomized to bimekizumab at baseline in BE VIVID, BE READY, and BE SURE. At Week 16, 693 patients achieved ≥90% reduction from baseline in Psoriasis Area and Severity Index (PASI 90), 503 achieved 100% reduction from baseline in PASI (PASI 100), 694 achieved absolute PASI ≤2, and 597 achieved body surface area (BSA) ≤1%, and continued into the OLE. Of these, 93.0% maintained PASI 90, 80.8% maintained PASI 100, 94.0% maintained PASI ≤2, and 90.3% maintained BSA ≤1% responses through to three years of bimekizumab treatment (mNRI). Among Week 16 PASI 90 responders, 96.8% and 72.5% also achieved Investigator's Global Assessment (IGA) 0/1 and PASI 100 at Week 16, respectively, and 92.2% and 73.4% achieved these responses at Year 3 (mNRI). Among Week 16 PASI 100 responders, 76.3% also achieved Dermatology Life Quality Index (DLQI) 0/1 at Week 16, and DLQI 0/1 response increased with continuous bimekizumab treatment to 89.0% at Year 3 (mNRI). Conclusions: High levels of clinical response were maintained through to three years of bimekizumab treatment in the vast majority of Week 16 responders. Long-term treatment with bimekizumab was efficacious, with important benefits on health-related quality of life (HRQoL), in patients with moderate to severe plaque psoriasis.

Background: Intravenous immunoglobulins (IVIG) have been increasingly used for various inflammatory dermatoses with success. Small case series and case reports suggest a role for IVIG in the management of refractory pyoderma gangrenosum (PG). Objective: The objective was to study the characteristics of PG patients treated with IVIG and the efficacy and safety of IVIG for patients with refractory PG. Methods: An analysis was performed of all patients with PG treated with IVIG from 2012 to 2022 at an Australian tertiary hospital seeing a high volume of PG patients. Results: We identified 12 patients, 9 females and 3 males, with median age of 61 years (29-77) at IVIG commencement. All patients were taking systemic corticosteroid therapy prior to IVIG treatment, and all had been treated with a steroid-sparing agent-including ten patients who had been treated with a biologic agent. IVIG was used with corticosteroids in one patient, concurrently with a steroid-sparing agent in nine patients and with a biologic agent in eight patients. Eleven patients demonstrated treatment response to IVIG-six with excellent response and five with good response. Three patients had complete healing of their most active ulcer. One patient did not respond to IVIG. Nine patients were able to wean their prednisolone dose and one patient was able to cease prednisolone. Four adverse events were recorded, and only one patient had to cease treatment due to aseptic meningitis and headaches. Conclusion: Our experience suggests that IVIG may be an efficacious treatment for patients with refractory PG due to its pleiotropic and immunomodulatory effects, particularly for patients with malignancy or other systemic conditions where high-dose immunosuppressive agents are contraindicated.

Background and objectives: The role of therapeutic drug monitoring for ustekinumab in the treatment of Crohn's disease has not been defined. This study aimed to explore the relationship of serum ustekinumab trough concentration (UTC) with clinical and biochemical disease outcomes in a real-world setting. Methods: We performed a retrospective analysis of Crohn's disease patients treated at a single tertiary centre. Ustekinumab was given as a single intravenous induction dose, followed by maintenance subcutaneous injections every 4 to 8 weeks. Rates of clinical remission (Harvey-Bradshaw Index ≤ 4), biochemical remission (C-reactive protein < 5 mg/l and faecal calprotectin < 150 μg/g) and complete remission were assessed at baseline and at the time of UTC testing during maintenance therapy. The association between baseline variables and UTC was tested using linear regression. We also performed an external validation analysis of UTC cut-offs established in four previously published studies. Results: This study included 43 patients. Compared to 8-weekly dosing, a 2.49- and 2.65-fold increase in UTC was associated with 6-weekly and 4-weekly dosing respectively. However, there was no significant difference in clinical, biochemical or complete remission among the dosing groups. An external validation of previously published optimal UTC cut-offs found low predictive value for our patient population. Conclusions: In this study, dosing interval was the only determinant significantly associated with a higher UTC for patients on maintenance ustekinumab therapy. While a higher UTC may be achieved with dose escalation, it was not associated with improved rates of clinical or biochemical response in our cohort.

Background: Inter-hospital transfer (IHT) of intensive care patients is a limited resource. We assessed the outcomes of patients with haemorrhagic stroke requiring IHT and intensive care and aimed to identify early prognostic factors of poor neurological outcome. Methods: We conducted a retrospective observational cohort study of patients admitted to a single tertiary intensive care unit (ICU) with haemorrhagic stroke after IHT between January 2014 and December 2018. Primary outcome was poor neurological outcome (modified Rankin Scale ≥4 at time of discharge from hospital or rehabilitation unit). Secondary outcomes were mortality rate, rate of intervention, rate of organ donation surgery (ODS) and potentially avoidable transfer (PAT). PAT was defined as transfer where the patient did not receive an intervention and had a poor neurological outcome. Results: Ninety patients were included in this study, 48 with intracerebral haemorrhage (ICH) and 42 with subarachnoid haemorrhage (SAH). Fifty-one (56.7%) patients had a poor neurological outcome, including 30 (33%) who died. Factors significantly associated with poor neurological outcome included age > 80 years, lower presenting Glasgow Coma Score (GCS) and bilaterally fixed and dilated pupils. Stepwise logistic regression demonstrated history of hypertension as significantly associated with poor neurological outcome in patients with ICH (P = 0.021). Seven (7.8%) patients had ODS. Sixty-four (71.1%) patients received intervention and 20 (22.2%) transfers were potentially avoidable. Conclusions: Patients in this cohort are at high risk of poor neurological outcome. Prognostic factors identified in this study may help referring, retrieval and receiving clinicians to discuss futility prior to pursuing IHT.

Objective: Idiopathic megarectum is characterized by abnormal, pronounced rectal dilatation in the absence of identifiable organic pathology. Idiopathic megarectum is uncommon and under-recognized. This study aims to describe the clinical features and management of idiopathic megarectum. Methods: A retrospective review was undertaken on patients diagnosed with idiopathic megarectum with or without idiopathic megacolon over a 14-year period until 2021. Patients were identified from the hospital's International Classification of Diseases codes, and pre-existing clinic patient databases. Patient demographics, disease characteristics, healthcare utilization and treatment history data were collected. Results: Eight patients with idiopathic megarectum were identified; half of the patients were female, with the median age of symptom onset being 14 years (interquartile range [IQR] 9-24). The median rectal diameter measured was 11.5 cm (IQR 9.4-12.1). The most common presenting symptom was constipation, bloating and faecal incontinence. All patients required prior sustained periods of regular phosphate enemas and 88% were using ongoing oral aperients. Concomitant anxiety and or depression were found in 63% of patients and 25% were diagnosed with an intellectual disability. Healthcare utilization was high with a median of three emergency department presentations or ward admissions related to idiopathic megarectum per patient over the follow-up period; 38% of patients required surgical intervention during the period of follow-up. Conclusion: Idiopathic megarectum is uncommon and associated with significant physical and psychiatric morbidity and high healthcare utilization.

Background Pituitary abscess (PA) is a rare condition and not well understood. We aimed to describe a case and perform a comprehensive systematic review to explore presenting symptoms, radiological findings, endocrine abnormalities and mortality. Aim To identify presenting symptoms, radiological findings, endocrinological abnormalities and predictors of mortality for PA. Methods We systematically reviewed the literature to identify all case reports of PA. Data regarding presentation, mortality, radiological findings, endocrinological abnormalities and treatment was extracted. Results We identified 488 patients from 218 articles meeting the inclusion criteria. Mortality was 5.1%, with days to presentation (OR 1.0005, 95%CI 1.0001–1.0008, p < 0.01) being the only identified independent predictor of mortality. Mortality rates have decreased over time, with cases published prior to 2000 having higher mortality rates (OR 6.92, 95%CI 2.80–17.90, p < 0.001). The most common symptom was headache (76.2%), followed by visual field defects (47.3%). Classical signs of infection were only present in 43%. The most common imaging feature on magnetic resonance imaging (MRI) was high T2 and low T1 signal of the pituitary gland with peripheral contrast enhancement. Over half (54.8%) were culture negative, with the most common bacterial organism being staphylococcus aureus (7.8%) and fungal organism being aspergillus (8.8%). The most common endocrine abnormality was hypopituitarism (41.1%), followed by diabetes insipidus (24.8%). Whilst symptoms resolved in most patients, persistent endocrine abnormalities were present in over half of patients (61.0%). Conclusion PA is associated with significant mortality, with delayed presentation increasing risk of mortality. Ongoing endocrinological abnormalities are common. Given the non-specific clinical presentation, the appearance of high T2, low T1 and peripheral contrast enhancement of the pituitary on MRI should prompt consideration of this rare disease.

Purpose: Structural valve deterioration (SVD) remains a limitation on the use of bioprosthetic valves, with patient and valve-related factors contributing to early SVD. The Trifecta valve has been reported to have excellent hemodynamics but studies have highlighted early failure. We present a review and case series at a New Zealand tertiary hospital defining early SVD as failure within 3 years of implant. Methods: A retrospective review from January 2015 to July 2019 included 525 patients undergoing surgical aortic valve replacement with 263 patients receiving an Abbott Trifecta or Trifecta Glide Technology (GT) valve. Our review found an acceptable safety profile for the valve with excellent hemodynamics, with a low mortality, stroke, and permanent pacemaker rate. Results: Three patients out of 263 were identified from the study period as having early SVD requiring reintervention within 3 years of valve implantation leading to a 1.14% failure rate. One of the valves that had early SVD was a new generation Trifecta GT. An additional four patients were identified to have valves implanted prior to the study period and had valve failure at greater than 3 years post implantation. Five cases had cusp tears as their mechanism of failure, raising concerns about durability. Conclusion: The Trifecta valve has an acceptable safety profile and offers good hemodynamics due to the externally mounted leaflets. However, our experience of early SVD and failure is concerning for valve durability. Further comparison to other bioprosthetic valves and longer term follow-up are required to characterize the mechanism of failures.

Introduction Despite the availability of effective, subsidised hepatitis B treatment, linkage to care and treatment rates remain very low globally. In Australia, specially trained primary care physicians (general practitioner, GPs) can prescribe hepatitis B treatment, however, most hepatitis B care occurs in specialist clinics. Increasing hepatitis B management by GPs in primary care clinics is essential to achieve national hepatitis B linkage to care and treatment targets by 2030. This pilot study determines the feasibility, acceptability and effectiveness of Simply B, a novel GP hepatitis B e-support package designed to increase hepatitis B management by GPs in primary care clinics. Methods and analysis This study will be conducted in three parts: Part A: A prospective open-label pilot intervention study, comparing the proportion of people with hepatitis B who are managed by their GP in primary care clinics before, 12 months and 24 months after implementation of the Simply B electronic hepatitis B support package. Part B: A nested qualitative health services feasibility study using semistructured interviews and thematic analysis Part C: Cost-effectiveness analysis. Ethics and dissemination This study has received ethics approval by St Vincent’s Hospital. Data management and analysis will be centralised through the Department of Gastroenterology, St Vincent’s Hospital. Trial registration number NCT05614466 .

Introduction/aims: Lower limb sensory nerve action potentials are an important component of nerve conduction studies. Most testing of the sural and superficial fibular nerves involves antidromic techniques above the ankle, which result in a falsely unobtainable response in 2-6% of healthy people. Cadaver, surgical and more recent ultrasound series suggest this may relate to the site of fascia penetration of the nerve, and it is hypothesised that a modified technique may be more likely to produce reliable responses and reduce false-negative errors. Methods: This paper evaluates a variety of recording distances for both nerves in 100 healthy controls, including varying recording electrode positions and techniques, to provide the optimal electrodiagnostic information in healthy control subjects. Results: Shorter stimulation distances produce higher-amplitude responses but become confounded by increasing stimulation artefact at very short distances, with the best balance found at around 10 cm. In both sural and superficial fibular nerves, amplitude increases by approximately 10%/cm compared to the standard 14 cm distance. The Daube superficial fibular technique produced a higher amplitude than the Izzo Intermediate technique (by 22.46%, p < 0.001). The calculated upper limit of normal for side-to-side variation in amplitude was around 50% in the sural nerve but over 70% in the superficial fibular nerve. Discussion: It is proposed that the 10 cm recording distance for both nerves is optimal, with minimal false-negatives and a higher amplitude elicited than with existing techniques. This article is protected by copyright. All rights reserved.

Background: In 2014, infliximab (IFX) was listed on the Australian Pharmaceutical Benefits Scheme for acute severe ulcerative colitis (ASUC) and is now the preferred option for medical salvage, superseding cyclosporin (CsA). Optimal dosing schedules for IFX remain unknown. Aim: We aim to evaluate the effect of changing from predominantly CsA to almost exclusively IFX for the treatment of steroid refractory ASUC on colectomy rates. Methods: A retrospective review was performed of patients admitted with ASUC between 2012-2020. Patients were categorised into two groups according to year of presentation - either "historical treatment" cohort (2012-2014), when CsA was primarily used, or "contemporary treatment" cohort (2014-2020) when IFX was mostly prescribed, in either standard or intensive doses. Results: 139 patients were included; 37 in the historical treatment cohort and 102 in the contemporary treatment cohort. In the historical treatment cohort, 12/37 received salvage therapy, 8 (67%) with CsA. In the contemporary treatment cohort, 49/102 patents received salvage therapy, 40 (82%) with IFX, of whom 22 (53%) received intensified doses. Colectomy rates were similar at 30 days, 6 months and 12 months between historical and contemporary treatment cohorts (14% vs 12%, p = 0.77, 19% vs 18%, p >0.99; and 22% vs 18%, p = 0.63 respectively). Difference in 12-month colectomy rates between standard vs intensive IFX did not meet statistical significance (3/21 (14%) vs 9/22 (41%), respectively; p = 0.09). Conclusion: There was no difference in 30-day, 6-month or 12-month colectomy rate between the historical treatment and contemporary treatment cohorts. The use of IFX, rather than CsA, even at intensified dosing has not appeared to reduce the colectomy rate observed in our patients. This article is protected by copyright. All rights reserved.

Objective: To evaluate the feasibility of testing and treating people who inject drugs at a supervised injecting facility for hepatitis C virus (HCV) infection. Design: Retrospective cohort study. Setting, participants: People who inject drugs who attended the Melbourne supervised injecting facility, 30 June 2018 - 30 June 2020. Main outcome measures: Proportion of people tested for hepatitis C; proportions of people positive for anti-HCV antibody and HCV RNA, and of eligible people prescribed direct-acting antiviral (DAA) treatment; sustained virological response twelve weeks or more after treatment completion. Results: Of 4649 people who attended the supervised injecting facility during 2018-20, 321 were tested for hepatitis C (7%); 279 were anti-HCV antibody-positive (87%), of whom 143 (51%) were also HCV RNA-positive. Sixty-four of 321 had previously been treated for hepatitis C (20%), 21 had clinically identified cirrhosis (7%), eight had hepatitis B infections (2%), and four had human immunodeficiency virus infections (1%). In multivariate analyses, people tested for hepatitis C were more likely than untested clients to report psychiatric illness (adjusted odds ratio [aOR], 9.65; 95% confidence interval [CI], 7.26-12.8), not have a fixed address (aOR, 1.59; 95% CI, 1.18-2.14), and to report significant alcohol use (aOR, 1.57; 95% CI, 1.06-2.32). The median number of injecting facility visits was larger for those tested for hepatitis C (101; interquartile range [IQR], 31-236) than for those not tested (20; IQR, 3-90). DAA treatment was prescribed for 126 of 143 HCV RNA-positive clients (88%); 41 of 54 with complete follow-up data were cured (76%). Conclusions: People who attend supervised injecting facilities can be tested and treated for hepatitis C on site. Models that provide streamlined, convenient hepatitis C care promote engagement with treatment in a group in which the prevalence of hepatitis C is high.

Background: In 2007, Australia introduced a national human papillomavirus (HPV) vaccination program. In 2017, the onset of cervical screening changed from 18 to 25 years of age, utilising human papillomavirus (HPV) nucleic acid testing. The objective of the study is to describe the HPV genotypes and HPV16 variants in biopsies from women ≤ 25 years of age with cervical carcinoma (CC) (cases), compared with those aged >25 years (controls), in a pre-vaccination cohort. Methods: HPV genotyping of archival paraffin blocks (n = 96) was performed using the INNO-LiPA HPV Genotyping assay. HPV16-positive samples were analysed for variants by type-specific PCR spanning L1, E2 and E6 regions. Results: HPV16 was the commonest genotype in cases (54.5%, 12/22) and controls (66.7%, 46/69) (p = 0.30), followed by HPV18 (36.3%, 8/22 vs. 17.3% 12/69, respectively) (p = 0.08). Furthermore, 90% (20/22) of cases and 84.1% (58/69) of controls were positive for HPV16 or 18 (p = 0.42); 100% (22/22) of cases and 95.7% (66/69) of controls had at least one genotype targeted by the nonavalent vaccine (p = 0.3). The majority of HPV16 variants (87.3%, 48/55) were of European lineage. The proportion of unique nucleotide substitutions was significantly higher in cases (83.3%, 10/12) compared with controls (34.1%, 15/44), (p < 0.003, χ2, OR 9.7, 95%CI 1.7-97.7). Conclusions: Virological factors may account for the differences in CCs observed in younger compared with older women. All CCs in young women in this study had preventable 9vHPV types, which is important messaging for health provider adherence to new cervical screening guidelines.

Background: Increasing long-term breast cancer survivorship has highlighted the importance of patient-reported outcomes such as health-related quality of life (HRQoL) in addition to traditional outcomes that were used to define successful operative management. This study aimed to describe HRQoL in patients who underwent breast cancer resection in a regional Australian setting and identify the psychosocial, demographic, and operative characteristics associated with poor HRQoL. Methods: Consecutive patients who underwent breast cancer resection between 2015 and 2022 were included. Patients were asked to complete a survey instrument that included validated measures of HRQoL, emotional distress, fear of cancer recurrence (FCR), and social support. Demographic, disease, and operative data were collected from the medical record of the respondents. Results: Forty-six patients completed the survey (100% female, mean age = 62.68 years). Most HRQoL domains were significantly lower than an Australian reference population. HRQoL was more strongly associated with psychosocial factors (emotional distress, FCR, and social support) but was also associated with socioeconomic status, stage of cancer at presentation, and surgical complications. HRQoL was not related to breast conservation, management of the Axilla, or time since operation. Conclusion: Long-term changes in HRQoL should be considered during the management and surveillance of breast cancer patients in regional Australia.

Solitary pulmonary nodules, mostly detected on incidental chest radiographs or computed tomography (CT) scans, pose a significant diagnostic dilemma to physicians. In the United States in 2018, lung cancer accounted for 14% of new cancers in men and 13% of new cancers in women. There are two main types of lung cancer: small‐cell lung cancer (SCLC) and non‐SCLC (NSCLC). This chapter focuses on the various imaging tools utilized for the detection, staging, and treatment of lung cancers. After the initial diagnosis of NSCLC, most patients are further assessed with contrast‐enhanced CT. Most pleural malignancies are of metastatic origins, likely secondary to lung and breast cancers, lymphoma, and gastric carcinoma. Tumors in the anterior mediastinum are rare, and imaging plays apivotal role in evaluating such tumors. The most common causes of anterior mediastinal masses include thymoma, thyroid disease, lymphoma, and teratoma.

Gynecologic malignancies involve the female reproductive organs and are an important cause of morbidity and mortality worldwide. There are five main types of gynecologic cancer: vaginal, vulvar, cervical, endometrial, and ovarian. This chapter discusses the latter two malignancies, endometrial and ovarian. The majority of endometrial cancer cases are detected early, with a history of abnormal vaginal bleeding reported as the most common symptom. Recent studies have introduced a variety of imaging modalities such as ultrasound, computed tomography (CT), magnetic resonance imaging, and fluorodeoxyglucose positron emission tomography/CT to play a complementary role in the pre‐treatment assessment of endometrial cancers. Based on pathological findings, brachytherapy can be given as monotherapy or in combination with external beam radiotherapy after surgery for endometrial cancer. Ovarian cancer is the leading cause of gynecologic cancer‐related death, primarily due to delayed detection.

Multiple myeloma (MM) is a disease of older people, yet factors relating to comorbidity and frailty may threaten treatment tolerability for many of this heterogeneous group. There has been increasing interest in defining specific and clinically relevant frailty assessment tools within the MM population, with the goal of using these frailty scores not just as a prognostic instrument, but also as a predictive tool to allow for a frailty-adapted treatment approach. This paper reviews the various frailty assessment frameworks used in the evaluation of MM patients, including the International Myeloma Working Group Frailty Index (IMWG-FI), the Mayo Frailty Index and the simplified frailty scale. While the IMWG-FI remains the most widely accepted tool, the simplified frailty scale is the most user-friendly in busy day-to-day clinics based on its ease of use. This paper summarises the recommendations from the Myeloma Scientific Advisory group (MSAG) of Myeloma Australia, on the use of frailty assessment tools in clinical practice and propose a frailty-stratified treatment algorithm to aid clinicians in tailoring therapy for this highly heterogeneous patient population. This article is protected by copyright. All rights reserved.