Dr Julie Burrows

Objective: To examine associations between extended medical graduates' rural clinical school (RCS) experience and geographic origins with practising in rural communities five and eight years after graduation. Design, participants: Cohort study of 2011 domestic medical graduates from ten Australian medical schools with rural clinical or regional medical schools. Main outcome measures: Practice location types eight years after graduation (2019/2020) as recorded by the Australian Health Practitioner Regulation Agency, classified as rural or metropolitan according to the 2015 Modified Monash Model; changes in practice location type between postgraduate years 5 (2016/2017) and 8¿(2019/2020). Results: Data were available for 1321 graduates from ten universities; 696 were women (52.7%), 259 had rural backgrounds (19.6%), and 413 had extended RCS experience (31.3%). Eight years after graduation, rural origin graduates with extended RCS experience were more likely than metropolitan origin graduates without this experience to practise in regional (relative risk [RR], 3.6; 95% CI, 1.8¿7.1) or rural communities (RR, 4.8; 95% CI, 3.1¿7.5). Concordance of location type five and eight years after graduation was 92.6% for metropolitan practice (84 of 1136 graduates had moved to regional/rural practice, 7.4%), 26% for regional practice (56 of 95 had moved to metropolitan practice, 59%), and 73% for rural practice (20 of 100 had moved to metropolitan practice, 20%). Metropolitan origin graduates with extended RCS experience were more likely than those without it to remain in rural practice (RR, 2.0; 95% CI, 1.3¿2.9) or to move to rural practice (RR, 1.9; 95% CI, 1.2¿3.1). Conclusion: The distribution of graduates by practice location type was similar five and eight years after graduation. Recruitment to and retention in rural practice were higher among graduates with extended RCS experience. Our findings reinforce the importance of longitudinal rural and regional training pathways, and the role of RCSs, regional training hubs, and the rural generalist training program in coordinating these initiatives.

Objective: Intravenous antimicrobial therapy within 1 h of the diagnosis of septic shock is recommended in international sepsis guidelines. We aimed to evaluate the association between antimicrobial timing and mortality in patients presenting to the ED with septic shock. Methods: Post-hoc analysis of 1587 adult participants enrolled in the Australasian Resuscitation in Sepsis Evaluation (ARISE) multicentre trial of early goal-directed therapy for whom the time of initial antimicrobial therapy was recorded. We compared participants who had initiation of antimicrobials within the first hour (early) or later (delayed) of ED presentation. A propensity score model using inverse probability of treatment weighting was constructed to account for confounding baseline covariates. The primary outcome was 90-day mortality. Results: The median (interquartile range) time to initiating antimicrobials was 69 (39¿112) min with 712 (44.9%) participants receiving the first dose within the first hour of ED presentation. Compared with delayed therapy, early administration was associated with increased baseline illness severity score and greater intensity of resuscitation pre-randomisation (fluid volumes, vasopressors, invasive ventilation). All-cause 90-day mortality was also higher; 22.6% versus 15.5%; unadjusted odds ratio (OR) 1.58 (95% confidence interval [CI] 1.16¿2.15), P = 0.004. After inverse probability of treatment weighting, the mortality difference was non-significant; OR 1.30 (95% CI 0.95¿1.76), P = 0.1. Live discharge rates from ICU (OR 0.81, 95% CI 0.72¿0.91; P = 0.80) and hospital (OR 0.93, 95% CI 0.82¿1.06; P = 0.29) were also not different between groups. Conclusion: In this post-hoc analysis of the ARISE trial, early antimicrobial therapy was associated with increased illness severity, but 90-day adjusted mortality was not reduced.

Objective: This study was a prospective, randomized controlled trial of rapid sequence intubation (RSI) with cricoid pressure (CP) within the emergency department (ED). The primary aim of the study was to examine the link between ideal CP and the incidence of aspiration. Method: Patients¿>¿18 years of age undergoing RSI in the ED of two hospitals in New South Wales, Australia, were randomly assigned to receive measured CP using weighing scales to target the ideal CP range (3.060¿4.075¿kg) or control CP where the weighing scales were used, but the CP operator was blinded to the amount of CP applied during the RSI. A data logger recorded all CP delivered during each RSI. Immediately after intubation, tracheal and esophageal samples were taken and underwent pepsin analysis. Results: Fifty-four RSIs were analyzed (25 measured/29 control). Macroscopic contamination of the larynx at RSI was observed in 14 patients (26%). During induction (0¿50 seconds), both groups delivered in-range CP. During intubation (51¿223 seconds), laryngoscopy was associated with a reduction in mean CP below 3.060 kg in both groups. When compared, there was no statistically significant difference between the groups. For 11 patients, pepsin was detected in the oropharyngeal sample, while three were positive for tracheal pepsin. Seven patients (four control/three measured) were treated for clinical aspiration during hospitalization. As a result of the finding that neither group could maintain ideal range CP during laryngoscopy, the trial was abandoned. Conclusion: Laryngoscopy provides a counter force to CP, which is negated to facilitate tracheal intubation. The concept that a static 3.060 to 4.075¿kg CP could be maintained during laryngoscopy and intubation was rejected by our study. Whether a lower CP range could prevent aspiration during RSI was not explored by this study.

Study objective The influence of the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) on the conduct of future sepsis research is unknown. We seek to examine the potential effect of the new definitions on the identification and outcomes of patients enrolled in a sepsis trial. Methods This was a post hoc analysis of the Australasian Resuscitation in Sepsis Evaluation (ARISE) trial of early goal-directed therapy that recruited 1,591 adult patients presenting to the emergency department (ED) with early septic shock diagnosed by greater than or equal to 2 systemic inflammatory response syndrome criteria and either refractory hypotension or hyperlactatemia. The proportion of participants who would have met the Sepsis-3 criteria for quick Sequential Organ Failure Assessment (qSOFA) score, sepsis (an increased Sequential Organ Failure Assessment score =2 because of infection) and septic shock before randomization, their baseline characteristics, interventions delivered, and mortality were determined. Results There were 1,139 participants who had a qSOFA score of greater than or equal to 2 at baseline (71.6% [95% confidence interval {CI} 69.4% to 73.8%]). In contrast, 1,347 participants (84.7% [95% CI 82.9% to 86.4%]) met the Sepsis-3 criteria for sepsis. Only 1,010 participants were both qSOFA positive and met the Sepsis-3 criteria for sepsis (63.5% [95% CI 61.1% to 65.8%]). The Sepsis-3 definition for septic shock was met at baseline by 203 participants (12.8% [95% CI 11.2% to 14.5%]), of whom 175 (86.2% [95% CI 81.5% to 91.0%]) were also qSOFA positive. Ninety-day mortality for participants fulfilling the Sepsis-3 criteria for sepsis and septic shock was 20.4% (95% CI 18.2% to 22.5%) (274/1,344) and 29.6% (95% CI 23.3% to 35.8% [60/203]) versus 9.4% (95% CI 5.8% to 13.1%) (23/244) and 17.1% (95% CI 15.1% to 19.1% [237/1,388]), respectively, for participants not meeting the criteria (risk differences 11.0% [95% CI 6.2% to 14.8%] and 12.5% [95% CI 6.3% to 19.4%], respectively). Conclusion Most ARISE participants did not meet the Sepsis-3 definition for septic shock at baseline. However, the majority fulfilled the new sepsis definition and mortality was higher than for participants not fulfilling the criteria. A quarter of participants meeting the new sepsis definition did not fulfill the qSOFA screening criteria, potentially limiting its utility as a screening tool for sepsis trials with patients with suspected infection in the ED. The implications of the new definitions for patients not eligible for recruitment into the ARISE trial are unknown.

Background: Pregnancy can be a stressful time for many women. There is ample evidence of numerous physical and mental health inequities for Indigenous Australians. For those Indigenous women who are pregnant, it is established that there is a higher incidence of poor physical perinatal outcomes when compared with non-Indigenous Australians. However, little evidence exists that examines stressful events and post-traumatic stress disorder (PTSD) symptoms in pregnant women who are members of this community. Aims: To quantify the rates of stressful events and PTSD symptoms in pregnant Indigenous women. Methods: One hundred and fifty rural and remote Indigenous women were invited to complete a survey during each trimester of their pregnancy. The survey measures were the stressful life events and the Impact of Events Scale. Results: Extremely high rates of PTSD symptoms were reported by participants. Approximately 40% of this group exhibited PTSD symptoms during their pregnancy with mean score 33.38 (SD¿=¿14.37) significantly higher than a study of European victims of crisis, including terrorism attacks (20.6, SD¿=¿18.5). Conclusions: The extreme levels of PTSD symptoms found in the women participating in this study are likely to result in negative implications for both mother and infant. An urgent response must be mounted at government, health, community development and research levels to address these findings. Immediate attention needs to focus on the development of interventions to address the¿high¿levels of PTSD symptoms that pregnant Australian Indigenous women¿experience.