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Colorectal cancer (CRC) diagnosed following a cancer-negative colonoscopy is termed as post-colonoscopy CRC (PCCRC). The World Endoscopy Organization has recently standardized the definition of PCCRC-3Y (CRC developing within 3 years of a cancer-negative colonoscopy). In the present study, we sought to assess PCCRC-3Y rate, perform root-cause analyses, and identify factors associated with development of PCCRC at a tertiary referral hospital in Australia.All patients undergoing colonoscopy from 2011 to 2018 were matched to a population-based cancer register. PCCRC-3Y rate was assessed for years 2011-2015. All PCCRC cases that developed within 6-48 months after a cancer-negative colonoscopy underwent root-cause analyses. Descriptive statistics were used to summarize data.Among 17 828 patients undergoing colonoscopy, 367 CRC cases were diagnosed during the study period. This included nine PCCRC cases, which developed at a median of 14 months (range 7-34 months) after cancer-negative colonoscopy. The PCCRC-3Y rate for years 2011-2015 was 2.16% (95% CI 0.91-5.15). All nine PCCRC cases were moderately or poorly differentiated adenocarcinomas; seven of nine were early-stage CRC (stages I and II) and six of nine probably represented missed lesions at index colonoscopy despite an apparently adequate examination. History of inflammatory bowel disease (IBD) (odds ratio [OR] 21.9, 95% confidence interval [CI] 4.6-103.7, P 0.001) and diverticulosis (OR 5.4, 95% CI 1.4-20.5, P = 0.01) were significantly associated with development of missed CRC.In our tertiary referral colonoscopy cohort, PCCRC-3Y rate was 2.16% (95% CI 0.91-5.15). IBD and diverticulosis were significantly associated with risk of PCCRC. The majority of PCCRC lesions were likely missed at index colonoscopy, despite an apparently adequate examination.

High-quality gastroscopy is critical for early diagnosis of upper gastrointestinal cancers (UGCs), and assessment of missed cancers may serve as a key quality metric. Using a prospective gastroscopy database and data linkage with the Queensland Cancer Registry, we assessed the risk of developing UGC within 3 years of a cancer-negative gastroscopy at an Australian tertiary centre. Additional aims were to identify factors predictive of missed cancer, perform root cause analyses for missed cancers and assess overall survival.We identified patients who were diagnosed with UGC within 3 years of undergoing gastroscopy between 2011 and 2016. Non-mucosal cancers, cancers distal to duodenum and patients undergoing surveillance were excluded. Cases diagnosed within 6 months of gastroscopy were defined as detected cancers, while those developing within 6-36 months were defined as missed cancers. Post-endoscopy UGC rate (PEUGIC-3Y) was calculated as ratio of missed over total cancers detected. Demographic, clinical, endoscopic and histologic variables were analysed.A total of 17,131 gastroscopies were performed for 10,393 patients during the study period. One hundred and twenty-six UGCs were diagnosed, including 120 detected UGCs and 6 missed UGCs. The overall PEUGIC-3Y rate was 4.8% (95% CI 2.1-10.4). The missed UGCs included 3 gastric adenocarcinomas, 2 gastro-oesophageal junction adenocarcinomas and 1 oesophageal squamous cell carcinoma. At the preceding 'cancer-negative gastroscopy', no macroscopic abnormalities were detected at the site of future UGC in 5/6 patients. A UGC developed in 2/6 patients despite an apparent adequate examination at index gastroscopy. Age, sex, indication for endoscopy and cancer location or histology were not predictive of missed cases, and survival was comparable between groups.We demonstrate that the PEUGIC-3Y rate was 4.8% (95% CI 2.1-10.4). The majority of missed cases were adenocarcinomas of the gastro-oesophageal junction or stomach and developed in segments which were found to be normal at index gastroscopy, highlighting the challenges in detecting subtle mucosal lesions in the upper gastrointestinal tract. While overall survival between patients with detected and post-gastroscopy cancers was comparable, these ultimately represent potential missed opportunities for diagnosing an early cancer and underscore the need for quality improvement in gastroscopy.

Objective: Early recognition and treatment for sepsis is critical in improving patient outcomes. The present study sought to examine whether triage location was associated with time to appropriate antibiotics in a cohort of ED patients with septic shock. Methods: Septic shock patients were identified from a database of ED patients admitted with infection. Demographic, clinical and outcome data were reported by triage location. Time to event analyses sought to identify the association between triage location and time to appropriate antibiotic. Secondary outcome variables included ED and hospital length of stay (LOS), 30-day mortality, and ICU admission. Results: Time to appropriate antibiotic administration was longer for those patients triaged to lower acuity (242 min) compared to higher acuity (98 min, P < 0.01) locations. After adjustment for severity of illness, hospital LOS, ED LOS and 30-day mortality were similar regardless of the triaged location. Admission to ICU was lower for patients triaged to lower (7.3%) compared to higher (47.3%) acuity treatment locations. Conclusions: We identified a sub-group of septic shock patients triaged to a lower acuity treatment location who received significant delays to antibiotics. This research area deserves closer examination to potentially recognise septic shock earlier in the continuum.

Incidental gastrointestinal tract (GIT) uptake is found in up to 6.3% of patients undergoing positron emission tomography (PET). This may be physiologic or pathologic and requires endoscopic assessment.To determine the diagnostic yield of endoscopy in this setting and characterise PET avidity as a predictor of clinically significant findings.We retrospectively reviewed all consecutive patients undergoing upper endoscopy or colonoscopy for incidentalA total of 255 patients (62% male, median age 67 years) underwent colonoscopy or sigmoidoscopy for 276 separate areas of PET avidity in the colon. Malignancy was found in 44 cases (16%), while a significant polyp was found in an additional 103 cases (37%). Neoplastic change was found more often in case of intense compared with non-intense PET avidity (OR 3.40, 95% CI 1.95-5.93, p0.001), and in focal compared with diffuse uptake (OR 5.97, 95% CI 2.9-12.2, p0.001). Upper GIT endoscopy was performed in 75 patients (46 male, median age 63 years) for 77 isolated areas with PET avidity. Malignancy was found in 16 cases (21%), and all were new primary lesions. Numerically, malignant findings were more common in intense (29.7%) than non-intense (12.5%) PET avidity (OR 2.96, 95%, CI 0.92-9.57, p=0.069).Both focal and intense colonic

The authors regret that the following information was published incorrectly. The errors that need to be corrected are as follows: 1 The primary outcome of improvements of participants over two months (8 weeks) was 61.7% not 41.7%.2 Fig. 1: Consort diagram was not published.3 Fig. 2: Changes in urinary urgency from baseline to week8 (p = 0.002) was not published4 Fig. 3: Changes in soiled underwear from baseline to week 8 was not published.5 The name of the product is Urox® Junior not Urox® Bedtime Buddy.The authors would like to apologise for any inconvenience caused.

To gain greater understanding of what it means to care for older patients dying from traumatic injuries in the emergency department.A Heideggerian phenomenological design using the methods of Van Manen.In-depth, face-to-face interviews were conducted with five emergency nurses who worked in an emergency department in Australia. Interview data were interpreted using a Heideggerian hermeneutic approach and guided by Van Manen's lifeworld analysis focusing on the experiential aspects of lived time (temporality) and lived space (spatiality) in the phenomenon.The older patient reflects the passage of chronological time. This temporal aspect shaped the participant experience as there was a sudden awareness of the impact of the injuries sustained on the fragile physical condition of the patients. There was an unexpectedness and unpreparedness which was related to a precognitive assumption that the older patient would die from an age-related comorbid condition. Also of significance was the sacred liminal space in which the nurses worked to facilitate the dying patient transition from life to death.The existential dimensions of temporality and spatiality revealed new insights into what it means to care for elderly patients dying from traumatic injuries. Temporal aspects were shaped by the longevity of the lives of patients and spatiality explored the liminal space where participants were morally guided to deliver end of life care with dignity and respect for a long-lived life taken by trauma.The findings may contribute to further understanding of what shapes the experience for emergency nurses delivering EOL care in the ED, with specific relevance and focus on the older patient with traumatic injuries. Hermeneutic research may also encourage clinicians to explore phenomena to reveal new understandings that will inform further dialogue and future research.

Background Nocturnal enuresis or ‘bedwetting’, is a form of night-time urinary incontinence occurring in younger children. A diagnosis can be socially disruptive and psychologically stressful for a child. The most common strategies used by parents are waking the child during the night to use the bathroom and limiting the child's water intake before going to bed. Hypothesis/Purpose To determine if a herbal capsule formulation taken once daily can reduce incidence and frequency of nocturnal enuresis in children. Study Design This randomised double-blind placebo-controlled trial evaluated the efficacy of an herbal medicine product to reduce the symptoms of nocturnal enuresis. Participants, aged between 6 and 14 years of age, were recruited from the community in Australia. They were randomised via computerised random-number generation at study enrolment to receive one or two oral capsules in the morning of either Urox® (Bedtime Buddy®) or placebo. The Paediatric Quality of life (Pin-Q) was used as a quality-of-life measure and waking wet, fluid intake and urinary urgency per week were monitored. Results Forty-one children completed the trial with an attrition rate of 16%. There were more males (64.6%) compared to females (35.4%) and the mean age was 8.6 years. Forty-one point seven percentages (41.7%) of participants had improvements in bed wetting by two months which was a highly clinically relevant effect (Cohen's D = 0.98). The primary outcome found that there was a statistically significant reduction in NE (p = 0.034; CI 0.086–2.095) and between groups using longitudinal analysis (p = 0.04, Coefficient -1.12, CI 95% -2.20 - -0.04). In the secondary outcomes, urinary urgency reduced statistically significantly for the intervention (p = 0.002; a reduction of 18.3% difference for Bedtime Buddy compared to an increase of 3.7% for the placebo). Conclusion Urox® (Bedtime Buddy®) may assist children in reducing nocturnal enuresis compared to placebo. In addition, it may assist in reducing daily incontinence and urinary urgency.

Background The objective of this study was to explore factors associated with the triage category assigned by the triage nurse for patients ultimately diagnosed with acute myocardial infarction. Methods This was a retrospective analysis of 12 months of data, on adult emergency department patients ultimately diagnosed with acute myocardial infarction. Data were obtained from hospital databases and included patient demographics, patient clinical characteristics and nurses’ experience. Results Of the 153 patients, 20% (95% CI: 14–27%) were given a lower urgency triage category than recommended by international guidelines. Compared to patients who were triaged Australasian Triage Category 1 or 2, patients with an Australasian Triage Category 3–5 were older (mean age 76 versus 68 years), more likely to be female (63% versus 32%), more likely to present without chest pain (93% versus 35%) and less likely to have a cardiac history (3.3% versus 17.9%). A slightly higher proportion of patients Australasian Triage Category 3–5 were triaged by an experienced nurse (50%) compared to patients categorised Australasian Triage Category 1–2 (35.2%) but this finding did not reach statistical significance. Conclusions One in five presentations was given a lower urgency triage category than recommended by international guidelines, potentially leading to delays in medical treatment. The absence of chest pain was the defining characteristic in this group of patients, along with other factors identified by previous research such as being of female sex and elderly.

To examine the safety and efficacy of the Improved Assessment of Chest pain Trial (IMPACT) protocol, a strategy for accelerated assessment of patients presenting to emergency departments (EDs) with chest pain.IMPACT was an intervention trial at a single tertiary referral hospital (Royal Brisbane and Women's Hospital) during February 2011 - March 2014. 1366 prospectively recruited patients presenting to the ED with symptoms of suspected acute coronary syndrome (ACS) were stratified into groups at low, intermediate or high risk of an ACS.High risk patients were treated according to NHFA/CSANZ guidelines. Low and intermediate risk patients underwent troponin testing (sensitive assay) 0 and 2 hours after presentation. Intermediate risk patients underwent objective testing after the second troponin test; low risk patients were discharged without further objective testing.The primary outcome was an ACS within 30 days of presentation. Secondary outcomes were ED and hospital lengths of stay (LOS).The IMPACT protocol stratified 244 (17.9%) patients to low risk, 789 (57.7%) to intermediate risk, and 333 (24.4%) to high risk categories. The overall 30-day ACS rate was 6.6%, but there were no ACS events in the low risk group, and 14 (1.8%) in the intermediate risk group. The median hospital LOS was 5.1 hours (IQR, 4.2-5.6 h) for low risk and 7.7 hours (IQR, 6.1-21 h) for intermediate risk patients.The IMPACT protocol safely and efficiently allowed a large proportion of patients presenting to EDs with chest pain to undergo accelerated assessment for risk of an ACS.Australian New Zealand Clinical Trials Registry ACTRN12611000206921.

Purpose: To examine if demographic factors influence patients' self reports of satisfaction with care provided by nurse practitioners (NPs) in rural urgent care centers (UCCs). Data sources: Data were collected between December 2009 and February 2010 using an 18-item self-report survey from a convenience sample of 53 patients in two rural UCCs. Conclusions: No statistical significance was noted in regards to patient satisfaction for the demographic factors age, gender, country of upbringing, or education level. Presence of health insurance was a significant factor, with uninsured patients rating higher levels of satisfaction. However, based on patients' responses to role clarity for this survey, it is evident that there continues to be insufficient public understanding of the role of NPs. Implications for practice: The future of the NP relies on patient approval as well as acceptance of the role. This study joins the pioneering efforts towards describing what patient satisfaction is and supports NPs serving as providers in rural, nonprimary care venues. By identifying influential factors of satisfaction, NPs can bridge the gap between availability of quality care versus a lack of access and inform policy changes in the future.

Objective To evaluate the incidence of major adverse cardiac events (MACE) at 1 year in emergency department (ED) patients with possible acute coronary syndromes, stratified by high sensitivity troponin (hs-cTnI) concentrations using sex-specific cut points compared with overall cut points. Methods In a multicentre observational study of 2841 patients, presentation hs-cTnI concentrations were categorised using sex-specific (women 16 ng/L; men 34 ng/L) and overall (26 ng/L) cut points. The primary outcome was MACE occurring within 1 year of presentation. Patients with hs-cTnI values concentrations within these categories were reported by sex and 1-year MACE. Net reclassification improvement (NRI) was computed to measure the change in prediction after altering the hs-cTnI cut points, and was calculated separately for events and non-events. Results Application of sex-specific 99th percentile cut points rather than the overall cut point of 26 ng/L, reclassified 25 females from having a non-elevated troponin to having an elevated troponin, and 29 males from having an elevated troponin value to having a non-elevated troponin value on presentation. Of these, 7 (28.0%) females and 12 (41.4%) males had a 1-year MACE. There was no reclassification improvement for those with or without 1-year MACE (NRI events =−1.5%, 95% CI −4.0% to 1.1%; NRI non-events −0.04%, 95% CI −0.5% to 0.4%). Conclusions Sex-specific cut points improve the identification of women but not men at risk for 1-year MACE. The net-effect across the whole ED population with possible cardiac chest pain is minimal. Lowering the clinical cut point for both sexes may be appropriate for prognostic purposes. Trial registration number ISRCTN No. 21109279, ACTRN12609000283279.

Objectives To compare the predictive ability of three risk stratification tools used to assess patients presenting to the ED with potential acute coronary syndrome. Design Pre-planned analysis of an observational study. Setting A single tertiary referral hospital. Participants 1495 patients presented with chest pain. 948 patients were screened and enrolled. Patients with at least 5min of chest pain suggestive of ACS were eligible. Interventions Subjects were risk categorised using the Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines (HFA/CSANZ), the TIMI score and the GRACE score. Three strata of the TIMI and GRACE score were used to compare to the HFA/CSANZ risk categories. Main outcome measurement 30-Day cardiac event rates including cardiac death, acute myocardial infarction and unstable angina. Results There were 152 events in 91 patients (9.6%). The discriminatory ability of the scores determined by the AUC was 0.83 (95% CI 0.79–0.87) for the GRACE score, 0.79 (95% CI 0.74–0.83) for TIMI score and 0.75 (95% CI 0.70–0.80) for HFA/CSANZ. The AUCs with three strata of the GRACE and TIMI scores were 0.76 (95% CI 0.72–0.81) and 0.68 (95% CI 0.62–0.73) respectively. Conclusions All three scores were similar in performance in quantifying risk in ED patients with possible ACS. The GRACE score identified a sizable low risk cohort with high sensitivity and NPV but complexity of this tool may limit its utility. Improved scores are needed to allow early identification of low- and high-risk patients to support improvements in patient flow and ED overcrowding.

To examine if demographic factors influence patients' self reports of satisfaction with care provided by nurse practitioners (NPs) in rural urgent care centers (UCCs).Data were collected between December 2009 and February 2010 using an 18-item self-report survey from a convenience sample of 53 patients in two rural UCCs.No statistical significance was noted in regards to patient satisfaction for the demographic factors age, gender, country of upbringing, or education level. Presence of health insurance was a significant factor, with uninsured patients rating higher levels of satisfaction. However, based on patients' responses to role clarity for this survey, it is evident that there continues to be insufficient public understanding of the role of NPs.The future of the NP relies on patient approval as well as acceptance of the role. This study joins the pioneering efforts towards describing what patient satisfaction is and supports NPs serving as providers in rural, nonprimary care venues. By identifying influential factors of satisfaction, NPs can bridge the gap between availability of quality care versus a lack of access and inform policy changes in the future.

Although earnings per share is the most widely used financial statistic, procedures for computing it remain complex, arbitrary, and inconsistent. The authors say we need a fresh look at the issue, and explore current change proposals by the ISASC and the FASB.

Up to now, employers have used a variety of methods to account for postemployment benefits. But FAS 112 changes all that. Employers now must accrue the expected cost of benefits likely to be paid.