What are the predictors of change in multimorbidity among people with HIV? : a longitudinal observational cohort study

Introduction: Multimorbidity is common among people living with HIV (PLWH), with numerous cross-sectional studies demonstrating associations with older age and past immunosuppression. Little is known about the progression of multimorbidity, particularly in the setting of long-term access to antiretrovirals. This study aims to determine factors predictive of change in multimorbidity in PLWH. Methods: People living with HIV who attended a regional HIV service were recruited to a consented observational cohort between September 2016 and March 2020. Demographic data, laboratory results and a Cumulative Illness Rating Scale (CIRS) were collected at enrolment and first clinical review of every subsequent year. Change in CIRS score was calculated from enrolment to February 2021. Associations with change were determined through univariate and multivariate linear regression. Results: Of 253 people, median age was 58.9 [interquartile range (IQR): 51.9–64.4] years, 91.3% were male, and HIV was diagnosed a median of 22.16 years (IQR: 12.1–30.9) beforehand. Length of time in the study was a median of 134 weeks (IQR: 89.0–179.0), in which a mean CIRS score change of 1.21 (SD 2.60) was observed. Being older (p < 0.001) and having a higher body mass index (p = 0.008) and diabetes (p = 0.014) were associated with an increased likelihood of worsening multimorbidity. PLWH with a higher level of multimorbidity at baseline were less likely to worsen over time (p < 0.001). Conclusion: As diabetes and weight predict worsening multimorbidity, routine diabetes screening, body mass index measurement, and multimorbidity status awareness are recommended

The first simultaneous pancreas, renal transplant in a patient with HIV in Australia

We report the first case of a simultaneous pancreas and renal transplantation, in Australia, in a 45 year old male with long standing human immunodeficiency virus infection, type 1 diabetes mellitus and diabetic nephropathy requiring haemodialysis. This patient experienced previous virological failure and subsequent resistance to most nucleoside and non-nucleoside reverse transcriptase inhibitors. However, using novel combinations of anti-retroviral agents, along with careful monitoring, successful outcomes were achieved during the peri and post transplantation period, with excellent pancreas and renal graft function at one year

"You're actually part of the team" : a qualitative study of a novel transitional role from medical student to doctor

Background Optimizing transitions from final year of medical school and into first post graduate year has important implications for students, patients and the health care system. Student experiences during novel transitional roles can provide insights into potential opportunities for final year curricula. We explored the experiences of medical students in a novel transitional role and their ability to continue learning whilst working as part of a medical team. Methods Novel transitional role for final year medical students were created in partnership by medical schools and state health departments in 2020 in response to the COVID-19 pandemic and the need for a medical surge workforce. Final year medical students from an undergraduate entry medical school were employed as Assistants in Medicine (AiMs) in urban and regional hospitals. A qualitative study with semi-structured interviews at two time points was used to obtain experiences of the role from 26 AiMs. Transcripts were analyzed using deductive thematic analysis with Activity theory as a conceptual lens. Results This unique role was defined by the objective of supporting the hospital team. Experiential learning opportunities in patient management were optimized when AiMs had opportunities to contribute meaningfully. Team structure and access to the key instrument, the electronic medical record, enabled participants to contribute meaningfully, whilst contractual arrangements and payments formalized the obligations to contribute. Conclusions The experiential nature of the role was facilitated by organizational factors. Structuring teams to involve a dedicated medical assistant position with specific duties and access to the electronic medical record sufficient to complete duties are key to successful transitional roles. Both should be considered when designing transitional roles as placements for final year medical students

Contact tracing for STIs : new resources and supportive evidence

Background Contact tracing of sexual partners is an important part of the clinical management of sexually transmissible infections (STIs) and initiation of contact tracing is the responsibility of the diagnosing clinician. Research has shown that some general practitioners would like to improve their skills in this area. Objective This article outlines new resources and evidence to assist GPs to initiate contact tracing when a patient is diagnosed with an STI. Discussion Most STIs are diagnosed in general practice so the involvement of GPs in contact tracing is crucial. The aims of contact tracing are to prevent re-infection of the index case, minimise complications and reduce the population prevalence of STIs in the community. Contact tracing begins with a conversation with the index patient about informing their sexual partner(s). The patient can then decide to inform their own contacts (patient referral) or organise for someone else to inform them (provider referral). Initiating contact tracing in general practice can be particularly effective if the resources and methods are tailored to the specific needs of the index patient. New resources provide clearer guidelines and tools to assist GPs in this area

Pelvic inflammatory disease : management of new-onset low abdominal pain in young women

Pelvic inflammatory disease (PID) is a highly variable syndrome that should be considered in all young women presenting with new-onset low abdominal pain. Prompt antibiotic treatment is essential to prevent potentially serious complications. Tests are often negative for sexually transmitted infection but rapid clinical improvement with treatment supports the diagnosis of PID

[In Press] Teaching to address overdiagnosis

Overdiagnosis is a concept that presents both opportunities and challenges in medical education. Overdiagnosis can be considered the detection or labelling of a condition that was never going to cause harm, or the application of a diagnostic label to ordinary life experiences. Multiple drivers to overdiagnosis have been identified and health professionals are one of the drivers. Doctors, in particular, play a critical role in making diagnoses, meaning they are an integral part of any pathway, leading to overdiagnosis. While including overdiagnosis in a medical curriculum has been suggested, there is no agreement about what ought to be taught. This lack of consensus is a reflection of the lack of clarity about overdiagnosis in general. An understanding of the terminology can be useful before considering the place of overdiagnosis within medical curriculum (table 1). Preventing overdiagnosis is a key step in reducing many of the potential harms of low-value care

Multimorbidity, not human immunodeficiency virus (HIV) markers predicts unplanned admission among people with HIV in regional New South Wales

Background: Multimorbidity and unplanned admissions are common among people with human immunodeficiency virus (PWH). Aims: To determine factors predictive of unplanned admission among PWH in regional New South Wales and compare care coordination between people with and without unplanned admissions. Methods: A prospective cohort study of PWH attending a regional human immunodeficiency virus (HIV) service was conducted. Baseline HIV-specific results and multimorbidity markers including Cumulative Illness Rating Scale (CIRS) were assessed as predictors of time to first unplanned admission using Cox regression analysis. Care coordination markers were compared between people with and without unplanned admission, using χ2 statistic for proportions and t-test for means. Results: A cohort of 181 PWH was followed for a maximum of 5 years. During a total of 739 person-years of follow up, 39 (20.6%) patients reached the endpoint of unplanned admission. In multivariate analysis, the baseline CIRS score was predictive of unplanned admission (P < 0.001). Age, HIV-specific markers and missed visits were not predictive of unplanned admission. For patients with an unplanned admission, discharge summaries were documented for 22/39 (56.4%). Of 180 PWH with a visit after baseline, 131 (72.8%) had a letter to a general practitioner and 79 (43.7%) had two or more prescribers. Having two or more prescribers was more common in people with an unplanned admission than in those without (64.1% vs 38.0%, P = 0.004). Conclusion: Unplanned admission among PWH is predicted by multimorbidity. Care for PWH should include coordinated management of other health conditions in order to reduce their severity and prevent unplanned admissions

Medical students’ awareness of overdiagnosis and implications for preventing overdiagnosis

Abstract Overdiagnosis is a growing health issue, yet our understanding of medical students’ exposure to this concept within medical education is limited. Our aim was to explore students’ experience of diagnostic learning to identify how overdiagnosis may be understood by students. During in-person and online semi-structured interviews throughout 2021, we explored the education experience of twelve Western Sydney University medical students in years 3–5. Through inductive thematic analysis we identified four themes. These themes encompassed student commitment to learning about diagnosis, lack of certainty surrounding diagnosis and emotional factors of medical care, overdiagnosis as seen through the lens of high and low-value care during clinical placements and student-identified missed learning opportunities related to overdiagnosis. This study found that medical students develop inherent knowledge of overdiagnosis through an interplay of personal factors, medical school curriculum and the setting in which their training takes place. Our findings allow insight for future improvement of medical curriculum to produce exceptional medical graduates

Vulval Crohn's disease

We report a case of vulval Crohn’s disease, the diagnosis of which was complicated by the presence of sexually transmissible infections

Contact tracing in a regional sexual health clinic : audit outcomes and implications for sexually transmissible infection control

Objective: To evaluate contact tracing outcomes in a regional sexual health clinic (SHC) and to investigate contact tracing outcome measures. Method: A retrospective audit of contact tracing activities for all 126 cases of Chlamydia trachomatis, 19 cases of Neisseria gonorrhoeae and two cases of early syphilis diagnosed during 2004 was conducted at a regional SHC in Queensland, Australia. Results: Patient referral was used for almost all contact tracing. The ratio of index cases to contacts reported by the index case as known to be treated and seen at the clinic was 1:0.71 and 1:0.26 respectively. Ratios of index cases to contacts for chlamydial infection and gonorrhoea were similar. Records identified that past partners were treated less often than current regular partners and were rarely seen at the clinic. The ratio of total index cases to total clients seen as contacts, including contacts of index cases diagnosed elsewhere, was 1:0.52. Implications: Improving information and resources for index cases should be a priority of any contact tracing program, with a focus on strategies to increase contact tracing of past partners. A method of evaluating contact tracing processes can include summary outcome data such as the ratio of total index cases to total clients seen as contacts and the proportion of contacts testing positive. Such measures may be useful in evaluating new contact tracing strategies and may also be applicable for the development of a national standard for contact tracing