An association between exposure to environmental tobacco smoke and development of peripheral arterial disease or clinically significant arterial injury in non-smokers is supported by moderate quality evidence in the literature. Larger, longitudinal observational studies addressing current limitations, including sources of bias, inconsistency and imprecision, are needed to provide more robust and consistent evidence. Regardless, evidence of potential detrimental impacts supports ongoing restrictions on freedom to smoke in public areas, including the workplace, and has implications for those exposed in the home environment.

In this cohort, PTA is a favourable alternative to BYP for PAD of the lower limbs as it is less costly, does not result in a greater re-intervention rate at 1 year and has been previously demonstrated to have comparable clinical outcomes. Given the limitations of this retrospective analysis, a prospective cost-effectiveness analysis is recommended.

Background Hepatic encephalopathy (HE) as a consequence of cirrhosis with portal hypertension has a profound impact on quality of life for both patients and caregivers, has no gold-standard diagnostic test, and is a risk factor for mortality. Spontaneous portosystemic shunts (SPSS) are common in patients with cirrhosis, can be challenging to identify, and in some cases, can drive refractory HE. Cross-sectional shunt size greater than 83mm2 is associated with liver disease severity, overt HE, and mortality. Case presentation We report a patient with refractory HE and frequent hospitalization in the context of an occult spontaneous portal-umbilical portosystemic shunt with an estimated cross-sectional area of 809mm2. Following identification and angiographic retrograde transvenous obliteration of the SPSS using plugs, coils and sclerosant, there was improvement in neurocognitive testing and no further hospitalization for HE. Conclusion SPSS in the context of cirrhosis with portal hypertension can contribute to the debilitating effects of refractory HE. This case highlights the opportunity to search for SPSS in patients with HE unresponsive to therapy as angiographic obliteration is usually safe, well-tolerated, and clinically effective.

IntroductionCardiac cirrhosis is common in patients with advanced heart failure and can limit heart transplant eligibility. We examined the outcomes of patients with cardiac cirrhosis following orthotopic heart transplantation.Material and methodsA retrospective matched cohort study of adult patients with cirrhosis undergoing heart transplantation at an Australian hospital from 2009 to 2017 was performed. Cirrhosis was established by either (a) histopathology or (b) combination of radiological features of cirrhosis and portal hypertension plus clinical features of portal hypertension. Primary objectives were to assess mortality, perioperative, and long‐term complications. Matching was performed with non‐cirrhotic patients undergoing heart transplantation in a 4:1 ratio.ResultsFive patients with biopsy‐proven cirrhosis or portal hypertension and 20 matched controls without cirrhosis were included. Additionally, 5 patients with clinical and radiological evidence of cirrhosis were assessed separately. The groups were well‐matched for age at transplant, year of transplant, gender, and comorbidities. Mortality was more frequent but not significantly greater in the cirrhosis group with 2 deaths within 4 months of transplant compared to 1 death each in the no cirrhosis and suspected cirrhosis groups (40%, 5%, 20% P = .40). The median duration of intensive care unit stay was longer in the cirrhosis group compared to the suspected cirrhosis group (8 vs 6 days, P = .03); however, there was no difference in total hospitalization (P = .56) or in median duration of admission (0.64) compared to the no cirrhosis group.ConclusionsThese findings suggest that there is greater mortality associated with cases of definite cirrhosis compared to suspected or matched controls following orthotopic heart transplantation; however, statistical significance was not reached. Admission length and complication rates were similar compared to those without cirrhosis. Future studies are warranted to further evaluate mortality risk in a larger population.

Background Acute-on-chronic liver failure (ACLF) represents a rising global healthcare burden, characterised by increasing prevalence among patients with decompensated cirrhosis who have a 28-day transplantation-free mortality of 33.9%. Due to disease complexity and a high prevalence of socio-economic disadvantage, there are deficits in quality of care and adherence to guideline-based treatment in this cohort. Compared to other chronic conditions such as heart failure, those with liver disease have reduced access to integrated ambulatory care services. The LivR Well programme is a multidisciplinary intervention aimed at improving 28-day mortality and reducing 30-day readmission through a home-based, liver optimisation programme implemented in the first 28 days after an admission with either ACLF or hepatic decompensation. Outcomes from our feasibility study suggest that the intervention is safe and acceptable to patients and carers. Methods We will recruit adult patients with chronic liver disease from the emergency departments, in-patient admissions, and an ambulatory liver clinic of a multi-site quaternary health service in Melbourne, Australia. A total of 120 patients meeting EF-Clif criteria will be recruited to the ACLF arm, and 320 patients to the hepatic decompensation arm. Participants in each cohort will be randomised to the intervention arm, a 28-day multidisciplinary programme or to standard ambulatory care in a 1:1 ratio. The intervention arm includes access to nursing, pharmacy, physiotherapy, dietetics, social work, and neuropsychiatry clinicians. For the ACLF cohort, the primary outcome is 28-day mortality. For the hepatic decompensation cohort, the primary outcome is 30-day re-admission. Secondary outcomes assess changes in liver disease severity and quality of life. An interim analysis will be performed at 50% recruitment to consider early cessation of the trial if the intervention is superior to the control, as suggested in our feasibility study. A cost-effectiveness analysis will be performed. Patients will be followed up for 12 weeks from randomisation. Three exploratory subgroup analyses will be conducted by (a) source of referral, (b) unplanned hospitalisation, and (c) concurrent COVID-19. The trial has been registered with the Australian New Zealand Clinical Trials Registry. Discussion This study implements a multidisciplinary intervention for ACLF patients with proven benefits in other chronic diseases with the addition of novel digital health tools to enable remote patient monitoring during the COVID-19 pandemic. Our feasibility study demonstrates safety and acceptability and suggests clinical improvement in a small sample size. An RCT is required to generate robust outcomes in this frail, high healthcare resource utilisation cohort with high readmission and mortality risk. Interventions such as LivR Well are urgently required but also need to be evaluated to ensure feasibility, replicability, and scalability across different healthcare systems. The implications of this trial include the generalisability of the programme for implementation across regional and urban centres. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621001703897. Registered on 13 December 2021. WHO Trial Registration Data Set. See Appendix 1

This audit collates data on alcohol‐related gastrointestinal (GI) admissions at Monash Health, Victoria, during the prolonged, coronavirus disease 2019 (COVID‐19)–related lockdown July to October 2020 compared with the same periods in 2019 and 2021. We found a 58% increase in admissions in 2020 and a 16% increase in 2021, which also increased disproportionately to overall health service emergency presentations. Self‐reported alcohol consumption increased by 2.5‐fold and was greatest in 2020. Clinical severity was unchanged and cirrhosis was the only factor associated with severe disease. This study suggests an association between the pandemic‐related lockdown, alcohol consumption and alcohol‐related GI hospitalisation. Our study provides support for resourcing and adapting alcohol and other drug services during and beyond the COVID‐19 lockdown.

Background and Aim Patients with refractory ascites have frequent hospital admissions, which pose exposure risks in the context of the COVID‐19 pandemic. The aim of this study was to investigate the safety and efficacy of a novel 12‐week, multidisciplinary ambulatory care program allowing frequent low‐volume ascitic drainage through a tunneled, intraperitoneal catheter (IPC). Methods Adult patients with cirrhosis complicated by refractory ascites were recruited through a liver clinic in a tertiary health service in Melbourne, Australia from April to December 2020. All patients were enrolled in a 12‐week multidisciplinary program including medical, nursing, dietetics, and pharmacy support. A Rocket Medical IPC was inserted on day 1 with 1–2 L of ascitic fluid drained over 1–3 sessions per week either at the patients' homes or at the hospital day ward. Patients' demographics, death, complications, and self‐reported outcomes were recorded. Results Twelve patients were enrolled with a median of 65‐day (interquartile range [IQR]: 16.5–93) IPC duration between April and December 2020 across two periods of COVID‐related lockdown in Melbourne, Australia. There were no IPC‐related deaths. Early removal was necessitated in three patients due to leakage, nonadherence, and bacteremia. On day 30, the median self‐reported health score increased from 50 (IQR: 50–70) to 78 (IQR: 50–85), attributable to a reduction in symptom burden. Conclusion A multidisciplinary IPC program including the use of short‐term IPC was safe and associated with a self‐reported improvement in perceptions of health. In the context of the COVID‐19 pandemic, the program aimed to reduce patient and clinician exposure, which is maintaining engagement and management of decompensated cirrhosis.

Background: Urinary tract infections (UTIs) are one of the commonest reasons for hospital admission. Studies have demonstrated wide variation in treatment and indiscriminate use of third generation cephalosporins (ceftriaxone). 1 The aims of this study were to assess whether antibiotic use was in keeping with current guidelines and explore the possibility of minimizing third generation cephalosporin use based on local antimicrobial susceptibility patterns. In addition, the study assessed the clinical utility of bedside urinalysis.Methods: Data was collected for men and non-pregnant women aged ≥18 admitted to the Angliss Hospital under the General Medicine Unit with a diagnosis of UTI between January and August 2015.Results: 243 patient records were reviewed (mean age 69 AE 21 years, female 80%). UTI was uncomplicated in 177 (73%), complicated (i.e. associated with urological abnormalities) in 49 (20%) and catheterassociated (CAUTIs) in 17 (7%). A positive urine culture was present in 172 (71%), 131 (74%), 35 (71%) and 6 (35%) uncomplicated, complicated and CAUTIs respectively. Despite strong clinical suspicion of UTI, 44 patients (18%) grew mixed flora and 27 (11%) yielded no growth.Among those with a positive culture, Escherichia coli was identified in 133 (77%), 101 (77%) of uncomplicated, 31 (89%) of complicated and 1 (16%) of CAUTI. This was sensitive to first generation cephalosporins (cephazolin) in 88 (87%) uncomplicated and 24 (77%) complicated UTIs, however, the isolate was resistant in the CAUTI. 80% of the 21 E. coli isolates that were resistant to cephazolin were also resistant to ceftriaxone. Other pathogens included Enterococcus faecalis (6%); ESCAPPM organisms (6%); Klebsiella spp and Proteus mirabilis (6%, all sensitive to cephazolin) and Pseudomonas aeruginosa.Antibiotic choice was consistent with guidelines in 76 (43%) uncomplicated, 9 (18%) complicated and 4 (24%) CAUTIs. Ceftriaxone was the first line antibiotic used in 110 (45%) patients. Ceftriaxone use among patients who yielded a positive culture was 81 (47%) whereas 56 (69%) patients (39 (72%) uncomplicated and 17 (65%) complicated) could have potentially been treated with first generation cephalosporins based on their sensitivity results.In culture-positive cases, the finding of a positive leucocyte test on dipstick had a sensitivity of 90.6% and specificity of 20.8%. Nitrite positivity had the highest specificity (78.6%) but sensitivity was 43.9%. Conclusion:Our findings confirm poor adherence to guidelines as well as the indiscriminate use of third generation cephalosporins (ceftriaxone) when treating all types of UTIs. When parenteral antibiotics are indicated, first generation cephalosporins may be a safe first line treatment option for most uncomplicated and complicated UTIs. Furthermore, given the sensitivity patterns, ceftriaxone use in this setting may improve treatment efficacy only marginally. Clinical utility of urine dipstick was modest, which is consistent with previous studies.