Abdullah Al Alawi
Department of Medicine, Goyulburn Valley Health, Shepparton, Victoria, Australia 


Budd Chiari Syndrome case presentation and literature review 

Authors: Roshini Nadaraja1, Ja Hyuk Koo1, Ankita Singh1, Abdullah Al Alawi1, Janith de Silva1
Afiliations: 1Deaprtment of Medicine, Goyulburn Valley Health, Shepparton, Victoria, Australia

Background: Budd Chiari Syndrome (BCS) is defined as a hepatic venous outflow tract obstruction. This obstruction is independent of the mechanism, provided it is not due to cardiac disease, pericardial disease or veno-occlusive disease. BCS often clinically manifests as abdominal pain, ascites and hepatomegaly. BCS is predominantly prevalent in the West with different predispositions to gender and aetiology when compared to the East. However, due to its rarity and often insidious onset, the syndrome is only described based on small studies of prevalent cases.

The Case: We present a case of a 28 year old female with no previous comorbidities who presented to the Emergency Department of Goulburn Valley Health with a 3 day history of abdominal pain and distension with evidence of ascites and hepatomegaly on clinical examination. When investigated, she had markedly elevated liver transaminases, white cell count, C reactive protein, INR and APTT, as well as evidence of portal hypertension. Quadriphase CT scan showed occlusion of the hepatic vein. She was transferred to Austin Health where she underwent a Transjugular Intrahepatic Portosystemic Shunt (TIPS) successfully and was discharged from hospital with clinical and biochemical improvement.

Future plan: A literature review will be done to highlight the prevalence, aetiology and varying manifestations of BCS in different demographics and regions, as well as to review the current guidelines of diagnosis and management of this rare condition.

Management Of STEMI In A Rural Health Setting

Authors: Abdullah M. Al Alawi, Oluwafemi J. Afolayan, Helen Sands, Rathin Gosavi, Arup Bhattacharya, Tunde Ibrahim
Acknowledgement: Victorian cardiac outcome registry

Objective: To assess the quality of care of patients with ST segment elevation myocardial infarction (STEMI) in rural health setting

Design: Retrospective review of patients’ records with confirmed diagnosis of STEMI during the period 1st of January 2014 to 18th November 2015.Quality of care assessed using guidelines from the Australian National Heart Foundation/ Cardiac Society of Australia and New Zealand

Setting: Goulburn Valley Health is a rural hospital located 200km northeast of Melbourne that provides care for a catchment population of approximately 120,000 people from the City of Greater Shepparton ranging up to southern New South Wales. Owing to its location, fibrinolysis is offered to patients with diagnosed STEMI.

Main Outcome Measures:
1) Time between hospital presentations to first ECG
2) Door to needle time
3) Rate of adjuvant therapies post thrombolysis
4) Rate of transfer to a hospital with percutaneous coronary intervention (PCI) capabilities

Results: During the study period, there were 86 cases of confirmed diagnosis of STEMI. Mean patient age was 64 (SD=14 years) with 65% of the patients being males. 71% (61) of patients were brought to hospital by an ambulance and around 23% resided >50 km away from the hospital. Median time to first ECG was 10 minutes (IQR 11.5). In terms of ECG findings on presentation, 93% of ECGs showed ST elevation, 2% new LBBB and 5% other ECG abnormalities. 56 patients (65%) received thrombolytic therapy including the 12 cases who received pre-hospital thrombolysis. The median door to needle time was 37.5 mins (IQR: 29,60.5 minutes) and only 32% of patient received thrombolysis within 30 minutes. In terms of recommended adjunctive therapy post thrombolysis, 90% (38/44) of patients were prescribed clopidogrel and 98% (43/44) were prescribed LMWH or heparin. In-hospital outcomes included 7 (8%) deaths, 7 (8%) cardiogenic shocks and 6 (7%) patients who suffered re-infractions. In total, 73 (85%) patients were transfer to PCI equipped hospital, of whom 43 (59%) were transferred with within 6 hours and 53 (73 %) and 8 (11%) after 12 hours .

Conclusion: This audit shows the quality of care for a patient presenting with STEMI at GVH was adequate and concordant with our national protocols. However, the door to needle time was longer than recommended and we would suggest that more comprehensive strategies are required to improve pre-hospital notification and to shorten response times by medical teams. We also need to explore barriers causing delay in patients being transferred to a PCI capable hospital.

The Patterns Of Ordering Computed Tomography Pulmonary Angiogram (CTPA) For Diagnosis Of Pulmonary Embolism In Rural Health Settings

Authors: Adbullah M. Al Alawi , Jaganaathan Raman Srinivasan, Umar Khan, Sudaraka Wickremasena, Sean Hui, Gyu Sung Lee ,Ryan Evans, Geetha Meenakshisundaram and Arup Bhattacharya 
Corresponding author:  Abdullah Al Alawi

Background: Pulmonary embolism (PE) is a life-threatening condition with overall mortality of up to 30% when left untreated. CTPA is the gold standard investigation for diagnosis of PE.  Several studies showed this test is being over employed without using available predictive tools i.e. Wells score, Modified Geneva score & D-Dimer Standard

·         CXR should be initial investigation (Target 100%)
·         Wells/Geneva Score (Target 100%)
·         CXR documentation on CTPA request (Target 100%)
·         Diagnostic yield of CTPA (Target 15.4%)

Methodology: Retrospective review of patients’ records who had CTPA for suspected pulmonary embolism during a period 1st March 2015 to 28th Feb 2016. Patient’s demographics and components of different scoring system were obtained by manual review of patients electronic records

Result: A total of 261 CTPAs were done during this study period. In term of patient demographics, mean age was 63 years and 47 % (n= 124) of patients were female. PE was diagnosed in 34 patients (13%). Only 196 patients (75%) had CXR as an initial investigation. Wells score was used as a risk assessment tool in 5 patients (1.9%). CXR findings were documented in 5 CTPA request forms (1.9%). Acute kidney injury was noted in 27 patients post CTPA (10.3%).

Revised Geneva score was calculated post-CTPA for patients with diagnosis of pulmonary embolism. A total of 4 patients (11%) had a high probability on Revised Geneva score (score >11). Wells score could not be accurately calculated due to retrospective nature of the study. 

Conclusion: The diagnostic yield of CTPA with a positive result for pulmonary embolism was 13% which is below the recommended standards by Royal College of Radiology (UK) (15.4% to 37.4%). The findings were noted to be inferior compared with a similar study done in an Australian hospital2. These findings can be explained by the poor utilization of risk assessment tools (Geneva, Wells and D-Dimer) and not performing simple chest X-ray prior to CTPA. A protocol to request CTPAs is needed which is suited to the regional settings to avoid unnecessary CTPAs and its complications.