Series: Volume 9, Issue 1 2019

Ongoing research increasingly reveals that metastatic colorectal carcinoma (mCRC) is a highly heterogeneous entity. Despite extension of the median survival of mCRC patients due to advances in therapeutic options available, further improvement and better rationalisation of resources could be achieved by more accurately predicting individual patient prognoses and responses to specific treatments. It is hence important to further our understanding of prognostic and predictive biomarkers in mCRC to enable accurate estimation of treatment benefit for individual patients and therefore guide patient selection. This information can also be used for improving patient stratification in future studies. The aim of this literature review is to highlight potential prognostic and predictive clinical, pathological and molecular biomarkers in mCRC. Broad categories include patient and tumour markers, protein markers and cell-free DNA, inflammatory markers and genetic markers.

The potential prognostic and predictive values of factors such as performance status, BRAF mutational status and neutrophil:lymphocyte ratio (NLR) >5 are supported by consistently strong evidence, but interpretation of the roles of other factors is difficult due to inconsistent findings between studies; however, many studies examine only small cohorts of patients, thereby limiting statistical power and variability in cut-off points may have contributed to different findings between trials. Although existing evidence may be used to select patient treatments and guide stratification in trials, future research with larger patient cohorts and clarification of appropriate cut-off values may prove helpful in elucidating the value of these biomarkers.

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The primary goal of fasting prior to general anaesthesia is to reduce the risk of pulmonary aspiration, displacement of gastric contents into the lungs. As gastric volume, alongside patient age, current medications and type of surgery are associated with increased incidence of pulmonary aspiration. The preoperative fasting guidelines have been developed to reduce total fasting duration. Most recommend clear fluids up to two hours prior to surgery and solid food up to six hours prior to surgery. Reducing fasting time aims to minimize the negative metabolic effects of prolonged fasting, such as insulin resistance, catabolism, increased gastric acidity, discomfort, hypotension and dehydration. When combined with the negative effects associated with surgical trauma, many of these, particularly insulin resistance, have been associated with poor postoperative outcomes. Preoperative carbohydrate loading through the use of a glucose beverage has been examined as a method of reducing insulin resistance. There is a large amount of evidence suggesting it is a safe and effective preoperative tool. Patient compliance has been identified as a limitation of preoperative fasting guidelines, associated with a lack of understanding regarding their risk of pulmonary aspiration. Altering guidelines to include a default treatment program, consisting of carbohydrate treatment, minimum hydration requirements and enhancements in preoperative assessments to improve patient understanding, would likely improve patient outcomes.

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This review aims to summarise the current literature on employing exhaled breath volatile organic molecules (VOMs) as novel biomarkers for non-invasive testing in inflammatory bowel disease (IBD) patients. Inflammatory bowel disease is a multifactorial disease that significantly diminishes thequality of life of affected individuals. Currently, the tools employed in IBD diagnosis and monitoring are numerous, imprecise and invasive for patients. This has necessitated the need to develop new biomarkers that are accurate. The use of VOM breath testing is one such potential modality. This review discusses the efficacy of current IBD testing modalities and the principles of metabolic profiling. It evaluates the use of breath VOM profiling in IBD testing and postulates its implications for future practice. The VOM profiles of IBD patients are different to those of healthy individuals. VOM profiles also differ between IBD subcategories and correlate to disease severity. VOM profiling via the breath headspace is accurate, non-invasive and has the potential for point-of-care testing. VOM profiling offers an exciting avenue as a frontline diagnostic and monitoring tool for IBD patients and thus merits further research.

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In Australia, burns are common, accounting for around 5500 hospital injuries each year. The proper management of burn pain is crucial to the rehabilitation process and in reducing the chance of long term psychological sequelae, such as depression and post-traumatic stress disorder. A wide array of therapeutic options is available to the clinician in managing burn pain in a hospital setting. These evidence-based options include opioids, non-opioid medications, anxiolytics, anaesthetics, as well as relaxation techniques and cognitive behavioural therapy. In managing chronic pain, therapeutic options vary between pharmacological and non pharmacological approaches used for acute pain. Consideration of these pain relief options can optimise the management of patients with burns and maximise their rehabilitation, leading to earlier hospital discharge.

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The objective of this review article is to determine whether simulation-based education could enhance the teaching of paediatrics to Australian medical students.
A literature search of PubMed and Embase was performed and from 595 identified articles, 34 papers were included in this review. There are several benefits of simulation teaching in paediatrics, including skill acquisition, improvement, maintenance, enhanced confidence, better understanding of human factors, improved teamwork skills and an opportunity to debrief as well as the potential for downstream improvements in patient outcomes. However, several challenges of simulation teaching for paediatrics were acknowledged, such as resource availability. Approaches to overcoming these challenges were proposed by the use of low-fidelity manikins, alternatives to standardised patients, the judicious use of simulation education, optimisation of student preparation for simulation sessions, the use of registrars as simulation facilitators and the utilisation of remote facilitation. With further research regarding the impact of simulation teaching on real-life clinical performance as well as methods to optimise its delivery, efficiency and cost-effectiveness, paediatric simulation teaching has considerable potential to enhance education for medical students in Australia.

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