Topics

Infectious disease burden, antimicrobial use and resistance highlight the need for antimicrobial stewardship in Indigenous communities

Antimicrobial stewardship is a set of coordinated strategies to improve antimicrobial use, enhance patient outcomes, reduce antimicrobial resistance (AMR) and decrease unnecessary costs. In Australian publicly funded health care, it is required for hospital accreditation under the National Standards, with highly developed strategies for hospitals (inpatient and outpatient) and nursing homes.1 Strategies in primary health care are much less developed, in settings where almost one in two Australians are prescribed an antibiotic every year.2

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1 Perth Children's Hospital, Perth, WA
2 Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, WA
3 Canberra Hospital, Canberra, ACT
4 Queensland Statewide Antimicrobial Stewardship Program, Metro North Hospital and Health Services, Brisbane, QLD
5 Kimberley Aboriginal Medical Services Limited, Broome, WA
6 Victorian Infectious Disease Service, Royal Melbourne Hospital, and Peter Doherty Institute for Infection and Immunity, Melbourne, VIC
7 Menzies School of Health Research, Darwin, NT

Correspondence: asha.bowen@health.wa.gov.au

Acknowledgements:

The CRAMS Group includes membership from the Kimberley Aboriginal Medical Services (Dr Kerr Wright [former Medical Director] and Dr Lorraine Anderson [current Medical Director]), Top End Health Service (Ms Bhavini Patel, Dr Christine Connors, Mr John Shanks), Queensland Health (Ms Stacey McNamara, Dr Trent Yarwood, Dr Kathryn Daveson), Doherty Institute (Prof Jodie McVernon, A/Prof Steven Tong), Menzies School of Health Research (Mr Will Cuningham), the National Centre for Antimicrobial Prescribing (Dr Rodney James, A/Prof Kirsty Buising) and Telethon Kids Institute (A/Prof Asha Bowen). The CRAMS group has received funding for a pilot study of antimicrobial use in northern Queensland, Western Australia and the Northern Territory from HOT North (NHMRC APP1131932). A/Prof Bowen and A/Prof Tong are supported by NHMRC fellowships (APP 1088735 and 1065736 respectively).

Competing interests:

No relevant disclosures.

1. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. Sydney: ACSQHC, 2017. https://www.nationalstandards.safetyandquality.gov.au/ (viewed May 2019).
2. Van Boeckel TP, Gandra S, Ashok A, et al. Global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data. Lancet Infect Dis 2014; 14: 742–750.
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5. Queensland Health, Royal Flying Doctor Service (Queensland Section). Primary clinical care manual. 9th ed. Cairns: Rural and Remote Clinical Support Unit, Torres and Cape Hospital and Health Service, 2016. https://publications.qld.gov.au/dataset/primary-clinical-care-manual-9th-edition (viewed May 2019).
6. Antibiotic Expert Group. Therapeutic guidelines: antibiotic. 16th ed. Melbourne: Therapeutic Guidelines Ltd, 2019.
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8. O'Grady KA, Torzillo PJ, Chang AB. Hospitalisation of Indigenous children in the Northern Territory for lower respiratory illness in the first year of life. Med J Aust 2010; 192: 586–590. https://www.mja.com.au/journal/2010/192/10/hospitalisation-indigenous-children-northern-territory-lower-respiratory .
9. Hendrickx D, Bowen AC, Marsh JA, et al. Ascertaining infectious disease burden through primary care clinic attendance among young Aboriginal children living in four remote communities in Western Australia. PLoS One 2018; 13: e0203684.
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11. Davis JS, Cheng AC, McMillan M, et al. Sepsis in the tropical Top End of Australia's Northern Territory: disease burden and impact on Indigenous Australians. Med J Aust 2011; 194: 519–524. https://www.mja.com.au/journal/2011/194/10/sepsis-tropical-top-end-australias-northern-territory-disease-burden-and-impact .
12. Cuningham W, McVernon J, Lydeamore MJ, et al. High burden of infectious disease and antibiotic use in early life in Australian Aboriginal communities. Aust N Z J Public Health 2019; 43: 149–155.
13. Russell DJ, Zhao Y, Guthridge S, et al. Patterns of resident health workforce turnover and retention in remote communities of the Northern Territory of Australia, 2013‐2015. Hum Resour Health 2017; 15(1): 52.
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15. Macmorran E, Harch S, Athan E, et al. The rise of methicillin resistant Staphylococcus aureus: now the dominant cause of skin and soft tissue infection in Central Australia. Epidemiol Infect 2017; 1–10.
16. Hare KM, Grimwood K, Chang AB, et al. Nasopharyngeal carriage and macrolide resistance in Indigenous children with bronchiectasis randomized to long‐term azithromycin or placebo. Eur J Clin Microbiol Infect Dis 2015; 34: 2275–2285.
17. Turnidge JD, Gottlieb T, Mitchell DH, et al. Community‐onset Gram‐negative Surveillance Program annual report, 2012. Commun Dis Intell Q Rep 2014; 38: E54–E58.
18. van Hal SJ, Steinig EJ, Andersson P, et al. Global scale dissemination of st93: a divergent staphylococcus aureus epidemic lineage that has recently emerged from remote northern australia. Front Microbiol 2018; 9: 1453.
19. Australian Commission on Safety and Quality in Health Care. AURA 2017: second Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC, 2017. https://www.safetyandquality.gov.au/publications/second-australian-report-on-antimicrobial-use-and-resistance-in-human-health/ (viewed May 2019).
20. Alividza V, Mariano V, Ahmad R, et al. Investigating the impact of poverty on colonization and infection with drug‐resistant organisms in humans: a systematic review. Infect Dis Poverty 2018; 7: 76.
21. Collignon P, Beggs JJ, Walsh TR, et al. Anthropological and socioeconomic factors contributing to global antimicrobial resistance: a univariate and multivariable analysis. Lancet Planet Health 2018; 2: e398–e405.

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Perspectives

Inclusion of Indigenous Australians in biobanks: a step to reducing inequity in health care

Imogen Elsum, Callum McEwan, Emma E Kowal, Yvonne Cadet‐James, Margaret Kelaher and Lynn Woodward

Med J Aust 2019; 211 (1): . || doi: 10.5694/mja2.50219
Published online: 1 July 2019

Topics

Indigenous health

Medical genetics

Social determinants of health

Without improved practices and policy to guide the engagement and inclusion of Indigenous Australians in biobanks, the full health benefits provided by the genomic era will not be shared equitably

Biobanks are collections of biological specimens, with accompanying health and demographic information, stored and maintained for research purposes.1 Research may range from large scale population‐based longitudinal studies or more defined disease and tissue‐specific initiatives. In both observational and cohort studies, biobanks provide an invaluable resource that allows researchers to examine the complex range of factors which contribute to disease, without having to devote time to, and source funding for, the collection and storage of samples.

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1 Centre for Health Policy, University of Melbourne, Melbourne, VIC
2 Alfred Deakin Centre for Citizenship and Globalisation, Deakin University, Melbourne, VIC
3 Indigenous Education and Research Centre, James Cook University, Townsville, QLD
4 Centre for Health Policy, University of Melbourne, Melbourne, VIC
5 College of Medicine and Dentistry and Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD

Correspondence: callum.mcewan@unimelb.edu.au

Competing interests:

No relevant disclosures.

1. Paskal W, Paskal AM, Debski T, et al. Aspects of modern biobank activity ‐ comprehensive review. Pathol Oncol Res 2018; 24: 771–785.
2. Halverson CM, Ross LF. Engaging African‐Americans about biobanks and the return of research results. J Community Genet 2012; 3: 275–283.
3. Prictor M, Teare HJA, Kaye J. Equitable participation in biobanks: the risks and benefits of a “dynamic consent” approach. Front Public Health 2018; 6: 253.
4. Kowal E, Greenwood A, McWhirter RE. All in the blood: a review of Aboriginal Australians’ cultural beliefs about blood and implications for biospecimen research. J Empir Res Hum Res Ethics 2015; 10: 347–359.
5. Brunham LR, Chan SL, Li R, et al. Pharmacogenomic diversity in Singaporean populations and Europeans. Pharmacogenomics J 2014; 14: 555–563.
6. Smart A, Tutton R, Martin P, et al. The standardization of race and ethnicity in biomedical science editorials and UK biobanks. Soc Stud Sci 2008; 38: 407–423.
7. Metcalfe SA, Bittles AH, O'Leary P, Emery J. Australia: public health genomics. Public Health Genomics 2009; 12: 121–128.
8. Armstrong K, Micco E, Carney A, et al. Racial differences in the use of BRCA1/2 testing among women with a family history of breast or ovarian cancer. JAMA 2005; 293: 1729–1736.
9. Saulsberry K, Terry SF. The need to build trust: a perspective on disparities in genetic testing. Genet Test Mol Biomarkers 2013; 17: 647–648.
10. Kowal E. Genetic research in Indigenous health: significant progress, substantial challenges. Med J Aust 2012; 197: 19–20. https://www.mja.com.au/journal/2012/197/1/genetic-research-indigenous-health-significant-progress-substantial-challenges .
11. McWhirter RE, Mununggirritj D, Marika D, et al. Ethical genetic research in Indigenous communities: challenges and successful approaches. Trends Mol Med 2012; 18: 702–708.
12. National Centre for Indigenous Genomics. Governance framework. http://ncig.anu.edu.au/governance-framework (viewed May 2019).
13. Cohn EG, Hamilton N, Larson EL, Williams JK. Self‐reported race and ethnicity of US biobank participants compared to the US Census. J Community Genet 2017; 8: 229–238.
14. Tutton R. Biobanks and the inclusion of racial/ethnic minorities. Race Global Politics Health Inequity 2009; 3: 75–95.
15. Beaton A, Hudson M, Milne M, et al. Engaging Maori in biobanking and genomic research: a model for biobanks to guide culturally informed governance, operational, and community engagement activities. Genet Med 2017; 19: 345–351.
16. Australian Bureau of Statistics. Estimates of Aboriginal and Torres Strait Islander Australians, June 2016. https://www.abs.gov.au/ausstats/abs@.nsf/mf/3238.0.55.001 (viewed May 2019).
17. National Health and Medical Research Council. Biobanks information paper 2010. Canberra: NHMRC, 2010.

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Narrative review

Deep vein thrombosis: update on diagnosis and management

Paul C Kruger, John W Eikelboom, James D Douketis and Graeme J Hankey

Med J Aust 2019; 210 (11): . || doi: 10.5694/mja2.50201
Published online: 17 June 2019

Topics

Hematologic diseases

Pharmaceutical preparations

General medicine

Summary

Diagnosis of deep vein thrombosis (DVT) requires a multifaceted approach that includes clinical assessment, evaluation of pre‐test probability, and objective diagnostic testing.
Common symptoms and signs of DVT are pain, swelling, erythema and dilated veins in the affected limb.
The pre‐test probability of DVT can be assessed using a clinical decision rule that stratifies DVT into “unlikely” or “likely”. If DVT is “unlikely”, refer for D‐dimer test. If the D‐dimer level is normal, DVT can be excluded; if the D‐dimer level is increased, refer for compression ultrasound. If DVT is “likely”, refer for compression ultrasound.
When DVT is confirmed, anticoagulation is indicated to control symptoms, prevent progression and reduce the risk of post‐thrombotic syndrome and pulmonary embolism.
Anticoagulation may consist of a parenteral anticoagulant overlapped by warfarin or followed by a direct oral anticoagulant (DOAC) (dabigatran or edoxaban), or of a DOAC (apixaban or rivaroxaban) without initial parenteral therapy.
DOACs are the preferred treatment for DVT because they are at least as effective, safer and more convenient than warfarin. DOACs may require dose reduction or avoidance in patients with renal dysfunction, and should be avoided in pregnancy.
Recent evidence shows that DVT in patients with cancer may be treated with edoxaban (after discontinuation of 5 days of initial heparin or low molecular weight heparin [LMWH]) or rivaroxaban if patients prefer not to have daily injections of LMWH, but the risk of gastrointestinal bleeding is higher with DOACs than with LMWH in patients with gastrointestinal cancer.

1 Fiona Stanley Hospital, Perth, WA
2 PathWest Laboratory Medicine, Perth, WA
3 Population Health Research Institute, Hamilton, Canada
4 Hamilton Health Sciences, Hamilton, Canada
5 St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, Canada
6 University of Western Australia, Perth, WA

Correspondence: graeme.hankey@uwa.edu.au

Competing interests:

No relevant disclosures.

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Consensus statement

Diagnosis and management of heparin‐induced thrombocytopenia: a consensus statement from the Thrombosis and Haemostasis Society of Australia and New Zealand HIT Writing Group

Joanne Joseph, David Rabbolini, Anoop K Enjeti, Emmanuel Favaloro, Marie‐Christine Kopp, Simon McRae, Leonardo Pasalic, Chee Wee Tan, Christopher M Ward and Beng H Chong

Med J Aust 2019; 210 (11): . || doi: 10.5694/mja2.50213
Published online: 17 June 2019

Topics

Pharmaceutical preparations

Hematologic diseases

General medicine

Abstract

Introduction: Heparin‐induced thrombocytopenia (HIT) is a prothrombotic disorder that occurs following the administration of heparin and is caused by antibodies to platelet factor 4 and heparin. Diagnosis of HIT is essential to guide treatment strategies using non‐heparin anticoagulants and to avoid unwanted and potential fatal thromboembolic complications. This consensus statement, formulated by members of the Thrombosis and Haemostasis Society of Australia and New Zealand, provides an update on HIT pathogenesis and guidance on the diagnosis and management of patients with suspected or confirmed HIT.

Main recommendations:

A 4Ts score is recommended for all patients with suspected HIT prior to laboratory testing.
Further laboratory testing with a screening immunoassay or confirmatory functional assay is not recommended in individuals with a low 4Ts score. However, if there are missing or unreliable clinical data, then laboratory testing should be performed.
A positive functional assay result confirms the diagnosis of HIT and should be performed to confirm a positive immunoassay result.
Heparin exposure must be ceased in patients with suspected or confirmed HIT and initial treatment with a non‐heparin alternative instituted.
Non‐heparin anticoagulants (danaparoid, argatroban, fondaparinux and bivalirudin) used to treat HIT should be given in therapeutic rather than prophylactic doses.
Direct oral anticoagulants may be used in place of warfarin after patients with HIT have responded to alternative parenteral anticoagulants with platelet count recovery.

Changes in management as a result of this statement:

These are the first Australasian recommendations for diagnosis and management of HIT, with a focus on locally available diagnostic assays and therapeutic options.
The importance of examining both clinical and laboratory data in considering a diagnosis of HIT cannot be overstated.

1 St Vincent's Hospital, Sydney, NSW
2 St Vincent's Clinical School, University of New South Wales, Sydney, NSW
3 Royal North Shore Hospital, Sydney, NSW
4 Northern Blood Research Centre, Kolling Institute of Medical Research, Sydney, NSW
5 Calvary Mater Hospital, Sydney, NSW
6 Institute of Clinical Pathology and Medical Research, Sydney, NSW
7 Westmead Hospital, Sydney, NSW
8 Royal Adelaide Hospital, Adelaide, SA
9 St George Hospital, Sydney, NSW

Correspondence: Joanne.Joseph@svha.org.au

Competing interests:

Anoop Enjeti has received speaker fees from Bayer and Sanofi Aventis outside the submitted work. Simon McRae has received research funding from CSL and Roche outside the submitted work. Chee Wee Tan has received non‐financial support from Bayer Health and speaker fees from Pfizer outside the submitted work. Christopher Ward has received personal fees and non‐financial support from Aspen, personal fees from Instrumentation Laboratory (Werfen) and personal fees from Sanofi during the preparation of this consensus statement.

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Narrative reviews

Updates and advances in the treatment of Parkinson disease

Michael W Hayes, Victor SC Fung, Thomas E Kimber and John D O'Sullivan

Med J Aust 2019; 211 (6): . || doi: 10.5694/mja2.50224
Published online: 17 June 2019

Topics

Nervous system diseases

Summary

Parkinson disease (PD) is a complex neurodegenerative disorder that can present heterogeneously with a combination of motor and non‐motor symptoms.
α‐synuclein, a neuronal protein, can undergo aberrant conformational change resulting in the intra‐neuronal accumulation of toxic oligomers that form Lewy bodies, the pathological hallmark of PD.
There is evidence that pathological α‐synuclein exhibits prion‐like behaviour in its mode of transmission through the nervous system.
The choice of initial dopaminergic treatments should be individually tailored but long term outcomes appear to be equivalent.
There is level A evidence supporting the benefit of three different device‐assisted therapies in treating troublesome motor fluctuations and dyskinesias.
Stem cell transplantation as currently being trialled is predominantly a symptomatic therapy targeting only limited regions of the brain affected by PD, and will need to be proven to be not only as effective but as safe as currently available device‐assisted therapies.
New modes of treatment including active immunisation against oligomeric α‐synuclein and drugs that alter cellular metabolism show some promise.
The inability to effectively treat a range of non‐motor, non‐dopaminergic symptoms remains a major therapeutic challenge.

1 Concord Repatriation General Hospital, Sydney, NSW
2 Sydney Medical School, University of Sydney, Sydney, NSW
3 Westmead Hospital, Sydney, NSW
4 Royal Adelaide Hospital, Adelaide, SA
5 University of Adelaide, Adelaide, SA
6 Royal Brisbane and Women's Hospital, Brisbane, QLD
7 University of Queensland, Brisbane, QLD

Correspondence: michael.hayes1@health.nsw.gov.au

Competing interests:

No relevant disclosures.

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Perspectives

Ending preventable stillbirths among migrant and refugee populations

Jane Yelland, Elisha Riggs, Josef Szwarc and Stephanie J Brown

Med J Aust 2019; 210 (11): . || doi: 10.5694/mja2.50199
Published online: 10 June 2019

Topics

Women's health

Global health

Social determinants of health

Engaging migrant communities and health professionals is critical for addressing disparities in preventable stillbirth

1 Intergenerational Health Research Group, Murdoch Children's Research Institute, Melbourne, VIC
2 University of Melbourne, Melbourne, VIC
3 Victorian Foundation for Survivors of Torture, Melbourne, VIC

Correspondence: Jane.Yelland@mcri.edu.au

Acknowledgements:

We acknowledge the support of the Victorian Government's Operational Infrastructure Support Program. Jane Yelland is supported by a National Health and Medical Research Council (NHMRC) Translating Research into Practice Fellowship (2018–2019). Stephanie Brown is supported by an NHMRC Senior Research Fellowship (2016–2020).

Competing interests:

No relevant disclosures.

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Narrative review

Current diagnosis and management of erectile dysfunction

Christopher G McMahon

Med J Aust 2019; 210 (10): . || doi: 10.5694/mja2.50167
Published online: 3 June 2019

Topics

Sexual health

Summary

Erectile dysfunction (ED) is a common male sexual dysfunction associated with a reduced quality of life for patients and their partners.
ED is associated with increasing age, depression, obesity, lack of exercise, diabetes mellitus, hypertension, dyslipidaemia, cardiovascular disease and lower urinary tract symptoms related to benign prostatic hyperplasia.
The evaluation of men with ED requires a full medical and personally and culturally sensitive sexual history, a focused clinical examination, fasting glucose levels, a fasting lipid profile and, in select cases, a total testosterone level and a prostate‐specific antigen test.
Treatment of ED requires lifestyle modification, reduction of comorbid vascular risk factors, and treatment of organic or psychosexual dysfunction with either pharmacotherapy alone or in combination with psychosexual therapy.
Between 60% and 65% of men with ED, including those with hypertension, diabetes mellitus, spinal cord injury and other comorbid medical conditions, can successfully complete intercourse in response to the phosphodiesterase type 5 inhibitors (PDE5i) sildenafil, tadalafil, vardenafil and avanafil.
Patient‐administered intracorporal injection therapy using vasodilator drugs such as alprostadil is an effective treatment and is useful in men who fail to respond to oral pharmacological agents.
Surgical treatment of ED with multicomponent inflatable penile implants is associated with high satisfaction rates.
Penile arterial revascularisation and venous ligation surgery are associated with relatively poor outcome results in men with penile atherosclerotic disease or corporal veno‐occlusive dysfunction.

Australian Centre for Sexual Health, Sydney, NSW

Correspondence: cmcmahon@acsh.com.au

Competing interests:

Christopher McMahon is a paid investigator, member of an advisory board and speaker's panel for Pfizer, Eli Lilly and Menarini.

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Editorials

Protecting pregnant women and their newborn from life‐threatening infections

Helen S Marshall and Gayatri Amirthalingam

Med J Aust 2019; 210 (10): . || doi: 10.5694/mja2.50174
Published online: 3 June 2019

Topics

Women's health

Infectious diseases

Pediatric medicine

Pertussis and influenza vaccinations should be incorporated into antenatal care and accurately documented

Vaccination of pregnant women protects them against influenza and pertussis, and also delivers protective antibody to their fetus, protecting infants when they are at the highest risk of life‐threatening disease but are too young to be vaccinated.1

1 Women's and Children's Health Network, Robinson Research Institute, Adelaide, SA
2 Adelaide Medical School, University of Adelaide, Adelaide, SA
3 Public Health England, London, United Kingdom

Correspondence: helen.marshall@adelaide.edu.au

Competing interests:

Helen Marshall is an investigator in clinical vaccine trials sponsored by pharmaceutical companies, but receives no personal payments from these companies. Her institution receives funding for investigator‐led studies from GSK, Pfizer, and Sanofi–Pasteur. Helen Marshall is a member of the Australian Technical Advisory Group on Immunisation (ATAGI), but this Editorial reflects her personal views and not those of ATAGI.

1. Marshall H, McMillan M, Andrews RM, et al. Vaccines in pregnancy: the dual benefit for pregnant women and infants. Hum Vaccin Immunother 2016; 12: 848–856.
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7. Collins J, Alona I, Tooher R, Marshall H. Increased awareness and health care provider endorsement is required to encourage pregnant women to be vaccinated. Hum Vaccin Immunother 2014; 10: 2922–2929.
8. Mohammed H, McMillan M, Roberts CT, et al. A systematic review of interventions to improve uptake of pertussis vaccination in pregnancy. PLoS One 2019; 14: e0214538.
9. Mertz D, Geraci J, Winkup, et al. Pregnancy as a risk factor for severe outcomes from influenza virus infection: a systematic review and meta‐analysis of observational studies. Vaccine 2017; 35: 521–528.
10. Public Health England. Pertussis vaccination in pregnancy, dTaP/IPV (Boostrix‐IPV^® or Repevax^®): PGD template (GW‐139). 1 Apr 2019. https://www.gov.uk/government/publications/pertussis-vaccination-in-pregnancy-dtapipv-boosterix-or-repevax-pgd-template (viewed Apr 2019).
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12. Public Health England. Pertussis vaccination programme for pregnant women update: vaccine coverage in England, October to December 2016 (Health Protection Report 11[8]). 24 Feb 2017. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/594799/hpr0817_prntl-prtsss-VC.pdf (viewed Apr 2019).
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Perspectives

A perfect storm: fear of litigation for end of life care

Geoffrey K Mitchell, Lindy Willmott, Ben P White, Donella Piper, David C Currow and Patsy M Yates

Med J Aust 2019; 210 (10): . || doi: 10.5694/mja2.50164
Published online: 3 June 2019

Topics

Palliative care

Ethics and law

Substance‐related disorders

Should doctors fear legal sanction for using opioids at the end of life?

A perfect storm arises from a rare confluence of adverse meteorological factors, and is a metaphor for an especially bad situation caused by a combination of unfavourable circumstances (www.oed.com). Health care at the end of life has been significantly disturbed by two converging fronts. The first is very public conversations relating to opioid overuse. The second is the current tension between standard end‐of‐life care and voluntary assisted suicide.

1 University of Queensland, Brisbane, QLD
2 Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, QLD
3 University of New England, Armidale, NSW
4 University of Technology Sydney, Sydney, NSW
5 Queensland University of Technology, Brisbane, QLD

Correspondence: G.Mitchell@uq.edu.au

Acknowledgements:

This study was funded through the National Health and Medical Research Council (APP1061254).

Competing interests:

No relevant disclosures.

1. Roxburgh A, Hall WD, Dobbins T, et al. Trends in heroin and pharmaceutical opioid overdose deaths in Australia. Drug Alcohol Depend 2017; 179: 291–298.
2. Royal Australian College of General Practitioners. Government to warn almost 5000 GPs over high rates of opioid prescribing. Melbourne: RACGP, 2018. https://www1.racgp.org.au/newsGP/Professional/Government-to-warn-almost-5000-GPs-over-high-rates (viewed Apr 2019).
3. Royal Australian College of General Practitioners. GPs pulling back from palliative care over opioid crackdown fears. Melbourne: RACGP, 2018. https://www1.racgp.org.au/newsGP/Professional/GPs-pulling-back-from-palliative-care-over-opioid (viewed Apr 2019).
4. Gardiner C, Gott M, Ingleton C, et al. Attitudes of health care professionals to opioid prescribing in end‐of‐life care: a qualitative focus group study. J Pain Symptom Manage 2012; 44: 206–214.
5. Australian Pain Management Association. National pain strategy: pain management for all Australians. Sydney: APMA, 2010. https://www.painaustralia.org.au/improving-policy/national-pain-strategy (viewed Apr 2019).
6. Government of Western Australia. Government to introduce Bill to legalise voluntary assisted dying and improve end‐of‐life choices for Western Australians. Perth: Government of Western Australia, 2018. https://www.mediastatements.wa.gov.au/Pages/McGowan/2018/11/Government-to-introduce-Bill-to-legalise-voluntary-assisted-dying-and-improve-end-of-life-choices-for-Western-Australians.aspx (viewed Apr 2019).
7. Sulmasy DP. The last low whispers of our dead: when is it ethically justifiable to render a patient unconscious until death? Theor Med Bioeth 2018; 39: 233–263.
8. Curlin FA. Palliative sedation: clinical context and ethical questions. Theor Med Bioeth 2018; 39: 197–209.
9. Willmott L, White B, Piper D, et al. Providing palliative care at the end of life: should health professionals fear regulation? J Law Med 2018; 26: 214–245.

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Research

Respiratory syncytial virus‐associated hospitalisations in Australia, 2006–2015

Gemma L Saravanos, Meru Sheel, Nusrat Homaira, Aditi Dey, Edward Brown, Han Wang, Kristine Macartney and Nicholas J Wood

Med J Aust 2019; 210 (10): . || doi: 10.5694/mja2.50159
Published online: 27 May 2019

Topics

Infectious diseases

Environment and public health

Health services administration

Respiratory tract diseases

Abstract

Objective: To estimate rates of respiratory syncytial virus (RSV)‐associated hospitalisation across the age spectrum, and to identify groups at particular risk of serious RSV‐associated disease.

Design, setting and participants: Retrospective review of National Hospital Morbidity Database data for all RSV‐associated hospitalisations in Australia, 2006–2015.

Main outcomes and measures: RSV‐coded hospitalisation rates by age, sex, Indigenous status, jurisdiction, and seasonality (month and year); hospital length of stay; in‐hospital deaths.

Results: During 2006–2015, there were 63 814 hospitalisations with an RSV‐specific principal diagnostic code; 60 551 (94.9%) were of children under 5 years of age. The hospitalisation rate for children under 5 years was 418 per 100 000 population; for children under 6 months of age it was 2224 per 100 000 population; the highest rate was for infants aged 0–2 months (2778 per 100 000 population). RSV‐coded hospitalisation rates were higher for adults aged 65 or more than for people aged 5–64 years (incidence rate ratio [IRR], 6.6; 95% CI, 6.2–7.1), and were also higher for Indigenous Australians than other Australians (IRR, 3.3; 95% CI, 3.2–3.5). A total of 138 in‐hospital deaths were recorded, including 82 of adults aged 65 years or more (59%).

Conclusions: Prevention strategies targeting infants, such as maternal or early infant vaccination, would probably have the greatest impact in reducing RSV disease rates. Further characterisation of RSV disease epidemiology, particularly in older adults and Indigenous Australians, is needed to inform health care strategies.

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1 National Centre for Research Immunisation and Surveillance, Sydney, NSW
2 The University of Sydney Children's Hospital, Westmead Clinical School, Sydney, NSW
3 School of Women's and Children's Health, University of New South Wales, Sydney, NSW
4 Sydney Children's Hospital Randwick, Sydney, NSW
5 Sydney Medical School, University of Sydney, Sydney, NSW

Correspondence: gemma.saravanos@health.nsw.gov.au

Acknowledgements:

This study formed part of Gemma Saravanos’ doctoral research at the University of Sydney Children's Hospital at Westmead Clinical School, funded by a University of Sydney Postgraduate Award and supported by the National Centre for Immunisation Research and Surveillance (NCIRS). Nicholas Wood is supported by a National Health and Medical Research Council Career Development Fellowship. We acknowledge the Australian Institute of Health and Welfare for providing the hospitalisation data.

Competing interests:

No relevant disclosures.

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