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    Mycobacterial mimicry in a man from Myanmar

    David WJ Griffin, G Khai Lin Huang, Philippe Lachapelle, Steven YC Tong and Siddhartha Mahanty
    Med J Aust 2019; 210 (8): . || doi: 10.5694/mja2.50133
    Published online: 6 May 2019

    A 26‐year‐old refugee from Myanmar was referred to the infectious diseases unit of an Australian teaching hospital for assessment of suspected recurrent pulmonary tuberculosis (TB). He had arrived in Australia 3 months earlier, after spending the preceding 5 years in Malaysia. He was diagnosed with presumed pulmonary TB in Malaysia in 2013, in the context of a productive cough and suspicious chest x‐ray findings, without microbiological confirmation. He completed treatment with 6 months of first line anti‐TB therapy (2 months of rifampicin, isoniazid, pyrazinamide and ethambutol, followed by 4 months of rifampicin and isoniazid).

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      Acute kidney injury in Indigenous Australians in the Kimberley: age distribution and associated diagnoses

      Joseph V Mohan, David N Atkinson, Johan B Rosman and Emma K Griffiths
      Med J Aust 2019; 211 (1): . || doi: 10.5694/mja2.50061
      Published online: 29 April 2019

      Abstract

      Objective: To describe the frequencies of acute kidney injury (AKI) and of associated diagnoses in Indigenous people in a remote Western Australian region.

      Design: Retrospective population‐based study of AKI events confirmed by changes in serum creatinine levels.

      Setting, participants: Aboriginal and Torres Strait Islander residents of the Kimberley region of Western Australia, aged 15 years or more and without end‐stage kidney disease, for whom AKI between 1 June 2009 and 30 May 2016 was confirmed by an acute rise in serum creatinine levels.

      Main outcome measures: Age‐specific AKI rates; principal and other diagnoses.

      Results: 324 AKI events in 260 individuals were recorded; the median age of patients was 51.8 years (IQR, 43.9–61.0 years), and 176 events (54%) were in men. The overall AKI rate was 323 events (95% CI, 281–367) per 100 000 population; 92 events (28%) were in people aged 15–44 years. 52% of principal diagnoses were infectious in nature, including pneumonia (12% of events), infections of the skin and subcutaneous tissue (10%), and urinary tract infections (7.7%). 80 events (34%) were detected on or before the date of admission; fewer than one‐third of discharge summaries (61 events, 28%) listed AKI as a primary or other diagnosis.

      Conclusion: The age distribution of AKI events among Indigenous Australians in the Kimberley was skewed to younger groups than in the national data on AKI. Infectious conditions were common in patients, underscoring the significance of environmental determinants of health. Primary care services can play an important role in preventing community‐acquired AKI; applying pathology‐based criteria could improve the detection of AKI.

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      • 1 The University of Western Australia, Perth, WA
      • 2 Rural Clinical School of Western Australia, University of Western Australia, Broome, WA
      • 3 Curtin University, Perth, WA
      • 4 Kimberley Aboriginal Medical Services, Broome, WA


      Acknowledgements: 

      We thank Julia Marley (Kimberley Research, University of Western Australia) for critically reviewing our manuscript.

      Competing interests:

      No relevant disclosures.

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        Traumatic spinal cord injury in Victoria, 2007–2016

        Ben Beck, Peter A Cameron, Sandra Braaf, Andrew Nunn, Mark C Fitzgerald, Rodney T Judson, Warwick J Teague, Alyse Lennox, James W Middleton, James E Harrison and Belinda J Gabbe
        Med J Aust 2019; 210 (8): . || doi: 10.5694/mja2.50143
        Published online: 29 April 2019

        Abstract

        Objective: To investigate trends in the incidence and causes of traumatic spinal cord injury (TSCI) in Victoria over a 10‐year period.

        Design, setting, participants: Retrospective cohort study: analysis of Victorian State Trauma Registry (VSTR) data for people who sustained TSCIs during 2007–2016.

        Main outcomes and measures: Temporal trends in population‐based incidence rates of TSCI (injury to the spinal cord with an Abbreviated Injury Scale [AIS] score of 4 or more).

        Results: There were 706 cases of TSCI, most the result of transport events (269 cases, 38%) or low falls (197 cases, 28%). The overall crude incidence of TSCI was 1.26 cases per 100 000 population (95% CI, 1.17–1.36 per 100 000 population), and did not change over the study period (incidence rate ratio [IRR], 1.01; 95% CI, 0.99–1.04). However, the incidence of TSCI resulting from low falls increased by 9% per year (95% CI, 4–15%). The proportion of TSCI cases classified as incomplete tetraplegia increased from 41% in 2007 to 55% in 2016 (P < 0.001). Overall in‐hospital mortality was 15% (104 deaths), and was highest among people aged 65 years or more (31%, 70 deaths).

        Conclusions: Given the devastating consequences of TSCI, improved primary prevention strategies are needed, particularly as the incidence of TSCI did not decline over the study period. The epidemiologic profile of TSCI has shifted, with an increasing number of TSCI events in older adults. This change has implications for prevention, acute and post‐discharge care, and support.

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        • 1 Monash University, Melbourne, VIC
        • 2 The Alfred Hospital, Melbourne, VIC
        • 3 Victorian Spinal Cord Service, Austin Hospital, Melbourne, VIC
        • 4 National Trauma Research Institute, Melbourne, VIC
        • 5 Royal Melbourne Hospital, Melbourne, VIC
        • 6 University of Melbourne, Melbourne, VIC
        • 7 Royal Children's Hospital, Melbourne, VIC
        • 8 Murdoch Children's Research Institute, Melbourne, VIC
        • 9 Kolling Institute, University of Sydney, Sydney, NSW
        • 10 Agency for Clinical Innovation, Sydney, NSW
        • 11 Research Centre for Injury Studies, Flinders University, Adelaide, SA
        • 12 Health Data Research UK, Swansea University Medical School, Swansea University, Swansea, United Kingdom


        Correspondence: ben.beck@monash.edu
        Acknowledgements: 

        We thank the Victorian State Trauma Outcome Registry and Monitoring (VSTORM) group for providing Victorian State Trauma Registry data. We also thank Sue McLellan for her assistance with providing the data. The VSTR is funded by the Department of Health and Human Services, Victoria and the Transport Accident Commission. Ben Beck was supported by an Australian Research Council Discovery Early Career Researcher Award Fellowship (DE180100825). Peter Cameron was supported by a National Health and Medical Research Council Practitioner Fellowship (545926). Warwick Teague's role as director of trauma services was supported by a grant from the Royal Children's Hospital Foundation. Belinda Gabbe was supported by an Australian Research Council Future Fellowship (FT170100048).

        Competing interests:

        No relevant disclosures.

        • 1. Bickenbach JR, Officer A, Shakespeare T, et al. International perspectives on spinal cord injury. Geneva: World Health Organization; International Spinal Cord Society, 2013. http://apps.who.int/iris/bitstream/10665/94190/1/9789241564663_eng.pdf?ua=1 (viewed May 2017).
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          Early success with room for improvement: influenza vaccination of young Australian children

          Frank H Beard, Alexandra J Hendry and Kristine Macartney
          Med J Aust 2019; 210 (11): . || doi: 10.5694/mja2.50141
          Published online: 29 April 2019
          Correction(s) for this article: Erratum | Published online: 7 April 2025

          Immunisation providers should offer annual influenza vaccination for children aged 6 months to 5 years and report it to the Australian Immunisation Register


          • 1 National Centre for Immunisation Research and Surveillance, Children's Hospital at Westmead, Sydney, NSW
          • 2 University of Sydney, Sydney, NSW


          Competing interests:

          No relevant disclosures.

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            Qualified privilege legislation to support clinician quality assurance: balancing professional and public interests

            Susannah Ahern, Ingrid Hopper and Erwin Loh
            Med J Aust 2019; 210 (8): . || doi: 10.5694/mja2.50124
            Published online: 22 April 2019

            A review of the legislation may be warranted to assess the balance between professional and public interests

            Patient health‐related datasets are protected by national and state‐based privacy laws which establish requirements for data security that safeguard identified patient information.1,2,3 Nevertheless, these data may potentially be accessed by third parties in accordance with the law — for example, in connection with freedom of information requests or legal proceedings — by statutory bodies such as the Australian Health Practitioner Regulatory Agency, or by jurisdictional health complaints commissions. Patient information from health service medical records is regularly used in medico‐legal proceedings, a recent significant example of which was the Bawa‐Garba case in the United Kingdom,4 discussed below.


            • Monash University, Melbourne, VIC


            Correspondence: susannah.ahern@monash.edu
            Competing interests:

            No relevant disclosures.

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              Updated Australian consensus statement on management of inherited bleeding disorders in pregnancy

              Scott Dunkley, Julie A Curtin, Anthony J Marren, Robert P Heavener, Simon McRae and Jennifer L Curnow
              Med J Aust 2019; 210 (7): . || doi: 10.5694/mja2.50123
              Published online: 15 April 2019

              Abstract

              Introduction: There have been significant advances in the understanding of the management of inherited bleeding disorders in pregnancy since the last Australian Haemophilia Centre Directors’ Organisation (AHCDO) consensus statement was published in 2009. This updated consensus statement provides practical information for clinicians managing pregnant women who have, or carry a gene for, inherited bleeding disorders, and their potentially affected infants. It represents the consensus opinion of all AHCDO members; where evidence was lacking, recommendations have been based on clinical experience and consensus opinion.

              Main recommendations: During pregnancy and delivery, women with inherited bleeding disorders may be exposed to haemostatic challenges. Women with inherited bleeding disorders, and their potentially affected infants, need specialised care during pregnancy, delivery, and postpartum, and should be managed by a multidisciplinary team that includes at a minimum an obstetrician, anaesthetist, paediatrician or neonatologist, and haematologist. Recommendations on management of pregnancy, labour, delivery, obstetric anaesthesia and postpartum care, including reducing and treating postpartum haemorrhage, are included. The management of infants known to have or be at risk of an inherited bleeding disorder is also covered.

              Changes in management as a result of this statement: Key changes in this update include the addition of a summary of the expected physiological changes in coagulation factors and phenotypic severity of bleeding disorders in pregnancy; a flow chart for the recommended clinical management during pregnancy and delivery; guidance for the use of regional anaesthetic; and prophylactic treatment recommendations including concomitant tranexamic acid.


              • 1 Institute of Haematology, Royal Prince Alfred Hospital, Sydney, NSW
              • 2 The Children's Hospital at Westmead, Sydney, NSW
              • 3 Australian Haemophilia Centres Directors’ Organisation, Melbourne, VIC
              • 4 Royal Prince Alfred Hospital, Sydney, NSW
              • 5 Royal Adelaide Hospital, Adelaide, SA
              • 6 Haemophilia Treatment Centre, Westmead Hospital, Sydney, NSW


              Correspondence: scottmdunkley@gmail.com
              Acknowledgements: 

              We are grateful to Steph P'ng, John Rowell, Tim Brighton, Huyen Tran and Ian Douglas for their helpful feedback and comments. We acknowledge Ruth Hadfield for medical writing and editing assistance.

              Competing interests:

              No relevant disclosures.

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              • 34. Van Der Linde R, Favaloro EJ. Tranexamic acid to prevent post‐partum haemorrhage. Blood Transfus 2018; 16: 321–323.
              • 35. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post‐partum haemorrhage (WOMAN): an international, randomised, double‐blind, placebo‐controlled trial. Lancet 2017; 389: 2105–2116.
              • 36. Bolton‐Maggs PH, Chalmers EA, Collins PW, et al. A review of inherited platelet disorders with guidelines for their management on behalf of the UKHCDO. Br J Haematol 2006; 135: 603–633.
              • 37. Haljamäe H. Thromboprophylaxis, coagulation disorders, and regional anaesthesia. Acta Anaesthesiol Scand 1996; 40(8 Pt 2): 1024–1040.
              • 38. Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003; 28: 172–197.
              • 39. Stedeford JC, Pittman JA. Von Willebrand's disease and neuroaxial anaesthesia. Anaesthesia 2000; 55: 1228–1229.
              • 40. Curnow J, Pasalic L, Favaloro EJ. Treatment of von Willebrand Disease. Sem Thromb Hemost 2016; 42: 133–146.
              • 41. Rodeghiero F. Von Willebrand disease: pathogenesis and management. Thromb Res 2013; 131 Suppl 1: S47–S50.
              • 42. American Academy of Family Physicians. Advanced Life Support in Obstetrics (ALSO). http://www.aafp.org/cme/programs/also.html (viewed Mar 2019).
              • 43. Babarinsa IA, Hayman RG, Draycott TJ. Secondary post‐partum haemorrhage: challenges in evidence‐based causes and management. Eur J Obstet Gynecol Reprod Biol 2011; 159: 255–260.
              • 44. Hoveyda F, MacKenzie IZ. Secondary postpartum haemorrhage: incidence, morbidity and current management. BJOG 2001; 108: 927–930.
              • 45. Begley CM, Gyte GM, Devane D, et al. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev 2015; (3): CD007412.
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              • 47. Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Management of postpartum haemorrhage (PPH). https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Management-of-Postpartum-Haemorrhage-(C-Obs-43)-Review-July-2017.pdf?ext=.pdf (viewed Nov 2018).
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              • 49. Andrew M, Paes B, Milner R, et al. Development of the human coagulation system in the healthy premature infant. Blood 1988; 72: 1651–1657.
              • 50. Kulkarni R, Lusher J. Perinatal management of newborns with haemophilia. Br J Haematol 2001; 112: 264–274.
              • 51. Kulkarni R, Lusher JM. Intracranial and extracranial hemorrhages in newborns with hemophilia: a review of the literature. J Pediatr Hematol Oncol 1999; 21: 289–295.
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              • 53. Australian Haemophilia Centre Directors’ Organisation. Guidelines for the treatment of inhibitors in haemophilia A and haemophilia B. Melbourne: AHCDO, 2010. http://www.ahcdo.org.au/documents/item/16 (viewed Nov 2018).
              • 54. Australian Haemophilia Centre Directors’ Organisation and National Blood Authority, Australia. Guidelines for the management of haemophilia in Australia. Melbourne: AHCDO, 2016. https://www.blood.gov.au/system/files/HaemophiliaGuidelines-interactive-updated-260317v2.pdf (viewed Nov 2018).
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                Resilient health systems: preparing for climate disasters and other emergencies

                Gerard J FitzGerald, Anthony Capon and Peter Aitken
                Med J Aust 2019; 210 (7): . || doi: 10.5694/mja2.50115
                Published online: 15 April 2019

                A system that integrates all aspects of health care is essential for facing future challenges

                After another Australian summer of record‐breaking temperatures, bushfires, floods and widespread drought, it is clear that our health systems should be strengthened to cope with the challenges of climate change. We must also reduce the carbon footprint of health care,1 and continue to advocate that Australia play its part in dealing with the fundamental causes of climate change. In May, the 21st biennial congress of the World Association for Disaster and Emergency Medicine (WADEM) will be hosted by Brisbane. The congress will bring together investigators and practitioners from around the world to discuss disaster health care, future risks, community vulnerabilities, and the strategies required by resilient health systems.


                • 1 Queensland University of Technology, Brisbane, QLD
                • 2 Sydney School of Public Health, University of Sydney, Sydney, NSW
                • 3 Health Disaster Management Unit, Queensland Health, Brisbane, QLD


                Correspondence: gj.fitzgerald@qut.edu.au
                Competing interests:

                No relevant disclosures.

                • 1. Malik A, Lenzen M, McAlister S, McGain F. The carbon footprint of Australian health care. Lancet Planet Health 2018; 2: e27–e35.
                • 2. Hanna EG, McIver LJ. Climate change: a brief overview of the science and health impacts for Australia. Med J Aust 2018; 208: 311–315. https://www.mja.com.au/journal/2018/208/7/climate-change-brief-overview-science-and-health-impacts-australia
                • 3. Kishore N, Marqués D, Mahmud A, et al. Mortality in Puerto Rico after Hurricane Maria. N Engl J Med 2018; 379: 162–170.
                • 4. Burns P, Douglas K, Hu W. Primary care in disasters: opportunity to address a hidden burden of health care. Med J Aust 2019; 210: 297–299.
                • 5. Australian Institute of Health and Welfare. Emergency department care 2017–18: Australian hospital statistics (Cat. No. HSE 216; Health Services Series No. 89). Canberra: AIHW, 2018.
                Online responses are no longer available. Please refer to our instructions for authors page for more information.

                  Primary care in disasters: opportunity to address a hidden burden of health care

                  Penelope L Burns, Kirsty A Douglas and Wendy Hu
                  Med J Aust 2019; 210 (7): . || doi: 10.5694/mja2.50067
                  Published online: 15 April 2019

                  General practitioners provide a flexible response to the changed needs of the disaster‐affected population

                  In Australia, “a land … of droughts and flooding rains,”1 disasters affect our lives annually, the majority of which are weather‐related.2 They are a part of the landscape, taking the form of cyclones, floods, bushfires, droughts and other phenomena. Cyclone Debbie, which hit northern Queensland in 2017, the Tathra bushfires, which affected the south coast of New South Wales in 2018, and the thunderstorm asthma event in Melbourne in 2016 are just a few recent examples. Such catastrophic events affect rural and urban communities and coastal and inland locations. No community in Australia is exempt, which is reflected in the recent shift in focus by national and international disaster management policy to prioritise improving local community capacity to respond and recover.3,4


                  • 1 Australian National University, Canberra, ACT
                  • 2 Western Sydney University, Sydney, NSW


                  Correspondence: Penelope.Burns@anu.edu.au
                  Acknowledgements: 

                  We thank the Royal Australian College of General Practitioners Foundation for their support on some early work in this field.

                  Competing interests:

                  No relevant disclosures.

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                    The importance of public health genomics for ensuring health security for Australia

                    Deborah A Williamson, Martyn D Kirk, Vitali Sintchenko and Benjamin P Howden
                    Med J Aust 2019; 210 (7): . || doi: 10.5694/mja2.50063
                    Published online: 15 April 2019

                    Coordination is required to future‐proof Australia's capacity and leadership in public health genomics

                    Infectious diseases are an ever‐present risk to society, particularly because of globalisation and the threat of antimicrobial‐resistant organisms. Recently, a World Health Organization (WHO) team conducted a joint external evaluation of Australia's core capacities under the International Health Regulations. The evaluation gave Australia a high scorecard in all areas relevant to protecting health from emerging infectious disease threats.1 However, an area that the evaluation team highlighted for critical improvement was the integration of whole genome sequencing‐based surveillance into existing communicable diseases control systems in the Australian setting.1 While Australia scored highly for laboratory testing of priority diseases, the team recommended “integration of laboratory testing data with epidemiological data particularly in the context of whole genome sequencing”.1


                    • 1 University of Melbourne, Melbourne, VIC
                    • 2 National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT
                    • 3 University of Sydney, Sydney, NSW


                    Competing interests:

                    No relevant disclosures

                    • 1. World Health Organization. Joint external evaluation of IHR core capacities of Australia: mission report, 24 November ‐ 1 December 2017. Geneva: WHO, 2018. http://apps.who.int/iris/handle/10665/272362 (viewed Feb 2019).
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                    • 4. Australian Government Department of Health. National Health Genomics Policy Framework 2018‐2021. http://www.health.gov.au/internet/main/publishing.nsf/Content/national-health-genomics-policy-framework-2018-2021 (viewed Feb 2018).
                    • 5. Allard MW, Strain E, Melka D, et al. Practical value of food pathogen traceability through building a whole‐genome sequencing network and database. J Clin Microbiol 2016; 54: 1975–1983.
                    • 6. Kwong JC, Stafford R, Strain E, et al. Sharing is caring: international sharing of data enhances genomic surveillance of Listeria monocytogenes. Clin Infect Dis 2016; 63: 846–848.
                    • 7. Grant K, Jenkins C, Arnold C, et al. Implementing pathogen genomics: a case study. London: Public Health England, 2018. https://www.gov.uk/government/publications/implementing-pathogen-genomics-a-case-study (viewed Feb 2018).
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                    • 9. Baker KS, Dallman TJ, Field N, et al. Genomic epidemiology of Shigella in the United Kingdom shows transmission of pathogen sublineages and determinants of antimicrobial resistance. Sci Rep 2018; 8: 7389.
                    • 10. Neuert S, Nair S, Day MR, et al. Prediction of phenotypic antimicrobial resistance profiles from whole genome sequences of non‐typhoidal Salmonella enterica. Front Microbiol 2018; 9: 592.
                    • 11. Williamson D, Howden B, Stinear T. Mycobacterium chimaera spread from heating and cooling units in heart surgery. N Engl J Med 2017; 376: 600–602.
                    • 12. Vasant BR, Stafford RJ, Jennison AV, et al. Mild Illness during outbreak of Shiga toxin‐producing Escherichia coli O157 infections associated with agricultural show, Australia. Emerg Infect Dis 2017; 23: 1686–1689.
                    • 13. Gurjav U, Outhred AC, Jelfs P, et al. Whole genome sequencing demonstrates limited transmission within identified Mycobacterium tuberculosis clusters in New South Wales, Australia. PLOS One 2016; 11: e0163612.
                    • 14. Kwong JC, Mercoulia K, Tomita T, et al. Prospective whole‐genome sequencing enhances national surveillance of Listeria monocytogenes. J Clin Microbiol 2016; 54: 333–342.
                    • 15. Kwong JC, Lane CR, Romanes F, et al. Translating genomics into practice for real‐time surveillance and response to carbapenemase‐producing Enterobacteriaceae: evidence from a complex multi‐institutional KPC outbreak. PeerJ 2018; 6: e4210.
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                      The impact of rapid molecular diagnostic testing for respiratory viruses on outcomes for emergency department patients

                      Nasir Wabe, Ling Li, Robert Lindeman, Ruth Yimsung, Maria R Dahm, Kate Clezy, Susan McLennan, Johanna Westbrook and Andrew Georgiou
                      Med J Aust 2019; 210 (7): . || doi: 10.5694/mja2.50049
                      Published online: 8 April 2019

                      Abstract

                      Objective: To determine whether rapid polymerase chain reaction (PCR) testing for influenza and respiratory syncytial viruses (RSV) in emergency departments (EDs) is associated with better patient and laboratory outcomes than standard multiplex PCR testing.

                      Design, setting: A before‐and‐after study in four metropolitan EDs in New South Wales.

                      Participants: 1491 consecutive patients tested by standard multiplex PCR during July–December 2016, and 2250 tested by rapid PCR during July–December 2017.

                      Main outcome measures: Hospital admissions; ED length of stay (LOS); test turnaround time; patient receiving test result before leaving the ED; ordering of other laboratory tests.

                      Results: Compared with those tested by standard PCR, fewer patients tested by rapid PCR were admitted to hospital (73.3% v 77.7%; P < 0.001) and more received their test results before leaving the ED (67.4% v 1.3%; P < 0.001); the median test turnaround time was also shorter (2.4 h [IQR, 1.6–3.9 h] v 26.7 h [IQR, 21.2–37.8 h]). The proportion of patients admitted to hospital was also lower in the rapid PCR group for both children under 18 (50.6% v 66.6%; P < 0.001) and patients over 60 years of age (84.3% v 91.8%; P < 0.001). Significantly fewer blood culture, blood gas, sputum culture, and respiratory bacterial and viral serology tests were ordered for patients tested by rapid PCR. ED LOS was similar for the rapid (7.4 h; IQR, 5.0–12.9 h) and standard PCR groups (6.5 h; IQR, 4.2–11.9 h; P = 0.27).

                      Conclusion: Rapid PCR testing of ED patients for influenza virus and RSV was associated with better outcomes on a range of indicators, suggesting benefits for patients and the health care system. A formal cost–benefit analysis should be undertaken.

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                      • 1 Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW
                      • 2 NSW Health Pathology, Sydney, NSW
                      • 3 Prince of Wales Hospital, Sydney, NSW
                      • 4 Sydney Medical School, University of Sydney, Sydney, NSW


                      Correspondence: nasir.wabe@mq.edu.au
                      Acknowledgements: 

                      The project was part of a partnership project funded by a National Health and Medical Research Council of Australia Partnership Project Grant (APP1111925), in partnership with NSW Health Pathology and the Australian Commission on Safety and Quality in Healthcare.23

                      Competing interests:

                      No relevant disclosures.

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