Topics

Although hand transplantation has the potential to transform lives, the procedure is not without risk

March 2018 heralded 7 years since the only Australian to date received a hand transplant. The recipient has physically and psychologically integrated the transplanted hand and reports significantly improved quality of life;1 motor and sensory functions continue to improve incrementally with ongoing hand therapy. The Transplantation Society of Australia and New Zealand (TSANZ) Vascular Composite Allograft (VCA) Advisory Committee met during the TSANZ annual scientific meeting held in Melbourne in April 2018. Transplant physicians and surgeons and reconstructive microsurgeons comprise the advisory committee, with scope to co‐opt expert members (eg, in bioethics) as required. Despite the success of the seminal hand transplant in Australia, no further patients have progressed to the transplant waiting list. In light of this, the Advisory Committee reflects in this article on the status of hand transplantation internationally and considers its relevance for Australia.

1 Deakin University, Geelong, VIC
2 St Vincent's Hospital Melbourne, Melbourne, VIC

Correspondence: karen.dwyer@deakin.edu.au

Acknowledgements:

The views expressed in this manuscript reflect those of the TSANZ VCA Advisory Committee — Karen Dwyer (Chair), Jamie Burt, Tim Bennett, Frank Ierino, Sharon Ford, Kate Wyburn and Richard Allen — and have been ratified by the TSANZ Council — Stephen Alexander (President) and Toby Coates (President elect).

Competing interests:

No relevant disclosures.

1. Dwyer KM, Webb AR, Furniss HS, et al. First hand transplant procedure in Australia: outcome at 2 years. Med J Aust 2013; 199: 285–287. https://www.mja.com.au/journal/2013/199/4/first-hand-transplant-procedure-australia-outcome-2-years
2. Shores JT, Brandacher G, Lee WP. Hand and upper extremity transplantation: an update of outcomes in the worldwide experience. Plast Reconstr Surg 2015; 135: 351e–360e.
3. Burloux G. Hand transplant and body image. In: Lanzetta M, Dubernard JM, Petruzzo P, editors. Hand transplantation. Milan, Italy: Springer Milano, 2007; pp. 375–379.
4. Kanitakis J, Jullien D, Petruzzo P, et al. Clinicopathologic features of graft rejection of the first human hand allograft. Transplantation 2003; 76: 688–693.
5. Bhaskaranand K, Bhat AK, Acharya KN. Prosthetic rehabilitation in traumatic upper limb amputees (an Indian perspective). Arch Orthop Trauma Surg 2003; 123: 363–366.
6. Salminger S, Sturma A, Roche AD, et al. Functional and psychosocial outcomes of hand transplantation compared with prosthetic fitting in below‐elbow amputees: a multicenter cohort study. PLoS One 2016; 11: e0162507.
7. Petruzzo P, Lanzetta M, Dubernard J. International Registry on Hand and Composite Tissue Transplantation. Transplantation 2014; 98: 44.
8. Weissenbacher A, Hautz T, Zelger B, et al. Antibody‐mediated rejection in hand transplantation. Transpl Int 2014; 27: e13–e17.
9. Dwyer KM, Carroll R, Hill P, et al. Refractory vascular rejection in a hand allograft in the presence of antibodies against angiotensin II (type 1) receptor. Transplantation 2017; 101: e344–e345.
10. Kanitakis J, Petruzzo P, Badet L, et al. Chronic rejection in human vascularized composite allotransplantation (hand and face recipients): an update. Transplantation 2016; 100: 2053–2061.
11. Krezdorn N, Tasigiorgos S, Wo L, et al. Kidney dysfunction after vascularized composite allotransplantation. Transplant Direct 2018; 4: e362.
12. Pei G, Xiang D, Gu L, et al. A report of 15 hand allotransplantations in 12 patients and their outcomes in China. Transplantation 2012; 94: 1052–1059.
13. Dillon MP, Fortington LV, Akram M, et al. Geographic variation of the incidence rate of lower limb amputation in Australia from 2007–12. PLoS One 2017; 12: e0170705.
14. Lantieri L, Grimbert P, Ortonne N, et al. Face transplant: long‐term follow‐up and results of a prospective open study. Lancet 2016; 388: 1398–1407.
15. Aycart MA, Kiwanuka H, Krezdorn N, et al. Quality of life after face transplantation: outcomes, assessment tools, and future directions. Plast Reconstr Surg 2017; 139: 194–203.

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Research

Recruiting general practice patients for large clinical trials: lessons from the Aspirin in Reducing Events in the Elderly (ASPREE) study

Jessica E Lockery, Taya A Collyer, Walter P Abhayaratna, Sharyn M Fitzgerald, John J McNeil, Mark R Nelson, Suzanne G Orchard, Christopher Reid, Nigel P Stocks, Ruth E Trevaks and Robyn Woods

Med J Aust 2019; 210 (4): . || doi: 10.5694/mja2.12060
Published online: 28 January 2019

Topics

Health occupations

Statistics, epidemiology and research design

Abstract

Objective: To assess the factors that contributed to the successful completion of recruitment for the largest clinical trial ever conducted in Australia, the Aspirin in Reducing Events in the Elderly (ASPREE) study.

Design: Enrolment of GPs; identification of potential participants in general practice databases; screening of participants.

Setting, participants: Selected general practices across southeast Australia (Tasmania, Victoria, Australian Capital Territory, New South Wales, South Australia).

Major outcomes: Numbers of patients per GP screened and randomised to participation; geographic and demographic factors that influenced screening and randomising of patients.

Results: 2717 of 5833 GPs approached (47%) enrolled to recruit patients for the study; 2053 (76%) recruited at least one randomised participant. The highest randomised participant rate per GP was for Tasmania (median, 5; IQR, 1–11), driven by the high rate of participant inclusion at phone screening. GPs in inner regional (adjusted odds ratio [aOR], 1.45; 95% CI, 1.14–1.84) and outer regional areas (aOR, 1.86; 95% CI, 1.19–2.88) were more likely than GPs in major cities to recruit at least one randomised participant. GPs in areas with a high proportion of people aged 70 years or more were more likely to randomise at least one participant (per percentage point increase: aOR, 1.10; 95% CI, 1.05–1.15). The number of randomised patients declined with time from GP enrolment to first randomisation.

Conclusion: General practice can be a rich environment for research when barriers to recruitment are overcome. Including regional GPs and focusing efforts in areas with the highest proportions of potentially eligible participants improves recruitment. The success of ASPREE attests to the clinical importance of its research question for Australian GPs.

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1 Monash University, Melbourne, VIC
2 College of Health and Medicine, Australian National University School of Clinical Medicine, Canberra, ACT
3 Canberra Hospital, Canberra, ACT
4 University of Tasmania, Hobart, TAS
5 Curtin University, Perth, WA
6 University of Adelaide, Adelaide, SA

Correspondence: jessica.lockery@monash.edu

Acknowledgements:

The ASPREE study, including the design and implementation of the recruitment strategy, was supported by the National Institute on Aging and the National Cancer Institute at the National Institutes of Health in the United States (U01AG029824), the National Health and Medical Research Council (334047 and 1127060), Monash University, and the Victorian Cancer Agency. Bayer provided aspirin and the matching placebo. We acknowledge the dedicated and skilled staff in Australia and the Unites States who undertook the ASPREE trial. We are also most grateful to the ASPREE participants who so willingly volunteered for this study, and the general practitioners and medical clinics who supported the participants in the ASPREE study., (ASPREE): International Standard Randomized Controlled Trial Number Register (ISRCTN83772183) and clinicaltrials.gov (NCT01038583).

Competing interests:

No relevant disclosures.

1. Foster JM, Sawyer SM, Smith L, et al. Barriers and facilitators to patient recruitment to a cluster randomized controlled trial in primary care: lessons for future trials. BMC Med Res Methodol 2015; 15: 18.
2. Australian Bureau of Statistics. 4839.0. Patient experiences in Australia: summary of findings, 2015–16. Nov 2017. http://www.abs.gov.au/ausstats/abs@.nsf/mf/4839.0 (viewed Oct 2017).
3. Newington L, Metcalfe A. Factors influencing recruitment to research: qualitative study of the experiences and perceptions of research teams. BMC Med Res Methodol 2014; 14: 10.
4. Wing LMH, Reid CM, Ryan P, et al. A comparison of outcomes with angiotensin‐converting‐enzyme inhibitors and diuretics for hypertension in the elderly. N Engl J Med 2003; 348: 583–592.
5. Reid CM, Ryan P, Nelson M, et al. General practitioner participation in the second Australian national blood pressure study (ANBP2). Clin Exp Pharmacol Physiol 2001; 28: 663–667.
6. Hunt CJ, Shepherd LM, Andrews G. Do doctors know best? Comments on a failed trial. Med J Aust 2001; 174: 144–146. https://www.mja.com.au/journal/2001/174/3/do-doctors-know-best-comments-failed-trial
7. Goodyear‐Smith F, York D, Petousis‐Harris H, et al. Recruitment of practices in primary care research: the long and the short of it. Fam Pract 2009; 26: 128–136.
8. Page MJ, French SD, McKenzie JE, et al. Recruitment difficulties in a primary care cluster randomised trial: investigating factors contributing to general practitioners’ recruitment of patients. BMC Med Res Methodol 2011; 11: 35.
9. Paul CL, Piterman L, Shaw JE, et al. Poor uptake of an online intervention in a cluster randomised controlled trial of online diabetes education for rural general practitioners. Trials 2017; 18: 137.
10. Yallop JJ, McAvoy BR, Croucher JL, et al. Primary health care research — essential but disadvantaged. Med J Aust 2006; 185: 118–120. https://www.mja.com.au/journal/2006/185/2/primary-health-care-research-essential-disadvantaged
11. Askew DA, Clavarino AM, Glasziou PP, Del Mar CB. General practice research: attitudes and involvement of Queensland general practitioners. Med J Aust 2002; 177: 74–77. https://www.mja.com.au/journal/2002/177/2/general-practice-research-attitudes-and-involvement-queensland-general
12. Zwar NA, Weller DP, McCloughan L, Traynor VJ. Supporting research in primary care: are practice‐based research networks the missing link? Med J Aust 2006; 185: 110–113. https://www.mja.com.au/journal/2006/185/2/supporting-research-primary-care-are-practice-based-research-networks-missing
13. Winzenberg TM, Gill GF. Prioritising general practice research. Med J Aust 2016; 205: 55–57. https://www.mja.com.au/journal/2016/205/2/prioritising-general-practice-research
14. McNeil JJ, Woods RL, Nelson MR, et al. Baseline characteristics of participants in the ASPREE (ASPirin in Reducing Events in the Elderly) study. J Gerontol A Biol Sci Med Sci 2017; 72: 1586–1593.
15. McNeil JJ, Woods RL, Nelson MR, et al. Effect of aspirin on disability‐free survival in the healthy elderly. N Engl J Med 2018; 379: 1499–1508.
16. Williams CM, Maher CG, Hancock MJ, et al. Recruitment rate for a clinical trial was associated with particular operational procedures and clinician characteristics. J Clin Epidemiol 2014; 67: 169–175.
17. Silagy CA, Carson NE. Factors affecting the level of interest and activity in primary care research among general practitioners. Fam Pract 1989; 6: 173–176.
18. Nelson MR, Reid CM, Ames D, et al. Feasibility of conducting a primary prevention trial of low‐dose aspirin for major adverse cardiovascular events in older people in Australia: results from the ASPirin in Reducing Events in the Elderly (ASPREE) pilot study. Med J Aust 2008; 189: 105–109. https://www.mja.com.au/journal/2008/189/2/feasibility-conducting-primary-prevention-trial-low-dose-aspirin-major-adverse
19. Australian Bureau of Statistics. 2033.0.55.001. Census of population and housing: Socio‐Economic Indexes for Areas (SEIFA), Australia, 2016. IRSAD. http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/2033.0.55.001=2016=Main%20Features=IRSAD=20 (viewed Oct 2018).
20. Australian Bureau of Statistics. 1270.0.55.005. Australian Statistical Geography Standard (ASGS): Volume 5 — remoteness structure, July 2016. Mar 2018. http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/1270.0.55.005Main%20Features15July%202016?opendocument&tabname=Summary&prodno=1270.0.55.005&issue=July%202016&num=&view (viewed Oct 2018).
21. Williamson MK, Pirkis J, Pfaff JJ, et al. Recruiting and retaining GPs and patients in intervention studies: the DEPS‐GP project as a case study. BMC Med Res Methodol 2007; 7: 42.
22. Borgiel AEM, Dunn EV, Lamont CT, et al. Recruiting family physicians as participants in research. Fam Pract 1989; 6: 168–172.
23. Freedman B. Equipoise and the ethics of clinical research. N Engl J Med 1987; 317: 141–145.
24. Nuttall J, Hood K, Verheij TJ, et al. Building an international network for a primary care research program: reflections on challenges and solutions in the set‐up and delivery of a prospective observational study of acute cough in 13 European countries. BMC Fam Pract 2011; 12: 78.
25. Peterson KA, Lipman PD, Lange CJ, et al. Supporting better science in primary care: a description of practice‐based research networks (PBRNs) in 2011. J Am Board Fam Med 2012; 25: 565–571.
26. Gunn JM. Should Australia develop primary care research networks? Med J Aust 2002; 177: 63–66. https://www.mja.com.au/journal/2002/177/2/should-australia-develop-primary-care-research-networks

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Research Letter

Exposures to e‐cigarettes and their refills: calls to Australian Poisons Information Centres, 2009–2016

Carol Wylie, Aaron Heffernan, Jared A Brown, Rose Cairns, Ann‐Maree Lynch and Jeff Robinson

Med J Aust 2019; 210 (3): . || doi: 10.5694/mja2.12032
Published online: 28 January 2019

Topics

Emergency medicine

Environment and public health

Poisoning

The popularity of e‐cigarettes has increased in Australia since they first became available as smoking cessation tools; an estimated 1.3% of the New South Wales population used them in 2015, and as many as 8.4% had experimented with them.1 E‐cigarettes have been recommended by Public Health England and the Royal College of Physicians as safe smoking cessation tools.2,3 In Australia, a prescription is required for legally importing nicotine‐containing e‐cigarettes.4 The safety of these products for users and the risks for members of their households have not been established. Imported products may not conform to Australian standards, including having child‐resistant closures and appropriate labelling, and refill bottles containing highly concentrated nicotine solutions — one millilitre of which can be lethal if ingested by a child — can be purchased online.

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1 Queensland Poisons Information Centre, Lady Cilento Children's Hospital, Brisbane, QLD
2 Griffith University, Gold Coast, QLD
3 New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Sydney, NSW
4 University of Sydney, Sydney, NSW
5 Western Australian Poisons Information Centre, Sir Charles Gairdner Hospital, Perth, WA
6 Victorian Poisons Information Centre, Austin Health, Melbourne, VIC

Correspondence: Carol.Wylie@health.qld.gov.au

Acknowledgements:

We thank the poisons information specialists from the Queensland, New South Wales, Victorian and Western Australian centres.

Competing interests:

Jared Brown has received consultancy fees from GlaxoSmithKline Consumer for sitting on an advisory board regarding paracetamol.

1. Harrold TC, Maag AK, Thackway S, et al. Prevalence of e‐cigarette users in New South Wales. Med J Aust 2015; 203: 326. https://www.mja.com.au/journal/2015/203/8/prevalence-e-cigarette-users-new-south-wales
2. McNeill A, Brose LS, Calder R, et al. E‐cigarettes: an evidence update. A report commissioned by Public Health England (PHE No. 2015260). Aug 2015. https://www.gov.uk/government/publications/e-cigarettes-an-evidence-update (viewed Dec 2018).
3. Royal College of Physicians. Nicotine without smoke: tobacco harm reduction. London: RCP, 2016. https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0 (viewed Aug 2018).
4. Douglas H, Hall W, Gartner C. E‐cigarettes and the law in Australia. Aust Fam Physician 2015; 44: 415–418.
5. Noble MJ, Longstreet B, Hendrickson RG, Gerona R. Unintentional pediatric ingestion of electronic cigarette nicotine refill liquid necessitating intubation. Ann Emerg Med 2017; 69: 94–97.

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Letters

Medical assistance in dying: a disruption of therapeutic relationships

Douglas T Bridge, Sinead M Donnelly and Frank P Brennan

Med J Aust 2019; 210 (4): . || doi: 10.5694/mja2.12105
Published online: 21 January 2019

Topics

Ethics and law

Palliative care

General medicine

To the Editor: We commend William1 for his perceptive review of the complex issues involved in euthanasia and assisted suicide (EAS).1 In contrast to the euphemisms in the popular media, he confronts us with some uncomfortable realities: EAS is the intentional taking of a person's life (E) or facilitating suicide (AS); doctors considering EAS may be (unconsciously) demonstrating “countertransference of their helplessness onto the patient;” and relief of all suffering is a fantasy beyond the ability of doctors, politicians and lawyers.

1 Royal Perth Hospital, Perth, WA.
2 Capital and Coast District Health Board, Wellington, New Zealand.
3 Calvary Hospital, Sydney, NSW.

Correspondence: dtbridge@iinet.net.au

Competing interests:

No relevant disclosures.

1. Leeroy William. Medical assistance in dying: a disruption of therapeutic relationships. Med J Aust 2018 209: 286–287. https://www.mja.com.au/journal/2018/209/7/medical-assistance-dying-disruption-therapeutic-relationships
2. Leiva R, Cottle M, Ferrier C, et al. Euthanasia in Canada: a Cautionary tale. World Medical Journal 2018: 17–23.
3. Sulmasy DP, Finlay I, Fitzgerald F, et al. Physician‐assisted suicide: why neutrality by organized medicine is neither neutral nor appropriate. J Gen Intern Med 2018; 33: 1394–1399.
4. Australian and New Zealand Society for Palliative Medicine. Position statement: the practice of euthanasia and physician assisted suicide. ANZSPM; 2014. http://www.anzspm.org.au/c/anzspm?a=da&did=1005077 (viewed Oct 2018).
5. Australian and New Zealand Society for Geriatric Medicine. ANZSGM. Euthanasia, physician‐assisted suicide and end of life care — position statement. http://www.anzsgm.org/documents/FinalEuthanasiaDiscussionPointsAugust2014_final.pdf (viewed Oct 2018).

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Letters

Medical assistance in dying: a disruption of therapeutic relationships

Peter G Beahan

Med J Aust 2019; 210 (4): . || doi: 10.5694/mja2.12104
Published online: 21 January 2019

Topics

Ethics and law

Palliative care

General medicine

To the Editor: The Perspectives article by William1 states that medical assistance in dying may disrupt therapeutic relationships and will challenge beliefs.

Perth, WA

Correspondence: pbeahan@optusnet.com.au

Competing interests:

No relevant disclosures.

1. Leeroy William. Medical assistance in dying: a disruption of therapeutic relationships. Med J Aust 2018 209: 286–287. https://www.mja.com.au/journal/2018/209/7/medical-assistance-dying-disruption-therapeutic-relationships
2. Callinan K. Allow modern medicine to relieve agonizing end‐of‐life experiences. The Hill 2017; 25 Dec. https://thehill.com/opinion/healthcare/366374-allow-modern-medicine-to-relieve-agonizing-end-of-life-experiences (viewed Oct 2018).

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Research letters

Increased incidence of community‐associated Staphylococcus aureus bloodstream infections in Victoria and Western Australia, 2011–2016

Nabeel Imam, Simone Tempone, Paul K Armstrong, Rebecca McCann, Sandra Johnson, Leon J Worth and Michael J Richards

Med J Aust 2019; 210 (2): . || doi: 10.5694/mja2.12057
Published online: 21 January 2019

Topics

Infectious diseases

Statistics, epidemiology and research design

Standardised national surveillance of health care‐associated Staphylococcus aureus bloodstream infections (HA‐SABs)1 has found that rates are declining in Australia.2 The incidence of community‐associated SABs (CA‐SABs), however, has not been investigated. These infections frequently have complicated courses (eg, metastatic sites of infection)3 and high mortality (about 20%).4

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1 Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre, The Peter Doherty Institute for Infection and Immunity, Melbourne, VIC
2 Western Australia Department of Health, Perth, WA
3 Royal Melbourne Hospital, Melbourne, VIC

Correspondence: nabeel.imam@mh.org.au

Acknowledgements:

We acknowledge the infection control consultants in Victorian and Western Australian hospitals who collected the data we analysed. VICNISS is fully funded by the Victorian Department of Health and Human Services; HISWA is a program in the Public Health Division of the Department of Health Western Australia.

Competing interests:

No relevant disclosures.

1. Australian Commission on Safety and Quality in Health Care. Implementation guide for surveillance of Staphylococcus aureus bacteraemia. Sydney: ACSQHC, 2013. https://www.safetyandquality.gov.au/wp-content/uploads/2012/02/SAQ019_Implementation_guide_SAB_v10.pdf (viewed June 2018).
2. Worth LJ, Spelman T, Bull AL, Richards MJ. Staphylococcus aureus bloodstream infection in Australian hospitals: findings from a Victorian surveillance system. Med J Aust 2014; 200: 282–284. https://www.mja.com.au/journal/2014/200/5/staphylococcus-aureus-bloodstream-infection-australian-hospitals-findings
3. Tong SYC, Davis JS, Eichenberger E, et al. Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management. Clin Microbiol Rev 2015; 28: 603–661.
4. Turnidge JD, Kotsanas D, Munckhof W, et al. Staphylococcus aureus bacteraemia: a major cause of mortality in Australia and New Zealand. Med J Aust 2009; 191: 368–373. https://www.mja.com.au/journal/2009/191/7/staphylococcus-aureus-bacteraemia-major-cause-mortality-australia-and-new
5. Agostino JW, Ferguson JK, Eastwood K, Kirk MD. The increasing importance of community‐acquired methicillin‐resistant Staphylococcus aureus infections. Med J Aust 2017; 207: 388–393. https://www.mja.com.au/journal/2017/207/9/increasing-importance-community-acquired-methicillin-resistant-staphylococcus

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Research letters

Nicotine and other potentially harmful compounds in “nicotine‐free” e‐cigarette liquids in Australia

Emily Chivers, Maxine Janka, Peter Franklin, Benjamin Mullins and Alexander Larcombe

Med J Aust 2019; 210 (3): . || doi: 10.5694/mja2.12059
Published online: 14 January 2019

Topics

Environment and public health

Respiratory tract diseases

Awareness and use of e‐cigarettes is increasing in Australia.1 The thousands of available e‐liquids contain various excipients, nicotine, flavourings, and other additives. There is little to no regulation of their manufacture, and potentially dangerous ingredients and incorrect nicotine levels have been identified.2 Of particular concern is the frequency with which nicotine is detected in e‐liquids labelled “nicotine‐free”.2 E‐liquids containing nicotine cannot legally be sold in Australia,3 but inaccurate labelling means that users may unwittingly inhale this addictive substance, or retailers may sell incorrectly labelled nicotine‐containing e‐liquids to willing customers. The aim of our investigation was to assess the chemical composition of a range of e‐liquids available in Australia, focusing on nicotine and other potentially harmful compounds. Formal ethics approval was not required for this study.

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1 Telethon Kids Institute, Perth, WA
2 University of Western Australia, Perth, WA
3 Curtin University, Perth, WA

Correspondence: alexander.larcombe@telethonkids.org.au

Acknowledgements:

We acknowledge funding from the Australian Competition and Consumer Commission, Health Department of Western Australia, and from the National Health and Medical Research Council (APP1128231).

Competing interests:

No relevant disclosures.

1. Yong HH, Borland R, Balmford J, et al. Trends in e‐cigarette awareness, trial, and use under the different regulatory environments of Australia and the United Kingdom. Nicotine Tob Res 2015; 17: 1203–1211.
2. Trehy ML, Ye W, Hadwiger ME, et al. Analysis of electronic cigarette cartridges, refill solutions, and smoke for nicotine and nicotine related impurities. J Liq Chromatogr R T 2011; 34: 1442–1458.
3. Douglas H, Hall W, Gartner C. E‐cigarettes and the law in Australia. Aust Fam Physician 2015; 44: 415–418.
4. Goniewicz ML, Gupta R, Lee YH, et al. Nicotine levels in electronic cigarette refill solutions: a comparative analysis of products from the US, Korea, and Poland. Int J Drug Policy 2015; 26: 583–588.
5. Abdel‐Gawad H, Hegazi B. Fate of ¹⁴C‐ethyl prothiofos insecticide in canola seeds and oils. J Environ Sci Health B 2010; 45: 116–122.

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Guideline summary

The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelines

Preeti A Joshi, Jill Smith, Sandra Vale and Dianne E Campbell

Med J Aust 2019; 210 (2): . || doi: 10.5694/mja2.12102
Published online: 14 January 2019

Topics

Immune system diseases

Skin and connective tissue diseases

Environment and public health

Pediatric medicine

Abstract

Introduction: The Australasian Society of Clinical Immunology and Allergy, the peak professional body for clinical immunology and allergy in Australia and New Zealand, develops and provides information on a wide range of immune‐mediated disorders, including advice about infant feeding and allergy prevention for health professionals and families. Guidelines for infant feeding and early onset allergy prevention were published in 2016, with additional guidance published in 2017 and 2018, based on emerging evidence.

Main recommendations:

When the infant is ready, at around 6 months, but not before 4 months, start to introduce a variety of solid foods. (This is not a strict window of introduction but rather a recommendation not to delay the introduction of solid foods beyond 12 months.)
Introduce peanut and egg in the first year of life in all infants, regardless of their allergy risk factors.
Hydrolysed (partially and extensively) formula is no longer recommended for the prevention of allergic disease.

Changes in management a result of the guidelines: The guidelines specifically recommend introducing solid foods at around 6 months of age and introducing peanut and egg in the first year of life in all infants to prevent allergy development. Hydrolysed formula is no longer recommended for prevention of allergic disease. A new document outlining the reasons for and the method of peanut introduction to high risk infants is available for health professionals.

1 Australasian Society of Clinical Immunology and Allergy, Sydney, NSW
2 The Children's Hospital at Westmead, Sydney, NSW
3 University of Sydney, Sydney, NSW

Correspondence: preeti.joshi@health.nsw.gov.au

Competing interests:

Preeti Joshi is currently the chair of the ASCIA paediatric committee and the deputy chair of the National Allergy Strategy allergy prevention project. Sandra Vale is coordinator of the National Allergy Strategy. Jill Smith is the ASCIA CEO and company secretary. Dianne Campbell was chair of the ASCIA paediatric committee from 2011 to 2017, has received funding for unrelated research from the NHMRC, the Allergy and Immunology Foundation of Australasia and the Australian Food Allergy Foundation, and has received travel expenses to attend investigator meetings from DBV Technologies.

1. Odhiambo JA, Williams HC, Clayton TO, et al. Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three. J Allergy Clin Immunol 2009; 124: 1251–1258.e23.
2. Prescott SL, Pawankar R, Allen KJ, et al. A global survey of changing patterns of food allergy burden in children. World Allergy Organ J 2013; 6: 21.
3. Osborne NJ, Koplin JJ, Martin PE, et al. Prevalence of challenge‐proven IgE‐mediated food allergy using population‐based sampling and predetermined challenge criteria in infants. J Allergy Clin Immunol 2011; 127: 668–676.e2.
4. Mullins RJ, Dear KB, Tang ML. Time trends in Australian hospital anaphylaxis admissions in 1998‐1999 to 2011‐2012. J Allergy Clin Immunol 2015; 136: 367–375.
5. Mullins RJ, Wainstein BK, Barnes EH, et al. Increases in anaphylaxis fatalities in Australia from 1997 to 2013. Clin Exp Allergy 2016; 46: 1099–1110.
6. Australasian Society of Clinical Immunology and Allergy. ASCIA guidelines – infant feeding and allergy prevention. Sydney: ASCIA, 2016. https://www.allergy.org.au/health-professionals/papers/infant-feeding-and-allergy-prevention (viewed Nov 2018).
7. National Asthma Council Australia. Australian asthma handbook. Infant feeding and asthma prevention. http://www.asthmahandbook.org.au/prevention/primary/infant-feeding (viewed Nov 2018).
8. BI Nwaru ME, S. Ahonen, M. Kaila, et al. Age at the introduction of solid foods during the first year and allergic sensitization at age 5 years. Pediatrics 2010; 125: 50–59.
9. Netting MJ, Campbell DE, Koplin JJ, et al. An Australian consensus on infant feeding guidelines to prevent food allergy: outcomes from the Australian Infant Feeding Summit. J Allergy Clin Immunol Pract 2017; 5: 1617–1624.
10. Grade Working Group. What is GRADE? http://www.gradeworkinggroup.org/ (viewed Nov 2018).
11. Australasian Society of Clinical Immunology and Allergy. ASCIA guide for introduction of peanut to infants with severe eczema and/or food allergy. https://www.allergy.org.au/health-professionals/papers/ascia-guide-peanut-introduction (viewed Nov 2018).
12. Du Toit G, Roberts G, Sayre PH, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med 2015; 372: 803–813.
13. Du Toit G, Katz Y, Sasieni P, et al. Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol 2008; 122: 984–991.
14. Kramer MS, Kakuma R. Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child. Cochrane Database Syst Rev 2012; (9): CD000133.
15. Kramer MS, Kakuma R. Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child. Evid Based Child Health 2014; 9: 447–483.
16. Gunaratne AW, Makrides M, Collins CT. Maternal prenatal and/or postnatal n‐3 long chain polyunsaturated fatty acids (LCPUFA) supplementation for preventing allergies in early childhood. Cochrane Database Syst Rev 2015; (7): CD010085.
17. Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Vitamin and mineral supplementation and pregnancy. https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27sHealth/Statementandguidelines/Clinical-Obstetrics/Vitamin-andmineral-supplementation-in-pregnancy-(C-Obs-25)-Review-Nov-2014,-Amended-May-2015.pdf?ext=.pdf (viewed Nov 2018).
18. United States Food and Drug Administration. Eating fish: what pregnant women and parents should know. https://www.fda.gov/Food/ResourcesForYou/Consumers/ucm393070.htm (viewed Nov 2018).
19. Fiocchi A, Pawankar R, Cuello‐Garcia C, et al. World Allergy Organization‐McMaster University Guidelines for Allergic Disease Prevention (GLAD‐P): probiotics. World Allergy Organ J 2015; 8: 4.
20. Foolad N, Brezinski EA, Chase EP, Armstrong AW. Effect of nutrient supplementation on atopic dermatitis in children: a systematic review of probiotics, prebiotics, formula, and fatty acids. JAMA Dermatol 2013; 149: 350–355.
21. Osborn DA, Sinn JK. Probiotics in infants for prevention of allergic disease and food hypersensitivity. Cochrane Database Syst Rev 2007; (4): CD006475.
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23. Victora CG, Bahl R, Barros AJ, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016; 387: 475–490.
24. Grimshaw K, Logan K, O'Donovan S, et al. Modifying the infant's diet to prevent food allergy. Arch Dis Child 2017; 102: 179–186.
25. Osborn DA, Sinn J. Soy formula for prevention of allergy and food intolerance in infants. Cochrane Database Syst Rev 2006; (4): CD003741.
26. Boyle RJ, Ierodiakonou D, Khan T, et al. Hydrolysed formula and risk of allergic or autoimmune disease: systematic review and meta‐analysis. BMJ 2016; 352: i974.
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29. von Berg A, Filipiak‐Pittroff B, Schulz H, et al. Allergic manifestation 15 years after early intervention with hydrolyzed formulas–the GINI Study. Allergy 2016; 71: 210–219.
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43. Levin M, Goga A, Doherty T, et al. Allergy and infant feeding guidelines in the context of resource‐constrained settings. J Allergy Clin Immunol 2017; 139: 455–458.

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Research letter

Baby boomers and booze: we should be worried about how older Australians are drinking

Ann M Roche and Victoria Kostadinov

Med J Aust 2019; 210 (1): . || doi: 10.5694/mja2.12025
Published online: 14 January 2019

Topics

Substance‐related disorders

Gerontology

Alcohol research has traditionally focused on younger age groups; consumption patterns and predictors for older people have received only limited attention. However, the number of older Australians has increased substantially in recent years, accompanied by unprecedented changes in their alcohol consumption patterns. Older people are vulnerable to a range of alcohol‐related adverse effects, including falls and other injuries, diabetes, cardiovascular disease, cancer, mental health problems, obesity, liver disease, and early onset dementia and other brain injury.1,2,3 These vulnerabilities are a cause for clinical concern.

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National Centre for Education and Training on Addiction, Flinders University, Adelaide, SA

Correspondence: ann.roche@flinders.edu.au

Competing interests:

No relevant disclosures.

1. Crome I, Dar K, Janikiewicz S, et al. Our invisible addicts: first report of the Older Persons’ Substance Misuse Working Group of the Royal College of Psychiatrists. Second edition (College Report CR211). London: Royal College of Psychiatrists, 2018. https://www.rcpsych.ac.uk/files/pdfversion/CR211.pdf (viewed Aug 2018).
2. Scoccianti C, Cecchini M, Anderson AS, et al. European Code against Cancer 4th edition. Alcohol drinking and cancer. Cancer Epidemiol 2015; 39: S67–S74.
3. Schwarzinger M, Pollock BG, Hasan OSM, et al. Contribution of alcohol use disorders to the burden of dementia in France 2008–13: a nationwide retrospective cohort study. Lancet Public Health 2018; 3: e124–e132.
4. Australian Institute of Health and Welfare. National drug strategy household survey 2016: detailed findings. Canberra: AIHW, 2017. https://www.aihw.gov.au/reports/illicit-use-of-drugs/2016-ndshs-detailed/data (viewed Sept 2018).
5. National Health and Medical Research Council. Australian guidelines to reduce health risks from drinking alcohol (Cat. No. DS10). Canberra: NHMRC, 2009. https://www.nhmrc.gov.au/guidelines-publications/ds10 (viewed Sept 2018).
6. Wadd S, Lapworth K, Sullivan M, et al. Working with older drinkers. Bedford: Tilda Goldberg Centre, University of Bedfordshire, 2011. http://alcoholresearchuk.org/downloads/finalReports/FinalReport_0085 (viewed Aug 2018).
7. Barry KL, Blow FC. Drinking over the lifespan: focus on older adults. Alcohol Res 2016; 38: 115–120.

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Research

Screening for perinatal depression and predictors of underscreening: findings of the Born in Queensland study

Macarena A San Martin Porter, Kim Betts, Steve Kisely, Gino Pecoraro and Rosa Alati

Med J Aust 2019; 210 (1): . || doi: 10.5694/mja2.12030
Published online: 14 January 2019

Topics

Health services administration

Women's health

Mental disorders

Abstract

Objectives: To investigate screening with the Edinburgh Postnatal Depression Scale (EPDS) as part of Queensland prenatal care services, as well as maternal and socio‐demographic factors associated with not being screened.

Design, setting: Cross‐sectional retrospective analysis of data from the Queensland population‐based Perinatal Data Collection for July 2015 – December 2015.

Participants: All women giving birth in Queensland during the second half of 2015.

Main outcome measures: Screening with the EPDS, with the values “yes” (health professional recorded an EPDS score), “no” (health professional reported it was not performed), and “not stated”.

Results: Of 30 468 women who gave birth in Queensland, 21 735 (71.3%) completed the EPDS during pregnancy; 18 942 pregnant women were enrolled as public patients (91.0%) and 2762 as private patients (28.8%). After adjusting for other socio‐demographic factors, screening was less likely for women who were aged 36 years or more (v 25 years or younger: adjusted odds ratio [OR], 0.69; 95% CI, 0.60–0.79), enrolled as private patients (aOR, 0.05; 95% CI, 0.05–0.06), born overseas (aOR, 0.75; 95% CI, 0.68–0.82), Indigenous Australians (aOR, 0.47; 95% CI, 0.39–0.56), single or separated (aOR, 0.83; 95% CI, 0.73–0.94), or of higher socio‐economic status.

Conclusions: Four years after clinical guidelines recommending universal screening with the EPDS were published, screening rates for private and public health care patients differed markedly. Our results may inform future comparisons and analyses of the impact on screening of recent changes to Medicare definitions intended to increase that of women in private health care.

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1 Institute for Social Science Research, University of Queensland, Brisbane, QLD
2 University of Queensland, Brisbane, QLD
3 Curtin University, Perth, WA

Correspondence: m.sanmartinporter@uq.edu.au

Competing interests:

No relevant disclosures.

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International vascularised composite allotransplantation activity: implications for Australia

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Recruiting general practice patients for large clinical trials: lessons from the Aspirin in Reducing Events in the Elderly (ASPREE) study

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Exposures to e‐cigarettes and their refills: calls to Australian Poisons Information Centres, 2009–2016

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Medical assistance in dying: a disruption of therapeutic relationships

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Medical assistance in dying: a disruption of therapeutic relationships

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Increased incidence of community‐associated Staphylococcus aureus bloodstream infections in Victoria and Western Australia, 2011–2016

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Nicotine and other potentially harmful compounds in “nicotine‐free” e‐cigarette liquids in Australia

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The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelines

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Baby boomers and booze: we should be worried about how older Australians are drinking

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Screening for perinatal depression and predictors of underscreening: findings of the Born in Queensland study

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International vascularised composite allotransplantation activity: implications for Australia

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Recruiting general practice patients for large clinical trials: lessons from the Aspirin in Reducing Events in the Elderly (ASPREE) study

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Abstract

Exposures to e‐cigarettes and their refills: calls to Australian Poisons Information Centres, 2009–2016

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Medical assistance in dying: a disruption of therapeutic relationships

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Medical assistance in dying: a disruption of therapeutic relationships

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Increased incidence of community‐associated Staphylococcus aureus bloodstream infections in Victoria and Western Australia, 2011–2016

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Nicotine and other potentially harmful compounds in “nicotine‐free” e‐cigarette liquids in Australia

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The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelines

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Baby boomers and booze: we should be worried about how older Australians are drinking

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Screening for perinatal depression and predictors of underscreening: findings of the Born in Queensland study

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