Volume 208 Issue 11

Transcranial magnetic stimulation is a safe and efficient treatment for resistant major depressive disorders; including it in Medicare would enable a more equitable availability for patients

Saxby Pridmore

Antibiotic allergy testing programs will ensure that vulnerable patients receive appropriate antibiotic therapy

Jason A Trubiano · M Lindsay Grayson · Karin A Thursky · Elizabeth J Phillips · Monica A Slavin

Establishing mentally healthy workplaces will reduce the risk of burnout

Michael Baigent · Ruth Baigent

All study designs have their strengths and weaknesses, and it is critical to be aware of these when thinking about how best to address a particular research goal

Jennifer A Cleland · Steven J Durning · Erik Driessen

Time complicates all studies, but this can be managed by collecting detailed data on participants over time and using survival analysis

Adrian G Barnett · Christopher Oldmeadow · John R Attia

A 25-year-old man presented to hospital with 3 days of non-specific abdominal pain, vomiting and diarrhoea

Victoria Hall · Rekha Pai Mangalore · Simon He · Kerrie Stevens · Jason A Trubiano · Natasha E Holmes · Benjamin P Howden · Jason C Kwong

Doctors need not wait until they get sick to understand what it is like on the other side

Benjamin D Bravery

The vulva: a practical handbook for clinicians, 2nd edition

Rupert G Sherwood

And just like that …

Allis Hamilton

Effective ambulatory services and community heart failure care may mitigate its impact on our health care system

Amera Halabi · Derek P Chew

Adhering to evidence-based surveillance guidelines will optimise the use of health care resources

Bilel Jideh · Michael J Bourke

Early re-admission rates after hospitalisation for HF are primarily explained by differences in post-discharge management

Quan Huynh · Kazuaki Negishi · Carmine De Pasquale · James Hare · Dominic Leung · Tony Stanton · Thomas H Marwick

Nurse coordinators can help ensure adherence to guideline surveillance recommendations, reducing endoscopy workloads

Erin L Symonds · Kalindra Simpson · Michelle Coats · Angela Chaplin · Karen Saxty · Jayne Sandford · Graeme P Young AM · Charles Cock · Robert Fraser · Peter A Bampton

Lower medical fees and greater transparency would reduce the burden for people with cancer

Louisa G Gordon · Thomas M Elliott · Catherine M Olsen · Nirmala Pandeya · David C Whiteman

The focus should be on eliciting a thorough history and examining the patient for red flags

Lauren Ross · Adam de Gruchy · Uyen M Phan · Matthew Warrender-Sparkes · Ian P Wicks · John HY Moi

Despite recent advances in our knowledge of sarcoidosis, it remains a diagnosis of exclusion

Hasib Ahmadzai · Shuying Huang · Chris Steinfort · James Markos · Roger KA Allen · Denis Wakefield · Margaret Wilsher · Paul S Thomas

To the Editor:The Editorial by Harvey and Diug1 on the value of food fortification as a public health intervention was prompted by demonstration of the effectiveness of mandatory iodine fortification in reducing iodine deficiency.2 Mandatory fortification of wheat flour for bread making was introduced in Australia at the same time to prevent neural tube defects. Harvey and Diug state that the two are conceptually different, as the former addresses a population iodine deficiency, whereas folic acid fortification is to compensate a presumed genetic defect that cannot be individually recognised, thus raising ethical questions about exposing the many for the benefit of the few. However, this is the case in almost all public health interventions. Using an example of Harvey and Diug, we expose the whole population to the mandatory fortification of flour with thiamine to prevent Wernicke–Korsakoff syndrome, a condition largely confined to people with a chronic alcohol problem. The concern they raise about mandatory folic acid fortification1 is exposure to unmetabolised folic acid, proposed as possibly increasing adverse effects, but which have not been clearly or conclusively shown. They refer to an Irish study reporting that seven of the 68 children in the study had detectable levels of unmetabolised folic acid in their blood.3 Ireland does not have mandatory folic acid fortification; the main sources of folic acid were voluntarily fortified breakfast cereals and fortified milk — products that are fortified with relatively high levels of folic acid. In Australia, breakfast cereals and other food products are also permitted to be fortified voluntarily — breakfast cereals often contain around 200–300 μg of added folic acid per 100 g (or about 100 μg per serve). This compares with mandatory fortification of flour of 200–300 μg per 100 g flour, or about 40 μg folic acid per slice of bread. While either source could lead to circulating unmetabolised folic acid, the higher doses in voluntarily fortified products are more likely to do so. With the introduction of mandatory fortification, there was a reduction in neural tube defects.4 Importantly, there has been a 68% reduction in previously higher rates of neural tube defects in Indigenous people.5 Mandatory fortification provides a more equitable, consistent and cheaper source of folic acid to the population than voluntary fortification. Let’s leave mandatory folic acid fortification preventing neural tube defects in our population.

Carol Bower · Fiona J Stanley · Mike Daube

To the Editor:Tick-borne infectious diseases, including rickettsial infections, acquired in Australia or after international travel remain a diagnostic challenge.1 A 68-year-old man presented with umbilical pain 10 days after returning from a 2-month camping trip through the south-west of the United States (ie, Texas, New Mexico, Arizona, Colorado and Utah). On examination, a live tick was detected and removed from the patient’s umbilicus (Box). The umbilical pain resolved after tick removal. There was no development of fevers, constitutional symptoms, or rash to suggest a tick-borne illness. Laboratory investigations were unremarkable. He was educated about the signs and symptoms of tick-borne illnesses and prescribed a single dose of doxycycline 200 mg for prophylaxis due to his high risk exposure. The tick was identified as Dermacentor andersoni (Rocky Mountain wood tick), which is endemic to North America and not known to occur in Australia.2 D. andersoni adult ticks are principal vectors of Rickettsia rickettsii (the cause of Rocky Mountain spotted fever), and are associated with transmission of other pathogens to humans, including Colorado tick fever virus and Francisella tularensis (the cause of tularemia).2,3 Although isolated from D. andersoni ticks, transmission of Coxiella burnetii (the cause of Q fever) is uncommon. D. andersoni is not known to transmit Lyme disease.2 Analysis of the tick for rickettsial DNA was positive. No Borrelia DNA was detected. Rickettsia was isolated in cell culture and identified as Rickettsia peacockii based on sequencing of the 17kDa, OmpB, gltA and Sca4 genes. R. peacockii is a member of the spotted fever group of rickettsiae.3,4 The presence of R. peacockii in ticks is correlated with reduced prevalence of R. rickettsii.2,3 R. peacockii is closely related to R. rickettsii, and deletion or mutation of genes, possibly resulting in loss of virulence in R. peacockii, have been identified.3 R. peacockii is not known to be a pathogen of humans or other animals.3,4 Rickettsial serology 10 weeks after the tick bite showed detectable antibodies (titre, 1/256), predominantly to the spotted fever group of Rickettsia, compatible with exposure to R. peacockii identified in the tick. Unfortunately, definitive seroconversion or a rising antibody titre was not able to be demonstrated as no earlier sera were available for parallel testing. Pre-existing antibodies from a distant rickettsial exposure from his tick-prone lifestyle (history of extensive international camping trips) cannot be excluded. The patient remains asymptomatic 9 months later and is still an avid traveller. Tick-borne rickettsial infections in Australia include Queensland tick typhus (Rickettsia australis), Flinders Island spotted fever and Australian spotted fever (Rickettsia honei) and Q fever transmitted by ticks including Ixodes spp., Amblyomma triguttatum and Bothriocroton hydrosauri.1 With increasing international travel, recognition of tick-borne rickettsial diseases is becoming more important. Dermacentor ticks have been detected on livestock exported from North America into Europe.5 This case shows the ability of human ectoparasites, and their potentially pathogenic bacteria, to bypass stringent Australian quarantine controls. Further studies of Australian and imported tick-borne infections are required to increase understanding of these emerging infectious diseases. Box – Dermacentor andersoni removed from the patient’s umbilicus

Sadid F Khan · Mythili Tadepalli · John Stenos · Stephen R Graves · Tony M Korman

To the Editor:We congratulate Cheney and colleagues1 for throwing light on the contributions of overweight and obesity on adverse birth outcomes by analysing data from a teaching hospital in central Sydney.1 Around 16% of the women presenting between 2010 and 2014 were overweight, while 7% were obese. Furthermore, despite obesity being an important risk factor for adverse pregnancy outcomes, their study showed a lack of recording of body mass index (BMI) in patients’ records. Adverse pregnancy outcomes are more common among Indigenous Australian women than non-Indigenous women;2 obesity levels are high in pre-conception and in pregnancy, and the subsequent adverse impact on increased metabolic health in offspring is likely contributing to early onset of diabetes and chronic disease in Indigenous Australians. Hence, we want to extend the debate to report on what is happening in primary health care (PHC) settings for Indigenous women. We have analysed continuous quality improvement data from audits of adherence to evidence-based guidelines for maternal care in 65 Indigenous PHC centres (1091 patient records) across Australia during 2012–2014.3 The majority of women at most PHC centres had the first trimester weight recorded (mean, 90%; range, 60–100%), but there was wide variation in recording of BMI (mean, ∼ 60%; range, 0–100%) (Box). This indicates that most barriers to BMI recording are more to do with clinicians’ understanding of the value of and ability to calculate BMI than around women’s willingness to be weighed. For women with an abnormal BMI (mean, ∼ 30%; range, 0–100%), there was wide variation in documented BMI management plans (mean, ∼ 40%; range, 0–100%). Dealing with these generally low levels of recording and wide variation in recording between PHC centres is a vital early step in limiting the contribution of obesity to adverse pregnancy outcomes and improving long term health outcomes for the mother and baby. Women attending PHCs that had participated in continuous quality improvement activities were more likely to receive recommended pregnancy care related to screening and brief interventions for modifiable lifestyle-related risk factors, such as obesity.4,5 These findings support the incorporation of continuous quality improvement activities into the delivery of maternal care. Box – Record of scheduled maternal care services received by Indigenous women at Indigenous primary health care centres, 2012–2014* BMI = body mass index. * More information on how to interpret box plots is available in Gibson-Helm et al,3 page 21.

Jodie Bailie · Jacqueline A Boyle · Ross S Bailie

Dr Ben Saxon noticed that junior doctors were struggling to administer blood transfusions and he decided to help. An app called iTransfuse is the result

Cate Swannell

The AMA handed out its top awards to distinguished members of the medical profession at its national conference last month

Cate Swannell

Associate Professor Julian Rait, OAM, from the University of Melbourne, is the new President of the Australian Medical Association (AMA) Victoria, replacing Dr Lorraine Baker whose 2-year term has come to an end. Associate Professor Rait brings 25 years of clinical, research and leadership experience to the role. He is an eye specialist who joined the AMA as a young graduate from Melbourne Medical School in 1982. He most recently served the organisation as Chair of the Council of AMA Victoria and Chair of the Council of Private Specialist Practice for the Federal AMA. In the Victorian public health system, Associate Professor Rait led the Glaucoma Unit at the Royal Victorian Eye and Ear Hospital for 12 years from 1993 to 2005. Other leadership roles have included being Chair of the Board of the medical indemnity organisation, MDA National from 2008 to 2014; Chair of the Victorian branch of the Royal Australian and New Zealand College of Ophthalmologists; and Chair of Anglican Overseas Aid since 2013. He is also a Fellow of the Australian Institute of Company Directors. On Australia Day 2018, he was awarded a Medal of the Order of Australia (OAM) for service to ophthalmology and to the development of overseas aid. Associate Professor Rait said that the priority for AMA Victoria for the next 2 years will be to provide strong health leadership on behalf of patients and the medical profession. Key areas of focus will include mental health, general practice, rural medicine and doctor health and wellbeing. Dr Roderick McRae was elected new AMA Victoria Vice President. https://amavic.com.au/ The Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne has announced the winners of its annual Dean’s Honours, recognising recent graduates who have achieved the highest academic results in several of the Faculty’s flagship courses. Dr Callum Umstad has won most of Melbourne Medical School’s prizes, for his achievements in rheumatology, ophthalmology and surgery as well has having won the RMH Clinical School Long Case Prize, awarded to a second-year student who demonstrates outstanding ability to effectively communicate and interact with real patients while developing the aptitude of clinical reasoning. Dr Jeremy Clark impressed his professors with his ability to rapidly establish respectful, thoughtful relationships with patients. His clinical coach and ethics tutor, Professor Michael Pain, admired his inquiring and critical eye, saying Jeremy “frequently challenged me over clinical findings and we often disagreed on some ethical issues”. He also highlighted Jeremy’s appreciation of the “bigger picture” and his interest in medical history. Dr Daniel (Dong-Kyoon) Ko was previously awarded the RM Biggins Prize in Clinical Medicine, which is awarded to final-year students demonstrating both academic distinction and the “qualities of a future conscientious, generous physician”. From the School of Population and Global Health, You (Eunice) Wu was Treasurer of the Master of Public Health Student Association and worked as a research assistant for the Health Economics Unit in the Centre of Health Policy. In her final year, she completed a large project at PriceWaterhouseCoopers; contributing to a report that provided system-wide recommendations in order to improve outcomes in musculoskeletal health in Australia. From the School of Biomedical Sciences, Richard Yan, who started at the University as a Chancellor’s Scholar and is now in his first year of Medicine, is a previous recipient of the TF Ryan Prize for Anatomy, and the Ian Holmes Medal for Virology. In 2017, Richard was Treasurer of the Biomedicine Students Society, which raised $20 000 for Muscular Dystrophy Research. After a few years as a research assistant at the Burnet Institute and Walter and Eliza Hall Institute (WEHI), Joy Liu completed an Honours project on the parasitic worm ascaris, which causes chronic disease in children in low to middle income countries. In July, she returns to WEHI to start a PhD on an imaging-based project. https://mdhs.unimelb.edu.au/news-and-events/outstanding-students-lauded-in-deans-honours-celebration Bond University medical student Sean Adcock had the opportunity to experience the politics of health at the highest level when he joined Australia’s delegation to the World Health Assembly (WHA) in Geneva late in May. Sean, 22, was one of four students Australia-wide to receive a Global Voices Scholarship to attend the annual decision making congregation of the World Health Organization. Sean’s scholarship preparation got underway in early May with a 3-day pre-departure briefing in Canberra, where he was introduced to Australia’s WHA delegation, along with Senior Advisors to the Ministers for Health, Aged Care, Indigenous Health and Rural Health. https://bond.edu.au/news/56944/bond-medical-student-journeys-who-halls-power?context=hsm Four students at Flinders University’s College of Medicine and Public Health have been awarded the Vice-Chancellor’s Prize for Doctoral Thesis Excellence: Dr Qi Yang for her thesis entitled Identifying untapped microbial resources in the marine sponge microbiome supervised by Professor Chris Franco and Professor Wei Zhang (College of Medicine and Public Health); Dr Suvimol Charoensiddhi for Process development for functional food ingredients with gut health benefits from the brown seaweed Ecklonia radiata supervised by Professor Wei Zhang and Professor Chris Franco; Dr Katherine Morel for Parthenolide in the treatment and prevention of prostate cancer supervised by Professor Pam Sykes and Associate Professor Sonja Klebe and Dr Rebecca Ormsby; Dr Leena Baghdadi for Studies exploring the relationship between methotrexate use and blood pressure and arterial function in the rheumatoid arthritis population supervised by Professor Arduino Mangoni, Professor Richard Woodman and Professor Michael Shanahan. http://news.flinders.edu.au/blog/2018/05/15/high-distinction-phd-theses/

Cate Swannell