Volume 209 Issue 2

Improving GP registrars’ readiness for vocational training and transition into practice

Susan M Wearne · Parker J Magin · Neil A Spike

Despite progress made in chronic disease management in Australia, there is an ongoing need for better quality of care and services integration, as rates of chronic disease and multimorbidity continue to rise

Mark F Harris · Ben Harris-Roxas · Andrew W Knight

Active screening of patients newly diagnosed with hypertension is the best way to capture patients with primary aldosteronism early to maximise the benefits of treatment and minimise end-organ damage

Jun Yang · Peter J Fuller · Michael Stowasser

As a federal election looms, now is the time for coordinated, strategic and innovative action from a unified, agile collective committed to improving Australia’s health and nutrition

Alessandro Demaio · Alexandra Jones

A 58-year-old woman was admitted with chronic lower limb ulcers

Alicia R Jones · Kavita Kumareswaran

A 61-year-old man presented with left periorbital swelling and an upper lid laceration after a fall onto a chair

Matthew H Lee · Elaine Chong

Poisons Information Centres provide health services and the general public across Australia with the most up-to-date advice available

Geoffrey K Isbister

New assessment and treatment opportunities for people with severe asthma promise better outcomes

Peter G Gibson

A new approach to analysing routine data allows continuous monitoring of the characteristics of Australian general practices

Bich Tran · Peter Straka · Michael O Falster · Kirsty A Douglas · Thomas Britz · Louisa R Jorm

PIC data can inform strategic public health interventions that target age-specific poisoning hazards

on behalf of the Synthesis of the Network of Australian Poisons Services' Health Outcomes and Treatment (SNAPSHOT) investigators

Undertaking appendicectomies in children outside paediatric hospitals reduces waiting, delays, and unnecessary travel

Francisco J Schneuer · Susan E Adams · Jason P Bentley · Andrew JA Holland · Carmen Huckel Schneider · Leslie White · Natasha Nassar

Chronic idiopathic constipation (CIC) is one of the most common gastrointestinal disorders, with a global prevalence of 14%. It is commoner in women and its prevalence increases with age. There are three subtypes of CIC: dyssynergic defaecation, slow transit constipation and normal transit constipation, which is the most common subtype. Clinical assessment of the patient with constipation requires careful history taking, in order to identify any red flag symptoms that would necessitate further investigation with colonoscopy to exclude colorectal malignancy. Screening for hypercalcaemia, hypothyroidism and coeliac disease with appropriate blood tests should be considered. A digital rectal examination should be performed to assess for evidence of dyssynergic defaecation. If this is suspected, further investigation with high resolution anorectal manometry should be undertaken. Anorectal biofeedback can be offered to patients with dyssynergic defaecation as a means of correcting the associated impairment of pelvic floor, abdominal wall and rectal functioning. Lifestyle modifications, such as increasing dietary fibre, are the first step in managing other causes of CIC. If patients do not respond to these simple changes, then treatment with osmotic and stimulant laxatives should be trialled. Patients not responding to traditional laxatives should be offered treatment with prosecretory agents such as lubiprostone, linaclotide and plecanatide, or the 5-HT4 receptor agonist prucalopride, where available. If there is no response to pharmacological treatment, surgical intervention can be considered, but it is only suitable for a carefully selected subset of patients with proven slow transit constipation.

Christopher J Black · Alexander C Ford

Consideration of the clinical context, expert evaluation of thyroid sonography, careful selection of nodules for fine-needle aspiration, and standardised cytology reporting are important components in thyroid nodules assessment

Rosemary Wong · Stephen G Farrell · Mathis Grossmann

To the Editor:Salmonella infection manifests as enteritis and enteric fever, predominantly acquired overseas. When required, therapy with azithromycin, ciprofloxacin or ceftriaxone is recommended by the Therapeutic guidelines: antibiotic;1 however, reduced susceptibility to fluoroquinolones in Asia limits the use of ciprofloxacin unless susceptibility is confirmed.2 The Australian Bureau of Statistics recorded a 546% increase in short term departures to Indonesia over 10 years, with 1.2 million nationally in 2016.3 A 31-year-old man was taking long term azithromycin 250 mg daily to prevent bronchiolitis obliterans syndrome after a bilateral lung transplant several years earlier for cystic fibrosis. Three weeks after returning from Bali, he was admitted with fatigue, fever, diarrhoea and abdominal pain. He had acute kidney injury. His C-reactive protein level was 190 mg/L (reference interval [RI], < 5 mg/L) and procalcitonin concentration was 3.5 μg/L (RI, < 0.05 μg/L). A single set of blood cultures was negative. Stool culture isolated Salmonella enterica serovar Paratyphi B var Java, sensitive to ceftriaxone and ciprofloxacin, with a raised azithromycin minimum inhibitory concentration (MIC) of 64 mg/L by ETEST (bioMérieux); an MIC > 16 mg/L indicates non-wild-type4 and is associated with treatment failures. Owing to his immunocompromised state, the patient received a 14-day course of ciprofloxacin (MIC, 0.016 mg/L). Our review of 2015–2017 data from the Western Australian public pathology provider revealed that two of 31 typhoidal Salmonella isolates (Salmonella Paratyphi A and Salmonella Typhi bacteraemia, each acquired in India) and one of 15 non-typhoidal Salmonella isolates (S. typhimurium, no clinical details provided) had an azithromycin MIC > 16 mg/L. Ceftriaxone resistance was low at 0% (0/117) of typhoidal Salmonella and 0.4% (7/1648) of non-typhoidal Salmonella; ciprofloxacin resistance was higher at 48.0% (47/98) of typhoidal Salmonella and 6.8% (94/1384) of non-typhoidal Salmonella. By comparison, azithromycin MIC > 16 mg/L was found in 16.1% of typhoidal Salmonella from travellers returning to the Netherlands,5 and in 1.3% of non-typhoidal Salmonella in the United States.4 Azithromycin use while travelling probably selected for resistant Salmonella infection in this case. However, our data show that azithromycin susceptibility cannot be assumed in Salmonella infections; testing should therefore occur in serious cases, along with ongoing surveillance for evolving resistance.

Alan J Rogers · Gar-hing A Lee · Peter Boan

After 2 years as AMA president, Dr Michael Gannon takes on new responsibilities

Cate Swannell

Med J Aust 2018; 209 (2 Suppl).