Volume 210 Issue 5

Lack of national abortion data impedes development of sexual and reproductive health care policies and programs for young Australians

Jennifer L Marino · Susan M Sawyer

What are the problems in rural health service delivery and what can we do about them?

John Wakerman · John S Humphreys

Australia's implementation of the Sustainable Development Goals must advance the nation's health and wellbeing transparently and inclusively

Claire E Brolan · Nina Hall · Sandra Creamer · Ingrid Johnston · Jaya AR Dantas

Victoria's voluntary assisted dying law will soon come into effect; a remaining challenge is effective clinical implementation

Ben P White · Lindy Willmott · Eliana Close

A 56-year-old man presented with a 2-month history of continuous occipital pain that progressed to aching neck movements

Tsung‐Han Ho · Yaw‐Don Hsu

Clinical care guidelines for collecting and using information on the cultural heritage of patients are needed

Pupalan Iyngkaran · Michael Jelinek

The knownThe future pancreatic cancer burden attributable to tobacco smoking has not been estimated in Australia. The newNearly 22% of the future burden of pancreatic cancer is attributable to current and former smoking, 15% (5500 cases over the next 10 years) to current smoking alone. The smoking‐related burden of pancreatic cancer is markedly higher for men and for people under 65. The implicationsReducing smoking rates among men and people under 65 would have the greatest impact on reducing the future burden of pancreatic cancer in Australia.

Maria E Arriaga · Claire M Vajdic · Robert J MacInnis · Karen Canfell · Dianna J Magliano · Jonathan E Shaw · Julie E Byles · Graham G Giles · Anne W Taylor · Tiffany K Gill · Vasant Hirani · Robert G Cumming · R Paul Mitchell · Emily Banks · Julie Marker · Barbara‐Ann Adelstein · Maarit A Laaksonen

The known The format, content and conduct of medical handovers by hospital doctors are receiving increasing attention from health care policymakers.

David JR Morgan · Tania Harris · Ron Gidgup · Martin Whitely

The THANZ guideline for the diagnosis and management of VTE has been developed by the VTE Working Group based on up‐to‐date evidence and using an evidence‐based approach. The guideline aims to promote optimal management of VTE. The extended version of the guideline can be found on the THANZ website (www.thanz.org.au/resources/thanz-guidelines).

Huyen A Tran · Harry Gibbs · Eileen Merriman · Jennifer L Curnow · Laura Young · Ashwini Bennett · Chee Wee Tan · Sanjeev D Chunilal · Chris M Ward · Ross Baker · Harshal Nandurkar

TO THE EDITOR: In 2016, there were an estimated 490 000 cases globally of multidrug‐resistant (MDR) tuberculosis exhibiting resistance to isoniazid and rifampicin.1 The first case of MDR tuberculosis diagnosed in Tasmania occurred in 2016 in a Vietnamese‐born person. Vietnam was the second highest reported country of birth for overseas‐born patients with tuberculosis notified in Australia in 2014.2 The patient had previously tested positive for tuberculosis infection in an interferon‐γ release assay test performed in Tasmania in early 2016, but at the time, the patient was asymptomatic and had a normal chest x‐ray and a negative sputum culture. After an episode of colitis, a colon tissue biopsy specimen isolated Mycobacterium tuberculosis. Whole genome sequence of the isolate (TASMDR1), identified high confidence mutations for isoniazid, rifampicin, ethambutol and pyrazinamide, in accordance with the culture‐based drug susceptibility testing, and, in addition, it identified a mutation associated with streptomycin resistance.3 We became aware that a household contact of the Tasmania‐located patient with MDR tuberculosis had been diagnosed with pulmonary tuberculosis in Vietnam in 2012 and requested the drug susceptibility testing data for this isolate (VTB1) from the treating hospital in Ho Chi Minh City. VTB1 was resistant to isoniazid, rifampicin, ethambutol, pyrazinamide and streptomycin in culture‐based drug susceptibility testing. We therefore obtained a genomic DNA preparation of VTB1 to enable direct comparison with the TASMDR1 isolate collected in Tasmania. Next generation sequencing of VTB1 was performed on an Illumina platform and paired‐end reads were mapped to the M. tuberculosis H37Rv reference genome (NC_000962.3). The Box shows variants associated with drug resistance. In addition to drug resistance mutations, VTB1 shared all previously described variants in TASMDR1 with respect to H37Rv3 and, therefore, the two isolates were genetically indistinguishable. This is strongly indicative of transmission involving the two patients based on established single nucleotide polymorphism thresholds.4 It is most probable that the patient diagnosed in Tasmania contracted the MDR strain of M. tuberculosis during the episode of pulmonary disease diagnosed in the household contact in 2012 and that the infection remained latent until reactivating as extrapulmonary MDR tuberculosis in 2016. In conclusion, the global burden of latent tuberculosis infection has been estimated to be 23% of the world's population, which corresponds to about 1.7 billion people.5 Despite the immense prevalence of latent tuberculosis infection, there are few reports in the literature that confirm using genome variant analyses for the translocation of the MDR form of tuberculosis from one jurisdiction to another as a latent infection and its subsequent emergence as active MDR tuberculosis in a new host country. This type of transit of tuberculosis is difficult to detect with pre‐immigration screening practices that are reliant upon a diagnosis of pulmonary tuberculosis based on a chest x‐ray. The international movement of MDR tuberculosis in latent form, as has been determined in this case, is an area of concern and could be a significant challenge for future tuberculosis eradication. The growing application of genome sequencing in tuberculosis diagnostics and surveillance will help establish the level of MDR tuberculosis cases due to reactivation of latent tuberculosis infection. Box – Drug resistance determining mutations in a contact who presented with tuberculosis in Vietnam in 2012 (VTB1) and in the first confirmed patient with multidrug‐resistant (MDR) tuberculosis in Tasmania in 2016 (TASMDR1). The isolate from VTB1 and TASMDR1 share identical drug resistance mutations Isolates Drug Gene Function Mutation Substitution VTB1 and TASMDR1 Rifampicin rpoB (Rv0667) RNA polymerase β‐subunit gAc/gGc, tCg/tTg D435G, S450L Isoniazid katG (Rv1908c) Catalase‐peroxidase aGc/aCc S315T Pyrazinamide pncA (Rv2043c) Pyrazinamidase/nicotinamidase cCg/cTg P62L Ethambutol embB (Rv3795) Arabinosyltransferase B Atg/Gtg M306V Streptomycin rrs (MTB000019) 16S ribosomal RNA a/c a514c* * Substitution located in a non‐protein coding gene. ◆

Sanjay S Gautam · Greg Haug · Louise A Cooley · Micheál Mac Aogáin · Ronan F O'Toole

TO THE EDITOR: The article by Stevens and Schweitzer1 contains many useful teaching pearls for frontline physicians and generalists. I concur with the final diagnosis reached and the excellent teaching points emphasised in the article. I would like to make two important points regarding localisation. First, binocular diplopia can be caused by diseases in a variety of locations in the neurological axis, not just the extraocular muscle. Other possible locations include the brainstem, the cranial nerves (III, IV and/or VI), the neuromuscular junction and the orbit itself. Accompanying features will help distinguish the location; for example, the presence of hemiparesis, cerebellar signs, or lower cranial nerve abnormalities would localise to the brainstem. Second, localisation is critical before organising neuroimaging, as knowing where the lesion is will prove useful for the radiologist. The likelihood of subtle pathologies being detected by the radiologist increases significantly when the site of potential localisation is included in the clinical request information. This helps to reduce the possibility of false negatives or misinterpretation if clinical correlation is not applied to test requests.2 Finally, there are two differential diagnoses to consider in this case. Myasthenia gravis, an uncommon disorder of the neuromuscular junction, is known to be a great mimicker and can cause various patterns of ophthalmoparesis and diplopia3 and it should be considered in all cases of binocular diplopia. In the article by Stevens and Schweitzer,1 this diagnosis was less likely in the patient given the painful nature of the ophthalmoparesis. The other rare differential diagnosis with serious implications to consider is a dural (or indirect) carotid‐cavernous fistula. Patients with this condition can present with painful diplopia without significant visual loss; they are frequently misdiagnosed by specialists and are eminently treatable endovascularly.4 The absence of orbital signs (eg, proptosis) and ocular signs (eg, arterialised “corkscrew” conjunctival vessels) assisted in excluding this condition as a differential in this case.

Benjamin Nham

Professor Tony Kelleher will bring his own vision to the Kirby Institute, while continuing the legacy and achievements of his legendary predecessor

Cate Swannell