Research

Colonoscopy should also be considered in cases of infective endocarditis with an unclear source of infection

Eugene Athan · Ivana Cabiltes · Sarah Coghill · Steven J Bowe

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. Podcast with Ms Carol Wylie We undertook a retrospective analysis of calls to Australian Poisons Information Centres (PICs) during 2009–2016. PICs play a valuable role as health care sentinels when new products such as e‐cigarettes are introduced. Our study was exempted from formal ethics approval by the Children's Health Queensland Hospital and Health Service Human Research Ethics Committee. The numbers of calls about e‐cigarette exposures increased considerably across the study period (Box), although the overall PIC call volume was stable at about 164 000 cases per year. Of 202 sequential e‐cigarette‐related cases, 38% were from relatives of children worried about their exposure to the liquid component of an e‐cigarette after children were found with uncapped vials, sucking the mouthpiece, drinking from separated liquid containers, inhaling the liquid, eating the cartridge, or having splashed liquid in their eyes. Adults and adolescents were the subjects of calls in 126 cases (62%), including calls about the potential side effects of routine use or accidental ingestion, or about skin or eye splash exposures. Twelve calls followed deliberate administration for self‐harm, ten by oral ingestion and two by injection. The reported median concentration of the 43 commercial nicotine solutions involved was 20.2 mg/mL, (range, 0.06–200 mg/mL), but confirmatory testing was not performed and actual concentrations may be higher than labelled, as noted recently.5 Most patients had only mild symptoms at the time of the call to the PIC, mainly gastrointestinal disturbances; twelve had moderate symptoms, usually a gastrointestinal disturbance combined with sedation. The potential risks, however, should not be underestimated; we are aware that an infant recently died in Australia after ingesting a concentrated nicotine solution. Almost all exposures of children to nicotine‐containing e‐cigarette liquid require their hospitalisation for monitoring of possible toxic effects. Australian PIC data refer to calls about exposures to e‐cigarette liquid but may not reflect the prevalence of such exposures. These data nevertheless provide insights into patterns of exposure, usage, and the side effects of e‐cigarettes. Our study can assist health care practitioners when advising patients about the use of e‐cigarettes, and our findings indicate that nicotine‐containing products should be stored where children cannot access them. We would welcome any move to improve the safety of electronic cigarettes, including changes to their labelling, storage, and packaging. Box – Numbers of cases related to e‐cigarette exposures reported to Australian Poisons Information Centres, by calendar year and state* No calls were received about cases in the Northern Territory.

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

General practice can be a rich environment for research when barriers to recruitment are overcome

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 · Robyn Woods

Characterising the isolates responsible for infection would help identify virulence factors and the relatedness of isolates

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

The known: Rehabilitation reduces the patient's risk of death and disability after a stroke.

Elizabeth A Lynch · Shylie Mackintosh · Julie A Luker · Susan L Hillier

The known: Since 2011, Australian clinical guidelines recommend universal antenatal screening of pregnant women with the Edinburgh Postnatal Depression Scale (EPDS).

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

Older people face particular barriers obtaining advice or treatment for alcohol-related problems

Ann M Roche · Victoria Kostadinov

Overprescribing of these medications should be reduced, patients at greater risk identified, risk mitigation strategies implemented

Gillian E Caughey · Svetla Gadzhanova · Sepehr Shakib · Elizabeth E Roughead

The nicotine levels in three e-liquids were comparable with those of low dose nicotine e-liquids

Emily Chivers · Maxine Janka · Peter Franklin · Benjamin Mullins · Alexander Larcombe

The known: People who have experienced an acute coronary syndrome (ACS) are at high risk of further events. High blood cholesterol is an important modifiable factor that increases the risks of both initial and subsequent ACS events. The new: Only 55% of patients treated in Australia for ACS were undergoing intensive lipid‐lowering therapy 6 or 12 months after their hospitalisation. The major predictor of not receiving such therapy at follow‐up was its not being prescribed at hospital discharge. The implications: Improving oral lipid‐lowering therapy for people who have had an ACS should prevent recurrent coronary events.

David Brieger · Mario D'Souza · Karice Hyun · James C Weaver · Leonard Kritharides

The known: Pregabalin misuse is increasing worldwide, and is associated with acute psychiatric and medical harms, but patterns of pregabalin misuse in Australia have not been reported. The new: The rate of pregabalin‐related ambulance attendances has increased tenfold since 2012, associated with an increase in the national prescription rate. Patients frequently misused pregabalin with other sedatives, particularly benzodiazepines, and almost 40% of misuse‐related events requiring paramedic attendance were suicide attempts. The implications: Caution is required when prescribing pregabalin for patients using other sedatives. Misuse might be reduced by restricting dispensing of the drug.

Rose Crossin · Debbie Scott · Shalini Arunogiri · Karen Smith · Paul M Dietze · Dan I Lubman

More frequent gluten testing would reduce the risk for people with coeliac disease

Emma P Halmos · Dean Clarke · Catherine Pizzey · Jason A Tye-Din

Peer mentoring builds a sense of community and helps interns navigate their new professional environment

Sonia Chanchlani · Daniel Chang · Jeremy SL Ong · Aresh Anwar

Social media has the potential to change the face of public health messaging

Keira M Glasgow · Catherine R Bateman-Steel · Bradley Pope · Mark J Ferson

Ensure that cardiovascular disease risk factors are adequately controlled may reduce mortality

Wai H Lim · David W Johnson · Carmel Hawley · Charmaine Lok · Kevan R Polkinghorne · Matthew A Roberts · Neil Boudville · Germaine Wong

Further investigation of stillbirth in migrant women, particularly those of Indian or African background, is required for developing strategies for averting preventable stillbirths

Maryam Mozooni · David B Preen · Craig E Pennell

Clinicians and services should focus their attention on women at highest risk of unintended pregnancy

Angela J Taft · Mridula Shankar · Kirsten I Black · Danielle Mazza · Safeera Hussainy · Jayne C Lucke

Multicentre randomised controlled trials examining the efficacy of the chronic liver failure program are warranted

Jeyamani Ramachandran · Monowar Hossain · Chris Hrycek · Edmund Tse · Kate R Muller · Richard J Woodman · Billingsley Kaambwa · Alan J Wigg

Survival may be improved by surveillance, as it enables curative therapies to be initiated

Thai P Hong · Paul J Gow · Michael Fink · Anouk Dev · Stuart K Roberts · Amanda Nicoll · John S Lubel · Ian Kronborg · Niranjan Arachchi · Marno Ryan · William W Kemp · Virginia Knight · Vijaya Sundararajan · Paul Desmond · Alexander JV Thompson · Sally J Bell

The access of Indigenous patients to kidney transplantation needs to be improved

Namrata Khanal · Paul D Lawton · Alan Cass · Stephen P McDonald

A reliable and reproducible approach to determining the incidence and mortality rates of sepsis in Australian ICUs is needed

Manon Heldens · Marinelle Schout · Naomi E Hammond · Frances Bass · Anthony Delaney · Simon R Finfer

Substantial variation in inpatient rehabilitation rates is unexplained by patient factors, suggesting some low value care

Chris Schilling · Catherine Keating · Anna Barker · Stephen F Wilson · Dennis Petrie

The doctor–patient relationship can benefit from discussing health-related internet searches by adult patients

Anthony M Cocco · Rachel Zordan · David McD Taylor · Tracey J Weiland · Stuart J Dilley · Joyce Kant · Mahesha Dombagolla · Andreas Hendarto · Fiona Lai · Jennie Hutton

Relative survival for patients with B-cell non-Hodgkin lymphoma improved significantly with the introduction of rituximab

Fraser Wright · Greg Hapgood · Aravi Loganathan · Nathan Dunn · Shoni Philpot · Julie Moore · Peter Mollee