Research

Objectives: To test whether a summative workplace-based assessment (WBA) is feasible and acceptable for international medical graduates (IMGs). Design, setting and participants: A 6-month trial with 27 IMGs from teaching hospitals in Newcastle, Australia. IMGs were assessed by 65 trained assessors from different disciplines, using blueprinted ...

Balakrishnan R Nair AM, FRACP, FRCP, GradDipClinEpi · Michael J Hensley MB BS, PhD, FRACP · Mulavana S Parvathy MB BS, FRACGP · Deborah M Lloyd BA(Hons), DipEd, PhD · Brooke Murphy BA, MA, BLegStud · Kathy Ingham DipPractMgt, DipTrainAssess, DipBusMan · Julie M Wein DipBusMan · Ian M Symonds DM, FRCOG, FRANZCOG

Objectives: To explore the burden of illness associated with infectious syndromes and to measure the associated use of antimicrobials in residential aged care facilities (RACFs).Design, setting and subjects: Retrospective analysis of data for January 2006 to December 2010 from an infection surveillance system covering residents of four co-located RACFs, with a total of 150 residential care beds, in Melbourne, Victoria.Main outcome measures: Number of episodes and incidence of health care-associated infection (HCAI); rate of antimicrobial use; prescribing concordance with McGeer criteria for infection; frequency of clinical specimen collection.Results: There were 1114 episodes of an infectious syndrome over 267 684 occupied bed-days (OBD), affording an average HCAI rate of 4.16 episodes/1000 OBD annually over 5 years (95% CI, 3.92–4.41). The mean rate of antimicrobial use was 7.07 courses/1000 OBD (range, 6.71–7.84). Around 40% of antimicrobial prescribing was for episodes that did not fulfil the McGeer criteria for clinical infection; this included about half of suspected urinary tract and upper respiratory tract infections (URTI), and about one-third of suspected lower respiratory tract and skin infections. Antimicrobials were routinely prescribed for URTI and bronchitis. Of all episodes treated with antimicrobials, 36% had documentation that a clinical specimen was obtained.Conclusions: The HCAI rate remained relatively stable over time. Routine surveillance and feedback of infection rates to the facilities did not result in a noticeable decrease of infection burden over time. It is of immediate concern that antimicrobials were being prescribed for a large proportion of suspected infections that did not meet criteria for clinical infection. Opportunities exist to further improve the use of antimicrobials in the RACF setting.

Ching Jou Lim BPharm(Hons) · Susan C McLellan RN, GradCert InfectControl, GradDipNSInfectControl · Allen C Cheng FRACP, MPH, PhD · Joanne M Culton RN, GradCert InfectControl · Sneha N Parikh BA · Anton Y Peleg* MB BS, PhD, FRACP · David C M Kong* BPharm, MPharm, PhD

Objectives: To determine incidence and trends in antibiotic resistance in Australian Salmonella enterica subspecies enterica serovars Typhi (S. Typhi) and Paratyphi (S. Paratyphi) isolates over the past 26 years.Design: A retrospective analysis of consecutive microbiologically confirmed enteric fever isolates.Participants and setting: All S. Typhi and S. Paratyphi isolates from patients diagnosed with enteric fever in Australia between 1985 and 2010.Main outcome measures: Incidence and variation in antibiotic resistance over time and according to country of origin.Results: We analysed 2551 isolates, which originated from 74 countries or regions, mainly India (33%) and Indonesia (22%). The incidence among Australian residents increased from four to five before 2003 to seven cases per million person-years after 2003. Multidrug resistance (chloramphenicol, ampicillin, trimethoprim) and nalidixic acid resistance emerged rapidly from the early 1990s, with nalidixic acid resistance increasing to 70% in 2009–2010, while multidrug resistance was relatively stable at between 4% and 11%. Nalidixic acid and multidrug resistance rates are highest in isolates from the Indian subcontinent. Some countries in South-East Asia, such as Indonesia, had very low rates of resistance; however, this varied across the region.Conclusions: Nalidixic acid resistance has become widespread in enteric fever isolates from the Indian subcontinent and some parts of South-East Asia, justifying the use of ceftriaxone or azithromycin rather than ciprofloxacin as first-line treatment. However, resistance in some countries remains rare, potentially allowing treatment to be adjusted according to country of origin.

Robert J Commons MB BS, BMedSci, DipObsGyn · Emma McBryde MB BS, FRACP, PhD · Mary Valcanis BSc, MPH · Joan Powling BAgrSc · Alan Street MB BS, FRACP · Geoff Hogg BM, BS, FRACP

Objective: To estimate the number of cancers to be diagnosed in 2025 that could be prevented solely due to changes in diet and physical activity.Design and setting: We used an Australian population-based cancer database to estimate the total number of cancers to be diagnosed in 2025, by applying published age- and sex-specific population projections to current cancer incidence rates, and multiplying the projected numbers of cancers by estimates of population-attributable fractions.Main outcome measures: Projected number of preventable cancers that would be diagnosed in 2025.Results: Our projections suggest that there will be about 170 000 Australians diagnosed with cancer in 2025. This represents an increase of about 60% on the 2007 incidence. Almost 43 000 of these cancers (low estimate, 42 295; middle, 42 657; high, 43 990) could be prevented through improvements to diet and physical activity levels, including through their impact on obesity. It is likely that this is an underestimate of the true figure. The most preventable cancer types in 2025 were estimated to be bowel cancer and female breast cancer (10 049 and 7273 preventable cases, respectively).Conclusions: About 25% of cancers, or about 43 000 cancers in 2025, can potentially be prevented through improvements in diet and physical activity. It is imperative that governments, clinicians and researchers act now if we are to reduce the significant future human and financial burden of cancer.

Peter D Baade PhD · Xingqiong Meng PhD, MD · Craig Sinclair MPPM, BEd · Philippa Youl MPH

Objective: To describe the epidemiology, clinical features and diagnosis of Mycobacterium ulcerans infection occurring on the Bellarine Peninsula in Victoria. Design, setting and patients: Analysis of prospectively collected data on all patients with confirmed M. ulcerans infection reported from the Bellarine Peninsula and managed at Barwon Health ...

Sarah C Boyd MB BS · Eugene Athan MB BS, FRACP · N Deborah Friedman MB BS, FRACP · Andrew Hughes MB BS, FRACP · Aaron Walton MB BS, FRACP · Peter Callan MB BS, FRACS · Anthony McDonald MB BS, FRACS · Daniel P O’Brien MB BS, FRACP

Objective: To compare the unprecedented 91 cases of melioidosis in the Top End of the Northern Territory of Australia from 1 October 2009 to 30 September 2010 with the 540 cases in the preceding 20 years and postulate reasons for this year of very high melioidosis incidence.Design, setting and participants: Review of prospectively collected data on all patients with culture-confirmed melioidosis at Royal Darwin Hospital, the Top End’s tertiary referral centre, since 1 October 1989.Main outcome measures: Population-based annual incidence of melioidosis; differences in epidemiology, clinical presentations and outcomes for 2009–2010 compared with the preceding 20 years.Results: In 2009–2010, the estimated population-based incidence of melioidosis was 50.2 cases per 100 000 in the Top End population overall, and 102.4 cases per 100 000 in the Top End Indigenous population. The proportion of patients acquiring melioidosis in the Darwin urban area increased from 49% in 1989–2009 to 65% in 2009–2010 (OR, 1.96; 95% CI, 1.20–3.19). Among the 49 Indigenous Australian patients with melioidosis in 2009–2010, 63% acquired the infection in Darwin, compared with 35% of Indigenous patients in the previous 20 years (OR, 3.17; 95% CI, 1.62–6.24).Conclusions: In 2009–2010, the Top End had the highest annual incidence of melioidosis documented from anywhere to date. The prominent increase in cases in Darwin was associated with above average rainfall in Darwin during December 2009 to February 2010. The increase in the proportion of Indigenous Australians who acquired melioidosis in Darwin may reflect movement of some Indigenous people into Darwin from remote communities.

Uma Parameswaran MB BS · Robert W Baird MB BS, FRACP, FRCPA · Linda M Ward BAppSci, MMedSci · Bart J Currie FRACP, FAFPHM, DTMTH

Each year, over 1000 medical device incidents are reported to the Australian Therapeutic Goods Administration (TGA). The most recent published statistical reports from this scheme show 926 reports in 6 months (January–June 2009), of which 597 resulted in serious injury and 25 were associated with patient death. The 3 Fr peripherally inserted central catheter (PICC) is a medical device commonly used in infants ...

Joel M Dulhunty MB BS, MTH, PhD · Andreas Suhrbier BA, PhD · Graeme A Macaulay BEng(Med) · Jennifer C Brett BEng(Med) · Alexa V A van Straaten BA(Hons), MA, MPhil · Ian M Brereton BSc, PhD · Jillann F Farmer MB BS, FRACGP, FRACMA

Objective: To describe the frequency, characteristics and outcomes of reports of possible harms related to medical devices submitted to the Australian Therapeutic Goods Administration (TGA) using data made publicly available on the TGA website.Design and setting: A retrospective analysis, conducted in January 2012, of data made publicly available on the TGA website from January 2000 to December 2011.Main outcome measures: The number and nature of reports of medical device incidents, recalls and alerts.Results: Up to December 2011, 6812 incidents involving medical devices were reported to the TGA, although there were several periods where data were unavailable. Incidents were reported more frequently in later years, most often by device sponsors, and were often attributed to mechanical problems. 295 deaths and 2357 serious injuries have been related to incidents, with serious injury (597) highest in 2009. Most incidents involving medical devices were not investigated (47.5%), or, after investigation, no further action was taken (25.0%). During the same time period, there were 35 medical device recalls and 34 medical device alerts issued by the TGA, with no consistent increase over time.Conclusions: Despite TGA reform proposals, greater transparency is still needed. Issues that have not been addressed include patchy and conflicting data in the public domain and lack of explanations for the large proportion of uninvestigated reports. To maintain public confidence in the national regulatory system these problems need to be resolved.

Richard G McGee PGDipSurgAnat, MMed(ClinEpi) · Angela C Webster MMed(ClinEpi), PhD · Thomas E Rogerson BSc · Jonathan C Craig MMed(ClinEpi), PhD

In Australia, regionalised maternity care aims to ensure provision of the appropriate level of care to all women, through assessment of risk, referral and transfer. An important element of this care is providing high-quality, safe and accessible services to women and babies in rural and remote areas. For women who experience pregnancy complications, this means their needs may not necessarily be met by their local hospital. They may be admitted ...

Tim Badgery-Parker BSc(Hons), MBiostat · Jane B Ford BA(Hons), PhD · Mary G Jenkins RN, CM, MScM · Jonathan M Morris MB ChB, FRANZCOG, PhD · Christine L Roberts MB BS, FAFPHM, DrPH

Objective: To determine if the improvement in inpatient glycaemic control observed with basal–bolus insulin (BBI) over sliding-scale insulin (SSI) in the formal study setting translates to routine clinical conditions.Design, setting and patients: Cross-sectional study in which capillary blood glucose levels (BGLs) were prospectively measured four times daily for up to 8 days in 124 patients with type 2 diabetes admitted to a tertiary teaching hospital and treated with BBI between November 2008 and May 2010. Data from the BBI treatment group were compared with retrospective data from 96 patients treated with SSI between June 2001 and May 2006.Main outcome measures: Mean daily BGL; independent effect of insulin regimen on mean daily BGL.Results: Mean baseline BGL was not significantly different in patients receiving BBI and SSI (mean ± SD, 11.3 ± 4.1 v 10.6 ± 4.3 mmol/L; P = 0.23). After the first full day of therapy, mean daily BGL for patients receiving BBI was 1.6 ± 3.7 mmol/L lower than baseline BGL, and it remained 1.6–2.4 mmol/L lower than baseline throughout the study (P < 0.001). In contrast, there was no significant change in BGL for patients receiving SSI. Random effects regression analysis indicated that BBI was associated with a significantly lower mean daily BGL than SSI, independent of other variables (P < 0.001). The incidence of hypoglycaemia (BGL < 4 mmol/L) was significantly greater in patients receiving BBI than SSI (3.3% v 1.4%; P < 0.001), but there was no significant difference for severe hypoglycaemia (BGL < 2.8 mmol/L) (0.3 v 0.5%; P = 0.3).Conclusions: Under routine clinical conditions, BBI is effective and safe across a range of patients and appears to be superior to SSI. Clinical improvements reflected those seen in a strict formal study setting.

Greg W Roberts BPharm, FSHP · Norma Aguilar-Loza BN(Hon) · Adrian Esterman PhD · Morton G Burt MB ChB, PhD · Stephen N Stranks MB BS

Objective: To examine the differential in cancer survival between Indigenous and non-Indigenous people in Queensland in relation to time after diagnosis, remoteness and area-socioeconomic disadvantage.Design, setting and participants: Descriptive study of population-based data on all 150 059 Queensland residents of known Indigenous status aged 15 years and over who were diagnosed with a primary invasive cancer during 1997–2006.Main outcome measures: Hazard ratios for the categories of area-socioeconomic disadvantage, remoteness and Indigenous status, as well as conditional 5-year survival estimates.Results: Five-year survival was lower for Indigenous people diagnosed with cancer (50.3%; 95% CI, 47.8%–52.8%) compared with non-Indigenous people (61.9%; 95% CI, 61.7%–62.2%). There was no evidence that this differential varied by remoteness (P = 0.780) or area-socioeconomic disadvantage (P = 0.845). However, it did vary by time after diagnosis. In a time-varying survival model stratified by age, sex and cancer type, the 50% excess mortality in the first year (adjusted HR, 1.50; 95% CI, 1.38–1.63) reduced to near unity at 2 years after diagnosis (HR, 1.03; 95% CI, 0.78–1.35).Conclusions: After a wide disparity in cancer survival in the first 2 years after diagnosis, Indigenous patients with cancer who survive these 2 years have a similar outlook to non-Indigenous patients. Access to services and socioeconomic factors are unlikely to be the main causes of the early lower Indigenous survival, as patterns were similar across remoteness and area-socioeconomic disadvantage. There is an urgent need to identify the factors leading to poor outcomes early after diagnosis among Indigenous people with cancer.

Susanna M Cramb BAppSc(Med Sci), Grad Cert(Sc), MPH · Gail Garvey BEd, MEd · Patricia C Valery PhD, MD, MPH · John D Williamson BA(Hons), GradCert(PublicHlth), MEpi(Clin Epi) · Peter D Baade BSc, MMedSc, PhD

Objectives: To document temporal trends in maternal overweight and obesity in Australian women and to examine associations with pregnancy outcomes....

H David McIntyre MB BS, FRACP, MD · Kristen S Gibbons BMaths(Hons), BInfoTech · Vicki J Flenady MMedSc(ClinEpid) · Leonie K Callaway MB BS, PhD, FRACP

Objectives: To examine the prevalence of overweight and obesity in Australian secondary school students and identify factors associated with excess adiposity....

on behalf of the NaSSDA Study Team*

Plotting the trajectory of some common artery conditions.

on behalf of the REACH Registry Investigators

Putting a team-based intervention approach to the test.

Sandy M Hopper FRACP, FACEM · Franz E Babl MD, FRACP, FACEP · Claire E Stewart PGDipENB, RN · Jia Wei Woo BSc, MB BS

Objective: To assess whether emergency department (ED) overcrowding was reduced after the introduction of the 4-hour rule in Western Australia and whether any changes in overcrowding were associated with significant changes in patient mortality rates.

Gary C Geelhoed FRACP, FACEM, MD · Nicholas H de Klerk BSc, MSc, PhD

The first report on the 4-hour rule needs fleshing out.

Drew B Richardson MB BS(Hons), FACEM, GradCertHE

Do demographic changes alone explain our busy EDs?

Judy A Lowthian MPH, BAppSc(SpPath), LMusA · Andrea J Curtis BSc(Hons), PhD · Damien J Jolley MSc(Epidemiology), MSc, AStat · Johannes U Stoelwinder MD, FRACMA, FACHSE · John J McNeil PhD, FRACP, FAFPHM · Peter A Cameron MBBS, MD, FACEM

Substance misuse and intellectual disability take their toll.

Ernest M Hunter FRANZCP · Bruce D Gynther FRANZCP · Carrick J Anderson MB BS · Leigh-ann L Onnis GradDipPH · Jeffrey R Nelson PhD · Wayne Hall PhD · Bernhard T Baune PhD, MD, FRANZCP · Aaron R Groves FRANZCP

Build youth-centric services and they will come.

Elizabeth M Scott BSc(Hons), MB BS, FRANZCP · Daniel F Hermens BSc, GDipSci, PhD · Nicholas Glozier MB BS, FRANZCP, PhD · Sharon L Naismith MCN, DCN, CCN · Adam J Guastella PhD · Ian B Hickie MD, FRANZCP, AM

Objectives: To determine the long-term mortality pattern of adults with severe traumatic brain injury (TBI), and to identify the risk factors associated with death in this group.Design, patients and setting: Inception cohort study of 2545 adults consecutively discharged from one of three metropolitan tertiary, post-acute inpatient rehabilitation services of the New South Wales Brain Injury Rehabilitation Program from 1 January 1990 to 1 October 2007 after inpatient rehabilitation for primary TBI.Main outcome measure: Survival status at 1 October 2009.Results: 258 deaths were recorded in this sample, yielding a standardised mortality ratio of 3.19 (95% CI, 2.80–3.60). Risk of death remained elevated above societal norms for at least 8 years after discharge from rehabilitation. Mortality risk was increased by: functional dependence at discharge; age at injury; pre-injury drug and alcohol misuse; pre-injury epilepsy; and discharge to an aged care facility. The risk of death from external causes, and respiratory system and nervous system disorders was six to seven times higher, and the risk of death from disorders of the digestive system, and mental and behavioural disorders was five times higher in adults with severe TBI than in the general population.Conclusions: People who survive to discharge from inpatient rehabilitation following a severe TBI were found to have a sustained increase in risk of death for eight years post discharge. Various demographic and injury-related variables selectively increase mortality risk and may be modifiable in order to reduce the observed increase in mortality.

Ian J Baguley MB BS, FAFRM, PhD · Melissa T Nott BAppSc(Hons), PhD · Alison A Howle BSpPath · Grahame K Simpson BSocStud, MA, PhD · Stuart Browne MB BS, MD, FAFRM · A Clayton King MB BS, MD, FAFRM · Rachel E Cotter BA(Hons) · Adeline Hodgkinson MB BS, FAFRM

Objectives: To describe the epidemiology and toxicity of caffeinated energy drink exposures in Australia.Design, setting and subjects: Retrospective observational study analysing data from calls regarding energy drink exposures recorded in the database of an Australian poisons information centre over 7 years to 2010.Main outcome measures: Type of exposure; co-ingestants; symptoms reported; and reported hospitalisations.Results: Callers reported 297 exposures to energy drinks, which showed an increasing annual trend from 12 in 2004 to 65 in 2010. Median age for the 217 subjects with recreational exposure was 17 years (interquartile ratio [IQR], 15–21; range, 11–60) and 57% were male. One hundred recreational users co-ingested other substances, predominantly alcohol (50) or other caffeinated products (44). The number of energy drinks consumed in one session varied greatly (median, 5 units; IQR, 3–8; range, 1–80). Most subjects who reported recreational use reported experiencing symptoms (87%). The most common symptoms were palpitations, agitation, tremor and gastrointestinal upset. Twenty-one subjects had signs of serious cardiac or neurological toxicity, including hallucinations, seizures, arrhythmias or cardiac ischaemia. At least 128 subjects (57 with no co-ingestants) required hospitalisation.Conclusions: Reports of caffeine toxicity from energy drink consumption are increasing, particularly among adolescents, warranting review and regulation of the labelling and sale of these drinks. Educating adolescents and increasing the community’s awareness of the hazards from energy drinks is of paramount importance.

Naren Gunja MB BS, FACEM · Jared A Brown BPharm(Hons), MPH

Objective: To explore the current use of conventional and complementary medicines in Australians aged ≥ 50 years.Design, setting and participants: Cross-sectional postal survey sent to a random sample of 4500 Australians aged ≥ 50 years between June 2009 and February 2010.Main outcome measures: Prevalence of medicines use, reasons for medicines use and sources of medicines.Results: Response rate was 37.3%. Medicines use was very common; 87.1% of participants took one or more medicines and 43.3% took five or more in the previous 24 hours. Complementary medicines were used by 46.3% of participants, 87.4% of whom used both conventional and complementary medicines. The most commonly used medicines were antihypertensive agents (43.2% of participants), natural marine and animal products including fish oil and glucosamine (32.4%) and lipid-lowering agents (30.4%). Doctors recommended 79.3% of all medicines and 93.0% of conventional medicines. Pharmacists commonly recommended occasional medicines (ie, as needed), while friends, family and media most often influenced use of complementary medicines.Conclusions: The use of multiple medicines is common and higher than reported in the 1995 National Health Survey. Today, much medicines use is to prevent future disease by influencing risk factors. High levels of polypharmacy highlight the need to support the safe and effective use of medicines in the community. Although doctors recommend or prescribe most medicines, self-directed medication use is common. This highlights the need for consumer access to accurate information and strategies to improve health literacy about medicines.

Tessa K Morgan BSc, BA, MPH · Margaret Williamson BPharm, MPH, GradDipEpi · Marie Pirotta MB BS, MMed, PhD · Kay Stewart BPharm(Hons), PhD · Stephen P Myers PhD, BMed, ND · Joanne Barnes BPharm(Hons), PhD, MRPharmS

Objective: To determine survival rates of patients with lymphoma in South Australia.Design and setting: De-identified data from the SA Cancer Registry on all patients with lymphoma were analysed, as well as the subgroup treated at the Royal Adelaide Hospital (RAH). For non-Hodgkin lymphoma (NHL), we used the International Working Formulation (IWF) grading. SA and RAH data on survival rates were compared with those for the whole of Australia and the United States.Patients: All patients diagnosed with lymphoma and treated in SA in 1977–2007.Outcome measures: 5-year survival rates for patients with lymphoma, by type of lymphoma and age.Results: Of the total of 8651 patients with lymphoma, 939 were classified as having Hodgkin lymphoma (HL) and 7712 as having NHL. Of those with NHL, 1805 had low-grade, 3576 intermediate-grade, and 510 high-grade NHL. In another 1821 patients, the data were insufficient to make an IWF grading. There was a substantial increase in 5-year survival rates for patients with lymphoma between 1977 and 2007 in SA. While the increase in 5-year survival rates for HL was 7.6 percentage points, survival rates peaked at 88%. For NHL, there was an 18.7 percentage points increase in 5-year survival rates. The first significant increase of 7 percentage points was associated with the introduction of bone marrow transplantation; this was maintained with the increase in 5-year survival rates reaching 14 percentage points by 1995–1999. Since 1999, there has been a further increase of 5 percentage points in 5-year survival rates with the introduction of rituximab.Conclusion: Outcomes in patients with NHL have improved significantly, most likely because of the use of bone marrow transplantation and rituximab. Hospital- and state-based cancer registry data reflect the reality of population outcomes and the impact of new technologies.

Brendon J Kearney FRACP, FRACMA, AM · Luen Bik To MB BS, MD, FRACP · Daniel J Kearney MB BS, FRCPA · David Roder MPH, DDSc · Colin G Luke MB BS, MPH, MD · Ian D Lewis PhD, FRACP · Pratyush Giri FRACP, FRCPA

Objective: To determine current and projected supply, demand and shortfall of medical oncologists (MOs) and the Australian chemotherapy utilisation rate.Design, setting and participants: A 2009 cross-sectional observational study of Australian adult medical oncology practice work patterns.Instrument: Electronic or paper self-administered questionnaire.Main outcome measures: The 2009 and projected (2014) supply, demand and shortfall of full-time equivalent (FTE) MOs, and the chemotherapy utilisation rate.Results: 476 medical oncology positions comprising 234 FTE MOs were identified. Of the 150 medical oncology practices, 117 (78%) were in metropolitan locations and 33 (22%) were in rural locations. The average number of new patients seen per FTE MO was 270 patients (ranging by state from 191 to 343). The demand for FTE MOs was estimated at 326 to 391 in 2009 and 361 to 432 in 2014. The shortfall of FTE MOs was estimated at 92 to 157 in 2009 and 84 to 156 in 2014. The chemotherapy utilisation rate was 19%.Conclusions: The current shortage of MOs is expected to persist in the future. National strategies are needed to increase the capacity of the medical oncology workforce and the chemotherapy utilisation rate.

Prunella L Blinman BMed, FRACP · Peter Grimison MPH, PhD, FRACP · Michael B Barton OAM, MD, FRANZCR · Sally Crossing AM, BEc · Euan T Walpole MB BS, FRACP · Nora Wong BCom/BSocSc · Kay Francis BA(Hons), MA(Hons), MBA · Bogda Koczwara MB BS, FRACP, MBioethics