Research

Objective: To review patients with severe bilateral vestibular loss associated with gentamicin treatment in hospital. Design and setting: A retrospective case series of presentations to a balance disorders clinic between 1988 and 2010. Main outcome measures: Relationship between vestibulotoxicity and gentamicin dose or dosing profile; indications for prescribing gentamicin. Results: 103 patients (age, 18–84 years; mean, 64 years) presented with imbalance, oscillopsia or both, but none had vertigo. Only three noted some hearing impairment after having gentamicin, but audiometric thresholds for all patients were consistent with their age. In all patients, the following tests gave positive results: a bilateral clinical head-impulse test, a vertical head-shaking test for vertical oscillopsia, and a foam Romberg test. In 21 patients, imbalance occurred during gentamicin treatment (ignored or dismissed by prescribers in 20) and in 66 after treatment; the remaining 16 could not recall when symptoms were first noticed, except that it was after gentamicin treatment in hospital. Total gentamicin dose range was 2–318 mg/kg (mean, 52 mg/kg), daily dose range was 1.5–5.6 mg/kg (mean, 3.5 mg/kg), and duration was 1–80 days (mean, 17 days). Six patients had only a single dose; 26 had five or fewer doses. Serum gentamicin levels, measured in 82 patients, were in the recommended range in 59. Time to diagnosis ranged from 4 days to 15 years. Nephrotoxicity developed in 43 patients. Gentamicin dosage complied with contemporary or current Australian antibiotic guidelines in under half the patients. Conclusions: Gentamicin ototoxicity is vestibular, not cochlear, producing permanent loss of balance, but not of hearing. Gentamicin can be vestibulotoxic in any dose, in any regimen, at any serum level.

Rebekah M Ahmed MB BS, FRACP · Imelda P Hannigan RN · Hamish G MacDougall PhD · Raymond C Chan MB BS, FRACP, FRCPA · G Michael Halmagyi MD, FRACP

To describe the experience of hormone treatment of gender identity disorder (GID) in children and adolescents within a specialist clinic. Design, patients and setting: Cohort study by medical record review of children aged 0–17 years referred during 2003–2011 for management at the GID clinic in a tertiary paediatric referral centre — the Royal ...

Jacqueline K Hewitt MB BS, FRACP · Campbell Paul MB BS, FRANZCP · Porpavai Kasiannan DPM, MD, FRANZCP · Sonia R Grover MB BS, MD, FRANZCOG · Louise K Newman MB BS, PhD, FRANZCP · Garry L Warne MB BS, FRACP

Objective: To determine the risk and timing of a broad range of infective outcomes and mortality after splenectomy.Design, setting and participants: Analysis of a non-identifiable linked hospital discharge administrative dataset for splenectomy cases between July 1998 and December 2006 in Victoria, Australia.Main outcome measures: Age, sex, indication for splenectomy, infectious events ...

Claire Dendle MB BS, FRACP, GCHPE · Vijaya Sundararajan MD, MPH, FACP · Tim Spelman MB BS, BSc, GradCert(Stats) · Damien Jolley MSv(Epi), MSc(Stats) · Ian Woolley MB BS, FRACP, DTMH

Further studies are needed to develop evidence-based recommendations for vaccinations and prophylactic antibiotic regimensThroughout the ages, the function of the spleen was subject to much conjecture. It was variously thought to be both the centre of melancholy by the French and the centre for anger by the English (“to vent one’s spleen”). Of no doubt ...

David F M Looke FRACP, FRCPA, MMedSci · Naomi J Runnegar MB BS, FRACP, FRCPA

Objective: To determine the geographical, epidemiological and clinical features of sporotrichosis (a cutaneous fungal infection caused by Sporothrix schenckii) in the New South Wales mid-north coast.Design and setting: We undertook a retrospective case review of S. schenckii infections that occurred during the period 2000–2010. Microbiology laboratory staff and medical practitioners in ...

Shobini Sivagnanam BSc(Med), MB BS · Aiveen M Bannan MB BS, FRACP, MPH · Sharon C-A Chen FRACP, FRCPA, PhD · Anna P Ralph MB BS, FRACP, PhD

Objective: To determine whether the introduction of an acute surgical unit (ASU) resulted in a greater proportion of patients with acute cholecystitis receiving definitive surgery on index admission with no adverse change in surgical outcomes.Design, setting and participants: A retrospective study of medical records for patients presenting to Nepean Hospital with ...

Lester Pepingco BMedSc, MB BS(Hons) · Guy D Eslick PhD, FACE, FFPH · Michael R Cox MB BS, FRACS, MS

Objective: To describe the management and outcomes of a population-based cohort of patients with pancreatic cancer in Victoria, Australia.Design, setting and patients: Retrospective study based on questionnaires completed from medical histories of patients diagnosed with pancreatic cancer during 2002–2003 in Victoria who were identified from the Victorian Cancer Registry and followed up ...

Antony G Speer BE, MB BS, FRACP · Vicky J Thursfield BSc, GradDip(ApplStats) · Yvonne Torn-Broers BA(Hons) · Michael Jefford MB BS, PhD, FRACP

Objectives: To determine current colorectal cancer (CRC) screening rates and the level of adherence to screening guidelines at a community level.Setting: A cross-sectional cohort of at-risk people aged 56–88 years randomly selected from the Hunter Community Study (HCS), Australia.Main outcome measures: Proportion ever reporting undertaking any CRC testing; current screening ...

Ryan J Courtney BPsych(Hons) · Christine L Paul PhD · Robert W Sanson-Fisher PhD, MClinPsych · Finlay A Macrae MD, FRACP, FRCP · Mariko L Carey PhD · John R Attia MD, PhD · Mark A McEvoy MClinEpi

Objectives: To identify barriers to and facilitators of colorectal cancer (CRC) screening participation among different cultural subgroups in South Australia, and to describe how these might be shared or be distinct across these groups.Design, participants and setting: Qualitative study using individual interviews in Adelaide, South Australia, between July 2009 and December 2010. ...

Sara Javanparast MD, PhD · Paul R Ward PhD · Stacy M Carter MPH(Hons), PhD · Carlene J Wilson BA(Hons), MBA, PhD

Objectives: To document the existence and provisions of Australian universities’ policies on the competing interests of academic staff and university practices in recording, updating and making these declarations publicly accessible. Design and setting: ...

Simon Chapman PhD · Bronwen Morrell BA(Hons) · Rowena Forsyth BA(Hons), PhD · Ian Kerridge BMed(Hons), FRCPA, FRACP · Cameron Stewart BEcLLB(Hons1), PhD, FACLM(Hons)

Objectives: To measure eligibility for medical thromboprophylaxis using two Australasian guidelines — the Australia and New Zealand Working Party Guidelines [WPG] and the National Health and Medical Research Council Guidelines [NHMRCG]) — and ...

J Alasdair Millar PhD, FRACP, FRCP · Joanne E Lett MB ChB · Leonard J Bagley BPharm · Ian K Densie BSR

Objective: To assess the use of Prothrombinex-VF powder for injection (PTX-VF) at Royal Perth Hospital and analyse the efficacy and safety profile of PTX-VF.Design, setting and patients: A prospective observational audit ...

Paul C Kruger MB BS · Annette S Le Viellez BSc(MedSci) · Richard P Herrmann MB BS, FRCPA, FRACP

Objective: To determine the incidence of and factors associated with vitamin D deficiency rickets in Australian children.Design: 18-month questionnaire-based prospective observational study, using Australian Paediatric Surveillance Unit (APSU) data.Setting: ...

on behalf of the APSU Vitamin D Study Group

Objectives: To document and describe outpatient persistent pain management services in Australia.Design, participants and setting: Systematic survey conducted between 1 December 2008 and 31 January 2010 of 57 services providing outpatient care to adult clients with persistent pain, plus five specialised paediatric services throughout Australia.Main outcome measures: Service structure, including funding processes; activity, including client numbers, access to specialised services (inpatient care, pain relief interventions); waiting times; and use of allied-health-professional-based pain management programs.Results: Of 68 services identified, 57 participated in the study. The median waiting time from referral receipt to initial clinical assessment for a publicly funded outpatient adult pain management service was 150 days, compared with 38.5 days for a privately funded service (P < 0.05). There was substantial variability among providers in range of services offered, including provision and duration of allied-health pain management programs. The level of service provision for children and rural patients is notably lower than that reported for urban adult constituents.Conclusions: Persistent pain management services are currently unable to meet service requirements adequately, and waiting times are more prolonged for publicly funded than privately funded services. Greater service provision is required in rural areas and for children.

Malcolm N Hogg MB BS, GrDip(PM), FFPANZCA · Stephen Gibson BBSc, PhD · Amal Helou BHlthSc(Nursing), MM(PM) · Jacklyn DeGabriele BHlthSc(Nursing), GrDip(Midwifery) · Michael J Farrell BAppSc(Phty), MSc(Gerontology), PhD

Objective: To assess whether patients receiving opioid substitution therapy (OST) in general practice cause other patients sufficient distress to change practices — a perceived barrier that prevents general practitioners from prescribing OST.Design, setting and participants: A cross-sectional questionnaire-based survey of consecutive adult patients in the waiting rooms of a network of research general practices in New South Wales during August – December 2009.Main outcome measures: Prevalence of disturbing waiting room experiences where drug intoxication was considered a factor, discomfort about sharing the waiting room with patients being treated for drug addiction, and likelihood of changing practices if the practice provided specialised care for patients with opiate addiction.Results: From 15 practices (eight OST-prescribing), 1138 of 1449 invited patients completed questionnaires (response rate, 78.5%). A disturbing experience in any waiting room at any time was reported by 18.0% of respondents (203/1130), with only 3.1% (35/1128) reporting that drug intoxication was a contributing factor. However, 39.3% of respondents (424/1080) would feel uncomfortable sharing the waiting room with someone being treated for drug addiction. Respondents were largely unaware of the OST-prescribing status of the practice (12.1% of patients attending OST-prescribing practices [70/579] correctly reported this). Only 15.9% of respondents (165/1037) reported being likely to change practices if theirs provided specialised care for opiate-addicted patients. In contrast, 28.7% (302/1053) were likely to change practices if consistently kept waiting more than 30 minutes, and 26.6% (275/1033) would likely do so if consultation fees increased by $10.Conclusions: Despite the frequency of stigmatising attitudes towards patients requiring treatment for drug addiction, GPs’ concerns that prescribing OST in their practices would have a negative impact on other patients’ waiting room experiences or on retention of patients seem to be unfounded.

Simon M Holliday FAChAM, FRACGP, FACRRM · Parker J Magin PhD, FRACGP · Janet S Dunbabin PhD · Ben D Ewald MClinEpid, PhD · Julie-Marie Henry RN, DipAppSc(Nursing) · Susan M Goode BSc(Hons), DipMgmt · Fran A Baker BMath · Adrian J Dunlop PhD, GradDipEpi

Objective: To describe values of serum prostate-specific antigen (PSA) in older men without diagnosed prostate cancer, categorised by age and country of birth, and to describe self-reported prostate cancer screening. Design, participants and setting: A cohort study (the Concord Health and Ageing in Men Project) involving a representative sample of 1434 eligible ...

Melisa J Litchfield BAppSc, MPH(Hons) · Robert G Cumming MB BS, MPH, PhD · David P Smith BA, MPH, PhD · Vasi Naganathan MB BS, FRACP, PhD · David G Le Couteur FRACP, PhD · Louise M Waite MB BS, FRACP, PhD · Fiona M Blyth MB BS(Hons), FAFPHM, PhD · David J Handelsman MB BS, FRACP, PhD

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