Emergency medicine

TO THE EDITOR: After a high‐pressure injection injury with an oil‐adjuvant vaccine many patients are triaged exclusively as a needlestick injury. This incomplete classification reduces the likelihood for early identification of local or systemic infections or injury, zoonoses or allergic or anaphylactic reactions.1 A review of European agricultural workers showed that of 59 patients who experienced needlestick injuries, 20 cases (34%) involved oil‐adjuvant vaccines.2 Surgical intervention was reported in only 25 patients (42%),2 contradicting product label directions, which instruct that the wound should be incised and irrigated to remove the vaccine. A similar need for an improved treatment plan was recently articulated after a high‐pressure injection injury from a ruptured hydraulic hose in an Australian farmer.3,4 Oil in water emulsions are commonly used by Australian farmers to vaccinate sheep and goats against Mycobacterium avium subsp. paratuberculosis, which causes the chronic wasting condition ovine Johne disease in ruminants and camelids. The Australian Pesticides and Veterinary Medicines Authority (APVMA) is the independent federal authority that regulates the safe supply and use of veterinary medicines and agricultural chemicals for sale in Australia. The APVMA maintains the Australian Adverse Experience Reporting Program, which is a post‐market program that monitors roughly 5500 reports received annually from product registrants, medical and veterinary professionals, and members of the public. An epidemiological review shows that the peak time of year for high‐pressure oil‐adjuvant injection injuries in Australian adverse experience reports is in spring and summer (October–February), when livestock vaccination programs for young animals are at their peak. Potentially serious long term adverse outcomes, including amputation, are possible without appropriate early intervention as described on the product label.2,3,4 Of the 210 adverse experience reports in humans related to mineral oil injections reported over the life of all registered products, the most common immediate reactions mimicked those of a sharps injury: needlestick injury, a reaction at the injection site, pain and swelling (Australian Adverse Experience Reporting Program data). In order to be prepared for the high volume season for livestock vaccination programs, the APVMA recommends that medical professionals, particularly those serving populations heavily involved with primary production, revisit best practices for the management of this type of injury (Box). Health services are encouraged to include “high‐pressure injection injury” as a triage entry option to reduce the potential misinterpretation of a “needlestick injury” entry.4 Appropriate early intervention reduces the risk of subsequent complications and adverse outcomes. Underpinning the entire process is a need for health care professionals to receive appropriate training to recognise injuries of this type and initiate early intervention as per the product label and the manufacturer's instructions. Box – An example of appropriate triage and treatment for a patient presenting with a high‐pressure injection injury* *The green box indicates the occurrence of an injection incident, based on data from the Australian Adverse Experience Reporting Program. Checkpoint steps in the process that can have a significant impact on patient outcomes if omitted are indicated by orange boxes. † This is the most common formulation for injections containing Mycobacteria

Elvira Currie · Rhian Cope · Margaret C Hardy

TO THE EDITOR: Skin disease contributes to the health disadvantage of Indigenous Australians, and the recent publication of the healthy skin guidelines is welcome.1 Scabies is a significant health problem for some remote Indigenous communities, and the healthy skin guidelines describe a series of community‐based scabies control programs. These programs resulted in initial reductions in prevalence of scabies, but they were not sustained, as human scabies was eventually reintroduced.1 The guidelines used a systematic literature review to ensure that all relevant research was included. However, since the review of scabies was limited to studies of human scabies, implications of canine scabies may have been overlooked.2,3 Therefore, a statement such as “dog control programs are of no benefit to the community control of human scabies infestations” requires scrutiny. Canine scabies mites are distinguishable from human scabies mites by genotyping.4 Clinically, canine scabies can cause a transient human infestation, with no ongoing transmission cycle. The lesions of canine scabies occur primarily on body areas that have been in contact with dogs, and are intensely itchy after a shorter period compared with lesions of human scabies. The infestation is self‐limiting unless the person is reinfested.5 As with human scabies, the intense itch from infestation by canine scabies can lead to scratching and skin trauma, providing an entry point for bacterial infection. Complications such as post‐streptococcal glomerulonephritis and chronic renal disease can also arise from canine scabies. Moreover, outbreaks of scabies in humans can be caused by repeated transmission of canine scabies.5 Management of people affected by canine scabies includes treatment of affected dogs and their contacts.3 Comprehensive dog health programs provide broad‐based community benefits, including reduced injuries from dog attacks, improved community and workplace safety, reduced sleep disturbance from barking and fighting dogs, and enhanced dogs’ appearance, behaviour and wellbeing. Dogs are considered family members in some Aboriginal and Torres Strait Islander communities, sharing housing, bedding and food; hence, human and dog health and wellbeing are intimately linked. No trials have yet examined the impact of dog health programs on scabies transmission in humans or other health outcomes in the remote Indigenous communities where scabies is a public health problem.2 Without evidence from trials, the impact, or lack thereof, of dog health programs on human health is speculative.

Rosalie Schultz

My Health Record can support emergency department clinicians by providing timely and secure access to patients’ clinical histories

Paul Miles · Andrew Hugman · Angela Ryan · Fiona Landgren · Grace Liong

Decision support tools driven by artificial intelligence are a new clinical method that clinicians need to embrace

Christopher Pearce · Adam McLeod · Natalie Rinehart · Robin Whyte · Elizabeth Deveny · Marianne Shearer

TO THE EDITOR: We congratulate Heldens and colleagues1 for their work investigating the prevalence and mortality of sepsis within a tertiary hospital intensive care unit (ICU). As the authors rightly point out in their article and podcast, this requires careful screening, consistent diagnostic criteria, and considerable time and effort. The Australian and New Zealand Intensive Care Society (ANZICS) registry provides a highly specific, widely applicable, cost‐effective, timely and practical epidemiological measure of the prevalence and outcomes of sepsis and septic shock as a primary cause of ICU admissions throughout Australia and New Zealand.2 Findings from the registry appear consistent with those of Heldens and colleagues.1 However, their article confirms that there are more patients with sepsis within our ICUs than those who enter with this as an admission diagnosis. Between January 2016 and June 2018, 11.6% (43 529/374 442) of the ICU admissions reported to the ANZICS Adult Patient Database were due to sepsis as defined by the international Sepsis‐3 taskforce.3 In tertiary hospital ICUs, this was slightly higher at 12.1% (19 204/159 067), which is between 14.0% (121/864) by clinical criteria and 11.3% (98/864) by database criteria found within the first 24 hours of ICU admission by Heldens et al. With the recent addition of information about vasopressors and lactate levels, ANZICS can also now confidently identify patients with septic shock. Of 59 069 ICU admissions with available information, 3.3% (1978) had septic shock, again similar to the findings of Heldens et al. ICU admissions in the ANZICS registry due to sepsis or septic shock were associated with mortality of 15.1% and 26.7%, respectively. Heldens et al reported a similar mortality of 24% (8/33) with septic shock identified in the first 24 hours of admission (Appendix, table 4). The study by Heldens et al and the findings from the ANZICS registry are complementary. Together they highlight how the measurement of sepsis depends on the exact definition applied, and the population under consideration, which may vary between clinical practice, prospective observational and interventional studies, and widespread epidemiological comparisons.

David Pilcher · Sue Huckson · Peter Hicks

To the Editor: Behavioural and psychological symptoms of dementia can manifest as aggression directed towards staff or other residents,1 often culminating in recourse to the local emergency department as a “permanent solution”. What does the law say? Under Division 2, User Rights Principles 2014 (section 96-1, Aged Care Act 1997), the only circumstances in which a provider may ask a care recipient to leave a residential care service are if (i) the service is closing; or (ii) the service no longer provides suitable accommodation and care (as assessed by an aged care assessment team or at least two medical or other health practitioners chosen by the recipient who are competent to assess their care needs) and the provider has not agreed to provide the care that the recipient presently needs; or (iii) the recipient no longer needs the care provided, as assessed by an aged care assessment team; or (iv) the recipient has not paid any agreed fees for a reason within their control; or (v) or the recipient has intentionally caused serious damage to the service or serious injury to staff or another care recipient; or (vi) the recipient is away continuously for 7 days or more from the service for reasons not permitted by the Aged Care Act or an emergency. The approved provider must neither imply nor take action to make the care recipient leave, unless suitable alternative accommodation is available that is affordable and meets the care recipient’s needs. Written notice must be given of the decision and reasons for it. A person cannot be asked precipitously to leave a nursing home or, in practical terms, hospital staff or family cannot be told that a bed is no longer available without adhering to the guidelines above. Intention regarding injury and behavioural and psychological symptoms of dementia is complex and cannot be used as grounds for discharge without proper assessment. An alternative is to use the Dementia Behaviour Management Advisory Service and Severe Behaviour Response Teams (24-hour helpline: 1800 699 799), which provide clinical support for carers of people with behavioural and psychological symptoms of dementia. Aged care consumers need to be aware of their rights around security of tenure, and facilities should be resourced sufficiently to fulfil their commitments under the Aged Care Act to care for residents with behavioural and psychological symptoms of dementia.

Carmelle Peisah · Tiffany Jessop · Henry Brodaty

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

To the Editor:Tick-borne infectious diseases, including rickettsial infections, acquired in Australia or after international travel remain a diagnostic challenge.1 A 68-year-old man presented with umbilical pain 10 days after returning from a 2-month camping trip through the south-west of the United States (ie, Texas, New Mexico, Arizona, Colorado and Utah). On examination, a live tick was detected and removed from the patient’s umbilicus (Box). The umbilical pain resolved after tick removal. There was no development of fevers, constitutional symptoms, or rash to suggest a tick-borne illness. Laboratory investigations were unremarkable. He was educated about the signs and symptoms of tick-borne illnesses and prescribed a single dose of doxycycline 200 mg for prophylaxis due to his high risk exposure. The tick was identified as Dermacentor andersoni (Rocky Mountain wood tick), which is endemic to North America and not known to occur in Australia.2 D. andersoni adult ticks are principal vectors of Rickettsia rickettsii (the cause of Rocky Mountain spotted fever), and are associated with transmission of other pathogens to humans, including Colorado tick fever virus and Francisella tularensis (the cause of tularemia).2,3 Although isolated from D. andersoni ticks, transmission of Coxiella burnetii (the cause of Q fever) is uncommon. D. andersoni is not known to transmit Lyme disease.2 Analysis of the tick for rickettsial DNA was positive. No Borrelia DNA was detected. Rickettsia was isolated in cell culture and identified as Rickettsia peacockii based on sequencing of the 17kDa, OmpB, gltA and Sca4 genes. R. peacockii is a member of the spotted fever group of rickettsiae.3,4 The presence of R. peacockii in ticks is correlated with reduced prevalence of R. rickettsii.2,3 R. peacockii is closely related to R. rickettsii, and deletion or mutation of genes, possibly resulting in loss of virulence in R. peacockii, have been identified.3 R. peacockii is not known to be a pathogen of humans or other animals.3,4 Rickettsial serology 10 weeks after the tick bite showed detectable antibodies (titre, 1/256), predominantly to the spotted fever group of Rickettsia, compatible with exposure to R. peacockii identified in the tick. Unfortunately, definitive seroconversion or a rising antibody titre was not able to be demonstrated as no earlier sera were available for parallel testing. Pre-existing antibodies from a distant rickettsial exposure from his tick-prone lifestyle (history of extensive international camping trips) cannot be excluded. The patient remains asymptomatic 9 months later and is still an avid traveller. Tick-borne rickettsial infections in Australia include Queensland tick typhus (Rickettsia australis), Flinders Island spotted fever and Australian spotted fever (Rickettsia honei) and Q fever transmitted by ticks including Ixodes spp., Amblyomma triguttatum and Bothriocroton hydrosauri.1 With increasing international travel, recognition of tick-borne rickettsial diseases is becoming more important. Dermacentor ticks have been detected on livestock exported from North America into Europe.5 This case shows the ability of human ectoparasites, and their potentially pathogenic bacteria, to bypass stringent Australian quarantine controls. Further studies of Australian and imported tick-borne infections are required to increase understanding of these emerging infectious diseases. Box – Dermacentor andersoni removed from the patient’s umbilicus

Sadid F Khan · Mythili Tadepalli · John Stenos · Stephen R Graves · Tony M Korman