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Environmental health

Statistics Research 29 April 2019 Free

Evaluating recruitment strategies for AUSPICE, a large Australian community‐based randomised controlled trial

Novel, multifaceted recruitment methods are needed to obtain adequate participation in Australian randomised controlled trials

Roseanne Peel · Shu Ren · Alexis Hure · Tiffany‐Jane Evans · Catherine A D'Este · Walter P Abhayaratna · Andrew M Tonkin · Ingrid Hopper · Amanda G Thrift · Christopher R Levi · Jonathan Sturm · David Durrheim · Joseph Hung · Tom G Briffa · Derek P Chew · Phil Anderson · Lynelle Moon · Mark McEvoy · Philip M Hansbro · David A Newby · John R Attia

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Environmental health Expanding the evidence base in digital health 31 March 2019 Open Access

Gathering data for decisions: best practice use of primary care electronic records for research

Despite most Australians having most of their health‐related interactions in the primary care sector, primary care‐based research is disproportionately low. Access to quality EMR data, lack of resources to remunerate GPs, and a lack of understanding among some GPs of the value and importance of secondary use of EMR data are barriers to data sharing. Data extraction tools that enable ethical, secure and privacy‐protected access to routinely collected datasets nationally have been developed. The task now is to build trustworthy primary care data repositories for research that will provide researchers with timely access to quality‐assured general practice data. Linkage with other datasets could enable significant scale‐up of primary care‐based research in Australia, contributing new knowledge in public health, health promotion, economics and evidence‐based clinical care. Technologies that allow consumers to have greater control over how their data are used can provide better options to policy makers, hence investment in this area is essential. Educating clinicians and the public about the need for, and existence of, research based on de‐identified patient medical records has the potential to generate greater social licence and acceptance of this emerging area of study. This has the potential to generate significant gains in terms of service delivery, economics and patient health. We can “do the right thing” now, but we must never become complacent.

Rachel Canaway · Douglas IR Boyle · Jo‐Anne E Manski‐Nankervis · Jessica Bell · Jane S Hocking · Ken Clarke · Malcolm Clark · Jane M Gunn · Jon D Emery

Environmental health Research 25 March 2019 Free

Early initiation of antiretroviral therapy for people newly diagnosed with HIV infection in Australia: trends and predictors, 2004–2015

The known Treatment of people infected with human immunodeficiency virus (HIV) soon after diagnosis reduces the risk of transmission and HIV‐related morbidity. The proportion and characteristics of people who receive early treatment are not well described.

Hamish McManus · Denton Callander · Basil Donovan · Darren B Russell · Catherine C O'Connor · Stephen C Davies · David A Lewis · Margaret E Hellard · Marcus Y Chen · Kathy Petoumenos · Rick Varma · Aaron Cogle · Mark Alastair Boyd · Andrew Grulich · James Pollard · Nick Medland · Christopher K Fairley · Rebecca J Guy

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Digestive system diseases Research 11 March 2019 Free

The burden of pancreatic cancer in Australia attributable to smoking

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

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Health occupations Letters 18 February 2019 Free

Increasing registrations on the Australian Organ Donor Register

To the Editor: Many people are aware that Australia has an opt‐in system for recording organ donation decisions; and many are also aware that, historically, donation decisions were recorded on the driver's licence. What is not well known is that, in 2000, the Australian Organ Donor Register (AODR) was introduced as a register of consent (or objection), and that, between 2005 and 2012, the recording of donation decisions (except for South Australia) was transitioned from the driver's licence to registration on the national register, the AODR.1 Five years on, 53% of the people we surveyed in New South Wales (n = 802) were unaware that donation decisions were no longer recorded on the driver's licence,2 and less than a third of eligible Australians had registered their decision on the AODR.3 The implications of this are profound. Consent to donate by the next‐of‐kin in the intensive care unit is 90% when decisions are registered on the AODR, but only 44% when the decision is unknown.4 We have responded to the need to increase registration rates by developing5 an immediate registration opportunity, which combines the opportunity to discuss donation in a face to face interaction with the opportunity to register on the AODR immediately.2 Participants’ concerns, fears and questions about donation are prompted through a brief survey about organ donation beliefs, which facilitates discussion and allows misconceptions to be addressed. The participants are then asked if they would like to register on the AODR. This initiative has been successful in increasing AODR registrations among the general public at a range of locations in NSW in 2017,2 and we had even higher success rates when we rolled this out in two NSW hospital‐based settings (Box). Integral to the success of the immediate registration opportunity is the consistent finding that the public and health care staff simultaneously hold positive beliefs and negative concerns about organ donation. Addressing the tension created by these dichotomous beliefs through face to face interaction, coupled with the ease and immediacy of on‐the‐spot registration, facilitates the registration decision. We believe that offering the immediate registration opportunity nationally in hospital‐based settings and in the community has the potential to increase registrations in the AODR dramatically. Box – Percentage of participants who registered on the day at the public and private hospitals from particpants who had not yet registered and were eligible to do so

Gail Moloney · Michael Sutherland · Maddison Norton · Alison Bowling · Iain Walker

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Substance‐related disorders Letters 18 February 2019 Free

Unintended consequences of a cautious approach to e‐cigarette laws

To the Editor: The Australian Government's decision to uphold a restriction on Electronic Nicotine Delivery Systems (ENDS), or e‐cigarettes, is in keeping with its highly effective tobacco control framework. In its March 2017 ruling, the Therapeutic Goods Administration outlined the lack of long term safety data around ENDS and the emerging evidence suggesting that availability of these devices may be associated with an increase in cigarette smoking in young adults.1 While it remains illegal to sell ENDS products containing nicotine, an individual may import up to 3 months’ personal supply with a doctor's prescription.1 ENDS products are easily purchased online from overseas. Their attractive packaging and scent makes them appealing to children. As these products are not produced or licensed in Australia, there is no existing legislation around child‐safe packaging or labels warning of potential toxicity. The Centers for Disease Control and Prevention reported a rise in nicotine poisonings from one to 215 per month over a 5‐year period,2 the majority involving children aged under 5 years. Furthermore, a retrospective study of children aged under 6 years found that poisonings from liquid nicotine compared with traditional cigarettes were five times more likely to result in hospitalisation.3 Nicotine is both highly toxic and readily absorbable and, therefore, the potential for poisoning is high. Nicotine poisoning occurs through initial stimulation and ultimate blockade of the nicotinic acetylcholine receptor, resulting in hypotension, bradycardia and coma at high doses.4 The minimum potentially lethal dose of nicotine in humans is 60 mg.5 A review of e‐liquid products purchased online found the standard nicotine concentration to range between 0 and 36 mg/mL.6 Therefore, ingestion of even a small volume could cause serious harm or even death. We advocate for specific legislation to regulate the personal importation of these products. This legislation should include specific safety labelling highlighting the risks of poisoning in children and mandated supply in child‐proof packaging. Given the inherent difficulties in preventing and regulating the online trade of ENDS products, we strongly encourage the federal government to partner with organisations such as Quit Victoria to highlight the potential dangers of all imported nicotine products, whether they remain prohibited or not.

Christian Catalano · Noel E Cranswick · Jeff Robinson · Joanne Grindlay · Mick Creati · Margie H Danchin · Nicola Williams · Amanda Gwee

Letter to the Editor2
Emergency medicine Research Letter 28 January 2019 Free

Exposures to e‐cigarettes and their refills: calls to Australian Poisons Information Centres, 2009–2016

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

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