Health occupations

PAT ANDERSON, chair of the Lowitja Institute, Australia's National Institute for Aboriginal and Torres Strait Islander Health Research, provides generous praise to the authors of this work for their valuable contribution to research and practice of empowerment in Aboriginal health (http://www.lowitja.org.au/promoting-aboriginal-health-family-wellbeing-empowerment-approach). When you read this text you will find that the praise is well deserved. However, it would have been handy if it had also ...

Dameyon Bonson

Summary Health systems with strong primary care orientations are known to be associated with improved equity, better access for patients to appropriate services at lower costs, and improved population health. Team-based models of primary care have emerged in response to health system challenges due to complex patient profiles, patient expectations and health system demands. Successful team-based models of primary care require a ...

Lucio Naccarella BSc(Hons), GradDipTranscultural MentalHlth, PhD · Louise N Greenstock BSc(Hons), PGCertSS, PhD · Peter M Brooks AM, MD, FRACP

To the Editor: BCG is an effective vaccine to prevent tuberculosis (TB) in young children travelling to countries with a high prevalence of TB.1 Although it does not completely mitigate the risk of developing TB, nor the need for preventive therapy after a significant TB exposure, it provides about 80% protection against the severe forms of TB that affect infants and young children.2 In Australia, ...

Amanda Gwee · Ranmali Rodrigo · Dan Casalaz · Nicole Ritz · Nigel Curtis

To the Editor: O’Connor and colleagues have presented conclusions from their research1 that are congruent with my empirical observations. I congratulate them for highlighting the overriding themes, and add a perspective from England. The burgeoning of chronic treatable ocular diseases such as age-related macular degeneration means that hospital capacity is overwhelmed. The peaks in demand seen today surpass the best predictions from a decade ago; pharmacological ...

Jagdeep Singh Gandhi

Objective: To examine the frequency and causes of snorkelling-related deaths in Australia.Design, setting and subjects: We conducted a retrospective analysis of snorkelling-related deaths recorded in Australia from 1994 to 2006 inclusive, based on information from the Divers Alert Network Asia–Pacific database, the National Coroners Information System, coronial files from all states and territories, and annual national drowning reports.Main outcome measures: Number ...

John M Lippmann BSc, DipEd, MAppSc · John H Pearn MD, FRACP, FRCP

PATIENTS COMMONLY have problems in the mouth, nose and throat. This new book by Geoffrey Quail, who is Clinical Associate Professor at the Department of Surgery, Monash University, Melbourne, and Director of the Dental and Maxillofacial Surgery Unit at Southern Health, Melbourne, provides clear and succinct information on the diagnosis of conditions affecting these areas. It will be helpful to anyone who needs an illustrated and ...

Michael Barakate

Objective: To report the perspectives of optometrists, ophthalmologists and patients on a model of shared care for patients with chronic eye diseases. Design, setting and participants: Qualitative study of a model of shared care between optometrists and ophthalmologists for patients with stable age-related macular degeneration, diabetic retinopathy and glaucoma, trialled by the ...

Patricia M O’Connor PhD · C Alex Harper MB BS, FRANZCO · Cathy L Brunton BNurs · Sandra J Clews RN · Sharon A Haymes BScOptom, PhD, MPH · Jill E Keeffe OAM, PhD

Objectives: To examine the circumstances of animal exposure in a case series of Australian travellers who required rabies postexposure prophylaxis, and to assess the appropriateness of current guidelines for rabies pre-exposure vaccination.Design, participants and setting: Prospective case series of 65 returned travellers who presented to four Australian travel medicine clinics between 1 April 2009 and 31 July 2010 for rabies post-exposure prophylaxis.Main outcome measures: Demographic characteristics associated with risk of injury; countries where injuries occurred; circumstances of the injuries; and travellers’ experiences of obtaining postexposure prophylaxis overseas.Results: Animal bites and scratches occurred most commonly among travellers aged 20–29 years. Most injuries occurred in Bali, Indonesia (30 [46%]) and Thailand (21 [32%]), and the most common animals responsible for the injuries to the 65 travellers were monkeys (29 travellers [45%]) and dogs (27 [42%]). Thirty-nine of the travellers (60%) initiated contact with the animal. Forty travellers (62%) were able to commence rabies vaccination overseas, but only nine (14%) were able to obtain rabies immunoglobulin overseas.Conclusions: Most travellers had difficulty obtaining rabies postexposure prophylaxis overseas, resulting in significant delays in appropriate treatment. We recommend that current National Health and Medical Research Council guidelines for at-risk persons be broadened, and that the risk of rabies and the option of pre-exposure vaccination be discussed with all travellers to rabies-endemic areas.

Deborah J Mills MB BS · Colleen L Lau MB BS, MPH · Philip Weinstein MAppEpi, PhD, FAFPHM

A husband and wife became unwell after eating a fish from the Calder River in northern Western Australia. Gnathostomiasis was diagnosed, and treated with ivermectin and albendazole. Serological testing was positive for gnathostomiasis, and there has been no recurrence. These appear to be the first proven endemically acquired cases of gnathostomiasis in Australia, and demonstrate the difficulties in diagnosis and treatment. (MJA 2011; 195: 42-44) Clinical recordsPatient 1A 52-year-old man developed epigastric discomfort, nausea, diarrhoea and lethargy 10 days after eating a fish (identified by the patient as “black bream”, possibly Acanthopagrus berda or Hephaestus jenkinsi) caught from the Calder River in northern Western Australia (Box 1). The fish had been pan-fried whole over a camp fire, but the duration and thoroughness of cooking is unclear. The patient’s epigastric discomfort persisted, followed a week later by fevers and myalgia and then pruritic subcutaneous swellings and skin thickening over his chest and abdomen. He had no response to a prescribed course of antibiotics. His abdominal symptoms and myalgia continued and, over the next 2 months, multiple episodic swellings developed over his abdomen. The swellings progressed to involve both thighs and were associated with feelings of movement under his skin. Examination revealed right thigh oedema and skin induration with a “peau d’orange” appearance. Blood investigation showed marked eosinophilia (7.27 x 109/L; reference range, < 0.5 x 109/L). Doppler ultrasound examination showed no evidence of deep venous thrombosis, and results of computed tomography of the abdomen and pelvis were normal. Serological evaluation for vasculitis and autoimmune disease was unremarkable. A presumptive diagnosis of parasitic infection was made, and ivermectin 12 mg was prescribed. Rapid improvement occurred, with a reduction in the patient’s eosinophilia to 1.6 x 109/L. Serological evaluation for schistosomiasis, cysticercosis, filariasis, angiostrongyliasis and strongyloides was negative. Eight weeks later, recurrent swelling of the patient’s right leg was treated with ivermectin. Three months later, further cutaneous symptoms were treated with three doses of ivermectin, with a subsequent eosinophil count of 0.44 x 109/L. A serological test for gnathostomiasis was positive (24 kDa immunoblot test conducted by the Department of Helminthology, Mahidol University, Bangkok, Thailand) 8 months after initial onset of symptoms. A simultaneous enzyme-linked immunoabsorbent assay (ELISA) for Gnathostoma antibody was positive (titre, 0.901 at 1:20 dilution), and a repeat ELISA 14 months later showed a similar titre (0.823 at 1:20 dilution). No earlier blood sample was available to demonstrate seroconversion. There has not been any recurrence of symptoms or eosinophilia over the subsequent 6 years. Patient 2A 50-year-old woman (Patient 1’s wife) developed fevers and lethargy 12 days after eating the same fish as her husband. Vomiting and abdominal cramps followed, and settled down over 10 days. When she returned to Melbourne 4 months later, the patient’s blood samples revealed an eosinophilia of 1.6 x 109/L. A further 4 months later, a trial of ivermectin (12 mg weekly for two doses) was prescribed for gnathostomiasis, and 4 months later her eosinophil count was 0.23 x 109/L. Serological testing for amoebiasis, strongyloides, filariasis and schistosomiasis was negative. A test for gnathostomiasis (24 kDa immunoblot) was positive 8 months after initial symptoms. An ELISA for Gnathostoma was also positive 8 and 20 months after initial symptoms, with little change in titre (0.903 and 0.886, respectively). Sixteen months after the initial symptoms (9 months after ivermectin), a pruritic swelling over the upper right arm developed with associated eosinophilia. Eosinophilia and chronic symptoms resolved following a single dose of ivermectin 12 mg, and albendazole 400 mg twice daily for 21 days. Two months later, a transient pruritic swelling over the right buttock was treated with repeat ivermectin (12 mg weekly for two doses). Subsequently, the patient had recurrent swelling of the right deltoid muscle and was given three further ivermectin doses. Symptoms have not recurred during 5 years of observation. DiscussionGnathostomiasis is a foodborne zoonosis, a clinical syndrome caused most commonly by infection with the larvae of Gnathostoma spinigerum, but also by several other Gnathostoma species.1,2 Humans may become accidental hosts after ingesting third-stage larvae (Box 2). The larvae are unable to mature further in humans, and they migrate through visceral and cutaneous tissues. Larvae may be found in a range of intermediate and paratenic hosts including freshwater fish, snakes, frogs, snails and fowl.1,3 Consequently, the disease is endemic where these foods are consumed raw or undercooked, including South-East Asia and Japan, but more recently recognised in Latin America, China, India, Africa and in travellers returning from these areas.1,2 Locally acquired infection in Australia has not previously been confirmed.4 The Gnathostoma life cycle is illustrated in Box 2. Following ingestion of viable larvae, patients often develop fever, anorexia, abdominal discomfort, nausea and vomiting as larvae penetrate the gastrointestinal wall. This is usually associated with a marked eosinophilia. Subsequently, symptomatic disease may have either cutaneous or visceral manifestations depending on the larval migration pattern. Cutaneous disease is more common, typically presenting with intermittent migratory erythematous swellings, which may be pruritic or painful. Cutaneous symptoms usually occur within 4 weeks of larval ingestion, and last 1–2 weeks. In untreated patients, larvae may survive up to 15 years and cause recurrent symptoms, by which time eosinophilia may have resolved. Less common cutaneous manifestations include nodular lesions, skin abscesses, panniculitis or creeping eruptions. The main differential diagnoses include cutaneous larva migrans, larva currens, trichinosis and Calabar swellings secondary to loiasis. Visceral disease may involve almost any part of the body. Pulmonary disease may manifest as a cough, pleuritic chest pain, haemoptysis, lobar consolidation or pleural effusions. Gastrointestinal disease may be asymptomatic, but is more frequently associated with sharp abdominal pains or inflammatory masses, or may mimic an “acute surgical abdomen”. Ocular disease has a variety of manifestations and often allows direct visualisation of the larvae. Untreated, gnathostomiasis of the central nervous system (CNS) is associated with the highest mortality (8%–25%), and 30% of survivors have long-term sequelae.1 Typically, symptoms begin with acute radicular pain or headache, lasting up to 5 days, as the larva penetrates the CNS via spinal cord nerve roots. Focal paralysis and cranial nerve palsies usually follow, and may progress to eosinophilic meningoencephalitis or encephalomyelitis. Subarachnoid haemorrhage and other vascular complications are less common presentations of CNS gnathostomiasis. Imaging reveals the haemorrhagic migratory tracts of the larvae. The main differential diagnosis for CNS disease is Angiostrongylus cantonensis. Definitive diagnosis of gnathostomiasis requires parasite extraction and identification, however small parasite size (2–3 mm) makes this impractical, and thus is no longer recommended. Therefore, gnathostomiasis is a clinical diagnosis, supported by epidemiological history, blood eosinophilia (although alone not sensitive or specific) and serological testing. Serological tests have surpassed non-specific antigen injection techniques, and include immunoblot testing (which detects antibodies to specific L3 antigen with a molecular mass of 24 kDa) and ELISA (which detects IgG1 or IgG2 to the crude L3 antigen).6-8 The immunoblot test appears to be the most specific, but is difficult to perform.6-8 In a series of four patients with parasitologically confirmed gnathostomiasis, and 15 patients with a presumptive diagnosis of gnathostomiasis, the 24 kDa L3 antigen immunoblot test had a sensitivity of 100% for parasitologically confirmed gnathostomiasis and 33% for presumed gnathostomiasis.8 The authors commented that the lower sensitivity in presumptively diagnosed cases was probably due to initial incorrect diagnoses. In the same series, 64 patients with other parasitic infections and 19 healthy control subjects were also tested, with only one positive result, giving a specificity of 99%.8 An ELISA to detect subclass immunoglobulin levels for crude L3 antigen, avoiding the difficult purification step, has been proposed as an alternative diagnostic test. Detection of IgG1 has the greatest sensitivity (98%) making it an attractive initial test, and IgG2 does not appear to cross-react with other parasitic species, thus providing the best specificity (88%) for diagnostic confirmation of gnathostomiasis.7 Neither test is available commercially, but both the immunoblot and ELISA are performed at the Department of Helminthology, Mahidol University, Bangkok, Thailand. Nevertheless, serological investigations for gnathostomiasis have limited validation, making precise estimates of sensitivity and specificity difficult. Cross-reactions may occur, so caution with interpretation is paramount. In the patients described, an evaluation for other parasitic infections was made in order to reduce the possibility of a false positive result. Data comparing the outcomes of treatment regimens are limited to observational studies only. In a series of 49 patients treated with albendazole 400 mg twice daily for 21 days, over 93% achieved a cure at 6 months.9 In the same series, the efficacy was similar in 21 patients treated with ivermectin 0.2 mg/kg as a single dose.9 There are few data comparing combinations of ivermectin and albendazole. Longer observational studies indicate that treatment failures are common, as demonstrated in the two patients above, and thus repeat treatment is recommended if symptoms recur.10 Proven endemic human gnathostomiasis has not previously been reported in Australia, although cases suspected to have been locally acquired were described in the 1970s (non-specific antigen injection was used for confirmation).4 Gnathostoma infection of mammals has been described in Australia.11,12 Therefore, we believe these cases are the first confirmed cases of locally acquired human gnathostomiasis in Australia. The two patients had clinical syndromes compatible with gnathostomiasis, associated blood eosinophilia, positive serological results and supportive epidemiological history, and they responded to treatment. Importantly, neither of the patients had previously travelled outside Australia. Weaknesses of this report include that we were unable to definitively identify the fish species or determine how thoroughly the fish was cooked. Although it is a rare disease, gnathostomiasis needs to be considered in patients coming from endemic areas, and also in patients who have not left Australia, who present with migratory cutaneous lesions and associated peripheral blood eosinophilia. Visceral disease may be more difficult to diagnose due to the broad differential diagnoses, but gnathostomiasis must be considered in those with eosinophilic neurological syndromes due to the high mortality in untreated disease. 1 Calder River, West Kimberley region, northern Western Australia, where the “black bream” was caught 2 Gnathostoma life cycle5

Cameron J Jeremiah MB BS · Chanad S Harangozo MB BS, FRACP · Andrew J Fuller MB BS, FRACP, FRCPA

To the Editor: I found Van Der Weyden’s editorial “Whither medicine? The expansion of non-doctor practice”1 to be an unduly negative view of the emerging new clinical roles, such as nurse practitioners, in our health system. To imply, for example, that the access to prescribing rights for nurse practitioners is a significant challenge (rather than a help) to doctors is contrary to the experience of many such implementations of these roles. I have a clear view of the role of doctors. They should: be in charge and lead the decision-making process of multidisciplinary teams; be responsible for the cognitive and integrative aspects of clinical care, including the initial assessment and planning of management for undifferentiated patient presentations in all care settings; and provide high-level complex care, including procedural and diagnostic services that require their level of expertise. Doctors should not continue to provide clinical services that are not a good use of their considerable training and experience. These services, that could be provided by nurse practitioners, include routine monitoring and prescribing (under protocol and medical leadership) of maintenance treatments (such as haemodialysis treatment or routine diabetes review), and simple repetitive diagnostic or therapeutic procedures. In my experience, many doctors are bored with these intellectually limited aspects of their practice and find the quality of their clinical life substantially enhanced when given the opportunity to work in partnership with nurse practitioners. Again, in my experience, some tertiary-educated nurses are also bored with their limited clinical roles (still dominated by personal care) and can offer much more to the clinical team by focusing on the higher end of their skill base. There are clear differences between doctors and nurses in terms of selection process, education and training. However, this does not preclude both professional groups from looking at their scope of practice and focusing on the tasks that best use their expertise, rather than retaining roles based on custom and practice that are no longer relevant. If doctors embrace and lead the role redesign program, they can ensure that sensible delegations of their clinical tasks to other health practitioners can occur with benefit to all. Resistance and disengagement of doctors will not stop role redesign, as we clearly cannot sustain a health workforce in the future with a staffing model that has not changed materially for 100 years. Resistance and disengagement are more likely to lead to dysfunctional new roles being produced, without the necessary strong relationship with the medical profession required for the best patient care.

Brendan F Murphy

To the Editor: In his recent editorial,1 Van Der Weyden laments the “displacement” of doctors in modern health care by nurse practitioners and physician assistants, and bemoans the fact that discussion and debate about these matters is largely confined to medical tabloids such as Australian Doctor. In this context, the editorial cites unsubstantiated and inflammatory comments from Australian Doctor correspondents claiming that nurse practitioners place patients at risk.2,3 Remarks that nurse practitioners are “a disaster unfolding” and “people will die”3 are not only inflammatory but also inaccurate. Medical and nursing insiders have made these claims with self-appointed legitimacy and without evidence. They demonstrate a surprising level of ignorance about the role of nurse practitioners and the evidence base that supports their practice, particularly in emergency care.4 In an era where the drum of quality and safety in health care and evidence-based practice beats the loudest, where is the evidence to support such claims? Perhaps the lack of evidence is the reason why such claims implying that nurse practitioners present a risk to patients are housed in medical tabloids, where they escape the rigorous scrutiny of peer review that would otherwise expose this deficit. Van Der Weyden bewails that nurse practitioners are the only health professionals “whose skills and talents are extolled”.1 We doubt whether such trivialities are at the forefront of the minds of emergency nurse practitioners, who comprise a large proportion of nurse practitioners in Australia. As part of the broader health care team, their focus — and the focus of their physician, nurse and allied health colleagues — would be on the immediate and ongoing needs of their patients. Van Der Weyden asserts that an assumption of the equivalence of nurses and physicians underpins the political and industrial agenda for “doctor displacement” in general practice in Australia. Such an assertion is entirely moot. High-quality and safe health care cannot be realised by a monopoly of nurses, or physicians, or any other health profession. Nurses and physicians are only two of the many threads in the tapestry of high-quality, safe and evidence-based health care. Their success lies in symbiotic mutualism, not commensalism, amensalism, or parasitism. And, just like in tapestry, pulling any one thread from the fabric renders the picture incomplete.5 Unless there is substantial evidence to the contrary, bringing the safety of nurse practitioners into question is senseless, particularly given the well deserved support they have from their peers in the wider health community and their patients, both in Australia and overseas.

Ramon Z Shaban · Julie M Finucane · Dianne J Crellin