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Environmental health Perspectives 14 November 2019 Free

The 2019 report of the MJA–Lancet Countdown on health and climate change: a turbulent year with mixed progress

The lack of national policy means that Australia remains at significant risk of declines in health due to climate change — substantial and sustained national action is urgently required

Paul J Beggs · Ying Zhang · Hilary Bambrick · Helen L Berry · Martina K Linnenluecke · Stefan Trueck · Peng Bi · Sinead M Boylan · Donna Green · Yuming Guo · Ivan C Hanigan · Fay H Johnston · Diana L Madden · Arunima Malik · Geoffrey G Morgan · Sarah Perkins‐Kirkpatrick · Lucie Rychetnik · Mark Stevenson · Nick Watts · Anthony G Capon

Mja2 50405
Statistics Letters 21 October 2019 Free

Baby boomers and booze: we should be worried about how older Australians are drinking

To the Editor: We welcome the research letter by Roche and Kostadinov,1 who have reported an increasing trend in risky alcohol consumption among adults aged over 50 years. The Report of the Chief Health Officer Queensland in 20162 presented the trends for lifetime risky drinking3 and found a similar trend of risky drinking for males aged 65 years and older. While agreeing with the authors' overall message, there are concerns on the method used to assess trend, in particular, the highly significant P values for the relatively small change in prevalence. Population‐weighted counts, as presented in the research, are used to ensure that prevalence estimates are representative of the national population, but are inappropriate to use when determining the precision of the estimate. Using the weighted counts to calculate the χ2 statistic for trend effectively assumes that the population is the sample size (ie, 8 015 139 in 2016), when in fact the sample size was 23 772 in 2016.4 The effect of this is an overprecise estimate that results in a highly significant P value. Using the authors' table, a simple linear regression with prevalence as the outcome and year as the predictor can be used as a quick face validity check. This results in non‐significant trends for both risky and high risk groups; however, when these groups are combined a significant result is observed (significance level P < 0.05). My research into lifetime risky drinking also encountered this issue of incorporating population weights into trend analysis and this was resolved by using various regression techniques.5 Another advantage of using regression is the ability to incorporate interactions in models to test differences in trend between subgroups. Using this technique identified a statistical difference in lifetime risky drinking trends between people aged 18–29 years and people aged 65 years and older (P < 0.001) (Box). I believe that the authors' findings are important, but we need to take care that results are not discredited by choice of methodology. Interactive data visualisations of alcohol consumption and other risk factors trends for Queensland can be found at the Queensland health website.6 Box – Trends in prevalence of lifetime risky drinking, by age group, Queensland, 2010–2018* * Reproduced from Queensland Health's website.6

Tim Roselli

Mja2 50352
Cardiovascular diseases Letters 5 August 2019 Free

Adjunctive bacteriophage therapy for prosthetic valve endocarditis due to Staphylococcus aureus

To the Editor: Infective endocarditis with Staphylococcus aureus is associated with a high mortality despite optimal antibiotic therapy.1 The synergy between bacteriophages and antibiotics has been shown in vitro and in animal studies,2 and bacteriophages have demonstrated their value in severe bacterial infections.3 AB‐SA01 (AmpliPhi Biosciences) is a bacterial DNA‐free and protein‐free highly purified preparation of three obligately lytic Myoviridae, each at 109 plaque‐forming units per dose.4 This preparation has been recently used successfully for staphylococcal sinusitis by local irrigation.5 A protocol was established for bacteriophage therapy as an adjunct to standard care of severe staphylococcal infections under the auspices of the Therapeutic Goods Administration Special Access Scheme. Here, we report the first intravenous use of AB‐SA01 in a case of severe staphylococcal sepsis with prosthetic valve endocarditis. A 65‐year‐old man with a 30‐year‐old mechanical aortic valve presented with a week of malaise, severe exertional dyspnoea, and central pleuritic chest pain. He had been successfully treated for Haemophilus aphrophilus aortic valve endocarditis 8 years earlier with antibiotics alone. Examination revealed fever, tachypnoea, tachycardia and borderline hypotension (90–100 mmHg systolic), with a praecordial systolic murmur and click. There was no cardiac, renal or hepatic failure or any evident peripheral embolic sequelae of endocarditis (haematuria, splinter haemorrhages) at this stage. Blood cultures repeatedly grew an identical methicillin‐sensitive S. aureus determined by whole genome sequencing, and the patient received high dose intravenous flucloxacillin, ciprofloxacin and rifampicin (Box). Transoesophageal echocardiography confirmed vegetations on prosthetic aortic and native mitral valves, and the aortic root was thickened with possible paravalvular root abscess. Scheduled cardiopulmonary bypass for operative source control was postponed after a haemorrhagic infarction in the distribution of the left anterior cerebral artery on day −7 (ie, a week before starting bacteriophage therapy), despite concerns regarding development of an aortic root abscess, ongoing fevers and hypotension. Intravenous AB‐SA01 was administered twice a day for 14 days in conjunction with the patient's prescribed antibiotics, commencing (Day 1) 9 days after his first positive blood culture. Blood cultures were negative at onset of bacteriophage therapy, and the C‐reactive protein, temperature, and white cell count results showed downward trends within 24 hours (Box). This trajectory was only interrupted by splenic infarction and occlusion of the superior mesenteric artery 48 hours after commencement, which was proven on computed tomography scan (not shown). No fevers, tachycardia, hypotension or rashes were detected after bacteriophage infusions and no adverse sequelae were attributable to the therapy. The patient recovered after 40 days of antibiotic therapy and returned to his home state for follow‐up. A positron emission tomography scan on Day 80 showed no fluorodeoxyglucose‐avid lesions, including intracardiac lesions. Repeat echocardiogram on Day 98 for progressive heart failure showed severely dilated left ventricle with moderate mitral and trivial aortic regurgitation. A possible mechanical aortic valve vegetation and paravalvular phlegmon were again demonstrated. Blood cultures were negative. He declined surgical intervention and died on Day 103. To our knowledge, this was the first case of staphylococcal prosthetic valve endocarditis treated with intravenous bacteriophage (AB‐SA01), which complies with good manufacturing practice standards.4 Bacteriophage infusions were well tolerated. Future controlled trials are needed to evaluate adjunctive bacteriophage therapy, especially when surgical intervention is not feasible. Box – Graphical representation of antimicrobial treatment, bacteriophage therapy and inflammatory markers − = negative blood cultures; + = positive blood cultures; CRP = C‐reactive protein; SMA = superior mesenteric artery; WCC = white cell count. ◆

Timothy Gilbey · Josephine Ho · Louise A Cooley · Aleksandra Petrovic Fabijan · Jonathan R Iredell

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

Mja2 50117
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

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

Mja2 12108

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