Topics

Sports participation by children and adolescents is generally high in Australia and New Zealand,1,2 and many children sustain head injuries of varying severity during such activities. Concussion has received increasing attention, but less is known about the risk of severe acute intracranial injuries in children with sports‐related head injuries.3

Please login with your free MJA account to view this article in full

CREATE AN ACCOUNT

Please note: institutional and Research4Life access to the MJA is now provided through Wiley Online Library.

View on Wiley Online Library

1 Royal Children's Hospital, Melbourne, VIC
2 Murdoch Children's Research Institute, Melbourne, VIC
3 University of Melbourne, Melbourne, VIC
4 Perth Children's Hospital, Perth, WA
5 University of Western Australia, Perth, WA
6 Queensland Children's Hospital, Brisbane, QLD
7 Children's Health Research Centre, University of Queensland, Brisbane, QLD
8 Women's and Children's Hospital, Adelaide, SA
9 Children's Hospital at Westmead, Sydney, NSW
10 The Townsville Hospital, Townsville, QLD
11 Bristol Royal Hospital for Children, Bristol, United Kingdom
12 University of Padova, Padova, Italy
13 Starship Children's Health, Auckland, New Zealand
14 University of Auckland, Auckland, New Zealand

Correspondence: franz.babl@rch.org.au

Acknowledgements:

The study was funded by grants from the National Health and Medical Research Council (NHMRC; project grant GNT1046727, Centre of Research Excellence for Paediatric Emergency Medicine GNT1058560); the Murdoch Children's Research Institute, Melbourne; the Emergency Medicine Foundation, Brisbane (EMPJ‐11162); Perpetual Philanthropic Services (2012/1140); Auckland Medical Research Foundation (3112011) and the A + Trust (Auckland District Health Board); WA Health Targeted Research Funds 2013; and the Townsville Hospital and Health Service Private Practice Research and Education Trust Fund; and was supported by the Victorian Government Infrastructure Support Program. Franz Babl was partly funded by an NHMRC Practitioner Fellowship and a Melbourne Campus Clinician Scientist fellowship. Stuart Dalziel was partly funded by the Health Research Council of New Zealand (HRC13/556).

Competing interests:

No relevant disclosures.

1. Australian Bureau of Statistics. 4156.0. Sports and physical recreation: a statistical overview, 2012. Dec 2012. http://www.abs.gov.au/ausstats/abs@.nsf/Products/76DF25542EE96D12CA257AD9000E2685?opendocument (viewed Sept 2018).
2. Brocklesby J, McCarty G., Active NZ. Main report — the New Zealand Participation Survey 2017. Wellington: Sport New Zealand, 2018. https://sportnz.org.nz/assets/Uploads/Main-Report.pdf (viewed Sept 2018).
3. Davies GA, Anderson V, Babl FE, et al. What is the difference in concussion management in children as compared with adults? A systematic review. Br J Sports Med 2017; 51: 949–957.
4. Babl FE, Borland ML, Phillips N, et al. Paediatric Research in Emergency Departments International Collaborative (PREDICT). Accuracy of PECARN, CATCH and CHALICE head injury decision rules in children: a prospective cohort study. Lancet 2017; 389: 2393–2402.
5. Kuppermann N, Holmes JF, Dayan PS, et al. Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically‐important traumatic brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374: 1160–1170.

Online responses are no longer available. Please refer to our instructions for authors page for more information.

Research letters

Health care for older people in rural and remote Australia: challenges for service provision

Fergus W Gardiner, Alice M Richardson, Lara Bishop, Abby Harwood, Elli Gardiner, Lauren Gale, Narcissus Teoh, Robyn M Lucas and Martin Laverty

Med J Aust 2019; 211 (8): . || doi: 10.5694/mja2.50277
Published online: 30 September 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Health occupations

Emergency medicine

Statistics, epidemiology and research design

General medicine

Many Australians living in rural and remote areas of Australia need to travel hundreds of kilometres for health care service, or to wait for health service providers, such as the Royal Flying Doctor Service (RFDS), to visit them. The levels of acute and subacute hospital services in rural and remote areas are reported to be inadequate,1 as is, to a lesser extent, access to aged care services.2 The need to travel long distances is a major barrier for people in remote locations, particularly older people, seeking health care.

Please login with your free MJA account to view this article in full

CREATE AN ACCOUNT

Please note: institutional and Research4Life access to the MJA is now provided through Wiley Online Library.

View on Wiley Online Library

1 Royal Flying Doctor Service of Australia, Canberra, ACT
2 National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT
3 College of Health and Medicine, Australian National University, Canberra, ACT
4 Royal Flying Doctor Service, Queensland Section, Cairns, QLD

Correspondence: fergus.gardiner@rfds.org.au

Competing interests:

No relevant disclosures.

1. Davis J, Morgans A, Stewart J. Developing an Australian health and aged care research agenda: a systematic review of evidence at the subacute interface. Aust Health Rev 2016; 40: 420–427.
2. van Gaans D, Dent E. Issues of accessibility to health services by older Australians: a review. Public Health Rev 2018; 39: 20.
3. Australian Institute of Health and Welfare. Older Australia at a glance (AGE 87). Canberra: AIHW, 2018. https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance (viewed June 2019).
4. Gardiner FW, Gale L, Bishop L, Laverty M. Healthy ageing in rural and remote Australia: challenges and gaps in service provision to overcome. Canberra: The Royal Flying Doctor Service of Australia, 2018. https://www.flyingdoctor.org.au/assets/documents/RN069_Healthy_Ageing_Report_D3.pdf (viewed June 2019).
5. Cui X, Zhou X, Ma LL, et al. A nurse‐lead structured education program improves self‐management skills and reduces hospital readmissions in patients with chronic heart failure: a randomized and controlled trial. Rural Remote Health 2019; 19: 5270.

Online responses are no longer available. Please refer to our instructions for authors page for more information.

Letters

First reported case of extensively drug‐resistant typhoid in Australia

Annaleise Howard‐Jones, Alison M Kesson, Alexander C Outhred and Philip N Britton

Med J Aust 2019; 211 (6): . || doi: 10.5694/mja2.50316
Published online: 16 September 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Pharmaceutical preparations

Health occupations

Infectious diseases

To the Editor: The period from January to March marks the peak season for travellers returning to Australia, and typhoid is a key illness of concern. Since 2016, an extensively drug‐resistant (XDR) typhoid clade has emerged in Pakistan, showing resistance to all first‐line agents.1,2 Over the past 2 years, seven cases have been reported in returned travellers — mostly children — from Pakistan to England, Germany and the United States.1,3,4

1 Children's Hospital at Westmead, Sydney, NSW
2 University of Sydney, Sydney, NSW

Correspondence: philip.britton@health.nsw.gov.au

Competing interests:

No relevant disclosures.

1. Klemm EJ, Shakoor S, Page AJ, et al. Emergence of an extensively drug‐resistant Salmonella enterica serovar Typhi clone harboring a promiscuous plasmid encoding resistance to fluoroquinolones and third‐generation cephalosporins. MBio 2018; 9: pii e00105‐18.
2. World Health Organization. Disease outbreaks in Eastern Mediterranean Region (EMR), January to December 2018. WHO EMRO Weekly Epidemiology Monitor 2018; 11: 1. http://applications.emro.who.int/docs/epi/2018/Epi_Monitor_2018_11_52.pdf?ua=1 (viewed July 2019).
3. Chatham‐Stephens K, Medalla F, Hughes M, et al. Emergence of extensively drug‐resistant Salmonella Typhi infections among travelers to or from Pakistan — United States, 2016–2018. MMWR Morb Mortal Wkly Rep 2019; 68: 11–13.
4. Kleine CE, Schlabe S, Hischebeth GTR, Molitor E, Pfeifer Y, Wasmuth JC, et al. Successful therapy of a multidrug‐resistant extended‐spectrum β‐lactamase‐producing and fluoroquinolone‐resistant Salmonella enterica Subspecies enterica serovar Typhi infection using combination therapy of meropenem and fosfomycin. Clin Infect Dis 2017; 65: 1754–1756.
5. Khatami A, Khan F, Macartney KK. Enteric fever in children in Western Sydney, Australia, 2003–2015. Pediatr Infect Dis J 2017; 36: 1124–1128.

Online responses are no longer available. Please refer to our instructions for authors page for more information.

Narrative reviews

Pulmonary challenges of prolonged journeys to space: taking your lungs to the moon

G Kim Prisk

Med J Aust 2019; 211 (6): . || doi: 10.5694/mja2.50312
Published online: 16 September 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Anatomy and physiology

Health occupations

Respiratory tract diseases

Summary

Space flight presents a set of physiological challenges to the space explorer which result from the absence of gravity (or in the case of planetary exploration, partial gravity), radiation exposure, isolation and a prolonged period in a confined environment, distance from Earth, the need to venture outside in the hostile environment of the destination, and numerous other factors.
Gravity affects regional lung function, and the human lung shows considerable alteration in function in low gravity; however, this alteration does not result in deleterious changes that compromise lung function upon return to Earth.
The decompression stress associated with extravehicular activity, or spacewalk, does not appear to compromise lung function, and future habitat (living quarter) designs can be engineered to minimise this stress.
Dust exposure is a significant health hazard in occupational settings such as mining, and exposure to extraterrestrial dust is an almost inevitable consequence of planetary exploration. The combination of altered pulmonary deposition of extraterrestrial dust and the potential for the dust to be highly toxic likely makes dust exposure the greatest threat to the lung in planetary exploration.

University of California, San Diego, La Jolla, CA, USA

Correspondence: kprisk@ucsd.edu

Acknowledgements:

Many of the studies were funded by the National Aeronautics and Space Administration (NASA) and the National Space Biomedical Research Institute under various contracts and grants. G Kim Prisk is currently funded by the National Institutes of Health under R01 HL119263.

Competing interests:

No relevant disclosures.

1. Chancellor JC, Blue RS, Cengel KA, et al. Limitations in predicting the space radiation health risk for exploration astronauts. NPJ Microgravity 2018; 4: 8.
2. Yi B, Matzel S, Feuerecker M, et al. The impact of chronic stress burden of 520‐d isolation and confinement on the physiological response to subsequent acute stress challenge. Behav Brain Res 2015; 281: 111–115.
3. Perhonen MA, Franco F, Lane LD, et al. Cardiac atrophy after bed rest and spaceflight. J Appl Physiol 2001; 91: 645–653.
4. Lang T, Van Loon JJWA, Bloomfield S, et al. Towards human exploration of space: the THESEUS review series on muscle and bone research priorities. NPJ Microgravity 2017; 3: 8.
5. Widrick JJ, Knuth ST, Norenberg KM, et al. Effect of a 17 day spaceflight on contractile properties of human soleus muscle fibres. J Physiol 1999; 516: 915–930.
6. Glazier JB, Hughes JM, Maloney JE, West JB. Vertical gradient of alveolar size in lungs of dogs frozen intact. J Appl Physiol 1967; 23: 694–705.
7. Bryan AC, Milic‐Emili J, Pengelly D. Effect of gravity on the distribution of pulmonary ventilation. J Appl Physiol 1966; 21: 778–784.
8. West JB, Dollery CT, Naimark A. Distribution of blood flow in isolated lung: relation to vascular and alveolar pressures. J Appl Physiol 1964; 19: 713–724.
9. West JB. Pulmonary gas flow and gas exchange. In: West JB, editor. Respiratory physiology: people and ideas. New York: Oxford Press, 1966: 140–196.
10. Christofidou‐Solomidou M, Pietrofesa RA, Arguiri E, et al. Space radiation‐associated lung injury in a murine model. Am J Physiol Lung Cell Mol Physiol 2015; 308: L416–L428.
11. Sawin CF, Nicogossian AE, Rummel JA, Michel EL. Pulmonary function evaluation during the Skylab and Apollo‐Soyuz missions. Aviat Space Environ Med 1976; 47: 168–172.
12. Robertson WG, McRae GL. Study of man during a 56‐day exposure to an oxygen‐helium atmosphere at 258 mm Hg total Pressure. VII. Respiratory function. Aerosp Med 1966; 37: 453–456.
13. Elliott AR, Prisk GK, Guy HJ, West JB. Lung volumes during sustained microgravity on spacelab SLS‐1. J Appl Physiol 1994; 77: 2005–2014.
14. Guy HJ, Prisk GK, Elliott AR, West JB. Maximum expiratory flow‐volume curves during short periods of microgravity. J Appl Physiol 1991; 70: 2587–2596.
15. Elliott AR, Prisk GK, Guy HJ, et al. Forced expirations and maximum expiratory flow‐volume curves during sustained microgravity on SLS‐1. J Appl Physiol 1996; 81: 33–43.
16. Prisk GK, Guy HJ, Elliott AR, et al. Pulmonary diffusing capacity, capillary blood volume, and cardiac output during sustained microgravity. J Appl Physiol 1993; 75: 15–26.
17. Prisk GK, Fine JM, Elliott AR, West JB. Effect of 6 degrees head‐down tilt on cardiopulmonary function: comparison with microgravity. Aviat Space Environ Med 2002; 73: 8–16.
18. Guy HJ, Prisk GK, Elliott AR, et al. Inhomogeneity of pulmonary ventilation during sustained microgravity as determined by single‐breath washouts. J Appl Physiol 1994; 76: 1719–1729.
19. Prisk GK, Guy HJB, Elliott AR, et al. Ventilatory inhomogeneity determined from multiple‐breath washouts during sustained microgravity on Spacelab SLS‐1. J Appl Physiol 1995; 78: 597–607.
20. Verbanck S, Linnarsson D, Prisk GK, Paiva M. Specific ventilation distribution in microgravity. J Appl Physiol 1996; 80: 1458–1465.
21. Prisk GK, Elliott AR, Guy HJ, et al. Multiple‐breath washin of helium and sulfur hexafluoride in sustained microgravity. J Appl Physiol 1998; 84: 244–252.
22. Dutrieue B, Verbanck S, Darquenne C, Prisk GK. Airway closure in microgravity. Respir Physiol Neurobiol 2005; 148: 97–111.
23. Prisk GK, Lauzon AM, Verbanck S, et al. Anomalous behavior of helium and sulfur hexafluoride during single‐breath tests in sustained microgravity. J Appl Physiol 1996; 80: 1126–1132.
24. Lauzon AM, Prisk GK, Elliott AR, et al. Paradoxical helium and sulfur hexafluoride single‐breath washouts in short‐term vs. sustained microgravity. J Appl Physiol 1997; 82: 859–865.
25. Dutrieue B, Lauzon AM, Verbanck S, et al. Helium and sulfur hexafluoride bolus washin in short‐term microgravity. J Appl Physiol 1999; 86: 1594–1602.
26. Dutrieue B, Paiva M, Verbanck S, et al. Tidal volume single breath washin of SF6 and CH4 in transient microgravity. J Appl Physiol 2003; 94: 75–82.
27. Prisk GK, Guy HJB, Elliott AR, West JB. Inhomogeneity of pulmonary perfusion during sustained microgravity on SLS‐1. J Appl Physiol 1994; 76: 1730–1738.
28. Prisk GK, Elliott AR, Guy HJ, et al. Pulmonary gas exchange and its determinants during sustained microgravity on Spacelabs SLS‐1 and SLS‐2. J Appl Physiol 1995; 79: 1290–1298.
29. Lauzon AM, Elliott AR, Paiva M, et al. Cardiogenic oscillation phase relationships during single‐breath tests performed in microgravity. J Appl Physiol 1998; 84: 661–668.
30. Elliott AR, Prisk GK, Schöllman C, Hoffman U. Hypercapnic ventilatory response in humans before, during, and after 23 days of low level CO2 exposure. Aviat Space Environ Med 1998; 69: 391–396.
31. Prisk GK, Elliott AR, West JB. Sustained microgravity reduces the human ventilatory response to hypoxia but not hypercapnia. J Appl Physiol 2000; 88: 1421–1430.
32. Dijk DJ, Neri DF, Wyatt JK, et al. Sleep, performance, circadian rhythms, and light‐dark cycles during two space shuttle flights. Am J Physiol Regul Integr Comp Physiol 2001; 281: R1647–R1664.
33. Sá RC, Prisk GK, Paiva M. Microgravity alters respiratory abdominal and rib cage motion during sleep. J Appl Physiol 2009; 107: 1406–1412.
34. Migeotte PF, Prisk GK, Paiva M. Microgravity alters respiratory sinus arrhythmia and short‐term heart rate variability in humans. Am J Physiol Heart Circ Physiol 2003; 284: H1195–H2006.
35. Wantier M, Estenne M, Verbanck S, et al. Chest wall mechanics in sustained microgravity. J Appl Physiol 1998; 84: 2060–2065.
36. Prisk GK, Fine JM, Cooper TK, West JB. Pulmonary gas exchange is not impaired 24‐hours following extra‐vehicular activity. J Appl Physiol 2005; 99: 2233–2238.
37. Prisk GK, Fine JM, Cooper TK, West JB. Vital capacity, respiratory muscle strength, and pulmonary gas exchange during long‐duration exposure to microgravity. J Appl Physiol 2006; 101: 439–447.
38. Prisk G, Fine J, Cooper T, West J. Lung function is unchanged in the 1 G environment following 6‐months exposure to microgravity. Eur J Appl Physiol 2008; 103: 617–623.
39. Prisk GK. Microgravity and the respiratory system. Eur Respir J 2014; 43: 1459–1471.
40. Weibel ER. Morphometry of the human lung. New York: Academic Press, 1963.
41. Haase H, Baranov VM, Asyamolova NM, et al. First results of Po2 examinations in the capillary blood of cosmonauts during a long‐term flight in the space station “Mir”. International Astronautical Congress and International Astronautical Federation; 1990. Proceedings of the 41st Congress of the International Astronautical Federation; Dresden (Germany), 6–12 October 1990. Paris, France: International Astronautical Federation; pp. 1–4.
42. West JB, Dollery CT. Distribution of blood flow and ventilation‐perfusion ratio in the lung, measured with radioactive CO2. J Appl Physiol 1960; 15: 405–410.
43. Permutt S. Pulmonary circulation and the distribution of blood and gas in the lungs. Physiology in the space environment. Washington: National Academy of Science, National Research Council 1485B; 1967. pp. 38–56.
44. Verbanck S, Larsson H, Linnarsson D, et al. Pulmonary tissue volume, cardiac output, and diffusing capacity in sustained microgravity. J Appl Physiol 1997; 83: 810–816.
45. Van Muylem A, Antoine M, Yernault JC, et al. Inert gas single‐breath washout after heart‐lung transplantation. Am J Respir Crit Care Med 1995; 152: 947–952.
46. Conkin J, Klein JS, Acock KE. Description of 103 cases of hypobaric sickness from NASA‐sponsored research (1982–1999). Houston, TX: Johnson Space Center; 2003. Report No. NASA/TM‐2003‐212052. https://ston.jsc.nasa.gov/collections/TRS/_techrep/TM-2003-212052.pdf (viewed July 2019).
47. Waligora JM, Horrigan D, Conkin J, Hadley AT. Verification of an altitude decompression sickness prevention protocol for shuttle operations utilizing a 10.2‐psi pressure stage. NASA Technical Memorandum 58259. Houston, TX: NASA, 1984; pp. 1–44. https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/19840020323.pdf (viewed July 2019).
48. Cotes JE. Lung function assessment and application in medicine; 5th ed. Boston: Oxford Blackwell Scientific Publications, 1993: 251–262.
49. Prisk GK, Fine JM, Cooper TK, West JB. Pulmonary gas exchange is not impaired 24 h after extravehicular activity. J Appl Physiol 2005; 99: 2233–2238.
50. NASA Exploration Atmospheres Working Group. Recommendations for exploration spacecraft internal atmospheres: the final report of the NASA Exploration Atmospheres Working Group. NASA; 2010. Contract No. NASA/TP‐2010‐216134. https://ston.jsc.nasa.gov/collections/trs/_techrep/TP-2010-216134.pdf (viewed July 2019).
51. Graf JC. Lunar soils grain size catalog. Report No. NASA‐RP‐1265. NASA, 1993. https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/19930012474.pdf (viewed July 2019).
52. Linnarsson D, Carpenter J, Fubini B, et al. Toxicity of lunar dust. Planet Space Sci 2012; 74: 57–71.
53. Karmali F, Shelhamer M. The dynamics of parabolic flight: flight characteristics and passenger percepts. Acta Astronaut 2008; 63: 594–602.
54. Hoffman RA, Billingham J. Effect of altered G levels on deposition of particulates in the human respiratory tract. J Appl Physiol 1975; 38: 955–960.
55. Darquenne C, West JB, Prisk GK. Deposition and dispersion of 1‐μm aerosol boluses in the human lung: effect of micro‐ and hypergravity. J Appl Physiol 1998; 85: 1252–1259.
56. Darquenne C, Paiva M, West JB. Prisk GK. Effect of microgravity and hypergravity on deposition of 0.5‐ to 3‐μm‐diameter aerosol in the human lung. J Appl Physiol 1997; 83: 2029–2036.
57. Butler JP, Tsuda A. Effect of convective stretching and folding on aerosol mixing deep in the lung, assessed by approximate entropy. J Appl Physiol 1998; 83: 800–809.
58. Darquenne C, Prisk GK. Effect of small flow reversals on aerosol mixing in the alveolar region of the human lung. J Appl Physiol 2004; 97: 2083–2089.
59. Bennett WD, Chapman WF, Lay JC, Gerrity TR. Pulmonary clearance of inhaled particles 24 to 48 hours post deposition: effect of beta‐adrenergic stimulation. J Aerosol Med 1993; 6: 53–62.
60. Moller W, Häussinger K, Winkler‐Heil R, et al. Mucociliary and long‐term particle clearance in the airways of healthy nonsmoker subjects. J Appl Physiol. 2004; 97: 2200–2206.
61. Darquenne C, Prisk G. Deposition of inhaled particles in the human lung is more peripheral in lunar than in normal gravity. Eur J Appl Physiol 2008; 103: 687–695.
62. Darquenne C, Borja MG, Oakes JM, et al. Increase in relative deposition of fine particles in the rat lung periphery in the absence of gravity. J Appl Physiol 2014; 117: 880–886.
63. Lam CW, Scully RR, Zhang Y, et al. Toxicity of lunar dust assessed in inhalation‐exposed rats. Inhal Toxicol 2013; 25: 661–78.
64. Levine JS, Winterhalter D, Kerschmann RL. Dust in the atmosphere of mars and its impact on human exploration. Cambridge: Cambridge Scholars Publishing, 2018.

Online responses are no longer available. Please refer to our instructions for authors page for more information.

Editorials

Preventing RhD haemolytic disease of the fetus and newborn: where to next?

James P Isbister and Amanda Thomson

Med J Aust 2019; 211 (6): . || doi: 10.5694/mja2.50325
Published online: 16 September 2019

ARTICLE
AUTHORS
REFERENCES

Non‐invasive fetal RhD genotyping will enable ethical and cost‐effective targeting of prophylaxis

There are many unique and inspiring aspects to the story of haemolytic disease of the fetus and newborn. This once common, mysterious, and potentially devastating disease has been known for centuries. It may have been the reason for the shocking obstetric history of Katherine of Aragon, the first wife of Henry VIII; the course of British history might have been very different had anti‐RhD been available in Tudor England.1

1 Sydney Medical School, Sydney, NSW
2 Australian Red Cross Blood Service, Sydney, NSW

Correspondence: james.isbister@sydney.edu.au

Competing interests:

James Isbister is a member of the Independent Advisory Committee of the Australian Red Cross Blood Service and Chair of the National Blood Authority Patient Blood Management Implementation Steering Committee. Amanda Thompson is a member of the National Blood Authority expert reference group for development of a clinical practice guideline on the use of RhD immunoglobulin in maternity care.

1. Maclennan H. A gynaecologist looks at the Tudors. Med Hist 1967; 11: 66–74.
2. Diamond L, Blackfan K, Baty J. Erythroblastosis fetalis and its association with universal edema of the fetus, icterus gravis neonatorum and anemia of the newborn. J Pediatr 1932; 1: 269–309.
3. Darrow RR. Icterus gravis (erythroblastosis) neonatorum. An examination of etiologic considerations. Arch Pathol 1938; 25: 378–417.
4. Levine P, Burnham L, Katzin EM, Vogel P. The role of iso‐immunization in the pathogenesis of erythroblastosis fetalis. Am J Obstet Gynecol 1941; 42: 925–937.
5. Bowman J. Thirty‐five years of Rh prophylaxis. Transfusion 2003; 43: 1661–1666.
6. McBain RD, Crowther CA, Middleton P. Anti‐D administration in pregnancy for preventing Rhesus alloimmunisation. Cochrane Database Syst Rev 2015; CD000020.
7. Thyer J, Wong J, Thomson A, et al. Fifty years of RhD immunoglobulin (anti‐D) therapy in Australia: celebrating a public health success story. Med J Aust 2018; 209: 336–339.
8. White SW, Cheng JC, Penova‐Veselinovic B, et al. Single dose v two‐dose antenatal anti‐D prophylaxis: a randomised controlled trial. Med J Aust 2019; 2011: 261–265.
9. Brinc D, Lazarus AH. Mechanisms of anti‐D action in the prevention of hemolytic disease of the fetus and newborn. Hematology Am Soc Hematol Educ Program 2009; 185–191.
10. Breveglieri G, D'Aversa E, Finotti A, et al. Non‐invasive prenatal testing using fetal DNA. Mol Diagn Ther 2019; 23: 291–299.

Online responses are no longer available. Please refer to our instructions for authors page for more information.

Perspectives

Public health and economic perspectives on acute rheumatic fever and rheumatic heart disease

Jeffrey Cannon, Dawn C Bessarab, Rosemary Wyber and Judith M Katzenellenbogen

Med J Aust 2019; 211 (6): . || doi: 10.5694/mja2.50318
Published online: 16 September 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Cardiovascular diseases

Indigenous health

Health services administration

Environment and public health

With the care costs for the thousands of new cases predicted to occur by 2031, can we afford “business as usual”?

The group A streptococcus (GAS) bacterium causes possibly the most diverse range of diseases compared with any other pathogen. Resulting from an autoimmune reaction to GAS throat infection, and possibly skin infection, acute rheumatic fever (ARF) and its common consequence of rheumatic heart disease (RHD) have been described as “diseases of poverty” because they are highly prevalent in socio‐economic disadvantaged settings.1 Although there is a clear gradient between disease prevalence and socio‐economic disadvantage, ARF and RHD were once also prevalent in low and high socio‐economic settings, including in Melbourne, among non‐Indigenous Australians during the 1930s and 1940s.2 That ARF rarely, if at all, occurs in modern Melbourne is testament to the reality that ARF and RHD can be eliminated Australia‐wide, but what will elimination of ARF and RHD take and can we afford “business as usual”?

1 Telethon Kids Institute, Perth, WA
2 Centre for Aboriginal Medical and Dental Health, University of Western Australia, Perth, WA
3 George Institute for Global Health, Sydney, NSW
4 Western Australian Centre for Rural Health, University of Western Australia, Perth, WA
5 Group A Streptococcus and Rheumatic Heart Disease Research Group, Telethon Kids Institute, Perth, WA

Correspondence: jeffrey.cannon@telethonkids.org.au

Competing interests:

No relevant disclosures.

1. Carapetis JR, Beaton A, Cunningham MW, et al. Acute rheumatic fever and rheumatic heart disease. Nat Rev Dis Primers 2016; 2: 15084.
2. Holmes MC, Rubbo SD. A study of rheumatic fever and streptococcal infection in different social groups in Melbourne. J Hyg (Lond) 1953; 51: 450–457.
3. Colquhoun S, Condon J, Qin Li S, et al. Disparity in mortality rates from rheumatic heart disease in the Australian indigenous and non‐indigenous populations. Global Heart 2014; 9: e259–e260.
4. Australian Institute of Health and Welfare. Rheumatic heart disease and acute rheumatic fever in Australia: 1996–2012 (AIHW Cat. No. CVD 60). Canberra: AIHW, 2013. https://www.aihw.gov.au/reports/heart-stroke-vascular-disease/rheumatic-heart-disease-and-acute-rheumatic-fever/contents/table-of-contents (viewed July 2019).
5. Australian Institute of Health and Welfare. Australian Burden of Disease Study: impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011 (AIHW Cat. No. BOD 7). Canberra: AIHW, 2016. https://www.aihw.gov.au/reports/burden-of-disease/australian-bod-study-2011-indigenous-australians/contents/table-of-contents (viewed July 2019).
6. Roberts K, Maguire G, Brown A, et al. Echocardiographic screening for rheumatic heart disease in high and low risk Australian children. Circulation 2014; 129: 1953–1961.
7. Manyemba J, Mayosi BM. Penicillin for secondary prevention of rheumatic fever. Cochrane Database Syst Rev 2002; (3): CD002227.
8. Health Policy Analysis. Evaluation of the Commonwealth Rheumatic Fever Strategy — final report. Canberra: Commonwealth Department of Health, 2017.
9. Coffey PM, Ralph AP, Krause VL. The role of social determinants of health in the risk and prevention of group A streptococcal infection, acute rheumatic fever and rheumatic heart disease: a systematic review. PLoS Negl Trop Dis 2018; 12: e0006577.
10. Yeoh DK, Anderson A, Cleland G, Bowen AC. Are scabies and impetigo “normalised”? A cross‐sectional comparative study of hospitalised children in northern Australia assessing clinical recognition and treatment of skin infections. PLoS Negl Trop Dis 2017; 11: e0005726.
11. Wyatt K. Local action funded to eliminate rheumatic heart disease [media release]; Oct 2018. Office of the Hon Ken Wyatt. http://pandora.nla.gov.au/pan/159736/20181031-0031/www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2018-wyatt140.html (viewed Dec 2018).
12. Cannon J, Katzenellenbogen JM, Wyber R, et al. The cost of inaction on rheumatic heart disease: Technical report of the predicted human and economic toll of rheumatic heart disease for Aboriginal and Torres Strait Islander people by 2031. Perth: The END RHD CRE, Telethon Kids Institute, 2018.
13. Terreri MT, Ferraz MB, Goldenberg J, et al. Resource utilization and cost of rheumatic fever. J Rheumatol 2001; 28: 1394–1397.
14. Kingué S, Ba SA, Balde D, et al. The VALVAFRIC study: a registry of rheumatic heart disease in Western and Central Africa. Arch Cardiovasc Dis 2016; 109: 321–329.
15. Mitchell AG, Belton S, Johnston V, et al. “That heart sickness”: young Aboriginal people's understanding of rheumatic fever. Med Anthropol 2019; 38: 1–14.
16. Marika M, Mitchell A, Ralph A, et al. Words from Arnhem land: Aboriginal health messages need to be made with us rather than for us. The Conversation. 2018; 22 Nov. https://theconversation.com/words-from-arnhem-land-aboriginal-health-messages-need-to-be-made-with-us-rather-than-for-us-100655 (viewed July 2019).
17. Wyatt K. New Roadmap to Eliminate Rheumatic Heart Disease [media release]; Feb 2018. Office of the Hon Ken Wyatt. http://pandora.nla.gov.au/pan/159736/20181031-0031/www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2018-wyatt022.html (viewed Feb 2019).
18. Australian Labor Party. A fair go for Australia. Labor National Platform: 2018. https://www.alp.org.au/media/1539/2018_alp_national_platform_constitution.pdf (viewed Feb 2019).

Online responses are no longer available. Please refer to our instructions for authors page for more information.

Research

Paracetamol poisoning‐related hospital admissions and deaths in Australia, 2004–2017

Rose Cairns, Jared A Brown, Claire E Wylie, Andrew H Dawson, Geoffrey K Isbister and Nicholas A Buckley

Med J Aust 2019; 211 (5): . || doi: 10.5694/mja2.50296
Published online: 2 September 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Emergency medicine

Poisoning

Pharmaceutical preparations

Digestive system diseases

Mental disorders

Environment and public health

Abstract

Objectives: To assess the numbers of paracetamol overdose‐related hospital admissions and deaths in Australia since 2007–08, and the overdose size of intentional paracetamol overdoses since 2004.

Design, setting: Retrospective analysis of data on paracetamol‐related exposures, hospital admissions, and deaths from the Australian Institute of Health and Welfare National Hospital Morbidity Database (NHMD; 2007–08 to 2016–17), the New South Wales Poisons Information Centre (NSWPIC; 2004–2017), and the National Coronial Information System (NCIS; 2007–08 to 2016–17).

Participants: People who took overdoses of paracetamol in single ingredient preparations.

Main outcome measures: Annual numbers of reported paracetamol‐related poisonings, hospital admissions, and deaths; number of tablets taken in overdoses.

Results: The NHMD included 95 668 admissions with paracetamol poisoning diagnoses (2007–08 to 2016–17); the annual number of cases increased by 44.3% during the study period (3.8% per year; 95% CI, 3.2–4.6%). Toxic liver disease was documented for 1816 of these patients; the annual number increased by 108% during the study period (7.7% per year; 95% CI, 6.0–9.5%). The NSWPIC database included 22 997 reports of intentional overdose with paracetamol (2004–2017); the annual number increased by 77.0% during the study period (3.3% per year; 95% CI, 2.5–4.2%). The median number of tablets taken increased from 15 (IQR, 10–24) in 2004 to 20 (IQR, 10–35) in 2017. Modified release paracetamol ingestion report numbers increased 38% between 2004 and 2017 (95% CI, 30–47%). 126 in‐hospital deaths were recorded in the NHMD, and 205 deaths (in‐hospital and out of hospital) in the NCIS, with no temporal trends.

Conclusions: The frequency of paracetamol overdose‐related hospital admissions has increased in Australia since 2004, and the rise is associated with greater numbers of liver injury diagnoses. Overdose size and the proportion of overdoses involving modified release paracetamol have each also increased.

Please login with your free MJA account to view this article in full

CREATE AN ACCOUNT

Please note: institutional and Research4Life access to the MJA is now provided through Wiley Online Library.

View on Wiley Online Library

1 NSW Poisons Information Centre, Children's Hospital at Westmead, Sydney, NSW
2 University of Sydney, Sydney, NSW
3 Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW
4 Royal Prince Alfred Hospital, Sydney, NSW
5 University of Newcastle, Newcastle, NSW
6 Calvary Mater Newcastle, Newcastle, NSW

Correspondence: rose.cairns@health.nsw.gov.au

Acknowledgements:

This study was supported by a National Health and Medical Research Council Program Grant (1055176). We acknowledge the Australian Institute of Health and Welfare for providing the National Hospital Morbidity Database data, and the National Coronial Information System (NCIS), managed by the Victorian Department of Justice and Community Safety, for providing the coronial data. We thank the staff of the New South Wales Poisons Information Centre for their contributions to the NSWPIC database.

Competing interests:

No relevant disclosures.

1. Larson AM, Polson J, Fontana RJ, et al. Acetaminophen‐induced acute liver failure: results of a United States multicenter, prospective study. Hepatology 2005; 42: 1364–1372.
2. Huynh A, Cairns R, Brown JA, et al. Patterns of poisoning exposure at different ages: the 2015 annual report of the Australian Poisons Information Centres. Med J Aust 2018; 209: 74–79. https://www.mja.com.au/journal/2018/209/2/patterns-poisoning-exposure-different-ages-2015-annual-report-australian-poisons.
3. Gummin DD, Mowry JB, Spyker DA, et al. 2016 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 34th annual report. Clin Toxicol 2017; 55: 1072–1252.
4. Bateman DN, Carroll R, Pettie J, et al. Effect of the UK's revised paracetamol poisoning management guidelines on admissions, adverse reactions and costs of treatment. Br J Clin Pharmacol 2014; 78: 610–618.
5. Cairney DG, Beckwith HKS, Al‐Hourani K, et al. Plasma paracetamol concentration at hospital presentation has a dose‐dependent relationship with liver injury despite prompt treatment with intravenous acetylcysteine. Clin Toxicol 2016; 54: 405–410.
6. Chiew AL, Isbister GK, Kirby KA, et al. Massive paracetamol overdose: an observational study of the effect of activated charcoal and increased acetylcysteine dose (ATOM‐2). Clin Toxicol 2017; 55: 1055–1065.
7. Hawton K, Fagg J, Simkin S, et al. Trends in deliberate self‐harm in Oxford, 1985–1995: implications for clinical services and the prevention of suicide. Br J Psychiatry 1995; 171: 556–560.
8. Hawton K, Bergen H, Simkin S, et al. Long term effect of reduced pack sizes of paracetamol on poisoning deaths and liver transplant activity in England and Wales: interrupted time series analyses. BMJ 2013; 346: 1–9.
9. Hawton K, Simkin S, Deeks J, et al. UK legislation on analgesic packs: before and after study of long term effect on poisonings. BMJ 2004; 329: 1076–1079.
10. Hawton K, Townsend E, Deeks J, et al. Effects of legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom: before and after study. BMJ 2001; 322: 1–7.
11. Bernal W. changing patterns of causation and the use of transplantation in the United Kingdom. Semin Liver Dis 2003; 23: 227–236.
12. Bateman DN, Gorman DR, Bain M, et al. Legislation restricting paracetamol sales and patterns of self‐harm and death from paracetamol‐containing preparations in Scotland. Br J Clin Pharmacol 2006; 62: 573–581.
13. Bateman DN. Limiting paracetamol pack size: has it worked in the UK? Clin Toxicol 2009; 47: 536–541.
14. Morthorst BR, Erlangsen A, Nordentoft M, et al. Availability of paracetamol sold over the counter in Europe: a descriptive cross‐sectional international survey of pack size restriction. Basic Clin Pharmacol Toxicol 2018; 122: 643–649.
15. Chiew AL, Fountain JS, Graudins A, et al. Summary statement: new guidelines for the management of paracetamol poisoning in Australia and New Zealand. Med J Aust 2015; 203: 215–218. https://www.mja.com.au/journal/2015/203/5/summary-statement-new-guidelines-management-paracetamol-poisoning-australia-and.
16. Cairns R, Brown J, Buckley N. The impact of codeine re‐scheduling on misuse: a retrospective review of calls to Australia's largest poisons centre. Addiction 2016; 111: 1848–1853.
17. Pedan A. Analysis of count data using the SAS system. Twenty‐Sixth Annual SAS Users Group International Conference, Long Beach (US), 22–25 Apr 2001; paper 247‐26. https://support.sas.com/resources/papers/proceedings/proceedings/sugi26/p247-26.pdf (viewed June 2019).
18. Australian Bureau of Statistics. 3105.0.65.001. Australian historical population statistics, 2016. Apr 2019. https://www.abs.gov.au/AUSSTATS/abs@.nsf/mf/3105.0.65.001 (viewed June 2019).
19. The Acetaminophen Hepatotoxicity Working Group. Recommendations for FDA interventions to decrease the occurrence of acetaminophen hepatotoxicity [report]. Feb 2008. https://www.litigationandtrial.com/files/2011/12/2009-4429b1-02-FDA.pdf (viewed Nov 2018).
20. Gunnell D, Hawton K, Murray V, et al. Use of paracetamol for suicide and non‐fatal poisoning in the UK and France: are restrictions on availability justified? J Epidemiol Community Health 1997; 51: 175–179.
21. Australian Department of Health, Therapeutic Goods Administration. Paracetamol: changes to pack size [media release]. 26 Aug 2013. https://www.tga.gov.au/media-release/paracetamol-changes-pack-size (viewed July 2019).
22. Chiew AL, Isbister GK, Page CB, et al. Modified release paracetamol overdose: a prospective observational study (ATOM‐3). Clin Toxicol 2018; 56: 810–819.
23. European Medicines Agency. Modified‐release paracetamol‐containing products to be suspended from EU market [EMA/118413/2018]. 19 Feb 2018. https://www.ema.europa.eu/medicines/human/referrals/paracetamol-modified-release (viewed Nov 2018).
24. Australian Department of Health, Therapeutic Goods Administration. Interim decision in relation to paracetamol (modified release) [Interim decisions and invitation for further comment on substances referred to the March 2019 ACMS/ACCS meetings]. 6 June 2019. https://www.tga.gov.au/book-page/15-interim-decision-relation-paracetamol-modified-release (viewed July 2019).
25. New South Wales Poisons Information Centre. 2013 annual report. https://www.poisonsinfo.nsw.gov.au/site/files/ul/data_text12/4918535-NSWPIC_Annual_Report_2013.pdf (viewed July 2019).

Online responses are no longer available. Please refer to our instructions for authors page for more information.

Research

The increasing use of shave biopsy for diagnosing invasive melanoma in Australia

Sara L de Menezes, John W Kelly, Rory Wolfe, Helen Farrugia and Victoria J Mar

Med J Aust 2019; 211 (5): . || doi: 10.5694/mja2.50289
Published online: 2 September 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Neoplasms

Surgical procedures, operative

Immune system diseases

General medicine

Abstract

Objective: To assess changes in the choice of skin biopsy technique for assessing invasive melanoma in Victoria, and to examine the impact of partial biopsy technique on the accuracy of tumour microstaging.

Design: Retrospective cross‐sectional review of Victorian Cancer Registry data on invasive melanoma histologically diagnosed in Victoria during 2005, 2010, and 2015.

Setting, participants: 400 patients randomly selected from each of the three years, stratified by final tumour thickness: 200 patients with thin melanoma (< 1.0 mm), 100 each with intermediate (1.0–4.0 mm) and thick melanoma (> 4.0 mm).

Main outcome measures: Partial and excisional biopsies, as proportions of all skin biopsies; rates of tumour base transection and T‐upstaging, and mean tumour thickness underestimation following partial biopsy.

Results: 833 excisional and 337 partial diagnostic biopsies were undertaken. The proportion of partial biopsies increased from 20% of patients in 2005 to 36% in 2015 (P < 0.001); the proportion of shave biopsies increased from 9% in 2005 to 20% in 2015 (P < 0.001), with increasing rates among dermatologists and general practitioners. Ninety‐four of 175 shave biopsies (54%) transected the tumour base; wide local excision subsequently identified residual melanoma in 65 of these cases (69%). Twenty‐one tumours diagnosed by shave biopsy (12%) were T‐upstaged. With base‐transected shave biopsies, tumour thickness was underestimated by a mean 2.36 mm for thick, 0.48 mm for intermediate, and 0.07 mm for thin melanomas.

Conclusion: Partial biopsy, particularly shave biopsy, was increasingly used for diagnosing invasive melanoma between 2005 and 2015. Shave biopsy has a high rate of base transection, reducing the accuracy of tumour staging, which is crucial for planning appropriate therapy, including definitive surgery and adjuvant therapy.

Please login with your free MJA account to view this article in full

CREATE AN ACCOUNT

Please note: institutional and Research4Life access to the MJA is now provided through Wiley Online Library.

View on Wiley Online Library

1 Victorian Melanoma Service, Alfred Hospital, Melbourne, VIC
2 Monash University Central Clinical School, Melbourne, VIC
3 Victorian Cancer Registry, Cancer Council Victoria, Melbourne, VIC
4 Skin and Cancer Foundation, Melbourne, VIC

Correspondence: victoria.mar@monash.edu

Acknowledgements:

We acknowledge the staff at the Victorian Melanoma Service, Alfred Hospital, and the Victorian Cancer Registry for their support, which made this investigation possible.

Competing interests:

Victoria Mar received honoraria (speaker’s fees) from Bristol Myers Squibb and Merck in 2018 for work unrelated to this article.

1. Ng JC, Swain S, Dowling JP, et al. The impact of partial biopsy on histopathologic diagnosis of cutaneous melanoma: experience of an Australian tertiary referral service. Arch Dermatol 2010; 146: 234–239.
2. Cancer Council Australia; Melanoma Guidelines Working Party. Clinical practice guidelines for the diagnosis and management of melanoma. Updated Apr 2018. https://wiki.cancer.org.au/australia/Guidelines:Melanoma (viewed May 2019).
3. Swetter SM, Tsao H, Bichakjian CK, et al. American Academy of Dermatology. Guidelines of care for the management of primary cutaneous melanoma. J Am Acad Dermatol 2019; 80: 208–250.
4. National Institute for Health and Care Excellence. Melanoma: assessment and management [NICE guideline NG14]. July 2015; update 23 May 2019. https://www.nice.org.uk/guidance/ng14/evidence (viewed June 2019).
5. Kelly JW, Henderson MA, Thursfield VJ, et al. The management of primary cutaneous melanoma in Victoria in 1996 and 2000. Med J Aust 2007; 187: 511–514. https://www.mja.com.au/journal/2007/187/9/management-primary-cutaneous-melanoma-victoria-1996-and-2000.
6. Egnatios GL, Dueck AC, Macdonald JB, et al. The impact of biopsy technique on upstaging, residual disease, and outcome in cutaneous melanoma. Am J Surg 2011; 202: 771–777.
7. Mir M, Chan CS, Khan F, et al. The rate of melanoma transection with various biopsy techniques and the influence of tumor transection on patient survival. J Am Acad Dermatol 2013; 68: 452–458.
8. Zager JS, Hochwald SN, Marzban SS, et al. Shave biopsy is a safe and accurate method for the initial evaluation of melanoma. J Am Coll Surg 2011; 212: 454–460.
9. Hieken TJ, Hernandez‐Irizarry R, Boll JM, et al. Accuracy of diagnostic biopsy for cutaneous melanoma: implications for surgical oncologists. Int J Surg Oncol 2013; 2013: 196493.
10. Lowe M, Hill N, Page A, et al. The impact of shave biopsy on the management of patients with thin melanomas. Am Surg 2011; 77: 1050–1053.
11. Mills JK, White I, Diggs B, et al. Effect of biopsy type on outcomes in the treatment of primary cutaneous melanoma. Am J Surg 2013; 205: 585–590.
12. Mahul B Amin. American Joint Committee on Cancer. AJCC cancer staging manual. New York: Springer, 2017.
13. Long GV, Hauschild A, Santinami M, et al. Adjuvant dabrafenib plus trametinib in stage III BRAF‐mutated melanoma. N Engl J Med 2017; 377: 1813–1823.
14. Weber J, Mandala M, Del Vecchio M, et al. Adjuvant nivolumab versus ipilimumab in resected stage III or IV melanoma. N Engl J Med 2017; 377: 1824–1835.
15. Cancer Council Victoria. Victorian Cancer Statistics. http://vcrdata.cancervic.org.au/vs (viewed May 2019).
16. Saco M, Thigpen J. A retrospective comparison between preoperative and postoperative Breslow depth in primary cutaneous melanoma: how preoperative shave biopsies affect surgical management. J Drugs Dermatol 2014; 13: 531–536.
17. Farberg AS, Rigel DS. A comparison of current practice patterns of US dermatologists versus published guidelines for the biopsy, initial management, and follow up of patients with primary cutaneous melanoma. J Am Acad Dermatol 2016; 75: 1193–1197.e1.
18. Silverstein D, Mariwalla K. Biopsy of the pigmented lesions. Dermatol Clin 2012; 30: 435–443.
19. Lutz K, Hayward V, Joseph M, et al. Current biopsy practices for suspected melanoma: a survey of family physicians in Southwestern Ontario. Plast Surg 2014; 22: 175–178.
20. Troxel DB. Pitfalls in the diagnosis of malignant melanoma: findings of a risk management panel study. Am J Surg Pathol 2003; 27: 1278–1283.
21. Ng PC, Barzilai DA, Ismail SA, et al. Evaluating invasive cutaneous melanoma: is the initial biopsy representative of the final depth? J Am Acad Dermatol 2003; 48: 420–424.
22. Merck Sharp & Dohme Corp. Safety and efficacy of pembrolizumab compared to placebo in resected high‐risk stage III melanoma (MK‐3475‐716/KEYNOTE‐716). Clinicaltrials.gov; updated 14 June 2019. https://www.clinicaltrials.gov/ct2/show/NCT03553836 (viewed June 2019).
23. Patrawala S, Maley A, Greskovich C, et al. Discordance of histopathologic parameters in cutaneous melanoma: clinical implications. J Am Acad Dermatol 2016; 74: 75–80.
24. Karimipour DJ, Schwartz JL, Wang TS, et al. Microstaging accuracy after subtotal incisional biopsy of cutaneous melanoma. J Am Acad Dermatol 2005; 52: 798–802.

Online responses are no longer available. Please refer to our instructions for authors page for more information.

Clinically important sport‐related traumatic brain injuries in children

Topics

Author

Health care for older people in rural and remote Australia: challenges for service provision

Topics

Author

First reported case of extensively drug‐resistant typhoid in Australia

Topics

Author

Pulmonary challenges of prolonged journeys to space: taking your lungs to the moon

Topics

Summary

Author

Preventing RhD haemolytic disease of the fetus and newborn: where to next?

Author

Public health and economic perspectives on acute rheumatic fever and rheumatic heart disease

Topics

Author

Paracetamol poisoning‐related hospital admissions and deaths in Australia, 2004–2017

Topics

Abstract

Author

The increasing use of shave biopsy for diagnosing invasive melanoma in Australia

Topics

Abstract

Author

Integrating palliative care and symptom relief into responses to humanitarian crises

Topics

Author

Adolescent immunisation in young people with disabilities in Australia

Topics

Author

Clinically important sport‐related traumatic brain injuries in children

Topics

Author

Comment

Do you have any competing interests to declare? *

Health care for older people in rural and remote Australia: challenges for service provision

Topics

Author

Comment

Do you have any competing interests to declare? *

First reported case of extensively drug‐resistant typhoid in Australia

Topics

Author

Comment

Do you have any competing interests to declare? *

Pulmonary challenges of prolonged journeys to space: taking your lungs to the moon

Topics

Summary

Author

Comment

Do you have any competing interests to declare? *

Preventing RhD haemolytic disease of the fetus and newborn: where to next?

Author

Comment

Do you have any competing interests to declare? *

Public health and economic perspectives on acute rheumatic fever and rheumatic heart disease

Topics

Author

Comment

Do you have any competing interests to declare? *

Paracetamol poisoning‐related hospital admissions and deaths in Australia, 2004–2017

Topics

Abstract

Author

Comment

Do you have any competing interests to declare? *

The increasing use of shave biopsy for diagnosing invasive melanoma in Australia

Topics

Abstract

Author

Comment

Do you have any competing interests to declare? *

Integrating palliative care and symptom relief into responses to humanitarian crises

Topics

Author

Comment

Do you have any competing interests to declare? *

Adolescent immunisation in young people with disabilities in Australia

Topics

Author

Comment

Do you have any competing interests to declare? *

Pagination