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The epidemiology of bloodstream infections has changed during the early 21st century, and our understanding of complex host–pathogen relationships continues to evolve. Enterococci have emerged as major community and health care pathogens; the association of colorectal neoplasia with enterococcal infections has recently been reported, particularly with community‐acquired Enterococcus faecalis bacteraemia of unknown source.1,2
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Effective therapies are available, but too few patients are receiving them
There is a significant amount of evidence that intensive statin therapy reduces the likelihood of cardiovascular events in people who have had an acute coronary syndrome (ACS), and such therapy is given the highest grade of recommendation in Australian clinical practice guidelines.1 Post hoc analyses of randomised trials of treatment with statins, statins and ezetimibe, or, more recently, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors indicate that patients who achieve very low low‐density lipoprotein cholesterol (LDL‐C) levels are at very low risk of cardiovascular events after an ACS, and that the rates of adverse events related to attaining such levels are not increased.2,3 In the Improved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE‐IT), the combination of simvastatin and a non‐statin LDL‐lowering treatment (ezetimibe) reduced LDL‐C levels to a median 1.4 mmol/L, and this was associated with reduced numbers of clinical events.4 In the Odyssey Outcomes trial, a combination of statins and alirocumab (a PCSK9 inhibitor) reduced LDL‐C levels to below 1.0 mmol/L and this was associated with reduced numbers of major adverse cardiovascular events.3 These trials provide further support for the LDL‐C hypothesis of cardiovascular risk, which suggests that the risk of a cardiovascular event is reduced by about 22% for each 1.0 mmol/L reduction in LDL‐C levels.2
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Overseas experience need not portend the future of prescription drug misuse in Australia
Dispensing data indicate that pregabalin prescribing in Australia is rising rapidly, and the numbers of self‐poisonings and deaths are also increasing.1 This mirrors the European and North American experience of escalating misuse and harms.2,3 Although Australian guidelines recommend it only as second line treatment for neuropathic pain,4 pregabalin is now the seventh most expensive drug in terms of Pharmaceutical Benefits Scheme (PBS) expenditure.5
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Although hand transplantation has the potential to transform lives, the procedure is not without risk
March 2018 heralded 7 years since the only Australian to date received a hand transplant. The recipient has physically and psychologically integrated the transplanted hand and reports significantly improved quality of life;1 motor and sensory functions continue to improve incrementally with ongoing hand therapy. The Transplantation Society of Australia and New Zealand (TSANZ) Vascular Composite Allograft (VCA) Advisory Committee met during the TSANZ annual scientific meeting held in Melbourne in April 2018. Transplant physicians and surgeons and reconstructive microsurgeons comprise the advisory committee, with scope to co‐opt expert members (eg, in bioethics) as required. Despite the success of the seminal hand transplant in Australia, no further patients have progressed to the transplant waiting list. In light of this, the Advisory Committee reflects in this article on the status of hand transplantation internationally and considers its relevance for Australia.
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The views expressed in this manuscript reflect those of the TSANZ VCA Advisory Committee — Karen Dwyer (Chair), Jamie Burt, Tim Bennett, Frank Ierino, Sharon Ford, Kate Wyburn and Richard Allen — and have been ratified by the TSANZ Council — Stephen Alexander (President) and Toby Coates (President elect).
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Objective: To assess the factors that contributed to the successful completion of recruitment for the largest clinical trial ever conducted in Australia, the Aspirin in Reducing Events in the Elderly (ASPREE) study.
Design: Enrolment of GPs; identification of potential participants in general practice databases; screening of participants.
Setting, participants: Selected general practices across southeast Australia (Tasmania, Victoria, Australian Capital Territory, New South Wales, South Australia).
Major outcomes: Numbers of patients per GP screened and randomised to participation; geographic and demographic factors that influenced screening and randomising of patients.
Results: 2717 of 5833 GPs approached (47%) enrolled to recruit patients for the study; 2053 (76%) recruited at least one randomised participant. The highest randomised participant rate per GP was for Tasmania (median, 5; IQR, 1–11), driven by the high rate of participant inclusion at phone screening. GPs in inner regional (adjusted odds ratio [aOR], 1.45; 95% CI, 1.14–1.84) and outer regional areas (aOR, 1.86; 95% CI, 1.19–2.88) were more likely than GPs in major cities to recruit at least one randomised participant. GPs in areas with a high proportion of people aged 70 years or more were more likely to randomise at least one participant (per percentage point increase: aOR, 1.10; 95% CI, 1.05–1.15). The number of randomised patients declined with time from GP enrolment to first randomisation.
Conclusion: General practice can be a rich environment for research when barriers to recruitment are overcome. Including regional GPs and focusing efforts in areas with the highest proportions of potentially eligible participants improves recruitment. The success of ASPREE attests to the clinical importance of its research question for Australian GPs.
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The ASPREE study, including the design and implementation of the recruitment strategy, was supported by the National Institute on Aging and the National Cancer Institute at the National Institutes of Health in the United States (U01AG029824), the National Health and Medical Research Council (334047 and 1127060), Monash University, and the Victorian Cancer Agency. Bayer provided aspirin and the matching placebo. We acknowledge the dedicated and skilled staff in Australia and the Unites States who undertook the ASPREE trial. We are also most grateful to the ASPREE participants who so willingly volunteered for this study, and the general practitioners and medical clinics who supported the participants in the ASPREE study., (ASPREE): International Standard Randomized Controlled Trial Number Register (ISRCTN83772183) and clinicaltrials.gov (NCT01038583).
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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.
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We thank the poisons information specialists from the Queensland, New South Wales, Victorian and Western Australian centres.
Jared Brown has received consultancy fees from GlaxoSmithKline Consumer for sitting on an advisory board regarding paracetamol.
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Summary