How accurate is presumptive Chlamydia trachomatis treatment? A 6-month clinical audit of a walk-in sexual health service.

Background Chlamydia trachomatis (chlamydia) is highly prevalent and is an important sexually transmitted infection as it can lead to increased risk of HIV seroconversion; and if left untreated, can cause infertility in women. Clinical guidelines recommend treating chlamydia presumptively when presenting symptomatically; however, clinicians are now questioning this due to increasing prevalence of antimicrobial resistance. Methods To determine the accuracy of presumptive chlamydia treatment practices at a walk-in sexual health service in regional Australia, we audited all same-day screen and treat presentations prescribed azithromycin over a 6-month period in 2018. Results A total of 325 cases were included in the analysis. Over half (54%) the presentations returned negative pathology for all pathogens investigated. One quarter (25%) of presentations were positive for chlamydia, and (4%) reported a dual infection. A further one fifth (20%) were negative for chlamydia but positive for another pathogen. More symptomatic males than females returned positive pathology for chlamydia (8% vs 4%). Conclusions While presumptive treatment is recommended in the current guidelines, our findings indicate this resulted in over-treatment. Considering the increasing resistance patterns for Mycoplasma genitalium, which include azithromycin, presumptive treatments need to balance immediate client care needs against long-term community antimicrobial resistance outcomes. This internal audit provided a feedback mechanism to the walk-in sexual service, enabling modification of practices to provide more precise, individual clinical care within the bounds of current STI guidelines, while balancing wider the objectives of antimicrobial stewardship.

A rapid review of evidence to inform an ear, nose and throat service delivery model in remote Australia.

INTRODUCTION: This rapid literature review aimed to inform the development of a new sustainable, evidence-based service delivery model for ear, nose and throat (ENT) services across Cape York, Australia. This work seeks to investigate the research question: 'What are the characteristics of successful outreach services which can be applied to remote living Indigenous children?' METHODS: A comprehensive search of three major electronic databases (PubMed, CINAHL and MEDLINE) and two websites (HealthInfo Net and Google Scholar) was conducted for peer-reviewed and grey literature, to elicit characteristics of ENT and hearing services in rural and remote Australia, Canada, New Zealand and the USA. The search strategy was divided into four sections: outreach services for rural and remote communities; services for Indigenous children and families; telehealth service provision; and remote ear and hearing health service models. A narrative synthesis was used to summarise the key features of the identified service characteristics. RESULTS: In total, 71 studies met the inclusion criteria and were included in the review, which identified a number of success and sustainability traits, including employment of a dedicated ear and hearing educator; outreach nursing and audiology services; and telehealth access to ENT services. Ideally, outreach organisations should partner with local services that employ local Indigenous health workers to provide ongoing ear health services in community between outreach visits. CONCLUSION: The evidence suggests that sound and sustainable ENT outreach models build on existing services; are tailored to local needs; promote cross-agency collaboration; use telehealth; and promote ongoing education of the local workforce.

Acute kidney injury in Indigenous intensive care patients.

BACKGROUND: Patients presenting to intensive care units (ICUs) report high rates of acute kidney injury (AKI) requiring renal replacement therapy (RRT). Globally, Indigenous populations report higher rates of renal disease than their non-Indigenous counterparts. OBJECTIVES: This study reports the prevalence, presenting features, and outcomes of Indigenous ICU admissions with AKI (who require RRT) within an Australian ICU setting and compares these with those of Indigenous patients without AKI. METHOD: A retrospective database review examined all Indigenous patients older than 18 years admitted to a regional Australian ICU between June 2013 and June 2016, excluding patients with chronic kidney disease requiring dialysis. We report patient demography, presenting clinical and physiological characteristics, ICU length of stay, hospital outcome, and renal requirements at three months after discharge, on Indigenous patients with AKI requiring RRT. RESULTS: AKI requiring RRT was identified in 15.9% of ICU Indigenous patients. On univariate analysis, it was found that these patients were older and had a higher body mass index, lower urine output, and higher levels of creatinine and urea upon presentation than patients who did not have AKI. Patients with AKI reported longer ICU stays and a higher mortality rate (30%, p < 0.05), and 10% of these required ongoing RRT at 3 months. Multivariate analysis found significant associations with AKI were only found for presenting urine outputs, urea and creatinine levels. CONCLUSIONS: This study reports higher rates of AKI requiring RRT for Indigenous adults than non-Indigenous adults, as has been previously published. Benefits arising from this study are as follows: these reported findings may initiate early targeted clinical management and can assist managing expectations, as some patients may require ongoing RRT after discharge.

Psycho-social resilience, vulnerability and suicide prevention: impact evaluation of a mentoring approach to modify suicide risk for remote Indigenous Australian students at boarding school.

BACKGROUND: The proposed study was developed in response to increased suicide risk identified in Aboriginal and Torres Strait Islander students who are compelled to attend boarding schools across Queensland when there is no secondary schooling provision in their remote home communities. It will investigate the impact of a multicomponent mentoring intervention to increase levels of psychosocial resilience. We aim to test the null hypothesis that students' resilience is not positively influenced by the intervention. The 5-year project was funded by the Australian National Health and Medical Research Council from December 2014. METHODS/DESIGN: An integrated mixed methods approach will be adopted; each component iteratively informing the other. Using an interrupted time series design, the primary research methods are quantitative: 1) assessment of change in students' resilience, educational outcomes and suicide risk; and 2) calculation of costs of the intervention. Secondary methods are qualitative: 3) a grounded theoretical model of the process of enhancing students' psychosocial resilience to protect against suicide. Additionally, there is a tertiary focus on capacity development: more experienced researchers in the team will provide research mentorship to less experienced researchers through regular meetings; while Indigenous team members provide cultural mentorship in research practices to non-Indigenous members. DISCUSSION: Australia's suicide prevention policy is progressive but a strong service delivery model is lacking, particularly for Indigenous peoples. The proposed research will potentially improve students' levels of resilience to mitigate against suicide risk. Additionally, it could reduce the economic and social costs of Indigenous youth suicide by obtaining agreement on what is good suicide prevention practice for remote Indigenous students who transition to boarding schools for education, and identifying the benefits-costs of an evidence-based multi-component mentoring intervention to improve resilience.

The impact of a community-based risky drinking intervention (Beat da Binge) on Indigenous young people.

BACKGROUND: Alcohol misuse imposes substantial harm on Indigenous Australians whose health status is poorer than non-Indigenous Australians. Although Indigenous youth are over represented in Indigenous alcohol harms, few interventions addressing alcohol-related harm among Indigenous youth have been evaluated. Given this paucity of evidence, a survey was designed to evaluate the effects of a whole-of-community, anti-binge drinking intervention for young people in an Indigenous community in far north Queensland, Australia. METHODS: A cross sectional, baseline-post intervention study assessed the impact of a two year anti-binge drinking intervention targeting young people (18-24 years). A survey was developed and implemented at baseline and again two-years post-intervention, administered by young local people employed as research assistants. Survey respondents were recruited through snowballing techniques. Survey items asked about respondents' knowledge of binge drinking and standard drinks, involvement in alcohol-free social activities, frequency of short-term risky drinking (binge drinking), and mean alcohol expenditure during short-term risky drinking occasions. The intervention was called Beat da Binge. Two major events and multiple minor activities each year were implemented, focusing on drinking education, alcohol-free community-wide social events, and youth-specific sporting and social activities to facilitate self-empowerment. RESULTS: Beat da Binge was associated with a statistically significant 10% reduction in the proportion of survey respondents who reported that they had engaged in an episode of short-term risky drinking, in the frequency of short-term risky drinking for all beverage types except wine (ranging from 4% to 31% reductions), in mean expenditure on alcohol during short-term risky drinking sessions ($6.25) and in the proportion of activities with family/friends that usually include alcohol (7%). There were also statistically significant increases in awareness of binge drinking and standard drinks (28% and 21% respectively). In addition to alcohol-specific outcomes, there was a statistically significant 8 % increase in the proportions of respondents engaged in training as their main weekday activity, which was partly off-set by a 13% reduction in those whose main weekday activity was family care or home-related tasks. CONCLUSIONS: Reductions in the proportion of survey respondents who reported binge drinking, along with increases in awareness and involvement in alcohol-free social activities suggest the community-based intervention was effective. The potential impact of sample selection and self-reporting limitations on results need further investigation. There is an urgent need for Indigenous, community-driven public health programs that are well evaluated to both improve Indigenous health and the strength of the current evidence base to inform future community interventions.

Lifetime influences for cannabis cessation in male incarcerated indigenous australians.

INTRODUCTION: Urban non-indigenous populations report life events (marriages, employment) as influences for self-initiated cannabis cessation. However, this hasn't been investigated in remote indigenous populations with different social paradigms. METHODS: We investigate cannabis use, harms, and poly-substance misuse in 101 consenting male incarcerated indigenous Australians. Interviews applied quantitative and qualitative questions assessing demographic characteristics, criminal history, drug use, the Marijuana Problems Inventory (MPI), and cannabis-cessation influences. Comparisons used Chi Square, Analysis of Variance, and Nvivo software. RESULTS: Cannabis use groups (current users, ex-users, and never users) were demographically similar except that current users reported more juvenile legal problems, younger school departure, and lower school achievement (p < 0.05). Mean cannabis consumption was 12.3 cones/day. Incarceration and family responsibilities were the strongest cessation influences. Employment responsibilities and negative self-image were rarely cited as influences. DISCUSSION: High cannabis use, with its associated problems, is concerning. These identified influences indicate incarceration should be used for substance reduction programs, plus post-release follow-up. Community-based programs focusing on positive influences, such as family responsibilities and social cohesion, may be successful within indigenous populations with strong kinship responsibilities, rather than programs that focus solely on substance harms.

Operational use of household bleach to "crash and release" Aedes aegypti prior to Wolbachia-infected mosquito release.

Dengue (family Flaviviridae, genus Flavivirus, DENV) remains the leading arboviral cause of mortality in the tropics. Wolbachia pipientis has been shown to interrupt DENV transmission and is presently being trialled as a biological control. However, deployment issues have arisen on methods to temporarily suppress wild mosquito populations before Wolbachia-infected mosquito releases. By suppressing wild populations, fewer Ae. aegypti releases are required to achieve a sustainable Wolbachia density threshold. Furthermore, public distress is reduced. This study tests the application of domestic bleach (4% NaCIO) to temporarily "crash" immature Aedes populations in water-filled containers. Spray application NaClO (215 ppm) resulted in a mean 48-h mortality of 100, 100, 97, and 88% of eggs, second-instar larvae, fourth-instar larvae, and pupae, respectively. In the field, NaClO delayed ovipositing by 9 d in cooler months, and 11 d in hotter months, after which oviposition resumed in treated receptacles. We found bleach treatment of pot-plant bases did not cause wilting, yellowing, or dropping of leaves in two ornamental plants species. Domestically available NaClO could be adopted for a "crash and release" strategy to temporarily suppress wild populations of Ae. aegypti in containers before release of Wolbachia-infected mosquitoes. The "crash and release" strategy is also applicable to other mosquito species, e.g., Aedes albopictus (Skuse), in strategies using released mosquitoes.

Is the evidence-based medicine movement counter-productive: are randomised controlled trials the best approach to establish evidence in complex healthcare situations?

In the modern era, evidence-based medicine (EBM) has been embraced as the best approach to practising medicine, providing clinicians with 'objective' evidence from clinical research. However, for presentations with complex pathophysiology or from complex social environments, sometimes there remains no evidence, and no amount of research will obtain it. Yet, health researchers continue to undertake randomised controlled trials (RCT) in complex environments, ignoring the risk that participants' health may be compromised throughout the trial process. This paper examines the role of research that seeks to obtain evidence to support EBM. We provide examples of RCTs on ear disease in Aboriginal populations as a case-in-point. Decades of ear research have failed to yield statistically significant findings, demonstrating that when multiple factors are at play, study designs struggle to balance the known disease process drivers, let alone unknown drivers. This paper asks the reader to consider if the pursuit of research is likely to produce evidence in complex situations; or if perhaps RCTs should not be undertaken in these situations. Instead, clinicians could apply empirical evidence, tailoring treatments to individuals while taking into account the complexities of their life circumstances.

Arbovirus models to provide practical management tools for mosquito control and disease prevention in the Northern Territory, Australia.

Ross River virus (RRV) causes the most common human arbovirus disease in Australia. Although the disease is nonfatal, the associated arthritis and postinfection fatigue can be debilitating for many months, impacting on workforce participation. We sought to create an early-warning system to notify of approaching RRV disease outbreak conditions for major townships in the Northern Territory. By applying a logistic regression model to meteorologic factors, including rainfall, a postestimation analysis of sensitivity and specificity can create rainfall cut-points. These rainfall cut-points indicate the rainfall level above which previous epidemic conditions have occurred. Furthermore, rainfall cut-points indirectly adjust for vertebrate host data from the agile wallaby (Macropus agilis) as the life cycle of the agile wallaby is intricately meshed with the wet season. Once generated, cut-points can thus be used prospectively to allow timely implementation of larval survey and control measures and public health warnings to preemptively reduce RRV disease incidence. Cut-points are location specific and have the capacity to replace previously used models, which require data management and input, and rarely provide timely notification for vector control requirements and public health warnings. These methods can be adapted for use elsewhere.

The continuing role of Haemophilus influenzae type b carriage surveillance as a mechanism for early detection of invasive disease activity.

Prior to the introduction of Haemophilus influenzae type b (Hib) conjugate vaccines, Hib was the leading cause of bacterial meningitis in children under five years of age worldwide. In countries that have adopted Hib vaccination schedules, invasive disease has reduced markedly. Oro-naso pharyngeal carriage is recognized as the most significant source of infection. Hib carriage is significantly associated with poverty, such as overcrowding, poor ventilation in houses, lack of running water, and high smoking rates. Additionally, many Indigenous minority groups report high rates of Hib carriage. A resurgence of Hib disease among Alaskan children in the 1990s, lead to a change in approach to eliminate Hib disease and carriage in high-risk populations. This new approach identifies strategies for eliminating Hib disease focusing on the reservoirs of colonization within families and communities. Monitoring Hib carriage continues to offer an early warning system, whereby intervention could prevent invasive disease resurgence.

Efficacy of alpha-cypermethrin and lambda-cyhalothrin applications to prevent Aedes breeding in tires.

The efficacy of alpha-cypermethrin (Cyperthor) and lambda-cyhalothrin (Demand) to prevent mosquito larval colonization of water-containing receptacles was investigated using 2 differing applications in disused car tires in Darwin, Australia. Insecticide treatments were applied uniformly to the inside surfaces of 2 categories of tires: 1) dry tires that were partially filled with water 24 h after spraying and 2) wet tires partially filled with water prior to spraying. All mosquito larvae, pupae, and dead adults were collected from the treatment and control tires weekly over the 24-wk study period and were later identified to species in the laboratory. Control tires were colonized by Aedes notoscriptus in wk 2 and by Culex quinquefasciatus in wk 4. Aedes notoscriptus failed to colonize any alpha-cypermethrin-treated tires until wk 22 and did not colonize any lambda-cyhalothrin-treated tires during the 24-wk trial. Culex quinquefasciatus colonized alpha-cypermethrin and lambda-cyhalothrin-treated tires from wk 11 and wk 15, respectively. These results indicate both insecticides using either application method can prevent colonization of Ae. notoscriptus for at least 20 wk and demonstrate great potential for the prevention of breeding in receptacles for other receptacle-breeding Aedes species, such as the dengue vectors, Ae. aegypti and Ae. albopictus.

Participatory Action Research Applied to an Ear, Nose, and Throat Specialty Service Redesign in Remote Australia: A Mixed-Methods Study of Key Stakeholder Perspectives.

This mixed-methods study reports on the key stakeholders' perspectives on the ear, nose, and throat (ENT) service redesign in remote Australia, using a participatory action research (PAR) approach. A primary health care (PHC) clinician survey was conducted to assess local needs and possible educational gaps in clinical knowledge. This was followed by an internal stakeholder forum and a follow-up survey with Torres and Cape Hospital and Health Service staff to gain their perspectives on current service delivery and table ideas for a new ENT health service model. Qualitative data were analyzed inductively and grouped in emerging themes. Quantitative data were imported into tables and analyzed descriptively. PAR allowed for input from 19 PHC clinicians, 10 face-to-face stakeholders perspectives, and 18 stakeholder follow-up survey respondents. Four themes emerged: 1. Training for health workers in ENT management; 2. Improved local service access; 3. New referral pathways to improve continuity of care; and 4. Introduction of telehealth. PAR engaged key stakeholders, identifying gaps in ENT service delivery, and guided the development of the new service model. The inclusion of stakeholders throughout the service redesign process is likely to create a more sustainable model of care which already has local "buy-in".

Irukandji syndrome case series from Australia's Tropical Northern Territory.

STUDY OBJECTIVE: We describe Irukandji syndrome (a painful hypercatecholaminergic condition caused by jellyfish envenoming) in Australia's Northern Territory. METHODS: We collected prospectively a standardized data set on patients presenting to health facilities in the Northern Territory. Additional cases were identified retrospectively. Data collected included demographic, geographic, seasonal, and environmental features, as well as sting details, clinical manifestations, investigations, management, and outcomes. RESULTS: From 1990 to 2007, Irukandji syndrome affected 87 people. Age ranged from 1 to 51 years (64% male victims; 41% children [63% indigenous]). Activities associated with stings included snorkeling or scuba diving (35%) and swimming (29%). Stings commonly occurred in water greater than 2 m deep (63%), with fine weather (73%) and still or light breeze (70%). Seasonal variation was bimodal; peaks in May and October corresponded to prevailing offshore winds in the Darwin and Gove areas, respectively. Pain was severe (65%), with rapid onset (<30 minutes in 79%). Sting lesions (visible in 63%) were mild, and nematocysts (detected in 7 cases) had variable morphology. Systemic features were common, including hypertension and ECG abnormalities. Severe complications included troponin-level increases (2 cases) and cardiomyopathy with ventricular tachycardia (1 case), but no fatalities. Management included vinegar as first aid (66%), parenteral opioids (70%) (range 2 to 82.5 mg morphine equivalents in adults), and magnesium sulfate (3 cases). Hospital admission (49%) and aeromedical retrieval (16%) were commonplace. CONCLUSION: Irukandji syndrome in the Northern Territory was clinically consistent with previous studies but had distinct seasonal, geographic, and environmental features. Indigenous children in remote coastal communities are at risk, and there is room for improvement in prevention and management.

Emerging pneumococcal carriage serotypes in a high-risk population receiving universal 7-valent pneumococcal conjugate vaccine and 23-valent polysaccharide vaccine since 2001.

BACKGROUND: In Australia in June 2001, a unique pneumococcal vaccine schedule commenced for Indigenous infants; seven-valent pneumococcal conjugate vaccine (7PCV) given at 2, 4, and 6 months of age and 23-valent pneumococcal polysaccharide vaccine (23PPV) at 18 months of age. This study presents carriage serotypes following this schedule. METHODS: We conducted cross sectional surveys of pneumococcal carriage in Aboriginal children 0 to 6 years of age living in remote Aboriginal communities (RACs) in 2003 and 2005. Nasal secretions were collected and processed according to published methods. RESULTS: 902 children (mean age 25 months) living in 29 communities in 2003 and 818 children (mean age 35 months) in 17 communities in 2005 were enrolled. 87% children in 2003 and 96% in 2005 had received two or more doses of 7PCV. From 2003 to 2005, pneumococcal carriage was reduced from 82% to 76% and reductions were apparent in all age groups; 7PCV-type carriage was reduced from 11% to 8%, and 23PPV-non-7PCV-type carriage from 31% to 25% respectively. Thus non-23PPV-type carriage increased from 57% to 67%. All these changes were statistically significant, as were changes for some specific serotypes. Shifts could not be attributed to vaccination alone. The top 10 of 40 serotypes identified were (in descending order) 16F, 19A, 11A, 6C, 23B, 19F, 6A, 35B, 6B, 10A and 35B. Carriage of penicillin non-susceptible (MIC > or = 0.12 microg/mL) strains (15% overall) was detected in serotypes (descending order) 19A, 19F, 6B, 16F, 11A, 9V, 23B, and in 4 additional serotypes. Carriage of azithromycin resistant (MIC > or = 2 microg/mL) strains (5% overall), was detected in serotypes (descending order) 23B, 17F, 9N, 6B, 6A, 11A, 23F, and in 10 additional serotypes including 6C. CONCLUSION: Pneumococcal carriage remains high (approximately80%) in this vaccinated population. Uptake of both pneumococcal vaccines increased, and carriage was reduced between 2003 and 2005. Predominant serotypes in combined years were 16F, 19A, 11A, 6C and 23B. Antimicrobial non-susceptibility was detected in these and 17 additional serotypes. Shifts in serotype-specific carriage suggest a need more research to clarify the association between pneumococcal vaccination and carriage at the serotype level.

Evaluation of bifenthrin applications in tires to prevent Aedes mosquito breeding.

The efficacy of maximum label rates of bifenthrin applications to dry tires to prevent Aedes mosquito breeding was investigated by field colonization and bioassay trials in shaded and unshaded locations. Aedes notoscriptus and Culex quinquefasciatus larvae were the most abundant species present in the field colonization trial. Colonization and survival of Ae. notoscriptus larvae to the late instar occurred significantly earlier in treated tires in shaded compared with unshaded locations (P = 0.002). Bifenthrin applications in shaded tires only prevented early instar survival for approximately 2.6 wk. Aedes notoscriptus late instars did not appear in the treated unshaded tires. Culex quinquefasciatus colonized treated tires from the 2nd wk in both shaded and unshaded treatments. In the bioassay, water from bifenthrin-treated tires, through extrapolation, was found to kill approximately 100% of late instar Ae. notoscriptus for only approximately 2.0-2.2 wk in shaded and unshaded tires. Under conditions optimal for Aedes breeding, such as shaded locations, high ambient temperatures, high relative humidity, and high amounts of leaf/organic matter accumulations, bifenthrin may not be effective as a larval control measure in tires for greater than 2.0-2.6 wk.

Reducing ear, nose and throat (ENT) waitlists: Implications of a referral audit.

INTRODUCTION: Many specialist waitlists in Australian hospitals are long. One reason anecdotally reported for this is poor alignment of referrals with current recommended guidelines. This paper reports the findings of an audit undertaken in 2017 for ear, nose and throat (ENT) surgeon referrals submitted by primary health centres within Cape York, Australia. MATERIALS AND METHODS: 54 long-wait ENT referrals were reviewed against referral criteria for ENT presentations using the Clinical Prioritization Criteria (CPC) and two routinely applied clinical primary health care guidelines; with findings reported alongside patient demography. RESULTS: All of the long wait ENT referrals in the sample were for remote living Indigenous Australians, most were children (93%). One fifth of referrals fulfilled all referral criteria and were appropriate (22%); one third required further informaiton to support the referral, either audiology or clinical history (30%); and half were inappropriate referrals (48%). CONCLUSION: Although many referral submissions did not adhere to CPC or routine guidelines, this audit enabled the identification of improvements to the referral system including the development of a checklist and flow-chart, plus patient information resources aimed at improving patient adherence. A case can be made for a new service delivery model that provides ongoing primary health education and facilitates improved ENT access. These strategies may improve ENT referral quality and decongest current ENT specialist waitlists, while offering improved primary health care management of ear presentations.

The impact of the introduction of a toxicology service on the intensive care unit.

Objective: To examine the impact of a clinical toxicology service on toxicology patients admitted to an intensive care department Methods: The authors performed a retrospective chart audit of all patients presenting to Cairns Emergency Department (ED) over a five-year period from 2011 to 2016 with a toxicology diagnosis requiring Intensive Care Unit (ICU) admission. They were divided into two groups: pre-toxicology (1 April 2011 to 30 September 2012), and post-toxicology service (1 October 2012 to 31 of March 2016) introduction. Patients were identified using ED and ICU databases. Patient charts were manually searched, and data entered on a preformatted data extraction tool. The data were statistically compared pre- versus post-toxicology service introduction using univariate (t-tests and Pearson's Chi Square) and multivariate modelling. Where appropriate, continuous variables were log transformed to enable parametric analyses. Results: There were 37 patients in the pre-toxicology and 102 in the post-toxicology group, with an increased median APACHE III J score in the post toxicology group (39 vs. 49). The introduction of a toxicology service was associated with statistically significant reductions in median ICU length of stay (LOS) (32.9 vs. 20.6 h), median duration of mechanical ventilation (29.1 vs. 20.6 h) and median time to psychiatry review (19.4 vs. 6.7 h). The reduction in ICU LOS remained statistically significant (p = 0.036) when adjusted by sex, age and duration of mechanical ventilation. There was neither increase in mortality, nor readmissions from EDSSU to ICU. Conclusions: This study has demonstrated that the introduction of a toxicology service was associated with a reduction in median ICU LOS, duration of mechanical ventilation and time to psychiatric review in patients with a toxicology diagnosis admitted to our ICU.

Predictive indicators for Ross River virus infection in the Darwin area of tropical northern Australia, using long-term mosquito trapping data.

OBJECTIVES: To describe the epidemiology of Ross River virus (RRV) infection in the endemic Darwin region of tropical northern Australia and to develop a predictive model for RRV infections. METHODS: Analysis of laboratory confirmed cases of RRV infection between 01 January 1991 and 30 June 2006, together with climate, tidal and mosquito data collected weekly over the study period from 11 trap sites around Darwin. The epidemiology was described, correlations with various lag times were performed, followed by Poisson modelling to determine the best main effects model to predict RRV infection. RESULTS: Ross River virus infection was reported equally in males and females in 1256 people over the 15.5 years. Average annual incidence was 113/100 000 people. Infections peaked in the 30-34 age-group for both sexes. Correlations revealed strong associations between monthly RRV infections and climatic variables and also each of the four implicated mosquito species populations. Three models were created to identify the best predictors of RRV infections for the Darwin area. The climate-only model included total rainfall, average daily minimum temperature and maximum tide. This model explained 44.3% deviance. Using vector-only variables, the best fit was obtained with average monthly trap numbers of Culex annulirostris, Aedes phaecasiatus, Aedes notoscriptus and Aedes vigilax. This model explained 59.5% deviance. The best global model included rainfall, minimum temperature and three mosquito species. This model explained 63.5% deviance, and predicted disease accurately. CONCLUSIONS: We have produced a model that accurately predicts RRV infections throughout the year, in the Darwin region. Our model also indicates that predicted anthropogenic global climatic changes may result in an increase in RRV infections. Further research needs to target other high-risk areas elsewhere in tropical Australia to ascertain the best local climatic and vector predictive RRV infection models for each region. This methodology can also be tested for assessing utility of predictive models for other mosquito-borne diseases endemic to locations outside Australia.

Ross River virus and Barmah Forest virus infections: a review of history, ecology, and predictive models, with implications for tropical northern Australia.

The purpose of the present article is to present a review of the Ross River virus (RRV) and Barmah Forest virus (BFV) literature in relation to potential implications for future disease in tropical northern Australia. Ross River virus infection is the most common and most widespread arboviral disease in Australia, with an average of 4,800 national notifications annually. Of recent concern is the sudden rise in BFV infections; the 2005-2006 summer marked the largest BFV epidemic on record in Australia, with 1,895 notifications. Although not life-threatening, infection with either virus can cause arthritis, myalgia, and fatigue for 6 months or longer, resulting in substantial morbidity and economic impact. The geographic distribution of mosquito species and their seasonal activity is determined in large part by temperature and rainfall. Predictive models can be useful tools in providing early warning systems for epidemics of RRV and BFV infection. Various models have been developed to predict RRV outbreaks, but these appear to be mostly only regionally valid, being dependent on local ecological factors. Difficulties have arisen in developing useful models for the tropical northern parts of Australia, and to date no models have been developed for the Northern Territory. Only one model has been developed for predicting BFV infections using climate and tide variables. It is predicted that the exacerbation of current greenhouse conditions will result in longer periods of high mosquito activity in the tropical regions where RRV and BFV are already common. In addition, the endemic locations may expand further within temperate regions, and epidemics may become more frequent in those areas. Further development of predictive models should benefit public health planning by providing early warning systems of RRV and BFV infection outbreaks in different geographical locations.

Ear, nose, and throat surgical access for remote living Indigenous children: What is the least costly model?

RATIONALE, AIMS, AND OBJECTIVES: This costing evaluation compares three service delivery models for ear, nose, and throat (ENT) surgery for remote living Indigenous children to improve their hearing outcomes, with the aim to identify the least costly model. METHODS: The main outcome measure presented was the incremental cost difference between the base case (Model 1) and two alternative models (Model 2, 3). The costs in 2017 Australian dollars are assessed from two viewpoints: (1) health system perspective, and (2) patients and their families including travel out-of-pocket expenses, presented separately according to the funding source. RESULTS: Findings indicate that the least costly model offered low-risk ENT surgery from a state funded hospital in a remote setting, with high use of videoconference technology: TeleHealth (Model 3) could save $3626 to $5067 per patient, compared with patients travelling to a regional centre public hospital (Model 1). A federally funded scheme which allowed groups of patients to access a direct flight charter transfer to the private hospital in regional centre (Model 2) reduced the cost by $2178 to $2711 per patient when compared with standard care (Model 1). From a societal perspective, Model 1 required out-of-pocket patient expenses, with greater time away from home, and hence appears the least preferred option. CONCLUSIONS: The sensitivity analyses also demonstrate that Model 3 would be the more economical model for providing ENT surgery for remote living children. By proving an accurate assessment of the true costs of delivering these important ear and hearing health services, strategic health service planners may be better informed and sufficient budgets can be allocated to provide improved service delivery. The benefits of Model 3, over Models 1 or 2, would also incorporate improvements to patient safety as a result of reducing patient travel, which should in-turn, reduce failure-to-attend rates.